Irish Healthcare – time to adopt the Singaporean model?
There are many parallels between Ireland and Singapore, both small countries with populations of the order of 4.5 million, both open export focused economies, both competing for foreign direct investment. One area where Singapore is streets ahead of Ireland is in health care. With Ireland experiencing a fiscal crisis that threatens the economic sovereignty of the state, is it time to consider a different model for health care that could drastically reduce the cost of health care provision (€15.5bn this year in Ireland compared with a 2008 average of $381 per person or $1.5bn in Singapore) to the state while improving the standard of care. It is not only the cost to the state that is lower in Singapore, but also the total cost of health care provision. Health care in Singapore costs Singaporeans only 3.7% of GDP compared with 7.5% of GDP in Ireland (this underestimates the amount the Irish pay relative to their income as GDP overstates Irish income by 10-20%).
What do the Singaporeans get for they’re much reduced spend? Well, life expectancy at birth in Ireland is 78.07 years; in Singapore, it’s 82 years; In the UK it is 78.85. The Singaporean infant mortality rate is a mere 2.3 deaths in Ireland it is 5.14, in the UK it is 4.93.The Singaporean model works by mixing public and private health care in an optimally efficient manner. The current Irish system also mixes public and private health care, but does so in a much less efficient manner. Singaporean citizens, like Irish citizens, but unlike British citizens are responsible for selecting and paying for their own health care. This means that the market and not a bureaucracy determines the provisioning of health care services and ensures that citizens have an incentive to become informed, and unwasteful, consumers fostering competition among service providers to drive costs lower and service levels higher. The Singaporean model is based on a system of 3Ms – Medisave, Medisheild, and Medifund.
Unlike Ireland, however the market distorting insurance companies are not involved in paying day to day medical expenses. The state ensures citizens have enough cash to pay for health care via a mandatory health savings scheme (Medisave), funds are automatically deducted from citizens pay each month, supplemented by employer contributions and accumulated in personal health care accounts. These accounts remain the citizens property but are boxed off for meeting healthcare costs while the citizen is alive. The state provides for cover for serious (and expensive) health problems via a public health insurance scheme (Medisheild), but citizens are free to choose private alternatives if they wish. Medifund is a government run fund for meeting the costs of those Singaporeans who are unable to contribute to Medisave and Medisheild.
While a market based system may gall those used to the public health care provision provided by the NHS, it does seem to produce positive changes over time by allowing innovation by entreprenuers and competition on price and service levels. For example, in the last five years in Ireland a small startup company has enjoyed enormous success with their VHI branded Swift Care clinics. The clinics which promise to see every patient in under one hour specialise in dealing with non-life threatening accidents and emergencies. Not only do these clinics reduce inconvenience for their customers they also help to take the pressure of busy public A&E wards which deal with the real emergencies (car crashes, heart attacks etc). Another innovation helping to create an informed citizenry and reduce doctor and hospital visits is VHI’s Nurse Line service. Complementary to VHI policy holders Nurse Line is a 24 hour service providing remote diagnosis and first level medical advice.
It’s important to note that the Singaporean approach leverages the market as a means-to-an-end, that is quality affordable health care for all, rather than an ideological (free market) end in itself. To ensure that service providers do not price gouge or take advantage of vulnerable patients a health care regulator regulates service levels and costs.
Perhaps the biggest advantage of public health service is that the same quality health care is provided to all. However without a market pricing mechanism to allocate the finite resources (or funds) available to the service decisions on what health care services are available must be taken by a committee. For example in the UK, Tim Harford pointed out in his book “Undercover Economist” that treatments for some ailments that cause blindness aren’t provided under the NHS until they are well advanced and will only be performed to save one eye! The Singaporean model appears to solve this dilemma, patients can choose which treatments they spend their money on – and the government ensures that all patients have enough money to purchase services (and that no patient can duck out of the system by avoding making contributions to their own health care fund)
Is there a downside to such a system? Drastically reduced cost to the government (up to 90% cheaper) and quality market based health care solutions available to all. It certainly sounds better than the inefficient public / private mix we have in Ireland today, and givien the scale of our fiscal imbalances it is imperative we find innovative ways not only to reduce costs but to actually improve services available while doing so.
What was it Mary Harney said? Oh yes, Irish people should be more like the Singopeans. Poor but happy.
Have you ever been to Singapore, Garibaldy?
They certainly aren’t poor, I’ve never been in a cleaner, more efficiently run city, with excellent transport networks, affordable cost of living (imported consumer goods at a fraction of the price we pay, high quality dining out at a fraction of Irish prices etc), the best public transport system I’ve been on (by far) etc.
Singapore –
GDP – Per Capita (PPP): $51142
4th highest GDP per capita in the world according the International Monetary Fund.
http://en.wikipedia.org/wiki/List_of_countries_by_GDP_(PPP)_per_capita
That was a quote Mack, take it up with Harney if it’s wrong. Having said that, per capita GDP doesn not mean there can’t be lots of poor people.
Mack
You’ve not really outlined the system. It has a few features that are absolutely required, such as a public option, but you’ve not really outlined details. Or inequalities. Or any problems with the system. People always gloss over this stuff on health, no matter what they argue for.
Also: isn’t percentage of GDP slightly disingenious here? The UK for example could spend more as a percentage of GDP than Sinapore, but significantly less if the GDP gap was big enough?
Anyhoo, the dangers of injecting private capital into health care is adequately outlined by this dazzling New Yorker article on US Health care costs:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
The thing is, though: the market isn’t a miracle. There is a finite amount of resources to be spent on health. Rationing ultimately must occur by one mechanism or another. If you want to sell this, sell it on the benefits rather than appeals to the amazingness of the market in abstract.
Ok, fair enough. I read it as an attempt to disparage the Singaporean model for Health Services by associating it with a reasonably unpopular Irish Health Minister who hasn’t achieved much in terms of improving the quality (or cost) of Irish health services delivered and by insinuating that Singaporeans enjoyed a lower standard of living than the Irish.
There is poverty in a lot of rich countries, including Ireland. I think she was certainly wrong to refer to the Singaporeans as poor unless she also meant we were poor.
I am not suggesting we copy every Singaporean policy, just this one, which does seem to produce better much results on the average at much reduced costs.
Whatever Ireland does it should steer well clear of the American model which now consumes almost 20% of the US economy ( 2.5 trillion dollars) basically divvied up between the private health insurers , private for profit hospitals , the medical and legal professions , drug manufacturers and medical related large corporations. The ‘american ‘ patient is the poor sucker at the bottom of the feeding frenzied merchants listed above .
While not exactly a Ponzi scheme there has to be a name for a health care system that leaves 50 million people uninsured -the highest rate of infant mortality in the world -the most expensive surgical operations , forces over a million people annually into official bankruptcy and employs some 400,000 people whose sole job is to read the very small print in over 1,000 plus private health insurance contracts so that claims can be denied .
Madoff was in the wrong business. Had he gone into direct investment in health care he could still be making billions .
If the Singaporeans have found a way to mix public and private health care insurance so that the focus is on the care and health of the patients then good luck to them .
The Singaporeans may also have non forgiving laws that punish those private health care providers that abuse or gouge patients by putting these white collar criminals following conviction up against a wall and executing them by firing squad .
This at least in the past would not be acceptable in western cultures . Perhaps we can learn a few more lessons from the Singaporeans other than their inexpensive health care system ?
Kensei -
I thought the most important features of the Singaporean system where
1. The Medisave system for meeting day to day medical expenses. In Irish terms this would introduce a free-at-the-point-of-use health service while keeping the market/ pricing/ choice mechanism of driving competition and innovation between service providers
2. The option of public and private health insurance providers. Most Irish people are familar with private health insurance and the Irish health insurance market is not yet bedivelled with the problems that plague the US market (driving costs up), that public health insurance solves, but perhaps it will be.
3. The fund that insures all citizens have access to funds to meet health care provisions.
–
I suspect you skim read most of what was written above, because I did mention market regulation and did say it the market was merely a means to an end. Tim Harford devotes a whole chapter in the Undercover Economist on how market based resource allocation via pricing can produce superior outcomes (win-win) over resource allocation by beuracracy in health service provision. I’ll update with some later on.
There are plenty of links to explore there if you are interested.
kensei ,
‘the dangers of injecting private capital into health care is adequately outlined by this dazzling New Yorker article on US Health care costs:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Kensei- thanks for linking to that article by Dr Gawande . I believe that President Obama has made that particular article compulsory reading for everyone involved in his Health Care policy review team as he struggles to make the urgent changes necessary for the USA before health care consumes the entire economy
Perhaps the Singaporeans have found a ‘market ‘ related system which works but then perhaps Doctors and Lawyers and Private Insurance executives in Singapore don’t expect to be millionaires before they’re 35 ?
couple of factors that mite be stating the obivious but Singapore is basically a city state, so regionalism and travel distances are much less an issue. It is also a major transport hub for the world, which has created a large health tourism market to sibsidise the citizens, finally being shall we say a “soft authoritarian” state can ocassionally help
Greenflag -
but then perhaps Doctors and Lawyers and Private Insurance executives in Singapore don’t expect to be millionaires before they’re 35 ?
Most likely they don’t work within a system that protects their jobs from competition and guarantees high salaries at others expense. 300k for a consultant is 200k that easily could have been spent on health treatments for patients elsewhere. Super high wages for doctors and lawyers are a punitive tax on the ordinary working citizen. The unwarranted professional protectionism that shuts out competition is the mechanism that perpetuates the load that overburdens the poor.
Mack
I suspect you skim read most of what was written above, because I did mention market regulation and did say it the market was merely a means to an end. Tim Harford devotes a whole chapter in the Undercover Economist on how market based resource allocation via pricing can produce superior outcomes (win-win) over resource allocation by beuracracy in health service provision. I’ll update with some later on.
Nope, I read it. But the devil in health care is really, really, in the details. And broad brush stuff isn’t enough.
A more detailled if still favourable article here:
http://www.american.com/archive/2008/may-
june-magazine-contents/the-singapore-model
Rising health costs and moral hazard remains a problem, and I’d expectt hey’d be more of a problem in rip off Ireland. You have also brushed over the likes of co-payments.
Drumlins Rock –
Good points, we may always have to pay a little bit more for health in Ireland than the Singaporeans do. The cost to the state is over 10 times more at the minute, in Ireland, with lower health outcomes too boot.
The Singaporean system is clearly highly regarded. I think it’s worthy of Irish investigation, as the debate rarely stretches beyond a comparison of the British and American health care systems (somewhere between which the Irish system lies).
Kensei –
I link to that article you provide in the blog entry, by the way
I’m not saying that the Singapore model is perfect – merely that it is better than what we have at the minute (better outcomes, lower cost) and thus worth considering.
Mack
Good points, we may always have to pay a little bit more for health in Ireland than the Singaporeans do. The cost to the state is over 10 times more at the minute, in Ireland, with lower health outcomes too boot.
You are being somewhat disingenious here. The cost to the state is more because the state is providing the service. There are corresponding assets in the form of higher taxes to cover it. It doesn’t really amtter if the cost to the state is 10p if I’m paying three tiems as much in fees as I was in taxes. The key figure here is the 3.7% of GDP. I’d guess it would be seriously tough for Ireland to get anywhere near that figure, not being a city state.
It may well be possible to get better care for cheaper. But this is spurious, frankly.
Mack
I link to that article you provide in the blog entry, by the way
Oh right. You are apparently using it as a source for a figure. Being quite happy to take that as read, why would I go trawling further?
Anywho, thanks for further supporting my argument that it takes intelligent use of links to stop them being totally ignored. Turns out it was quicker to Google the subject.
‘The unwarranted professional protectionism that shuts out competition is the mechanism that perpetuates the load that overburdens the poor.’
I agree it’s ONE of the mechanisms. But not the whole story. I’d like to see a detailed breakdown of where the taxpayer’s monies go to fund the present system .
When ‘electricians ‘ strike for an 11% pay increase it’s portrayed as national sabotage but when the white collar professional medical establishment and consultants demand an extra 250,000 euros its ‘professional ‘ compensation ?
For what it’s worth I agree we should look beyond the UK and or USA for ‘solutions ‘ Did I not read a while back that we were looking at the Dutch system which is very effective and is a mix of provate and public ?
Kensei -
You are being somewhat disingenious here… There are corresponding assets in the form of higher taxes to cover it.
I see where you are going, but I think the core problem is there aren’t the taxes to cover it! 60bn in spending vs 30bn in tax revenues.
Raising taxes and forcing people to save into accounts (over which they retain ownership) aren’t quite the same thing. As taxes rise, the propensity to create or use the taxed resource falls. I.e if we increase income tax to 70% to solve the fiscal crises, I will for sure not be working 2 jobs (like I am this year), next year. God knows how many immigrants would leave. With a Medisave facility, if they permanently left the state we could refund them the balance in their accounts.
As an aside, I think the Singaporean system would produce cheaper health care in Ireland than the current Irish system.
To clarify -
God knows how many immigrants would leave. With a Medisave facility, if they permanently left the state we could refund them the balance in their accounts.
By offering to refund their Medisave accounts, Medisave would not be equivalent to a tax, but more like a savings account and would therefore increase the likelihood of immigrants coming / staying.
Mack
I see where you are going, but I think the core problem is there aren’t the taxes to cover it! 60bn in spending vs 30bn in tax revenues.
Using a short term crisis is just a little cheeky, there.
By offering to refund their Medisave accounts, Medisave would not be equivalent to a tax, but more like a savings account and would therefore increase the likelihood of immigrants coming / staying.
It’s not quite a tax. But it’s not quite saving, either. What happens if they fall ill while that account is rather empty? Who pays? And if they can simply bounce here and back depleting it…
Greenflag -
Yep, I’ve noticed the Dutch system being increasingly spoken of positively of late. Almost certainly also worth investigating. It could well be time to make a virtue of neccessity, why should we roll over and let this reccession beat us? It’s an opportunity to make the country great / or at least just a little bit better…
(submit word – better!)
Kensei -
Using a short term crisis is just a little cheeky, there.
I wish!
Article about inequality in singapore.
http://aussgworldpolitics.wordpress.com/2009/06/15/the-case-for-income-equality-in-singapore/
Big Bird –
You would expect (all else being equal) high levels of income inequality to lead to worse average outcomes in health though, would you not?
But Singapore has much better health outcomes than the USA (which is slightly less unequal). That would imply that the health system in Singapore is able to counteract the negative effects of income inequality within the state?
http://takingnote.tcf.org/2008/07/health-care-in.html
Note, I’m not suggesting we copy every policy Singapore implements (such as abolishing the minimum wage, or banning chewing gum!), just that it does appear to get better results in health for less spend.
Have you ever been to Singapore, Garibaldy?
They certainly aren’t poor, I’ve never been in a cleaner, more efficiently run city, with excellent transport networks, affordable cost of living (imported consumer goods at a fraction of the price we pay, high quality dining out at a fraction of Irish prices etc), the best public transport system I’ve been on (by far) etc.
And about 10 hangings and many more floggings per year. Have been there. Something creepily Stepford Wifeish about the place.
How do Singaporeans fare in the obesity stakes?
Surely life style and factors such as beer consumption per capita / tobacco usage etc must be factored in to the longevity comparison . IIRC the Japanese also live the ‘longest ‘ lives of the larger developed countries.
I’d hazard a guess that if the average Irishman or Briton cut down alcohol consumption by half and the cancer sticks by another half we’d probably live longer or equally as long as the Singaporeans?
‘why should we roll over and let this reccession beat us?’
I was’nt suggesting we should
Erasmus ,
‘And about 10 hangings and many more floggings per year. ‘
Sounds just like what Wall St needs to whip it into shape
?. Perhaps even the GOP you know the party of ‘family values ‘ and good christian living could do with a few strokes as well to ahem to improve their ‘christian ‘ credentials
And the subject for this weeks sermon from the First Church of Family Values ?
‘Defending the sanctity of marriage and the importance of hiking in Argentina ‘
The Rev Mark Sanford
Assoc Ministers – John Ensign
David Vitter
Senior Minister – Newt Gingrich
Choir Minister – Larry Craig
Youth Minister – Mark Foley
International affiliates and associations include the Orange Order in Ireland , and numerous religious orders of the Catholic Church who have ministered whippings among other diverse punishments for those who sin against family values over the centuries
Let him who is without sin cast the first stone eh ?
Over to you Mr Ahern
Greenflag -
Difficult to tell on the smoking, it’s a huge lagging factor and smoking rates are subject to significant changes overtime (e.g. the rise of female smoking in the West may lead to a balancing out of life expectancies). They won’t affect the infant mortality rates so much, which are over twice as good as the rates for Ireland or the UK.
In Singapore as of 2009 24% of males and 4% of females smoke.
http://www.singstat.gov.sg/pubn/papers/people/ssnmar09-pg12-16.pdf
This study puts the percentages as 36% of men and 7% of women among middle-aged and elderly Chinese Singaporeans (the largest and wealthiest ethnic group within Singapore).
http://jn.nutrition.org/cgi/content/full/135/10/2473
Erasmus – Stepford Wives, yeah I agree.
An interesting piece and I would like to know more about the Singaporean system. Although as a note you might also point out that public administrators in Singapore are better paid and of a higher quality than they are in many other countries. Public service is rewarded and carries high status.
But I do have an issue with your piece. You make the bald assertion that:
[i]“This means that the market and not a bureaucracy determines the provisioning of health care services and ensures that citizens have an incentive to become informed, and unwasteful, consumers fostering competition among service providers to drive costs lower and service levels higher.” [/i]
I have to say I am deeply sceptical of that claim without further data to demonstrate how that is actually happening. The problem with market driven solutions in healthcare is the inherent market failures in the health care market because of the nature of the product being consumed. The USA is the prime example of everything that is wrong with market driven health care. The traditional analogy of the USA market system is that it is like going to buy a car and having the salesman deciding what kind of car it will be and then a third party insurer pays for it. I think most people can figure out what is likely to happen in that scenario. That fundamentally is the problem. In the health care market the consumer of the product will never be a sovereign consumer as we rely on experts to make the decisions about what kind of care is delivered and with insurance a third party actually pays for it so cue the moral hazard problems. Your suggestion is that in Singapore the average healthcare consumer is able to avoid this and is in fact that mythological healthcare consumer with perfect information. This seems to me to be very unlikely. In reality it is much more likely that the providers i.e. doctors are making the real decisions about how much and what type of healthcare is being consumed not the patients. The question should be what kind of mechanism is being used to protect against the doctors inflating the amount and cost of the treatment provided. Your description is closer to a puff piece on the wonders of the market mechanism rather than I suspect an accurate description of what is actually controlling the cost and provision of medical services in Singapore. Unless of course they have figured out how to avoid the inherent market failure problem in the healthcare market but I seriously doubt it.
Hi Duncan,
In the book Undercover Economist, chapter “The Inside Story”, British (but US based) economist Tim Harford examines why the health care market in the United States fails. Knowledge held by market participants – primarily insurers and their customers is asymmetric (customers tend of have a better idea of whether or not they have a serious illness and thus need insurance) and the steps taken to remedy this situation cause distortions in the market. In fact he argues that a proper market simply can’t function. He also covers some of the advantages and disadvantages of the British system.
Having compared and contrasted the British system and the US system, he then sketched out the details of a public / private system that could solve the problem of developing a market that efficiently allowcates health care resources. (An efficient market being one, where no improvement can be made to the lot of one participant without harming the lot of another, and inefficient market (like the US and inherently public systems) being one where at least one change that improves everyone’s lot remains unimplemented.) He then announces that these principles have been successfuly deployed in Singapore for two decades.
The book itself is well worth a read. IIRC your based in the US – so here it is on amazon.com.
http://www.amazon.com/Undercover-Economist-Exposing-Poor-Decent/dp/0195189779
The inspiration for this very, very broad strokes overview (I’m not an economist, and don’t have the same 200 odd pages to reproduce Tim Harfords ideas
) was a blog entry by Irish economist Ronan Lyons where he delved in to the expenditure cuts likely to be recommended by Colm McCarthy’s ‘An Bord Snip Nua’ Public Sector Review Board in Ireland.
http://www.ronanlyons.com/2009/07/06/an-bord-snip-eile-public-sector-cuts-part-1/
To quote
Ultimately, Ireland needs to consider its health model. I would love to see policymakers explore a Singapore-style model of a mandatory personal health savings account, similar to a pensions account, taken out of tax paid and stored as an investment account, to be used for general medical expenses. In the meantime, though, further savings of about €1bn could be achieved through reform of the medical card scheme, long-term residential care and in particular the block grants given to hospitals.
Duncan
The question should be what kind of mechanism is being used to protect against the doctors inflating the amount and cost of the treatment provided
There is a regulatory body that prevents overpricing. I did highlight this in the blog entry.
Your description is closer to a puff piece on the wonders of the market mechanism rather than I suspect an accurate description of what is actually controlling the cost and provision of medical services in Singapore
Hmm. You are the second person to miss it, but I did cover it in the blog entry.
It’s important to note that the Singaporean approach leverages the market as a means-to-an-end, that is quality affordable health care for all, rather than an ideological (free market) end in itself. To ensure that service providers do not price gouge or take advantage of vulnerable patients a health care regulator regulates service levels and costs.
mack,
‘They won’t affect the infant mortality rates so much, which are over twice as good as the rates for Ireland or the UK.’
I would think that a lot more than 4% of females smoke in Ireland/UK and it’s accepted medical fact that women who smoke during pregnancy have higher rates of infant mortality . Also those who drink alcohol during pregnancy have a much higher risk of giving birth to ‘brain’ damaged children which in turn may lead to greater rates for infant mortality in these islands as opposed to Singapore .
Looks to me like Duncan Shipley Dalton is asking the pertinent questions re just what is controlling the costs in the Singaporean system .
Could it be that Singaporean doctors are more ‘ethical ‘ than their Irish or American counterparts ? or it’s probable that the ‘system ‘ in the USA and to a lesser extent in Ireland allows practitioners and corporations and private health care insurers to gouge the ‘consumer’ i.e taxpayers despite the latters so called access to perfect information.
I share Duncan S Dalton’s views generally on this issue and am extremely sceptical of the ‘free market ‘ achieving anything other than inflating the overall cost of health care . I’m all for self education and for people making themselves aware of the dangers for health re smoking and drinking to excess , lack of exercise etc but I don’t hold out much hope for the average consumer in any conflict with private health insurance companies (stateside anyway) . Britain and Ireland are shielded to a large extent from the kind of medical terrorism that is inflicted on a large section of the American people and yes even on those who ‘think ‘ they have insurance !
Duncan
The money quote from the New Yoprker article earlier:
“Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Mack
We are not missing it. There is a natural scepticism of the ability of regulators to control the costs especially with the political pressure that would be made brought to bear by outside interests. The complete failure of “light touch regulation” in the banking system is a case in point.
I am not in general a fan of regulators forcing price controls directly. That introduces political calculation and defeats the market mechanism. Far better if they have a way to influence the incentives or heavily punish the guilty. But both those rely on will.
Another killer quote form that article:
Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
There is a lot in that article, and I really recommend it. I like some of things done at the better clinics. And some market mechanisms are worthwhile, though that will be at the cost of variability of care. I’d just feel safer with the government ultimately controlling the purse strings, because ultimately I hire and fire them in a way I simply don’t with health care companies.
From:
http://www.healthbeatblog.org/2008/07/health-care-in.html
“These numbers owe little to HSAs. As the Canadian Medical Association Journal has put it, “Singapore’s MSA program itself has contributed less to cost control than the more recently introduced supply-side tactics” Hsiao also notes that “the well-executed Medisave scheme in Singapore could not contain costs, so it is unlikely that such a scheme could do so here.” And Barr eloquently concludes that while HSAs are an institutionally distinctive feature of Singaporean health care, “the practical and spiritual heart of the system lies in control and parsimony.”
In the end, Singapore’s health care experience isn’t an argument for consumer-driven medicine, but for targeted government interventions and smart, timely, regulation of over-treatment. One of the world’s most successful health care systems is built on the principle that personal responsibility is good, but it has practical limits—and the understanding that when it comes to health care, more can easily become too much.”
Market theory suggests that when the market price of some good is zero, that the demand can rise to infinity. Healthcare may not be quite like this, but when there is no cash to pay for failing to take care of your body, and when you will be treated with more care and attention than you are used to, you will tend to overconsume healthcare.
“the practical and spiritual heart of the system lies in control and parsimony.”
I can just see the consultants and the INO lining up for that and not going bawling to the meeja. Of course, in Singapore it helps that press freedom is not quite the Irish model either
http://www.freedomhouse.org/uploads/fop08/CountryReportsFOTP2008.pdf (at page 187)
“Your suggestion is that in Singapore the average healthcare consumer is able to avoid this and is in fact that mythological healthcare consumer with perfect information. This seems to me to be very unlikely. In reality it is much more likely that the providers i.e. doctors are making the real decisions about how much and what type of healthcare is being consumed not the patients. The question should be what kind of mechanism is being used to protect against the doctors inflating the amount and cost of the treatment provided.” – Duncan Shipley Dalton
This is a completely ridiculous argument that is underpinned by nothing more substantial than socialist paranoia about the free market system. The consumer relies on advice from professionals in just about every area of life and doesn’t have problems with, for example, an architect involving them for an office building when they commissioned a five bedroomed house. Following your logic would lead to, for example, all lawyers being employed by the State so that the public are not invoiced excessive amounts. There is no need to be so paranoid about people who work for profit.
In reality, most government healthcare that is paid for by the State is not provided by employees of the State. Unless you make it mandatory for all healthcare workers to work for the State on a fixed wage, you cannot eliminate the free market from the system (and only then in respect to labour costs but not to the more substantial costs of infrastructure, equipment, medications, ect). When the Irish State, for example, pays the cost of a GP visit for a pensioner, what is to stop that GP from bringing poor old granny back every week for a check-up so that he can collect another £40 fee? Sweet FA, yet he does not call granny back every week, does he? (Okay, he may well do, but unless you prove your claim that he must do because the free market system makes everybody into an evil rogue, I’ll just go with my assumption that you are paranoid).
And suppose you do make all healthcare workers employees of the State, you will then have a situation where those workers won’t want to do any work beyond the minimum amount required because they have no incentive to do so. That will drive up the labour cost because you will need to employ more of them. In addition, you’ll be into a situation where a very poor standard of service is delivered because State workers are the laziest shits imaginable and the State never gets tough with its public sector (witness the insane level of wages paid to public sector workers in Ireland). Private healthcare clinics, on the other hand, are akin to hotels with the staff trained to offer top-rated service, and all run and ruthlessly efficient business lines that keeps costs under control. That is the level that we should be aiming for, not state-controlled backwardness.
The only future for healthcare is privatisation of hospitals and healthcare insurance. There should be no public healthcare whatsoever. All of it should be paid for by private insurance policies. Those who failed to take out insurance should have no right to become a burden on those who provided for their own needs. Most private insurers have agreed prices for services with private healthcare providers and direct their clients to them. If the client opts for a non-designated provider, then that client pays a percentage of the cost in addition to the cost of the policy. Since the private insurers are paying the private healthcare providers, they have a huge incentive and huge power to keep the cost of the service to a minimum. That free market system works perfectly when the government allow it to work.
Anyway, it’s all deckchairs on the Titanic stuff. Ireland’s projected tax revenue for 2009 will be €34 billion and its healthcare spending will be €18 billion, so that’s more than half of ever-declining tax revenue. Of course, allowing 109,500 immigrants into Ireland in 2007 and so on, such that Ireland saw the largest growth of population in recent history has nothing to do with why State services healthcare collapsed under the demands of that influx, not did it have anything to do with why the cost to the State of healthcare services rose 9% in 2008, and so on.
@Greenflag
“[The US has] the highest rate of infant mortality in the world”
Complete.
And utter.
Bollocks.
I think we can take a line through that to judge whether you have the slightest idea what you are talking about.
“Those who failed to take out insurance should have no right to become a burden on those who provided for their own needs”
Oh come on Harry – How about sick, ill, poor people. I dunno about you but that’s why I pay my taxes – to look after the needy.
“Those who failed to take out insurance should have no right to become a burden on those who provided for their own needs”
Oh come on Harry – How about sick, ill, poor people. I dunno about you but that’s why I pay my taxes – to look after the needy.
That was Dave, Dewi.
Sorry Harry.
“The state ensures citizens have enough cash to pay for health care via a mandatory health savings scheme (Medisave), funds are automatically deducted from citizens pay each month, supplemented by employer contributions and accumulated in personal health care accounts.”
Like for everything and even more with any insurance the devil is in the details.
Medisave and medishield coverage is enough to cover anything in limits of…?
I’d be surprised (really) if you found that that Medishield and Medisave can cover for anything more than an appendicectomy.
For anything else there is the family’s house mortgage.
Charles
As for the GDP per capita: Singapore is not a country, it is a town, with few infrastructures to develop.
It is easier when the workers are coming from abroad (neighbouring Malaysia), and not counted in the capita.
It is as if you were taking the GDP of London, with the Added Value of people coming to London everyday, but not counting them in the number of inhabitants; moreover any foreigner living in Singapore, needs a minimum income.
It helps with the statistics!
The disadvantage of the small size is that Singapore has to rely on immigration to enable its growth: 1 million more in 2007, 1.5 million more in 2008 out of a total population of 6!
Paddy Matthews (also Kensei, Duncan, Greenflag)
Yes I agree, it services and costs need to be regulated. Note that Medisave is a government run insurance scheme (public health insurance NOT private insurance) therefore the government have a very strong incentive to ensure price gouging is stamped out.
Charles
Medisave and medishield coverage is enough to cover anything in limits of…?
I’d be surprised (really) if you found that that Medishield and Medisave can cover for anything more than an appendicectomy.
I doubt that very much. Medisheild is public health insurance, in Ireland (which is were we are talking about applying the model), why would that work any differently than private health insurance (VHI, Quinn, Vivas etc) today?
Kensei -
because ultimately I hire and fire them in a way I simply don’t with health care companies.
In practice you will find industry bodies (hello Mr. Timmons, FG Shadow Health Minister) and Unions have more clout than you, or the poor customer / patient.
There is a natural scepticism of the ability of regulators to control the costs especially with the political pressure that would be made brought to bear by outside interests
Well, they appear to have succeeded in Singapore, while we in the West have been ‘coping’ at best…
Mack
In practice you will find industry bodies (hello Mr. Timmons, FG Shadow Health Minister) and Unions have more clout than you, or the poor customer / patient.
Concerted electorate anger can produce a response in government that it simply can’t in private practice. Influence of those bodies are means to an end: my vote and everyone else’s.
In large part the UK Tories were undone in the last decade by what they did to the NHS.
Well, they appear to have succeeded in Singapore, while we in the West have been ‘coping’ at best…
Big cultural differneces there, Mack. Like soft authoritarianism.
“Medisave funds cannot be used to purchase some types of obstetric care and long-term hospital care, and Medishield will not cover expenses associated with pre-existing conditions including stroke, coronary artery disease, chronic obstructive lung disease and cancer. It appears that Singapore’s MSA program itself has contributed less to cost control than the more recently introduced supply-side tactics.
The failure to control costs through the MSA approach is especially noteworthy, given several characteristics of the Singapore population that might have been expected to assist in minimizing expenditures. The population is comparatively younger than Europe’s, and the country has yet to confront the health costs associated with an aging population. Many citizens are immigrants with relatively low expectations of the role of the state in providing health care. An ethos of individual responsibility stands in contrast to the redistributive philosophies of most Western European societies. Many patients in Singapore turn to traditional Chinese medicine, a type of health care not covered by government plans but one that serves to reduce reliance on Western therapies.18 Finally, the Singapore economy grew rapidly for 2 decades after the mid-1970s; although the resulting high employment rate ensured that most citizens contributed to MSAs, it left the MSA system vulnerable to the impact of a slowdown in economic growth.
Given the magnitude of out-of-pocket costs borne by individuals, the costs of medical care in Singapore often cannot be met by elderly people, especially elderly widows who were never employed outside the home, and poor people. Indeed, the World Health Organization rated the city’s system 101st of 191 countries studied for fairness of financing. This below-average equity ranking, coupled with the documented inability of MSAs to justify their primary rationale of cost containment, suggests that the Singapore system undergo closer scrutiny before it is emulated.”
http://www.cmaj.ca/cgi/content/full/167/2/159
If I was being sardonic, I’d note that “elderly people, especially elderly widows who were never employed outside the home, and poor people” tend not to post too much to the kind of economic or political blogs that are most keen on market-based solutions.
Paddy –
There is Medifund to cover costs incurred by those who are not covered by Medisheild or Medisave.
What insurer would take on someone with an existing illness? (It’s a bit like trying to buy car insurance after a crash). It’s unfortunate but those without insurance when the get ill are stuck relying on public health (in Singapore Medifund).
What do the poor in Ireland rely on today? They have no VHI, Quinn or Vivas. Neither can the poor in the UK go private to get treatments not approved by NICE (the beuracracy that decides what treatments should be publicly available and which should not).
Health outcomes in Singapore are still hugely better. Infant mortality is less than half that of the UK with it’s NHS – life expectancy is significantly longer.
If in Ireland we adopted that model we could correct any problems with it – i.e. by making more funds available under the Medifund equivalent to ensure that no-one is denied quality healthcare. Isn’t that the goal? Or are you idealogically committed to the idea that only government can run hospitals and the like?
Or are you idealogically committed to the idea that only government can run hospitals and the like?
I’m ideologically committed to the notion that the level of treatment that people should get should depend on their needs and not on their income.
I’m also suspicious of ideas advanced by people who are young, healthy and ideologically committed to market solutions and which have the effect of screwing those who don’t share their good fortune.
The Singaporean system is a mix of both a market solution and public health – it represents a pragmatic attempt to strike a balance. The Irish system is also a mix of public and private health, but a much less successful and efficient one.
and which have the effect of screwing those who don’t share their good fortune.
Well, the Singaporean model should lead to an improvement in health outcomes for the poor in particular over the current Irish system and I’m sure it could be improved upon in implementation.
http://www.guardian.co.uk/society/2008/aug/28/health.socialexclusion
The report highlights stark disparities within the UK, as in most countries in the world. A boy in the suburb of Calton, Glasgow, can expect to live 28 years less than one brought up in Lenzie, a few miles away. One born in Hampstead, London, will live around 11 years longer than a boy from St Pancras, five stops down the underground Northern line
Are there similar discrepancies in the Republic? I’m assuming different parts of Dublin have similar patterns?