21 February 2006

Feeling Sick?

Feb 21, 2006
High prices for common drugs in HDB heartland

MY CHILD was sick, down with a bad cough, sore throat, runny nose and a slight fever on Feb 16. At 9pm, our family doctor had left so we went to another private clinic - 'Street 11 Clinic' at Block 139 Tampines Street 11.

After a brief consultation, she was given these medicines: cough syrup (one bottle, 'Dhasedyl, 90ml'); a packet of 'Danzen' (20 tablets, 5mg) for the throat; 'Telfast D' (10 tablets) for runny nose and antibiotics 'Klacid MR' (five 500mg tablets for throat and nose).

I was astonished when I received the bill. These medicines cost me $80. I am puzzled at the high cost because I believe that my daughter's symptoms were fairly common and she was treated by a locum.

I feel the clinic had either overcharged and jacked up the price of common drugs, or did it give me unnecessarily expensive drugs for a common illness?

I asked the receptionist for a breakdown of the cost of the various medicines. To my surprise, the staff informed me that the five antibiotic tablets alone cost $37.

I believe Health Minister Khaw Boon Wan had mentioned that affordable medicines be provided for patients at reasonable prices. Yet the clinic in our heartlands is charging drugs such as 'Klacid MR' at an exorbitant price. This is a worrying problem which I hope can be addressed to benefit the masses.

Gan Siok Wah (Mdm)

I wonder if any doctors read my blog. Maybe they can comment.

This reminds me of one of my old posts - where I wrote about a 92-year-old man who was charged $64 for a common cold and fever. His son-in-law related this to Health Minister Khaw Boon Wan who replied that Singaporeans should help their older relatives pay their medical bills.

That really wasn't very helpful.

I'm also reminded of another post I previously wrote, about foreign workers in Singapore going to see an unlicensed "doctor" operating an illegal medical practice somewhere in Little India. In response, the Health Ministry advised these workers not to see such practitioners and instead have "medical insurance coverage to protect themselves".

Ridiculous. If these foreign workers could afford to buy medical insurance from AIA or Prudential or NTUC Income, then they wouldn't be foreign workers.

What say you, Mr Tan Kin Lian?

27 comments:

L'oiseau rebelle said...

To my knowledge, Klacid is indeed an (extremely) expensive antibiotic.

But still, I know of cases where polyclinics charge more for drugs than doctors in private practice.

The other question is: Should the doctor have prescribed a cheaper antibiotic?

Ampulomet said...

I can sympathise with Mdm Gan's plight.

Having treated children both in cluster healthcare and in various heartland clinics, I can safely say that the prescribing practice in each setting is somewhat different.

If Mdm Gan's child were to attend Children's A&E in Singapore with the same symptoms, you would almost never get Klacid first time around. In Singapore paediatric practice, Klacid is a second-line antibiotic - that is, you might consider it if your first course of antibiotic wasn't working, or the infection seemed to present in an unusual way.

Also, the medical community has an obligation to reserve such second-line antibiotics for serious cases, in order to minimise drug resistance (a big problem in any developed country).

I didn't see the child, but he probably had a viral infection that didn't need antibiotics, let alone Klacid. The other meds are fine, since they only treat symptoms.

There isn't much that Khaw Boon Wan can do against such padding of private medical bills, but he should look to the adequate provision of GP or primary care through the polyclinic system. I am not overly troubled about the existence of these "Street 11" clinics, as long as anyone in Singapore can get to see an affordable GP 24 hours a day, instead of clogging up A&E.

Here's hoping...

Merv said...

You know,

the problem is that it is a private clinic.

I suppose being private, they can charge any price they want.

It would be a different story if they were overcharged by a poly-clinic.

Nothing to do with Health Minister or the govt.

Let the buyer beware i suppose.

moomooman said...

At least she got charged for what's the worth of the medicine. Try going to another public-listed clinic with bombastic name and numerous chains in suburban areas, you pay the same price for ineffective entry level medicine seen by an inexperience young doctor.

I wonder why no one complains about them.

tuck said...

i just recovered from a bad bout of flu. i resisted seeing the doctor. i took an 'educated' risk not to see a doc. it was self healing. but one must have a higher threshold of pain. for me, it was 4 days of discomfort.

bamboo said...

The doctors are force to do that in order to maintain their standard of living.

Nowadays I also don't see a doc.

hugewhaleshark said...

"I didn't see the child, but he probably had a viral infection that didn't need antibiotics, let alone Klacid."

Dude, and you're not "overly troubled" that this money grubbing doctor overmedicated a child to make a couple more bucks? In this, the age of antibiotic-resistant bacteria? Not to mention the drug probably wiped out all the kid's good bacteria as well.

minorF said...

The problem is that in Singapore, doctors have dispensing rights - which means that unethical doctors will prescribe expensive drugs for no good reason other than to pad their bottom line. It'll be a cold day in hell before we strip doctors of that right, so the only other remedy is to improve patient drug education. Ask your doctor about the medication prescribed, determine if you actually need it or not, and doctors also have to take the time to educate patients about what they are taking. Every doctor I've been to removes the package insert from boxed medicines - that's where information about the drug, side effects etc are all contained. My mom once asked the clinic assistant for the package insert and was rudely told off.

Right now, the doctors hold all the info, and that's wrong. I am always very pleased when a doctor takes the time to tell me what drugs s/he intends to prescribe, and asks if I need it or not. But then I am not the average bear (I worked with drug companies), the average resident is not at all empowered to challenge their doctor.

hugewhaleshark said...

I am glad to have a neighbourhood GP who dispenses medication responsibly, including antibiotics. He doesn't look as busy as his peers nearby. Maybe patients want to be irresponsibly medicated. But I respect what he does, and he has my business.

Anonymous said...

Maybe you can ask angrydr?

angry doc said...

Thanks for the invite, Mr Wang. I am a reader of your blog myself.

I won't comment on the doctor's clinical decision, or the practice of clinics dispensing drugs.

My point, quite separate from the author's question about drug costs, is that we need to reconsider our expectations of what a fair price for healthcare expenditure is.

If we accept that acute illnesses are part of living in a modern urban society, and set aside a budget to pay for the expenses, perhaps we wouldn't be so outraged by the costs.

As for how much profit those in the healthcare business should be allowed to make... well, that's a more complex question. :)

Dr Oz bloke said...

Your title "High prices for common drugs in HDB heartland" is wrong.

Telfast D and Klacid MR are NOT "common drugs in HDB heartland clinics"

Personally as a doctor I believe in empowering my patients with knowledge and information. However not all of them are interested.

If Mdm Gan was an informed person in this knowledge based day and age she would have known that antibiotics were not usually necessary for common Upper Respiratory Tract Infections, much less on the first visit!

She could have refused the Klacid MR. Or discussed with the doctor a bit more about the management decision.

I guess the doctor plays a part too. He/she should explain the problems and issues clearly. If there was really a need for Klacid MR then explain why. Perhaps offer to prescribe generic Clarithromycin instead if Mdm Gan was agreeable.

Other other hand there are patients who make requests for the "more better", "more stronger" medicine. We won't know if she was one of them.

For the matter, the percentage profits over the cost of non-generics is actually less than that of generics. So clinics earn less when they prescribe non-generics compared to generics which are cheaper for the patient.

So the counter complaint could come also. One day someone may write to ST forum about seeing some doctor who charged $20 for flu and prescribed cheap generics which can be found in SAF camp medical centres and did not work for him/her. And then they would say how these doctors are merely trying to profit more by selling cheap generics.

So how to win? You choose what type of practice you want to visit. There will be clinics that keep bills low by prescribing generics. There will be GPs who give you good new up-to-date drugs but are expensive and actually earn LESS profit.

You choose. Ask around at the market which clinic is which type.

hugewhaleshark said...

Hey there dr oz,

I find it surprising that doctors make more (I mean more $, not more %) on generics. Let's say a generic sells for $10 a course and a non-generic, high power alternative sells for $30. Maybe you make 60% on the generic = $6. To make the same $6 on the non-generic you only need to make 20%. You mean that the margins can be that different?

I infer from the tone of the letter that Mdm Gan did not ask for the expensive meds. Otherwise it will be contradictory to complain about the cost.

Other than that, I say more power to doctors who educate, and prescribe responsibly!

Anonymous said...

Let me have my two cents worth on the above mentioned article. (plus some other comments)

First and foremost, I am the so called "inexperienced" young doctor that people like moomooman described.

However, I doubt that a 50 year old doctor and a freshly blooded doctor just out of medical school would be unable to treat a viral URTI - for the simple reason that these illnesses are SELF LIMITING. Thus, no matter what medications are chosen/prescribed, the effect is the same - patient gets better after a couple of days.

There are obviously conditions which presently innocuously just like a simple viral URTI - and the young doctor is then blasted for being "inexperienced" and unable to pick up the "correct diagnosis." If someone came in with 1 day history of an illness, I doubt the top professors would be able to give an accurate diagnosis as well. However, the patient in this instance would then think, wow, even the professor is unable to treat me, its a good thing I came early and seeked such "experienced" help. He/She would then eagerly lap up any medication prescribed , cheap or otherwise.

Secondly, with regards to the article, let me try to make sense of what she wrote. She claimed " I am puzzled by the high cost because I believe that my daughter's symptoms was fairly common and she was treated by a locum". This obviously meant that she would have not been so irked had she been seen by the so called "experienced" in house doctor. So perhaps her annoyance stems from BOTH the fact that her daughter was prescribed expensive medications as well as been seen ONLY by a locum.

She then proceeds to say that the list of medications she listed were "common drugs." Unless I am mistaken - Klacid MR and Telfast are by no means "common". These are expensive branded patent medications.

Frankly, GPs are in no win situations. Prescribe cheap generics and patients complain about having to make multiple visits back to the clinic for "more medications and a consult", or worse, claim that the doctor's medications are "lousy." Prescribe something better - and then the issue of pricing comes in. Explain to patients that medications are NOT required for their particular illness - and they curse and swear at you for charging them $15 for 5 minutes of "talking". Explain to parents of the 2 year old child that a runny nose of 1 days duration with no other symptoms does not require treatment with antibiotics and they tell you that "the previous doctor gave and she got better very fast" and insist that antibiotics are required.

I think resentment basically stems from the fact that patients tend to doctor hop and compare different management styles. In this case, I just hope that Mdm Gan takes the trouble to find out more before she writes in to the press shooting her mouth off.

Dr Oz bloke said...

Here's some information for all people out there wondering how doctors can "decide" whether or not you need antibiotics in a typical flu or cold.

Actually there is a way to assess patients to help decide if they need antibiotics. We all learnt it in med school. Yet it is not widely practised. Read on to find out more and why.

Here's how :

Patient comes in with upper respiratory tract symptoms. Doctor suspects it might be bacterial in nature based on clinical symptoms and signs. Do note however that majority of common flu, colds, sore throats and bronchitis are caused by viruses.

Check out what the US CDC Campaigns are like.

http://www.cdc.gov/drugresistance/
community/snortsnifflesneezespot/
resources/vbchart.pdf

http://www.cdc.gov/drugresistance/
community/snortsnifflesneezespot/
index.htm

Anyway the doctor explains to the patient the possibilities and advises that they perform a "Throat Swab culture and sensitivity" or a "Sputum culture and sensitivity".

This involves swabbing the back of the throat with a sterile cotton swab near the tonsils. The swab is placed in a tube of culture medium. The culture is a laboratory test done to isolate and identify organisms that may cause infection in the throat. What happens is that the test is sent off and the patient gets symptomatic treatment.

The lab will grow the organisms in the culture and identify them. They will also place antibiotics chips into the agar and see which antibiotics kills the bacteria (you can see a zone of clearing around the antibiotic chip). The doctor then gets a report that details the type of bacteria found, and which antibiotic kills it. (Remember there is antibiotics resistance abound these days).

The doctor then gives the patient a call and asks if he/she is better. If not better come back to get the appropriate antibiotic that kills the identified bacteria in her system that is causing the infection.

http://www.nlm.nih.gov/medlineplus/
ency/article/003746.htm

This way we choose the appropriate antibiotic and know it is necessary. It might be Klacid, it might be something as cheap and simple as Penicillin!

Now for my patients who want to know more about whether they need antibiotics, this is what I tell them. The problem is this. The Labs charge $43.50 for the Throat Swab Culture. This is the COST PRICE to me the doctor. I tell patients this is the cost price which is what they will pay. I won't earn a cent from doing the test. You still want to do the test?

Most responses would be "What? $43.50 to do a test to decide if I need to take antibiotics that cost at the most $30? I think no need lah. You decide doctor. Want to give antibiotics you give. If don't need then don't need."

So I will tell them most flu and colds are viral in nature and antibiotics don't work. And I give them a print out of

http://www.cdc.gov/drugresistance/
community/snortsnifflesneezespot/
index.htm

and

http://www.cdc.gov/drugresistance/
community/snortsnifflesneezespot/
resources/vbchart.pdf

for further reference.

But I do tell them that if they don't get better after a 3-4 days or get worse, please come back and consult me because yes sometimes it is a bacterial infection that needs antibiotics.

Communication is the key lah!

Dr Oz bloke said...

Hugewhalshark wrote :" I find it surprising that doctors make more (I mean more $, not more %) on generics. Let's say a generic sells for $10 a course and a non-generic, high power alternative sells for $30. Maybe you make 60% on the generic = $6. To make the same $6 on the non-generic you only need to make 20%. You mean that the margins can be that different?"

The margins for generics are higher than 60%. But that is besides the point.

You see for the doctor earning the same amount of money in your example one patient's bill for her antibiotics is $10 while the other is a whopping 300% higher at $30! And the drug may actually be the same eg Clarithromycin (just different brands and manufacturers and dosing)

It makes a big difference in the psyche of a customer. This is where pricing in business comes in. After adding consultation of $18 and assuming just antibiotics prescribed it's either $28 or $48!. Which would you rather have?

Of course perhaps it would be better if the doctor explained to you and gave you the option of choosing generic vs non-generic then it would be up to you. That would be better right?

But I'm just wondering. Which would you choose?

Mr Wang Says So said...
This comment has been removed by a blog administrator.
Mr Wang Says So said...

Personally, I choose whatever whatever whatever. My employer has excellent medical benefits and basically covers all medical expenses for me and my family. So money is not the consideration.

However, I understand that if I show my employee group insurance healthcare card at the clinic, then sometimes the doctor will refuse to prescribe certain drugs because the insurer refuses to pay the clinic for certain (relatively more expensive) drugs ... even though those drugs may be the most appropriate ones in a particular case. Is this true?

Dr Oz bloke said...

"However, I understand that if I show my employee group insurance healthcare card at the clinic, then sometimes the doctor will refuse to prescribe certain drugs because the insurer refuses to pay the clinic for certain (relatively more expensive) drugs ... even though those drugs may be the most appropriate ones in a particular case. Is this true?"

The way the insurer generally works is that they will have a cap on payment. Depending on which company you are with, some insurance companies ask you to co-pay. Some will pay $X per visit.

Generally speaking, for insurance cases, doctors would try to keep bills within the payment coverage. It's good business sense. Of course depending on the doctor and clinic, the way they handles cases that need more expensive drugs is different.

Some may choose to make a loss by giving the patient the expensive medicine and not get the adequate remuneration from the insurer. But this is rare.

Most would give cheaper alternatives eg generic drugs.

I would say this though, at the present moment there are VERY FEW non-generics that are so essential and good that do not have a generic alternative. Very Very few.

In my opinion and experience, the difference in results for patients using generic and non-generic versions of the same drug are negligible. But it is much cheaper for the patients. At the same time it allows GPs to take one insurance covered patients like you without making a loss.

After all at the end of the day, that's the aim of the insurance company right? To keep costs low and yet give patients adequate medical care. Use of generics is the way to go to achieve those results.

Of course the pharmaceutical companies think otherwise. As it is there are no real "new" drugs coming out on the market. Most of the drugs are modifications of existing drugs or combinations of patent expired drugs with patent still valid drugs to become a "NEW" drug.

Anonymous said...

The cost of healthcare in Singapore is very affordable compared to European cities. The standard of healthcare offered is also stellar. Choosing to "go private" in Singapore isn't that extreme an option compared to say, the UK. In Mdm Gan's situation, her gripe seemed more $$$ than mis-prescription. I am not a doctor, but if it's $$$, I think we need to keep ourselves in check, doctors in this post have confirmed that Klacid is an expensive drug. If you want to go private, don't expect a government subsidy - we are not a welfare state. If you want private and cheap, then be prepared to pay high taxes and for everyone else's sick child.

Jolly Jester said...

I agree that communication is still the key. My GP near my house that i visit gives me a print out on the medical problems that I am having, listing out clearly the causes, symptoms, medication, what to avoid, etc of the illness, and he goes through it verbally as well. And for those who can't really read english he has chinese versions as well. Once I asked him further questions on my illness/drug, he took out a medical dictionary/encyclopedia, found the relevant section and showed it to me.

Now that's good service and transparency I am willing to pay more for(he charges a bit more than other GPs in my area). The open discussion about the illness and the treatment empowers us(patients) to understand more about our condition and the rationale behind the doctor's prescription.

As for whether he did remove the leaflet from the medicine, my impression was that the leaflet was present.

minorF said...

The doctor in question had a letter printed in the forum today, hopefully MrWang finds the time post it to close the loop. Seems like the original writer did not mention that her child was not responding to first line medication, which is why Klacid was prescribed.

A few things:
1/ Why didn't Mdm Gan return to the first doctor? There is a danger to doctor hopping.
2/ If she thought it was just a simple cold, then why did she see the doctor again or express surprise that she got more meds?
3/ Did the doctor explain things to Mdm Gan as he did in the letter?

Which brings me back to the point I raised before - PATIENT AWARENESS. And I do not advocate putting the onus on the doctors, the general public needs to learn about basic medications and health care utilisation. Otherwise the mismatched expectations will just get worse and worse and neither side comes out for the better.

recruitong said...

To the anon who posted on 22/2/2006, 1104pm, you wrote:

"I think resentment basically stems from the fact that patients tend to doctor hop and compare different management styles. In this case, I just hope that Mdm Gan takes the trouble to find out more before she writes in to the press shooting her mouth off."

Firstly doctor hop or not is not the point of contention here. But if you think about it further, why do patients hop around? Consider the next para...

2ndly even if Mdm Gan takes the trouble to find out more about being prescribed expensive drugs before shooting off the letter, it does not take away the fact that the locum or clinic in question did not communicate to her the high costs of such drugs during the consultation. Judging from her tone if she knew they are so expensive she wouldn't have opted for it, or at least if she chose to she wouldn't complain later. From my experience doctors would inform their patients before hand and seek their consent before dishing out drugs that are more expensive than usual. I think this is standard practice.

You see it is about communication. Patients do not have the knowledge and expertise, they also do not know the right questions to ask their doctors. It is therefore the doctors' responsibilities to explain and inform them as much as possible anything that would be out of the ordinary. That isn't too difficult is it? Doctors who are poor communicators are the ones who would experience "doctor hopping" from their patients. So don't blame the patients.

You are indeed an "inexperienced young doctor" as you have confessed, so go chalk up more experience points, ya? Otherwise with your kind of attitude and lack of empathy, i for one will take my business somewhere else.

Dr Oz bloke said...

http://www.straitstimes.asia1.com.sg/
forum/story/0,5562,373632,00.html?

The reply from Street 11 Clinic is out.

As usual one must always get all sides of the story.

In this case, it was just a problem of a lack of communication between Mdm Gan, the clinic and the doctors concerned.

Anonymous said...

To recruitong:

To ensure that this does not escalate into anything more than a flame war, let me just state the the basis of this post is to clarify a few misconceptions that you (and a fair number of Singaporeans) have, and not targeted against you.

You said "it does not take away the fact that the doctor or the clinic in question did not communicate the cost of the medications during the consultation". I agree that perhaps the doctor should have forewarned the patient that the antibiotics that he was going to prescribe would be costly. However, to say that the patient did not know the breakdown costs of the medications is a false one. I quote her original article "I asked the receptionist for a breakdown of the cost of the various medicines. To my surprise, the staff informed me that the five antibiotic tablets alone cost $37." Why choose to pay for the medications then if she knew the high costs then? I am certain that one could always reject the medications there and then - and then one of two outcomes would ensue: 1, the doctor could explain to her the necessity of the medications and she would accept it, grudgingly or otherwise, 2, she could have just said no thanks, reject the antibiotics and ask for a cheaper one. Why kick up a big fuss in the media? I have no doubts that the doctor in question/clinic could have improved their communications with the patient - but to suggest that responsibility of the outcome is solely that of the doctors/clinic is presumptious. But just to set the record straight - I always inform the patient myself or tell my clinic assistant to inform the patients when expensive branded medications are used in place of cheaper generics.

I now quote two statements that you made: "Patients do not have the knowledge and expertise, they also do not know the right questions to ask their doctors"

as well as

"Doctors who are poor communicators are the ones who would experience "doctor hopping" from their patients".

Let me deal with each one in kind. The first point strikes the nail on the head. The different expectations on both the part of the doctors and the patients. Yes, it is the responsibility of the doctor to educate, to help the patients make informed decisions, to come to a solution/management plan that suits the patient. However, it always always always takes two hands to clap. The doctor patient relationship is two way. If the patient does not know ANYTHING about his health, does not know ANYTHING about the medications he is taking, or worse, does not even know why he is at the doctor, where does the doctor start? Everything would then be a "best guess". The outcome naturally is less than satisfactory for both parties. The result? Poor patient satisfaction, doctor hopping and poor clinical outcomes. And it happens on a daily basis. Some Singaporeans are so blase about their own health it is astounding. Ask any doctor reading this forum and I am sure they come across these sort of patients on a daily basis. Ultimately, who is responsible for your health? Is it the doctor? The government? Or is it yourself?

Your second statement is true - but only partially. There are many reasons why patients doctor hop. Poor communications is just one of the myriad of reasons. Just off the cuff, I can list you the various reasons patients themselves have offered me when I asked them why they did not see the same doctor (and I did not mean MYSELF. I was asking them why they did not visit their PREVIOUS GP who treated them originally). Long waiting time, lack of MCs, so called "lousy medications", cheaper consults, far from mother-in-law house, near NTUC where I was etc. The list goes on.

I do not doubt that I need to improve my clinical skills, communication skills and many other skills - but along the way, I would certainly hope that the patients I see are as interested in their own health, as much as myself.

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