Monday, July 28, 2014

Professional Fees: Can Doctors Police themselves?

Can doctors police themselves? Well more often than not, the 'human' aspect of self-interest tempts and in some cases, overwhelms good sense and conscience--the classical if inescapable 'moral hazard' and conflict of interests.

As doctors, we have a duty and responsibility to determine this fine line, to ensure that our patients' interests are our first and foremost concern. We have to remind ourselves of our medical professionalism and the Tavistock principles that most of our peers from time immemorial have vouched to preserve--patients' rights, well-being, safety and altruism being the major pillars of our professional remit...

Tavistock Principles
  1. Rights
    • People have a right to health and health care.
  2. Balance
    • Care of individual patients is central, but the health of populations is also our concern.
  3. Comprehensiveness
    • In addition to treating illness, we have an obligation to ease suffering, minimise disability, prevent disease, and promote health.
  4. Cooperation
    • Healthcare succeeds only if we cooperate with those we serve, each other, and those in other sectors.
  5. Improvement
    • Improving healthcare is a serious and continuing responsibility.
  6. Safety
    • Do no harm.
  7. Openness
    • Being open, honest, and trustworthy is vital in healthcare.

From my social and personal perspective, ethical fee guidelines do need to be there; boundaries need to be drawn and established by peers or society.

If one chooses to charge professional fees far exceeding prescribed norms, then clearly venal interests have trumped common sense and practice... One veers perilously close to offering boutique-type medical services--not necessarily bad or wrong, but one that's similar to desirable luxury goods and services! But here's where most if not all patients or consumers of healthcare must have, a prior informed choice or alternative to decide...

Ultimately in most health services around the world, excessive fees and costs have been the bane against the concept of universal access to health for all. Point of care fees are known to deter and derail population health access for the worse.

Even when there are third party payers and insurance, there are limits as to how much these payers have the finite capacity or the willingness to reimburse. But society by virtue of its invisible hand of the free market can lend guidance or advice as to which or what health care services or fees would be considered excessive... However, more often than not, this top-down type of fluctuating market forces might be too slow and sporadic to influence common or safe practices...

As such, something as profound and indispensable as health cannot be let to its own devices to find its level of fair pricing... Professional fee's and overall health care costs should be dictated to some extent by market forces and then some, by overarching health authorities and policy makers, providing the necessary but difficult balance of controls and limits, as well as the bottom line social safety nets, when all else fails for those hapless patients who simply can't afford to pay.

Health for populations must be considered a social good that cannot simply be left to free market forces and so-called free competition! For most if not all, health must increasingly be considered a basic human right, and not just a market-driven aspiration or dream!


Dr D Quek said...

John Ng: I am so sorry to offer a contrarian view. I note that there are many amongst us who work strictly for Ferrari and bungalow houses and caviar dinners. During the Fees schedule discussion back in 2006, we worked hard to ask that there should be NO fees schedule, because, firstly, there can never be an adequate and fair fees schedule, because there are so many moving variables in terms of case complexities, operator experience and litigious risks. Secondly, even if you can devise one by some means, you can never review it frequent enough to keep up with market forces. Thirdly, for every fees schedule that one puts up, the ingenious doctors ( those "bungalow / Ferrari / caviar ) boys will find a way around them, ending up that "good boys" are held back while those boys will still get off. Of course, it would be good if doctors are all "angels" and endowed with a heavy dose of social responsibility and philanthropy. It may be better for medical centers and doctors all declare their fees and allow market forces to regulate. As I often argue, if we all wish to practice at Dr S Lim's level, we may only get one royalty patient a life time. I regret that a proper country like Singapore will make a law just for one "bad" apple.

Dr D Quek said...

Sorry John Ng, don't mean to say that there should be any imposition of fee schedules as per regulations or law, but that there should be some guidelines as adopted by almost every nation and insurance, including Medicare and Medicaid. Of course there must be an independent group to regularly assess changes and modification of the fees as to expertise, relative value scales, and even reduction based on degree of technical difficulty and skills as these become technically easier with time and advances, etc. Even lawyers have their fee schedules as a guide and arbitrators can then used these as a benchmark for which to settle dispute. However, when it comes to healthcare, unfortunately, some urgent therapies may make this difficult to adjudicate as patients have no power to choose and dither and are sometimes held ransom to the dictates of free for all professional or hospital fees.

Dr D Quek said...

As we progress, whether we like it or not, reimbursement models are bound to change for the 'worse' for doctors. Case-mix and DRGs style payments would come into the picture and global budgets then take over, may be not now, but say in 10 - 15 years. Then without these fees as guidelines, we'll be swallowed up by the hospital administrators and managers who would allocate as per their 'costs' estimates (which have been rising exponentially!). This will eventually squeeze and price us out to the lowest pittance ever, as they carve out their shares... in most private hospitals elsewhere, these professional fees are 'bargained' or negotiated as a portion of the total fees, or as tenured privileged wages, so we better get our act together before, we are all given just a salary plus minus bonuses and incentives, period!