Why does one patient see so many doctors?

More needs to be done to coordinate healthcare, especially for patients with chronic conditions - a problem that will only worsen with an ageing population.

A healthcare system is a complex machine of processes and stakeholders. Is Singapore putting in the right incentives to achieve the desired health outcomes? In particular, why do patients with chronic problems see so many doctors and still feel dissatisfied? Focusing on coordinated care may be the solution.

Consider this - in the healthcare system of an ideal world: Every citizen has one primary physician and they like each other. This doctor is capable of treating acute illnesses, common chronic conditions and providing appropriate screening for cancer. A specialist is seldom required but consulted when necessary.

Should the patient end up in an emergency department or be admitted to the hospital, the primary physician is updated automatically.

The doctor is never rushed and has time to answer all of his patient's queries.

This patient is not frustrated by long clinic waiting times or appointment rescheduling.

Everyone has money to pay their medical bills, eats recommended servings of fruit and vegetables, exercises for 30 minutes five times a week, and abstains from smoking and alcohol.

Sounds impossible? The Dutch system shows that some aspects are, in fact, achievable.


ST ILLUSTRATION: MANNY FRANCISCO

In a survey of 11 affluent countries, only 4 per cent of Dutch patients reported that their doctor "did not always or did not often know important information about their medical history", while others scored 10 per cent to 24 per cent.

Respectfully, the public cannot be absolved of all blame. Singapore loves its specialists. Many patients with stable diseases do not want to be discharged from their specialist. Many ask their primary care physicians to refer them to a specialist clinic only to find that the assessment and management is no different.

Dutch patients are more likely to feel that they receive "the support they needed from their health professionals to manage their health problems". They are less likely to experience duplicate tests being ordered, their regular doctor not being informed about specialist care and having interruption of care, post-discharge.

In the Dutch model, most citizens are registered with a primary physician of their choice. After-hours care is provided by cooperatives, which reduces the burden on emergency care and facilitates the electronic availability of a patient's long-term medical record.

Multi-disciplinary care is a common standard in its primary care system, with more than 90 per cent of practices hiring case managers or nurses to coordinate care. Care groups receive payments for taking the responsibility of managing chronic conditions and coordinating care.

As a physician, the empathetic thing to do is to focus on coordinated care. For every patient, each visit comes at the cost of travelling and consultation expenses. For patients who require ambulatory aid, this also means a similar opportunity cost for the family representative who accompanies them. Frequently, they are hired help.

Discussion of care becomes counterproductive as information on the patient's situation and treatment advice is distorted through passed messages. If consultations could be condensed into one, family members may find it easier to accompany patients.

Coordinated care is more efficient and leads to better outcomes and cost-effectiveness. It leads to less duplication of history-taking and investigations, unnecessary administrative work and preventable admissions. Unnecessary man-hours and procedures deplete public resources.

Coordinated care is also important because healthcare is a human right and public service. The level of public participation in a healthcare system is an indicator of the right to health and good management.

Patients and families now say too that coordinated care is needed.

10 MINUTES PER PATIENT

What are the constraints of Singapore's system? Specialists and primary care practices today have a long queue of patients sitting outside their consultation rooms.

To see every patient and finish the clinic on time, one has to spend, on average, 10 minutes per person. Bear in mind that people of all types walk through the door - those with simple medical problems and those with disastrous complications, both the reticent and the verbose.

Ten minutes is not enough time to spend with patients who have complex chronic medical problems. These patients are fragile and require attentive care to keep them out of hospitals.

When patients on follow-up give all the right answers to questions about their condition, it is very rewarding to be "efficient" and complete the consultation. When something is amiss, however, only the tireless and brave doctors will take the effort to spend more time figuring out their problems at a hefty price.

Time is the price the system pays for the experience of holistic care. The queue is delayed, every subsequent patient walks in more dissatisfied, the clinic staff painfully bear with verbal abuse and work overtime, and the first minute of consultation is spent apologising.

How are doctors rewarded? "Service" requirements are a compelling driver of performance in hospitals and clinics. It is a key performance indicator to see as many patients as possible in specialist and primary care clinics. Seeing the highest number of patients possible is further incentivised in the private sector owing to a fee-for-service (FFS) payment system. This makes popular and low-risk procedures rewarding.

For clinics that do not already have a case manager, dietitian or physical therapist, coordinated care for a poor and underweight elderly person with multiple comorbidities is far more troublesome and expensive than giving a young executive a nose job.

What is the public expectation? Respectfully, the public cannot be absolved of all blame. Singapore loves its specialists. Many patients with stable diseases do not want to be discharged from their specialist.

Many ask their primary care physicians to refer them to a specialist clinic only to find that the assessment and management is no different. Our specialists are world renowned and it is good that we recognise that. But it is a pity that we do not realise how crucial our primary care physicians are as the true pillars of a healthcare system.

WHAT IS NEEDED?

Singapore needs a system that values quality care. Progressive health systems globally are evolving to incentivise coordinated guideline-based chronic care and disincentivise over-servicing. Unnecessary clinic visits, tests, procedures and medications are examples of over-servicing.

We tolerate an environment of reimbursement that makes organising coordinated care more expensive and inconvenient than aesthetic medicine at our peril.

With the right incentives, the hiring of case managers to improve the efficiency and effectiveness of linking services, and spending more time with patients to understand their medical history and ensure compliance need not be costly.

Healthcare financing and delivery structures should urgently adapt to make the environment conducive to providing coordinated long-term chronic care.

Singapore needs to make more use of innovative methods of patient engagement to make sure they take responsibility for their own health. Telehealth, the use of information communications technology to support patient care, education and public health, holds many promises but needs to be regulated.

Patients should be able to track laboratory markers of chronic disease control, be it their blood glucose level, or latest HIV viral load, and take an active responsibility to maintain it. Telehealth allows patients and caregivers to have a virtual support group to help each other live with a chronic disease.

Health technology assessment is needed to evaluate these initiatives so that we know what works and can increase the scale of implementation. Policies on reimbursement and regulation are required urgently to ensure remote care is safe and of good quality, and is financed sustainably.

Another issue is to do with the National Electronic Health Record (NEHR), now ubiquitous to clinical care in all public institutions and which is an enabling factor in the transition of care between healthcare services.

If all general practitioners and private hospitals were to use the same system, we would decrease gaps in transition of care when a patient is discharged from the hospital ward or emergency department to his primary care physician.

Barriers to universal NEHR usage include the need to spend on hardware, software and manpower training. This may also involve a change in the culture of individual clinic practices. For this, we are thankful that the Agency for Integrated Care has set up Primary Care Pages, an online resource hub that facilitates the adoption of NEHR.

Ultimately, a closer look is required at the way healthcare is purchased and how providers are paid. A doctor's training and motivation are still important. But even as one instils the right values, incentivisation is a significant factor in driving and maintaining "good" performance.

I hope the discussion on coordinated chronic care is done with the acknowledgement that, despite competing priorities, the environment can be made more conducive for it to happen.

The growing burden of chronic non-communicable diseases in an ageing population is a public health issue all countries face. Singapore has done well globally on many public health indices. How well it responds to the global and local need for coordinated chronic care will determine the next chapter of its respectable healthcare system.

• The writer is a medical doctor from Singapore based in Thailand, where she participates in medical care and policy research for marginalised populations. She is a part-time Master of Public Health student at the Johns Hopkins Bloomberg School of Public Health.

A version of this article appeared in the print edition of The Straits Times on October 27, 2017, with the headline 'Why does one patient see so many doctors?'. Print Edition | Subscribe