Benjamin Ke Hao PNG
National University Health System, Singapore
Medical science has advanced significantly over the years and the repertoire of drugs available for therapeutic applications have also increased, promising better efficiency and efficacy. Patients and doctors alike, because of the availability of information through the Internet, are also better aware of these advances. This has increased their expectations and it is common nowadays that they expect such advances to be made available through their healthcare system. However, innovative medicines and therapies tend to be prohibitively expensive, as the movie “Dallas Buyers Club” illustrates.
Aired in 2013, “Dallas Buyers Club” tells the real life story of Rod Woodroof, a man diagnosed with HIV and how he rose above the challenges of his time to source for high-cost treatments from outside of the United States that were significantly cheaper. He then distributed them to other patients in the “Dallas Buyers Club”, amidst objections from the US Food and Drug Administration (FDA). This movie is not that far off from reality, where in Singapore, the same drug can be significantly cheaper if purchased from elsewhere in the region. The dilemma then is this: what role should the government play in funding such high-cost treatments and how much responsibility should clinicians, patients and other stakeholders take in such a situation? What expectations of access to care are ethically appropriate and financially sustainable? Sensible and responsive mechanisms within health systems are thus crucial, to ensure that today’s patients have access to the best possible care, whilst also ensuring sustainability for the benefit of tomorrow’s patients.
Singapore’s Health System
Singapore’s approach to social policy has been predominantly an asset-based one (Asher & Nandy, 2006) and this is epitomized by its Central Provident Fund (CPF) system, which has gained quite significant international recognition (Hately & Tan, 2003) over the years. An asset-based system is one where social welfare is enhanced through helping individuals accumulate assets and investments, as it is theorized to have more long-term benefits, as opposed to a system where income is directly given to individuals to help enable immediate consumption (Sherradan, 1991). Singapore’s CPF system is a fully funded social security savings plan that depends on contributions from employees and their employers that goes into the CPF account of each employee. The monies can then be apportioned and, subject to regulatory provisions, used for home ownership, education, healthcare and retirement. With regards to healthcare, each CPF account has a Medisave sub-account that can only be used for specific healthcare needs. Together with MediShield and Medifund, they form the “3Ms” that are the pillars of Singapore’s healthcare financing system. MediShield (or MediShield Life from end of 2015) is a low-cost catastrophic medical insurance scheme while Medifund is an endowment fund set up for medical needs and is designated to be the financial safety net for Singaporeans.
While the current system is typically sufficient to provide for basic and even some non-basic treatments today, managing high-cost non-standard treatments continue to be a challenge for healthcare professionals and a subject of international debate. As Singapore boasts one of the world’s best healthcare infrastructure (IMD, 2010) and gains access to advances in medical sciences that attracts patients from around the region, its healthcare system and institutions have to make practical decisions on whether (and when) to offer high-cost treatments when relatively standard but not the most advance treatments are readily available. A clear, accountable and effective approach to decision-making with respect to high-cost medicines and interventions is needed to avoid a situation of healthcare inequality where only the rich is able to benefit from advances in medicine, or otherwise becoming a healthcare system that is not sustainable in the long-term.
High Cost Medical Interventions
Singapore’s healthcare system has been acknowledged to be unique and possibly irreplicable elsewhere given the circumstances surrounding her unique birth as an independent State about 50 years ago (Ellis, Chen & Luscombe, 2014). Few countries have achieved Singapore’s per-capita ratio of healthcare expenditure to GDP, which is the lowest of all high income countries in the world (Haseltine, 2013). Even then, financial sustainability of high-cost medical treatments continues to be an issue. For example, a hemophilic patient with inhibitors typically requires Factor 8 Inhibitor Bypass Activity (FEIBA) for the treatment of his bleeds as it is one of the only two treatments available for bleeds in these patients (Tjønnfjord & Holme, 2007).
The cost can come up to about SGD 25,000 (or about USD 18,000) per month for a patient with frequent bleeds and as the treatment is considered “non-standard”, regular government subsidies do not apply. A hemophilic patient who needs these inhibitors is able to enjoy an excellent quality of life with treatment. However, at a cost of SGD 25,000, this patient may only be able to afford it through a combination of special financial assistance schemes by the government, contributions from charitable organizations and co-payment. Given that the intervention is arguably the only treatment for this unique medical condition, it illustrates the tension that can arise within a health system from an obligation to meet the healthcare needs of its constituent members on the one-hand, and its long-term financial sustainability on the other.
Improving Access through Shared Responsibility
Singapore’s healthcare system draws on fiscal measures to determine accessibility to healthcare resources. Primary physicians have wide discretion over what medical interventions to prescribe, but subject to affordability, also taking into account the subsidies available for a particular drug or service for indigent patients. Government subsidies generally apply primarily to standard drugs and investigations, while non-standard ones receive little to no subsidy, even where national specialist disease centers are concerned.
In August 2010, the Medication Assistance Fund (MAF) was set up to support non-basic drugs, provided patients meet certain clinical indicators pre-determined by the Ministry of Health (MOH). This fund was apportioned to healthcare institutions to administer. In 2011, the MAF scheme was expanded to the MAF Plus scheme, where instead of a MOH pre-determined list, the MAF Plus scheme allows each institution to determine for itself, through a specific set of guidelines and a peer-review mechanism, whether a non-basic drug should be subsidized under the fund. This arrangement confers a broader discretion to each healthcare institution, and provides more flexibility in recognition of the specializations of each institution – particularly the specialist disease centers (MOH, 2012).
In the MAF Plus scheme, only doctors who are consultants in seniority and above are allowed to apply for subsidies for their patients, in collaboration with the medical social worker. Applications must be endorsed by the relevant Heads of Department and approved by a committee chaired by the Chairman of Medical Board (CMB), or equivalent. The committee will review the scientific evidence provided by the doctor, who must also specify that all standard alternatives have been thoroughly considered and commit to the drug’s clinical effectiveness.
What is lacking though, is a systematic approach that tackles the issue of rare diseases, such as the case of hemophilia with inhibitors. For example, the Western Australian Department of Health is currently developing a state strategy for rare diseases (Department of Health — Western Australia, 2015) and the National Rare Diseases Working Group convened by the Australian Paediatric Surveillance Unit (APSU) is also preparing a draft for such a nation-wide strategy (APSU, 2015). In Japan, the Specified Disease Treatment Program (or “Tokutei Shikkan Chiryo Kenkyu Jigyo”) is studying not only the impact of rare diseases in Japan, but also subsidized medical care for patients with rare and intractable diseases (Japan Intractable Diseases Information Center, 2015). Such an approach could be helpful for Singapore, to study the short and long-term impact of rare diseases on her constituents, and to also devise strategies that tackle issues of research, clinical practice and financial sustainability in this area. The peer-review process that applications are subjected to within the MAF Plus Scheme is a good starting point, and the next step would perhaps be to convene a working group similar to the APSU and to consider a subsidy strategy that is allocated to a specific disease instead of a specific drug, in addition to other longitudinal research strategies.
The MAF and MAF Plus schemes are still evolving, having been the fruits of a Standard Drug List (SDL) Gap Analysis Project in 2007 undertaken by the Pharmacoeconomics and Drug Utilization Unit (PEDU) within MOH, and they are likely to continue to change to meet the future healthcare needs of the nation. From a health systems point of view, they offer a glimpse of what is possibly an approach to decision-making on high-cost medicines and interventions.
An asset-building social welfare system is not without its weaknesses. It has been argued that such a system is not replicable elsewhere because Singapore was able to avoid some of the healthcare costs associated with bigger countries than where Singapore was when she first gained independence in 1965 (Ellis, Chen & Luscombe, 2014), amongst other reasons. However, the healthcare system has also seen its strain in the recent years with the onset of a “silver tsunami”. Where hemophiliac patients are concerned, Singapore has attempted to resolve the issue of burgeoning healthcare spending by close working partnerships between the Government, philanthropic organizations, and healthcare providers, supported by regular and accountable peer reviews. In this way, the basic principles of shared responsibility and a long-term view of asset building continue to guide Singapore’s healthcare system in responding to the challenge of high-cost and non-standard medications and treatments.
Benjamin Png is a senior medical social worker (MSW) at NUH and has been working there for 8 years. He holds a BA (Social Work) and an MSc in Family & Systemic Psychotherapy. He leads a team of MSWs who work with neonates, children, adolescents and their families; and is part of the crisis intervention team working with children and adults involved in family violence. He is currently a member of the NUH Pediatrics Ethics and Advocacy Centre, Grantmaking and Operations Committee of the Ronald McDonald House Charities and the AIC Paediatrics and Adolescents' ACP Task Force. He was also admitted as a Fellow of the MOH Health Manpower Development Plan for 2009.