Submission of the Business Policy Unit of the British Chamber of Commerce in Hong Kong on Voluntary Health Insurance Scheme

Transcription

1 Submission of the Business Policy Unit of the British Chamber of Commerce in Hong Kong on Voluntary Health Insurance Scheme Introduction The vast majority of hospital healthcare needs in Hong Kong is provided by Hospital Authority hospitals. The British Chamber of Commerce supports the Hong Kong Government s ambition to provide greater balance in the provision of care between Government and private providers and in doing so to expand the capacity of the private hospital sector in Hong Kong. The Voluntary Health Insurance scheme (VHIS) is focused on incentivising greater access to quality and affordable private sector hospital care. We welcome the VHIS. Nonetheless, as a voluntary, rather than mandatory, scheme, overseas experience suggests that the take up of the VHIS will be substantially less than if the VHIS were mandatory. This is reflected in the Government s own projections of a very low uptake of VHIS coverage amongst Hong Kong s resident population (around 1 per cent according to recent public sources). Voluntary schemes overseas tend to attract higher-risk patients who stand to gain most from the provision of private services. Younger healthier patients who have a lower propensity to consume services tend not to be drawn to these schemes meaning that voluntary schemes can be plagued by problems of affordability and long term sustainability. Notwithstanding our concern over the voluntary status of the VHIS itself, there are also several aspects to the scheme as currently drafted that we suggest could be refined - to improve the efficiency and effectiveness of the scheme itself and to encourage the shift of the burden of care to private providers. In this context, we set out our comments on the proposals in two parts: The first part of our response sets out some strategic recommendations on the reforms overall and the refinements that we suggest are required; and Part two of our response contains some more detailed comments and recommendations on the drafting of the proposals themselves. Part 1: Strategic recommendations Our strategic observations on the VHIS are covered in six categories: 1. Access to primary care; 2. Additional private hospital capacity; 3. Incentivise provider efficiency; 4. Chronic disease management; 5. Transparency in healthcare pricing and medical inflation; and 6. Product choice in the private health insurance market Access to primary care We support the Government s proposals to include day-case and ambulatory procedures within the VHIS. We suggest that this will have a positive effect on reducing in-patient demand and hence promote the more efficient use of capacity in Hong Kong. However, we suggest that more could be done under the VHIS to promote access to primary care facilities. Page 1

2 One of the most striking lessons from overseas experience is that acute demand can be significantly reduced by promoting access to in-community care. By intervening at an earlier stage in the patient journey, acute demand can be reduced by managing patients in the community before hospital admission becomes necessary. Similarly, wellness and preventive care programmes, together with the enhanced provision of elderly care in a home setting would also seem (on the basis of international experience and cultural preference in Hong Kong) to provide an immediate solution to reducing pressure on hospital admissions. Moreover, remote and community healthcare also has a role in the provision of healthcare services in Hong Kong and could be further promoted. Government could therefore consider expanding the remit of the VHIS progressively into primary care. Measures to reduce demand such as Government-backed schemes to promote home caring would also be welcomed. In doing so, the VHIS could naturally play an important role in incentivising private health insurers to provide greater access to primary care providers, because more costly hospital treatments could potentially be avoided resulting in cost savings to the insurance industry. Recommendations Government should consider how best the VHIS can support broader access to primary care in Hong Kong specifically, by broadening coverage to include primary care in due course. The VHIS should also be complemented by demand-side, measures instigated by Government, to reduce demand for secondary healthcare. More support for elderly care in a home setting is an important example, as are programmes to improve access to primary care and care in the community. The Government should also invest in the delivery of wellness and preventative care programmes (e.g. vaccination and proven screening programmes) which will reduce the burden of care. Government should encourage good primary care outcomes by rewarding: screening; vaccination; and care of chronic diseases; as well as use of computers; and doctors forming more efficient group practices, rather than remaining single-handed. All Hong Kong ID card holders could have access to drugs prescribed by Hong Kong Registered Medical Practitioners under the Hospital Authority formulary, through a formalised reimbursement programme, regardless of whether the prescribing doctor is public or private. Government should work with the College of Family Physicians to enhance training and opportunities for primary care physicians to become Specialists in Family Medicine. 2. Additional private capacity Whilst the Government s consultation paper sets out an ambition to shift demand from Hospital Authority hospitals to private providers, we are concerned that there is inadequate private capacity to accommodate this shift. Almost 90 per cent of Hong Kong s in-patient beds are in Hospital Authority hospitals. The additional 900 beds suggested in the Page 2

3 consultation paper which are expected to be developed by private providers will represent only a 3 percent addition to the stock of beds. Unless there is reform of the means through which Government promotes and facilitates the development of private capacity, we are concerned that the fundamental aims of the VHIS will be undermined, because there will not be sufficient private capacity to achieve a meaningful shift in the provision of care. This also brings into question the procurement method used by Government to deliver private capacity. Currently, Public Private Partnership (PPP) models are used by Government Departments to procure capacity, mostly on a long-term, concession basis. However, the experience of our members is that these concessions, when tendered to private providers, are overly specified. This stifles innovative care solutions and degrades the ability of private providers to deliver healthcare capacity in a way that represents best value for Government. Moreover, fundamental good practice elements of PPP procurement, that we would expect to see, are missing - such as an awareness of the need to balance risks between Government and providers. Rather, we see onerous risks placed on providers, reducing their ability to deliver timely, quality and affordable capacity. The result is often a lengthy and poorly structured procurement process with little transparency for bidders. In our experience, this has undermined the delivery of efficient hospital capacity by the private sector in Hong Kong. A central, co-ordinated approach to the procurement of private capacity is urgently needed. This lack of capacity in the private sector does not simply relate to physical capacity the shortage of or private hospital beds. It also relates to the shortage of specialist doctors, nurses and paramedical staff in Hong Kong. Without reform of the licensing procedures for specialist doctors, we are concerned that the VHIS will simply encourage the transfer of medical specialists from the public to the private sectors, without delivering additional overall capacity in Hong Kong s healthcare system. Meanwhile, we believe that primary care doctors are relatively under-employed. The lack of primary care provision in the VHIS will move patients from primary care to hospital care, exacerbating over-capacity in the primary care sector and undercapacity in hospital care. Recommendations Establish a central body responsible for procuring private healthcare capacity in Hong Kong which actively leverages international and cross-sector Government experience in Hong Kong with respect to the effective procurement of infrastructure. This body would have a key role in structuring and managing the procurement and delivery of new private hospitals by the Hong Kong Government. Government must formulate policies to address the imbalance between specialists and primary care doctors in Hong Kong timed to coincide with the implementation of the VHIS. 3. Efficiency savings amongst providers Page 3

4 We commend the Government for including day-case and ambulatory procedures in the VHIS. Our view is that this should incentivise improvements in the use of capacity encouraging day-case surgeries and potentially reducing overnight stays. This should generate efficiencies in the use of current resources. Nonetheless, we also suggest that more could be done to promote efficiency by requiring the transparent reporting of outcomes and quality by all providers (public and private) in Hong Kong. This should include data on the length of stay, infection rates and patient outcomes (specifically morbidity, mortality, infection and re-admission rates) and include the establishment of disease and procedure registers (e.g. hip and knee joint replacement registers). To the extent that the VHIS could require the release of this information by providers greater efficiency of private capacity could be incentivised. One of the main lessons from healthcare efficiency achievements overseas has been that the transparent disclosure of information on outcomes and quality is a major contributor to improvements in efficiency, as well as being highly valued by patients themselves who are able to make more informed decisions in their choice of provider. Recommendation The VHIS should require providers to report quality and outcomes. As a minimum, and consistent with international good practice, this should include information on length of stay, infection rates, readmissions and patient outcomes. 4. The efficient management of long term conditions There is undoubtedly a need in Hong Kong to promote care of chronic conditions and thus reduce hospital admissions. Therefore we support the Government s proposed coverage of existing conditions in the VHIS, although we note that, with the exception of year one, individuals aged over 40 will not be eligible for coverage. Clearly therefore, the effectiveness of the VHIS in facilitating the more efficient treatment of pre-existing conditions could be undermined. We suggest that the Government evaluates the relative merits of expanding the coverage of pre-existing conditions in the VHIS, with respect to possible cost savings that could result from reduced hospital admissions. Lessons from other Countries suggest that with better out-patient management, significant cost savings are achievable from reduced admissions. Recommendation Government should evaluate the value for money that could be generated by extending the coverage of pre-existing conditions beyond year one applicants to the extent that this could deliver efficiency savings in terms of reduced admissions on a long-term basis. 5. Greater transparency in healthcare pricing Page 4

5 The key aim of the VHIS is to promote access to affordable private healthcare, and in so doing, shift the burden of provision from the public sector. To achieve this, we suggest that greater transparency is required on the prices charged by providers. We note that Hong Kong has the highest level of medical price inflation in Asia, and suggest that this is related to the lack of transparent and consistent pricing information from providers. Health insurers have very limited visibility into the prices charged by providers, and whether these are cost-reflective. As a result, premiums and prices escalate undermining the uptake of health insurance in the community. This must change in Hong Kong. With this in mind we were disappointed to note that recent revisions to the VHIS have replaced the requirement for providers to disclose prices on the basis of Diagnosis Related Groups (DRG s), with price information now being sought on the basis of categories of treatment. Indeed, the Hospital Authority already have a fully operational DRG-based costing system and the commercial architecture to support a DRGbased system is readily available in Hong Kong, as it is throughout Asia more generally. The initial ambition of the VHIS to require prices to be presented on the basis of DRG s represented global best practice. When presented on the basis of DRG s, prices can be compared between markets on a consistent basis. Should prices have been disclosed by all providers by DRG in Hong Kong under the VHIS, the presentation of prices on a consistent basis would, could, we suggest, have driven greater transparency in the market, promoted efficiency and tapered medical inflation over time. On the contrary, the current VHIS proposal to require providers to report prices by category without defining what a category is, could significantly undermine the comparative value of any pricing information received from providers. Prices will be derived and reported on an inconsistent basis. As a result, the comparative value of price information received will likely be undermined and hence the objectives of the VHIS to deliver greater transparency in pricing and efficiency in service provision will be substantially undermined. Should the VHIS not require price information to be disclosed on the basis of DRG s, we would suggest, as a minimum, that Government give consideration to establishing a healthcare pricing regulator to incentivise transparency in pricing and ultimately, efficiency. Recommendations To maximise the value of the VHIS, Government should focus on facilitating the efficient exchange of pricing information between providers, patients and health insurers. We suggest that the VHIS should require pricing data from providers on the basis of DRG s, as is the case in most other leading healthcare systems. Not only would such an approach represent best practice, but it would also drive efficiency and transparency into prices in Hong Kong which currently has the highest rate of medical inflation in the region. In the absence of a DRG-based pricing approach under the VHIS (which would be our strong preference and recommendation), we suggest that the Government establish a regulatory body responsible for gathering and reviewing prices received through the VHIS with the objective of incentivising transparency. Page 5

6 6. Greater product choice The VHIS as currently drafted sets minimum standards for the provision of Private Health Insurer benefit levels in Hong Kong. This will undoubtedly come at a price for health insurers, and could conceivably act to inflate premiums hence undermining the Governments objective of incentivising a shift in the provision of healthcare into the private sector. Premiums envisaged by the VHIS are perceived by many in society as being high relative to average monthly earnings in Hong Kong and with reference to disposable incomes. Whilst this may well change over time with greater coverage, the Government may also consider incentivising the provision of alternative, less comprehensive products, to the extent that these could co-exist with the VHIS with the single aim of improving the affordability of the VHIS and promoting take-up of private coverage amongst a broader populous of Hong Kong residents than is likely to be the case with the VHIS as currently structured. Another means of achieving this would be through the use of tax rebates or incentives such as grants. We also suggest that VHIS premiums could be made more affordable through the use of optional deductable items. This would promote cost certainty for patients, whilst preserving the desired level of care. This would seem to be a more efficient means of reducing premiums than imposing exclusions or benefit limits which could create uncertainty about the level and quality of care that the VHIS would deliver. Recommendations Civil Servants and Hospital Authority staff be offered VHIS in place of their existing schemes. So as to maximize the uptake of PHI cover in Hong Kong, the Government should consider the relative affordability of the VHIS relative to average disposable incomes and give consideration to providing appropriate tax incentives and grants, and other mutually inclusive PHI products; Government should also give consideration to lowering VHIS premiums by allowing optional deductable items to be considered by consumers hence lowering costs and premiums, whilst still delivering cost certainty and quality care. Government should also consider offering variations on the VHIS an example would be a variant covering more routine and preventative treatments, in addition to the core VHIS scheme as currently proposed. This would make the VHIS more affordable and increase the take-up of coverage amongst Hong Kong s population - ultimately relieving pressure on hospital admissions by encouraging preventative treatment at an earlier, and less costly stage. If group policies are not to be regulated by the VHIS (and we believe they should be), the ability for employees to convert to a VHIS compliant policy must be automatic, otherwise employees will suffer if their employers do not sufficiently fund their health insurance policy.. Page 6

7 Part 2: Detailed recommendations on the VHIS proposals Overall There is an internal inconsistency between the principle of no co-payment and no no-claim discount on the one hand and a 30% co-payment for advanced diagnostic imaging tests. Either one wishes to avoid financial penalties of any kind for patients seeking necessary healthcare, or one wishes to nudge patients towards responsible use of healthcare resources with financial and other incentives sufficient to discourage unnecessary use of resources without discouraging appropriate use of healthcare (especially preventive medicine and management of chronic diseases) with harsh financial penalties. Minimum Requirements Cash Benefits & Group Policies P39 Section 2.5 The Minimum Requirements of the VHIS would only be confined to individual Hospital Insurance. The VHIS does not intend to cover (a) any fixed pecuniary benefits (e.g. hospital cash, critical illness cover) which may be added to an individual Hospital Insurance policy; and (b) a group policy, i.e. a policy being held by an employer for the benefit of its employees. We agree with point (a) there is no need for VHIS to include cash benefits. However, on this subject, if an insurer wishes to offer hospital cash benefits, cash benefits should not be limited to patients in public hospitals if the insurance policy includes a cash benefit it should be paid wherever the patient is hospitalised. Paying a cash benefit only when the patient is in a public hospital is essentially paying the patient to use the public system when they have purchased an insurance policy intended to cover private treatment. We disagree with point (b). VHIS minimum standards should apply to group policies. If this requires employers to purchase more expensive policies on behalf of their employees there are several options: 1. The employers can pay and the employees enjoy an effective pay rise. 2. The employers can invite the employees to make up the difference in cost between the old non-compliant plan and the new VHIS plan 3. The Government can offer a more generous tax incentive to encourage companies to purchase compliant schemes. To do otherwise is to accept many working Hong Kong people with inadequate company provided insurance, which defeats the purpose of introducing VHIS. Minimum Requirements - Primary Care P39 Section 2.6 However, the role of primary care in the healthcare system should not be overlooked and has Page 7

8 important contribution (sic) in the process. We will discuss this perspective in Chapter 3. So we go to Chapter 3 for the discussion, which is reproduced in full here: On page 78: Section In this connection, the Food and Health Bureau has been taking forward a number of policy initiatives to strengthen primary care, promote prevention and early identification of disease, including starting a pilot programme to subsidise colorectal cancer screening for higher-risk groups; enhancing and turning the Elderly Health Care Voucher Pilot Scheme and Outreach Primary Dental Care Services for the Elderly in Residential Care Homes and Day Care Centres into recurrent support programmes; and exploring the feasibility of setting up an Integrated Elderly Centre on a pilot basis to provide one-stop, multi-disciplinary healthcare and social services for the elderly at the community level. This discussion is 102 words in length. If primary care indeed has an important contribution, it deserves a much fuller discussion. We believe VHIS should include primary care. Indeed, the Government s management of the patients it acquires responsibility for in the High Risk Pool will, according to section 4.17 on page 90, involve health maintenance, presumably via primary care? Section According to the Consultant, the cost of operating the HRP will be under better control if there are effective measures to promote better awareness of healthy lifestyle and encourage active care management. In this connection, we propose introducing care management programmes for HRP members, such as wellness programmes to induce behavioural changes and to promote greater health consciousness. Wellness programmes are a set of activities designed to proactively assist its members in making voluntary behavioural changes that improve their health and well-being. A wellness programme usually comprises gathering health information from members, developing education and intervention programmes to address identified risk factors, and possibly providing incentives to reward good performance. Overseas experience suggests that such types of care management programmes could drive better chronic disease management, thus achieving greater efficiency and better health outcomes. This implies that members of the High Risk Pool will enjoy preventive and primary care, but no one else will? How will this be funded and delivered under the VHIS? Cost Sharing - Advanced Diagnostic Imaging Tests Page 48 Section 2.33 Benefit coverage must include prescribed advanced diagnostic imaging tests, subject to a fixed 30% co-insurance to combat moral hazard. Why are only advanced diagnostic imaging tests at special risk of moral hazard? 30% is a high a figure. With modern medicine relying increasingly on advanced (and expensive) imaging, patients could end up paying 30% of a very large bill a cancer patient requiring MR and PET/CT scans could end up with a very large copay, and easily reach the $30K annual cap. Page 8

9 Because these tests are expensive, they are not less necessary, and it is inappropriate to arbitrarily restrict them via a financial penalty. If they are to be restricted to control costs, a better method is to set up clinical referral guidelines via an independent health advisory body, perhaps similar to the respected NICE - the United Kingdom National Institute for Health and Care Excellence ( Alternately, a lower copayment or deductible is enough to deter unnecessary use of imaging. It can either be a smaller fixed sum per investigation, or a lower percentage fee with a lower cap, or a policy with a deductible. A deductible is our preferred option. Cost Sharing - Principles Page 50, Section While cost-sharing arrangements by policyholders, such as co-insurance and deductible, could encourage judicious use of healthcare services, we note that such arrangements might reduce the attractiveness of VHIS plans and affect the desire of policyholders to seek necessary treatments We disagree. By offering a choice of deductibles, it is possible for individuals to reduce their premium by accepting a higher deductible. Equally, this could allow an individual to purchase a plan with higher benefits for the same premium. The better off would prefer the latter option, whereas the poorer may prefer not to pay a deductible, and accept that if their costs exceed their cover they will have to return to the public sector. (The proposed benefit limits appear very low.) We believe that a range of options for deductibles together with a range of premia depending on those deductibles is more likely to attract than repel policyholders. This is a fairer method than arbitrary cost sharing for advanced diagnostic imaging. Tax Deductions Page 92 Section 4.27 Capping tax deductions. The proposed tax deduction will be provided on a per person insured basis and the claims for tax deductions for dependants policies should be capped at, say, no more than three dependants per taxpayer We disagree. An individual with an income is doing a great public service by purchasing as many policies as possible, and should be able to claim the maximum tax deduction for every policy. One employed person might wish to purchase 9 or more VHIS policies! If a working man has a wife, who is not working, and two children, ie three dependents, and would like to purchase a policy for his domestic helper, his parents, and parents-in-law, this will be 9 policies. If, for example, he has other elderly or handicapped and non-working family members, he may wish to purchase additional policies. Why should he be restricted to tax deductions on only three? This is arbitrary. Page 9

10 In addition, the tax deductions should be for actual costs paid, not average premium. If one is paying for a 70-year-old with pre-existing conditions, the actual premium will be about $30,000. Why should one only receive a tax deduction on $3,600? This penalises the old and the sick. Pre-existing Conditions Page 45 Section 2.24 Coverage of pre-existing conditions. Insurers are required to cover pre-existing conditions, subject to a standard waiting period and reimbursement arrangement during the waiting period as follows: first year no coverage second year 25% reimbursement third year 50% reimbursement fourth year onwards full coverage We are not sure of the purpose of such a long time-period for pre-existing conditions to be covered. The only apparent reason is to reduce costs to the High Risk Pool (as explained in section 4.14 page 87 and section 4.15, page 88), but, in practice, this will discourage patients from taking out the insurance at all (having to wait three years to enjoy full coverage) thus reducing uptake and pushing inadequately covered patients back into public hospitals while leaving plenty of room for uncertainty and expensive argument about the definition of treatment for a pre-existing condition. We suggest a waiting period of 3-6 months. P For those who choose to subscribe to Hospital Insurance after the age of 40, they would still be able to enjoy the benefits of all other Minimum Requirements proposed for Standard Plan except for guaranteed acceptance (i.e. their applications for Hospital Insurance might be rejected by insurers) and the premium loading cap proposed for Standard Plan. Does this mean that individuals over 40 who fail to purchase in the first year may be left out entirely? What about over 40 s who are new to Hong Kong? What would happen to individuals leaving an employer who has not purchased a Conversion Option? Portability of policies P47 Section 2.30 Portability of policies. Re-underwriting would be waived when changing insurer if no claims made in a certain period of time (say, three years) immediately before transfer of policy. We are not sure of the rationale for this restriction. It places an arbitrary restriction on making a claim given that we assume all claims are necessary for health reasons, this Page 10

11 discouragement from using health insurance seems unhealthy. Indeed this is the rationale given for not requiring a No Claims Discount in the minimum requirements: p Although some agreed that no-claim discount might attract more lower-risk individuals and young people to join the HPS, others pointed out that no-claim discount might have the unintended effect of discouraging policyholders from seeking necessary treatments. Taking into account the above, we propose not to include no-claim discount as a Minimum Requirement. Cost-sharing restrictions P50 Section 2.39 Cost-sharing restrictions No deductible and co-insurance, except the 30% co-insurance fixed for prescribed advanced diagnostic imaging tests Annual cap of $30,000 on cost-sharing by policyholders (however, if the actual expenses exceed benefit limits, the excess amount is still payable by the policyholder) We are not entirely sure of the rationale for No deductible and co-insurance. Even relatively small and affordable deductibles and co-insurance have been shown to alter behaviour in a positive way. Why is this rationale applied only to diagnostic imaging? It would be better to have higher benefits for the same premia by positively influencing behaviour with co-insurance and deductibles than to leave patients with larger un-covered expenses once they have exceeded lower benefit limits. We believe the best system is to reduce premia or increase benefits by allowing the individual the option to choose the size of the deductible. The deductible is a known sum which the individual believes he or she can afford, whereas the gap left after coverage is exhausted is unknown and worrying. Many policies offer deductible size options, which can significantly affect premia, and are popular and well-established features of health insurance. Conversion Option Page 57 Section 2.60 We propose to require insurers to offer as an option to employers an elective component the Conversion Option in the group Hospital Insurance products offered to employers. Employers would be allowed to decide whether to purchase the group policy with the Conversion Option component. If the employer decides to purchase the group policy together with the Conversion Option, an employee covered by such group policy can exercise the Conversion Option upon retirement or leaving employment so that he/she can switch to an individual Standard Plan at the same underwriting class without re-underwriting, provided that the employee has been employed for a full year immediately before transfer to individual Standard Plan. If the insurer concerned does not practice individual underwriting for group policies, which is quite common in the local market, the employee only needs to pay for standard premium for individual Standard Plan irrespective of his/her health conditions. Page 11

12 We do not agree that Employers would be allowed to decide whether to purchase the group policy with the Conversion Option component. Employers are already being offered the option of offering their employees policies which do not meet the VHIS minimum standards. If this is the case, the conversion option must be compulsory. Diagnosis-Related Groups Pages Sections On diagnosis-related groups (DRG)-based packaged pricing: Section 2.43: we consider that it would take a relatively longer time for Hong Kong to develop an operable system of DRG suitable for local use in the private sector. The exercise would require comprehensive and regular collection, compilation and analysis of healthcare, claims and pricing data from the health insurance industry and healthcare service providers. Regular and structural review is also required to keep the DRG system up-to-date. As Hong Kong currently does not possess such sophisticated mechanism for conducting the above work, there will be significant challenges in implementing a DRG system in the short term. We believe that the DRG system is the best available, and, as part of the VHIS implementation exercise, the Government should fund local research and development of DRGs for Hong Kong, to cover both Hospital Authority and private hospitals. Benefit Levels Page 60 Table 3.1 Illustrative Outline of Benefit Schedule of Standard Plan Surgical limit (including surgeon, anaesthetist, operating theatre) (per surgery) Maximum $ 58,000 (varies by surgery type) This limit seems low, given it is the maximum, presumably for a complex surgical procedure. 1. Are these proposed benefit levels realistic? Will HK$58,000 really cover a complex major procedure such as an emergency neurosurgical procedure (for example for a stroke)? What if multiple procedures are required in the same admission for the same condition? Will they cover implants such as specialised revision joint replacements (for example for a person with a worn-out knee replacement) or spinal fusion implants (for example for a child with scoliosis)? 2. If benefits are to be dependent on the size/complexity of the medical procedure, this should be according to an objective standard, such as United States of America s Common Procedural Terminology [1] and Relative Value Units [2] systems, otherwise there will be argument about the size/complexity of procedures. On page 62: Example 3.1 Itemised Hospital Charges for Thyroidectomy Procedure This example shows us that the coverage is inadequate for a simple procedure such as a thyroidectomy, leaving the patient with a bill of HK$16,400 out of the notional HK$56,000 total bill. What if the bill is higher? It would be better for the patient to pay a greater proportion of the start of the bill (ie a co-payment or higher deductible a known and Page 12

13 quantified risk) than to pay 100% of the end of the bill (inadequate coverage leading to unknown and potentially unlimited risk). Primary Care P78 Section 3.31 In this connection, the Food and Health Bureau has been taking forward a number of policy initiatives to strengthen primary care, promote prevention and early identification of disease, including starting a pilot programme to subsidise colorectal cancer screening for higher-risk groups; enhancing and turning the Elderly Health Care Voucher Pilot Scheme and Outreach Primary Dental Care Services for the Elderly in Residential Care Homes and Day Care Centres into recurrent support programmes; and exploring the feasibility of setting up an Integrated Elderly Centre on a pilot basis to provide one-stop, multi-disciplinary healthcare and social services for the elderly at the community level. As far as we can see there is no integration of primary care into VHIS. This will have the perverse effect of encouraging hospital care in place of primary care, in other words, cure instead of prevention. References 1. Common Procedural Terminology. 2015, Chicago, Il: American Medical Association. 2. Medicare RBRVS. 2015, Chicago, Il: American Medical Association. Page 13