Notes on Healthcare from the Mer-Lion's Mouth

Maharaja’s Revenge Strikes in Indonesia

I've been lying in bed for days after getting a serious case of 3rd world food poisoning on a day trip to Bintan in Indonesia. This has allowed me to spend lots of time contemplating the importance of a good healthcare system, and to think about my opinions of how these things should work, given my ability to compare Singapore and the US. Even with all this time on my hands, there are still issues that are so complicated that I don't feel like I can form a finite opinion about how I think it should work, and all I can say is that I don't envy our president.

Last weekend, I made the classic mistake – I forgot that I wasn't in Singapore. Bintan, only 55 minutes by ferry from Singapore, looks kind of like Singapore, charges all fees in Singapore dollars and at Singapore prices, caters to Singaporeans, but in the end, it’s still Indonesia, and their water isn't from Singapore. Eating salad there was a terrible, terrible mistake. Beware of the food at the Nirwana Gardens Resort...

During the last week, I first got to experience the Indonesian medical system, or lack thereof. A “doctor” at the resort gave me acetaminophen to cure my excruciating stomach ailments and I had to call my lovely boyfriend, Eric, in the middle of the night, so that he could try to help me from far, far away. He called a number in the US for medical emergencies and I ended up talking to a doctor in Philadelphia who advised me to get back to Singapore if I could. This whole time my poor French roommate, Augustin, who was so, so helpful, and his poor Japanese guests who he was entertaining, all had to accompany me back to Singapore on the ferry – an experience I hope to forget as soon as possible.

After 2 days of serious pain, I started to feel better and was then struck with a second round of symptoms which I am now, once again, recovering from.

Thoughts on healthcare

This week I visited an American doctor from Minnesota at the “International Medical Clinic” that boasts that it is the "expats' top choice." Everyone in the entire clinic was foreign, and even the receptionist was an Aussie. Something about having a doctor’s office in Singapore look and feel just like a doctor’s office in the US seemed comforting, I didn’t even mind the golden-curled children chasing each other around while coughing all over everything. Dr. Mike’s Midwestern accent was the icing on the cake.

While it looked and sounded familiar, one thing was decidedly not familiar, and that is the attitude and procedures around paying for healthcare. Even with the most robust insurance available in the country, you always pay in advance and then get reimbursed when you file your claim. This means that you need to have the funds available on hand to pay for all of your medical services up front. Since the doctors don’t deal directly with insurance companies, it seems much, much more like a restaurant than a hospital, and you can choose your medicine based on the cost.

I find this particularly interesting because with the American healthcare debate, one idea that keeps coming forward is how things would be different if people knew how much their medical care cost up front– or if they had to put forth more of their own money for more expensive drugs or procedures. Would that reduce waste in the system?

Yesterday, when my symptoms relapsed and I ended up drastically dehydrated, my roommate, Shabnam, went with me to the A&E (ER) because it was after normal clinic hours. The first place we went was the “cheaper” hospital, Gleneagles, which we went to because the non-english-speaking taxi driver couldn’t understand us when we said “St. Mary’s.” Gleneagles had a 1.5 hour wait to talk to anyone and a staff who was exclusively interested in identifying and quarantining swine flu, yet required all people entering the hospital to fill out a form with the same pencil, which must have been oozing with swine flu from the last 100 patients – way to go, geniuses. When we found this out, we called Mt. Elizabeth, which was basically down the street, and they only had one patient waiting. Mt. Elizabeth is the more expensive hospital.

So, in Singapore, like in the US, one hospital was full of people using the ER as a normal doctor’s office, but unlike the US, the competition was clear and transparent. Mt. Elizabeth was like the newest American hospital with attentive staff and immediate attention, and the only difference was a 20% increase in the cost – something that didn’t matter to me, because my insurance covers any hospital in Singapore.

While I was lying at Mt. Elizabeth on an IV to rehydrate me, they brought me forms to sign to authorize that I was willing to pay extra for the tests to find out what was causing my problems (which turned out not to be what they tested and instead they tested just for the mineral content in my blood – way to go to make an extra buck…). But think of being in an American hospital, if you asked them to find out what was wrong with you, and they brought you some forms to sign to say that you were willing to pay? What if you didn’t have the money, and you knew they wouldn’t let you leave the hospital at the end of the night without paying? Would you accept the treatment? Would you roll yourself out of bed and head home hoping you just get better? Does this happen today? It might, I just haven’t had to experience it.

At the end of the night, before I left, I stood at the registration desk charging my care on my credit card. After I had been in their office for 3 hours from being sick, I stood at their registration desk waiting for card authorization, since their job with me was done, it apparently wasn’t their job to make sure that I could sit. Now I will submit the forms to my insurance provider who will reimburse me sometime in the next 2 months.

Since my care wasn’t that expensive, I’m not worried about how this is going to affect my finances, however, the immediate payment/reimbursement system can be a nightmare if you require any kind of ongoing treatment. A woman at my office moved to Singapore from Australia and discovered that she had breast cancer. Since her husband had a job in Singapore, she stuck around to get her treatment here. Once a week she charged $7,000 on her credit card for chemo. Can you imagine what that would do to your finances, if like her, you had to wait up to 8 weeks to get reimbursed? Good thing she has good savings and credit – what about the majority of the population who wouldn’t be able to afford that? What then?

Part of why Singaporean medical care is cheaper than the US is that the government subsidizes a lot of the medicine. However, many people are also limited in their choices of care because they can’t afford to pay extra to get seen immediately. This seems to be the case in all government sponsored healthcare systems, and I don’t think that there is any way out of that inequity.

I think that in general, the Singaporean system of showing you how much your care costs, and allowing you to upgrade to a better doctor or a better hospital because you can afford it is necessary. If I wasn’t that sick, I could go to the local clinic under my building and pay only $15 for a consultation. When I care most deeply about excellent care, I can pay $15 for a taxi to take me to Orchard to see an American doctor and pay $139, that I can then get reimbursed, because my employer sponsors additional insurance.

With an American government-supported universal healthcare system, there will have to be some level of inequity, unless we want everyone to be forced to wait at the dingy hospital out of “fairness” like they do in some particularly socialized European countries. I don’t think that the world is fair, and I think that people should be able to pay extra or have extra insurance to get the level of care they feel they need. The people who can’t afford that, are generally the people who don’t have insurance now anyway, so waiting 1.5 hours to see a doctor while not being bankrupted by the experience, is still a step up. I think that Singapore has this right – everyone can see a decent doctor, anyone who can, can pay more to see an excellent doctor. It’s socialism and capitalism at the same time.

I also think that it is good that people can see how much their care is costing so that they can make informed decisions. I don’t think it’s ok to be forced to pay on the spot, nor to be reminded that a potentially life-saving procedure will cost you your life savings. I think that more awareness is necessary, but people should not be forced to put their family’s finances above their own lives. I think that a compromise would be to show people the costs and require them to pay a percentage based on what insurance they have, say, 10% of the costs (lower or higher depending on your insurance premium – a very common system in Singapore) to make people feel invested, but not pressured to avoid a necessary procedure.

While I was initially shocked by how obvious it is that healthcare in Singapore is a “business” (it is in the US too, we just like to pretend it’s not because we don’t like the idea of profiting from people’s misfortunes), I found it to be more helpful in the end to feel like I could choose a doctor and hospital just as I could choose a restaurant, and that if I didn’t like something, I could just pick up and go down the street. This system here, clearly leads to higher standards to attract more customers, which creates a much better level of care than I have received in the US, even at the newest of medical centers (where I got to enjoy being treated for food poisoning after returning from India).

I will admit that one of the downsides of the “business” aspect of medical care is that I have not felt sure in some cases whether a doctor is offering me medicine because I need it or because it leads to more profits for the hospital. I found this to be especially true when talking to Singaporean doctors, who tend to hand out antibiotics and TamiFlu like candy, with almost no inspection of the patient beyond a short conversation and a weighing by the nurse. But, then in Singapore, those medicines tend to not cost remotely what they would cost in the US, so it isn’t really a big deal if they throw on some extra acetaminophen with my antibiotics.

Overall, my assessment is that the level of service that you receive in Singapore when you can pay slightly more through insurance or your own pocket, is far higher than the level of service I’m used to in the US. The ease of getting into a clinic is also astounding – I called the clinic in the morning and got in to see a doctor 2 hours later with no history with the doctor or clinic at all.

I like to know how much things cost, but I don’t like to pay up front, and I think that insurance should pay at the forefront (from the patient’s perspective). I think that a universal level of healthcare for everyone with the option of upgrades is really the most American option for a healthcare system – it’s the government ensuring the right to life, liberty, and the pursuit of happiness, while not limiting your ability to seek better standards for yourself, which is another principle that Americans hold very close to their hearts.

In the end, the most important thing to me in my recent experience has been having people around me who can take care of me, and that isn't something that the US or Singaporean systems are equipped to provide. Augustin has been bringing me food and drinks during lunch and after work - he even went across Singapore to the Carrefour to get Campbell's chicken noodle soup. Shabnam spent 4 hours with me at the hospital last night, and both have consistently taken care of me. While I am still reminded how alone I am in this far away country, particularly lonely when I am sick, they have been the best roommates I could have asked for as I await the days when loneliness and longing will no longer be a symptom of my everyday life.