NEWS VOLUME 39 NO.9 SEPTEMBER 2007 MICA (P) 048/02/2007 EDITORIAL BOARD Editor Dr Toh Han Chong Deputy Editor Dr Oh Jen Jen "... doctors should Members know their country’s Prof Chee Yam Cheng healthcare system, Dr Daniel Fung Dr Hsu Liyang and understand why Dr Lim Boon Leng things are done in Dr Jeremy Lim a particular way – Dr Tan Poh Kiang what are the trade- Dr Tan Wu Meng Dr Teo Eng Swee Cuthbert offs in the system in Ex-Officio Talking Healthcare which they work." Dr Wong Chiang Yin at Harvard By Dr Hsu Li Yang, Editorial Board Member Dr Raymond Chua Chief Administrator An Interview with Professor William Hsiao Ms Chua Gek Eng Editorial Manager rofessor William Hsiao has been the K T Li framework of national health systems, his team is Ms Krysania Tan (Li Kwoh-Ting) Professor of Economics at assisting in the health systems reforms of several Editorial Executive the Harvard School of Public Health since countries, including Vietnam, Cambodia, Taiwan, P Ms Adeline Chua 1992. He has been involved in healthcare economics, China, Sweden, Poland, Mexico and South Africa. as well as policy and social insurance research in Prof Hsiao has been interested in the Singapore both developed and developing countries, and is healthcare system for some time. In 1990, he was perhaps best known for leading the Resource-Based part of a team of economists invited to Singapore Relative Value Study which led to a series of NEJM for a panel discussion with government officials just The views and opinions papers – and far more importantly – a reordering prior to the launch of the Medishield programme. expressed in all the articles of the US Medicare physician reimbursement He has also written several articles contributing to are those of the authors. These are not the views payments that was passed by Congress and signed the ongoing debate in the US regarding the adoption of the Editorial Board nor into law in 1989. His current research focuses on of medical savings accounts (that is, Medisave), the SMA Council unless specifically stated so in developing an analytical model for diagnosing drawing upon the experience of Singapore in this writing. The contents of the causes for the successes or failures of national matter1,2. In his hugely popular Health Economics the Newsletter are not to be printed in whole or in health systems. course at the Harvard School of Public Health, the part without prior written He is also a regular advisor to US government Singapore healthcare system is one of five systems approval of the Editor. agencies, foreign governments and international that he discusses at some depth with his students, Published by the Singapore Medical Association, organisations such as World Bank, IMF, UNICEF comparing and contrasting between the different Level 2, Alumni Medical and World Health Organisation. Using an analytical models worldwide. Centre, 2 College Road, Page 3 Singapore 169850. Tel: 6223 1264 Fax: 6224 7827 CONTENT Email: [email protected] 7 President’s Forum - SMA Medical Students Assistance Fund 9 “Let’s Face It: We Are Mortals” 13 Keep It Simple! URL: http://www.sma.org.sg SMA Reg. No.: 14-17 Ethics and the Pharmaceutical Industry 18 Hobbit’s Aphorisms 20 A review on SiCKO the movie ROS 198/59 TAP 21 Siblings in Medicine SMA News September 2007 Vol 39 (9) 3 Page 1 – Talking Healthcare at Harvard was not clear to everyone. I felt that this was a gap Hsu Li Yang: Prof Hsiao, thank you for granting me this in our knowledge that I would like to work on, but interview. Can you tell me a bit about yourself and how I was busy with other research projects then, and you came to be involved in health economics? hence this was put aside for a time. William Hsiao: I was born in China, and came to HLY: What do you think every doctor or healthcare US with my family in 1948 when my father was professional should know about healthcare systems appointed as an advisor to the Kuomintang UN and their financing? In Singapore, for instance, we are delegation. We only expected to stay for two years. not taught very much of this in our medical school. But my father died unexpectedly, and with the ongoing civil war in China, our family elected not to WH: This is one of the biggest gaps in medical return. My mother worked as a housekeeper to pay education, not only in your country, but worldwide. for the family’s needs, but developed tuberculosis I believe that doctors should know their country’s and was incarcerated in a sanatorium for nine years healthcare system, and understand why things are – they had no effective treatment at that time. done in a particular way – what are the trade-offs in the system in which they work. Otherwise many I read Physics at the Ohio Wesleyan University, doctors will end up frustrated, or resentful, because but thought that I did not have the right talent for they perceive that many things are not optimal, or that kind of theoretical work. After graduation, I that they cannot practise the way they feel is best worked as an actuary for an insurance company for for their patients. a while, before moving on to the Social Security Administration (SSA) because I felt a need to HLY: Yes, we do have a number of frustrated doctors serve the government. As an actuary, you are in Singapore. always trying to predict trends and the future, but I realised that I was more interested in the causes WH: And this also makes the doctors less useful as of economic, demographic and social changes and a whole when it comes to improving the system. this interest could not be fulfilled at my job at the They can only offer clinical input – what is best SSA. So I read Economics at Harvard. practice, what has been done elsewhere – but then it is difficult for them to offer a solution that also But you are probably more interested in why I considers the system within which they operate. 48TH SMA COUNCIL became interested in healthcare systems? Dr Wong Chiang Yin But this is a problem we recognise and are trying President HLY: Yes. to address. Starting next school year, Harvard Dr Chong Yeh Woei Medical School will start a compulsory semester- 1st Vice President WH: Towards the end of the 1980’s, I was invited long course on Healthcare Economics and Systems Dr Toh Choon Lai by the Taiwanese government to assist with their for all medical students. nd healthcare reform. Taiwan had become successful 2 Vice President economically, but realised that its social systems HLY: You have described in your class how you Dr Raymond such as education and healthcare were not kept had been invited to Singapore in 1990. Did our Chua Swee Boon abreast of its economic development – common Medishield programme originate from your Honorary Secretary in developing countries. proposals then? Dr Lee Yik Voon Honorary Treasurer I had no idea at that time what constituted a national WH: No, I would not claim any credit for that at all. Dr Wong Tien Hua healthcare system – what were the key elements; There were three of us Economists invited by your Honorary Assistant Secretary what were objectively good or bad systems or even Ministry to present at a conference in Singapore Dr Abdul Razakjr Omar how to measure these things. Therefore I asked – Uwe Reinhardt from Princeton, Tom Pyle, who Honorary Assistant Treasurer the Taiwanese if they were willing to commission was the CEO of Harvard Pilgrims Health Plan, and a study to investigate these. They agreed, and I myself. We did not know what it was about initially, Members assembled a team of experts from US and Europe but the terms were generous, far too generous for Dr Tammy Chan Teng Mui – including people like Uwe Reinhardt, Bob Evans, what was essentially a one-day affair. and Tony Culyer – for this project. And what I Dr Chin Jing Jih found out was that none of the experts had a good After the conference, however, we met with a select Dr Lee Pheng Soon answer for these questions: they could describe the group of Ministry officials. They presented to us Dr Tan Sze Wee healthcare system of their own country, including the healthcare financing structure of Singapore. Dr Toh Han Chong what went well and what went wrong, but what The Medisave programme had been in place for a Dr Bertha Woon Yng Yng causes a good or bad outcome, and what should be few years by then, but it was obviously inadequate, Dr Yeo Sow Nam the basis and fundamentals of a good system? That especially for acute hospitalisation care – it has to Dr Yue Wai Mun Page 4 SMA News September 2007 Vol 39 (9) 4 Page 3 – Talking Healthcare at Harvard do with the distribution of risks and the amount “... competition does not have to that is saved under that programme. They then put to us a detailed proposal for a catastrophic be internal, a Singapore centre can insurance fund – what is now your Medishield. It was clear then that the question of moral hazard always compete with international was a weighty consideration. centres. For Singapore’s size, you will So no, we did not have a direct hand in developing have to pick diseases and conditions your Medishield programme. I believe we were for research where your country has invited so that we could be sounded out as to whether there were any alternatives, or any a competitive edge.” loopholes in this proposal.