Lets think of value driven care...

Value based care is considered by most in healthcare as a cost conscious and outcome based form of healthcare delivery. 

Sitting back to watch consultants or tech enthusiasts go on about how to provide such care to consumers, I feel there is a huge GAP to accept the reality in the way care is provided.

Asia lacks healthcare funding in general, where people are under insured and have large out of pocket spending. These usually translates to reduced access to care.

Singapore is a more advanced market in terms of insurance and healthcare access and needs to be considered with the first world on the quality of care and access to care. Value based care is a more recent concept even for Singapore, and though being evaluated, may need a lot more understanding.

The larger rewards within tertiary care, enable provider groups owning these various components to vertically integrate and funnel patients from primary care, into hospitals. With public hospitals owning most hospital beds, this practice of managing care in tertiary setting seems to be commonplace. For the patient, the hospital care opens access to their medical savings account and now mandated hospitalization insurance plans. These cover near all emergency and hospitalizations in Singapore. There is no question Singapore has really good quality and sufficient access to care.

There is also no denying that medical inflation is higher than general inflation in the region and more so in Singapore. There have been many allegations of overpricing by providers/ Doctors. The providers seem increasingly burdened with increased paperwork to validate their treatment and procedures. This is increasingly seen with managed care and provider panel Operators taking a hard line to restrict fees for consults. The model of taking a percentage of provider fees being charged by the panel Administrators was not seen as ethical and most have gone on to charge a fixed fee for their services. The model however still seems to encourage larger bills per encounter, with Doctors being squeezed on consult fees, having to look at pharma services and diagnostic tests for the margins needed to manage the clinic costs. 

The advantage the panel Administrators brought was outpatient care and made it easier on billing with cashless services to patients and their employers. Hospitals dealt directly with payers largely and did not need their services. Outpatient care is however not usually covered by insurers in the region and subsidized in parts by corporates and usually out of pocket by individuals. Though seen as first step to reduce hospitalization, few organizations have looked into a gatekeeper inhouse primary care service, likely due to costs involved.

With outpatient care, the challenges of managing services grow with the number of facilities and systems used to capture the data needed for reimbursement. Hospital informations systems are trying to reach out to connect and link the outpatient centers to provide a more seamless services platform. Technology is seen as a potential answer with a TOP down approach by tech consulting companies, providing a national electronic health record (NEHR) to integrate the various systems with an inter operable platform or lighter api linkage approach. The type of data being looked at may include socio economic factors that government feels may affect the affordability on access to care. 

The enormous efforts and cost in managing hospital care seems to keep increasing despite rising number of available beds and digitising to improve productivity. With the way the Hospitals in Singapore are dependent on fee for service, bill sizes and charging the payors, who are the independent insurers linked to mandatory savings account within the provident fund contributed by employers, keeps going up. The more the hospital based data is being used to identify patients that may need care, increasing cross referrals within tertiary care and itemised billing seems to keep adding to costs. There is now a move to link community data to the NEHR. It will likely improve the care given to patients transitioning between the community and Hospitals. The question is for the vast majority of patients being managed in community, such a heavy platform may add to cost of care, with clinics spending more on technology and manpower. The top down approach to grab primary care data for policy and improving tertiary care benefits doesn’t seem to provide additional tools to manage care within the outpatient clinic population in return. 

Chronic diseases management in outpatient setting to improve quality of life and shorter hospital stays would generally be the accepted way to bring value based care. Enabling this with top heavy investments in tertiary care is not viable for the above reasons. Panel management or national electronic records are unlikely to move this needle much as experienced by the medical inflation above national average in Singapore and the region. 

Ground up digital undertaking for managing care is a process we have been working with partners in the community to provide integrated preventive health, primary care, diagnostics and disease management at MyDoc. With this sort of economical data acquisition and simplified engagement opportunity, the vision to provide right care at the right time gets enabled. Asia is considered to face a faster growth in its aging population and health challenges than the current brick and mortar healthcare facilities can handle it. The experiences Singapore medical groups are gaining with managed care and technology, could be a valuable guide to the region. Creating the collaborations for seamless care delivery in outpatient setting will keep costs low. The leaders in this space should be cautious on adding costs unnecessarily and to use data built ground up to personalize health management.

There should be a measurement tool which could potentially demonstrate outcomes to the costs and time spent by healthcare professionals. There is simply no way the outpatient services can scale to match the demands of the aging population with growing chronic diseases if the existing conditions on lack of patient engagement and reactive healthcare delivery from clinical groups persist. The challenges even with virtual health to tackle patient education, physician availability, active disease management seems overwhelming. The need to collaborate within the outpatient setting while staying neutral to tertiary services is going to be important. The time has also come for payors to look beyond general wellness programs and fund active health plans that drive prevention and create a conducive environment for outpatient care services that keep their members away from tertiary care.

We are at a point where most are convinced on the need for value based care. The question glaring at us now is who the right providers are and who will pay for this.