Critics ask why primary care left out of health plan

The coming health care reform will draw a new landscape for medical insurance plans covering hospital care, but critics now question why the role of primary care is nowhere to be seen in the long-awaited overhaul.

The government tomorrow will reveal details of the controversial voluntary medical insurance scheme, which it hopes will cover at least 500,000 of Hong Kong's residents.

Regulated by the government, it is aimed at easing pressure on the public system by drawing more people to use private services. Insurers will have to guarantee policy renewal and cannot exclude those with pre-existing conditions. The standard plan will provide coverage for packaged medical services at private hospitals.

The young, old and those with pre-existing conditions will receive financial incentives and subsidies from the government, to be supported by a HK$50 billion fund over 25 years. The plan does not cover outpatient consultations and treatment.

Some medical professionals have voiced concerns over a lack of cost control and the absence of a gatekeeping role by primary care practitioners, warning this would lead to overuse of hospital care and specialist services, pushing up costs.

Unlike the national health systems in Canada and Britain, where family doctors control patients' accounts and referrals to specialists and hospitals, the Hong Kong reform does not give any gatekeeping role to primary care practitioners.

Dr Louis Shih Tai-cho, a member of the Health and Medical Development Advisory Committee that helped map out the scheme, says the reform is going in the wrong direction. 'The likely consequence is patients who get insured will use as many services as they can to maximise their benefits and medical costs will keep going up. I have voiced that in the committee meetings but obviously my concern is not heard.'

In the British National Health Service, primary care 'trusts' play a major role in commissioning secondary care and take up 80 per cent of the overall NHS budget. These powerful trusts purchase hospital and specialist care on behalf of patients.

Medical Association president Dr Choi Kin said patients in Canada had fixed family doctors. 'The family doctors are responsible for referrals to specialists and take care of the patients after their hospital or specialist care; it is a long-term relationship,' Choi said.

'The insurance scheme proposed here in Hong Kong is putting the cart before the horse because it focuses only on hospital care. We worry that the overall medical costs will keep going up.'

Academy of Medicine vice-president Dr Donald Li Kwok-Tung, a former president of the College of Family Physicians, said the reform should include 'some elements of preventive care on top of curative care'.

'For example, the insurance package should cover age-specific, evidence-based health assessment, following the model of Canada and Australia, where family doctors can conduct an annual health assessment for each patient,' Li said.

The government has previously said it would consider introducing life-course health assessment, but there is no sign of it in the scheme, despite repeated calls by the medical profession to introduce free screening for colon and breast cancer.

The Medical Association also questions whether the HK$50 billion fund will be enough to sustain the plan in the long run.

Patients' Rights Association spokesman Tim Pang Hung-cheong said his group did not support the scheme. 'What it does is help those who can afford private insurance to use private services, not improve the health of the whole population,' he said. 'The public sector will suffer a brain drain to the booming private market, affecting quality of service.'

But a person familiar with the government proposal argues that it is 'politically impossible' for the government to make a 'big bang', such as introducing a national health plan like those in Canada and Britain.

'We can't borrow straight overseas models here because it will mean too much change and lack of choices to the public, which most Hong Kong people don't like.'

The person said the government already has several primary care reform measures in the pipeline, such as setting up of a primary care directory, community health services centres and more public-private collaboration in the care of chronically ill patients in the community.

The plan has a three-year 'waiting period' before pre-existing conditions are fully covered, from zero in the first year, 25 per cent repayment of bills in the second, 50 per cent in the third and full coverage in the fourth. Annual premiums are proposed at HK$1,085 for people aged 20 to 24, up to HK$10,514 for over-85s.

Qualifying period

Insurers would cover pre-existing conditions after a qualifying period

The number of years insured patients would have to wait before pre-existing conditions were fully covered: 3