Health care system from the consumer perspective

Introduction

Remember the movie called the Platform shown on netflix some time ago? This was a Spanish sci fi social science thriller made in 2019. What has this got to do with the Health Care system in Singapore? Read on to find out.

What is the movie about? A group of residents live in a tower-like environment where people are switched between different floors every few days. Each day, a finite amount of food is served via a platform starting from the highest floor. The platform stops on each floor for a fixed amount of time before descending one floor at a time. It is better to be living on the higher floors because by the time the platform reaches the lower levels, there may not be much food left on it.

The Healthcare system I'm proud of

As a physician, I've been serving patients in hospital outpatient clinics for many years in Singapore's public health care system. Honestly, this is a system that is efficient and fair, and in terms of value-for-money, better than most healthcare systems in the world. I can say that because I have first hand experience with clinics in two first world western countries. Why is it then that we frequently hear complaints about the service in our clinics? In my opinion, this is largely due to patients' lack of understanding of how the system is organized, and how priorities are set.

Civic responsibility is crucial

In the Platform, residents who are insightful realised that the amount of food served in the platform is basically sufficent for everyone. However, because of avarice and FOMO, people on the higher floors consume more than what they need, leaving insufficient food for people in the lower levels, who will then starve. For the system to benefit everyone, it needs administrators or regulators who will portion out the food at each level. 

This reminds me of the 'Buffet syndrome' reported in Singaporean newspapers some years ago. This refers to the phenomenon where guests at a restaurant pile up their plates with so much food that they could not finish, resulting in huge wastage and also loss of resources. What is the reason for this behavior? Well, some patrons feel that they have paid for the buffet (a fix rate), so why not make the best of it? In the real world, such as in a restaurant running a business, resources are finite. This means that the system is worse off when people take more than their fair share. Eventually, patrons may have to pay higher prices in future visits.

Healthcare is a buffet until it's not

How is this related to the healthcare system? Doctors running a clinic list often are assigned a consultation room for a finite number of hours (which may be in the morning, or afternoon). The room has to be vacated after a number of hours because another physician needs to use it, or that the hospital closes when the essential servicing and support staff retire for the day. In these clinics, the appointment system assigns a certain number of patients in each session. I'll discuss what happens if there are unscheduled patients below. For now, let's assume that a fixed number of patients are scheduled and they all turn up at the appointed time. In reality, there might be some who fail to attend or fail to be punctual but let's assume for now they all do. 

For the sake of this article, assume each half day clinic lasts four hours or 240 minutes. If twenty-five patients are scheduled, each consultation can be nine and half minutes long. In a real clinic there are patients with different complexities and various social or psychological problems which require longer consultation times, and some very straight forward cases which can be seen at quicker rates. So it makes sense that for each patient that can be seen over five minutes, another can be reviewed over 15. You see the parallel with the buffet and The Platform now? Unlike the restaurant, this 'healthcare' buffet's good is time, which is the most finite resource, and only one consumer can enter the feast at any time. Whenever a patient takes a long time, later patients will have less. The patients who are seen earlier are like the residents who live on higher floors in The Platform. 

Doctors cannot be the guardian of the system

Since the doctors cannot be the guardian for the system to ensure that patients use the appropriate amount of resource (time), the patients themselves need to have a sense of what they need and not abuse the system. The primary mission of the doctors is to serve the wellbeing of each patient and prioritise that over serving the health of his practice or the sustainability of the healthcare system. It is dangerous to tweak this core mission of doctors though people have tried to play with electronic medical records, billing systems etc, to allocate resources according to complexity categories. Fundamentally, the construct of such buffet systems rely on the integrity and social conscience of each patient. That is true in the restaurant, and also true in the medical clinic. This is a no brainer and you don't need a degree in health economics to understand.

Now, what happens if there are unscheduled patients? This essentially stresses the system even more. These patients are now also competing for the same finite resource. And if they are given earlier appointments than scheduled patients, there is also some injustice, because earlier patients can exercise greater autonomy then others, equivalent to staying on a higher floor in the Platform.  

Modifying behavior to keep system efficient

How can patients behave using this knowledge about the clinic system. First, realise that there is a link between waiting time and consultation time. The reason why waiting time is more unpredictable for patients having a later appointment is because nobody can predict the mix of complex cases earlier in the list. The only way to ensure a short waiting time is to request for an earlier appointment. The most predictable appointment is of course, the first in the clnic session. 

If one understands this, then it is easy to understand why the patients who frequently request late appointments, whether for reasons related to transportation or personal convenience, end up being most unhappy. Because not only they have to wait for a longer time to be seen, their consults are often shorter. Having said that, there can only be one first case. But all patients in earlier part of the session have greater responsibility to ensure smooth running of the system, and should be self aware and alert to the passage of time during the consult. With greater privelege comes greater responsibility.

Those who understand the system will also avoid disruptive behavior. I've seen patients who kick up a ruckus in the waiting area just because of prolonged waiting time. There can only be one reason for prolonged waiting time, and that is healthcare resources being tied up with unexpectedly complicated cases. This scenario is not uncommon, and even more so in the pandemic, when healthcare is stretched due to problems in staffing and beds. By demanding attention prior to the consultation, healthcarers will be diverted from the patient in the consultation room, and this will result in a longer delay for the waiting patients. This principle is not complicated: spare a thought for others and cooperate with the system so everyone waits for a shorter time.

The effect of payment systems

Now, is this clinic equally robust if the system is financed by capitation (client count) instead of volume of service? (I say client instead of patient because capitation should also pay for healthy people in the system). I think the answer is yes. But the issues are more complex, especially if capitation is adopted in a tertiary and not primary care setting, so I will discuss that in a separate blog.

Conclusion

In conclusion, there is much to be said for the efficiency of a healthcare system that is delimited by time. In the ideal world, any one patient can take as long as he or she desires in a medical consult, but in reality, the system has shown to be most robust when everyone exercises civic responsibility and take only as long as he or she needs in the medical consult. 

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