Would you like set A, set B, or a la carte? That isn't a question being asked by a waiter in a restaurant, it is one that many patients at the city's private hospitals are being asked as they are offered a choice of fix-priced operations and itemised services. Fixed-priced 'packaged services' are a focus of discussion during the current three-month public consultation on the government's health-care reform. Health officials hope packaged services can increase fee transparency and encourage people to buy the government's voluntary medical insurance scheme. The officials also say fixed-priced packages can counter some doctors' 'seasonal prices', referring to their excessive medical charges. The reform has become a tug of war among the government, private hospitals, insurers and doctors for control of prices in the market. If packaged services become the mainstream service model in Hong Kong, the price-setting power will shift gradually from doctors to the other three parties. Instead of itemised charges, patients subscribing to the packages pay a lump-sum for everything, while hospitals take the risk of post-operative complications and extra stays required to fix those complications such as bleeding or infections. The differences in the real cost of individual patients are shared by all, meaning that patients and the hospitals also have to play a risk-sharing role. The plan has prompted heated debate. While patients give it the thumbs-up, doctors warn it would seriously damage their relations with patients by turning hospitals into production lines. Some say the move would create an 'ethical crisis' as it would prompt service providers to deliver medical care based on prices instead of patients' needs. The government wants to introduce a voluntary Health Protection Scheme to cover 300,000 to 500,000 people, covering packaged services for some common procedures. One private cardiologist said he strongly opposed packaged services. 'What the government wants to do is to control a big volume of patients and have them hooked with packaged services; private hospitals then work as the agents to put pressure on doctors' charges in order to put out an attractive price. Doctors will end up delivering packaged services as commercial products only,' the doctor said. 'With packaged services, doctors won't be rewarded for explaining more to patients so they'll tend to deliver only what's in the packages. It will be an ethical crisis.' Medical Association president Dr Choi Kin says packaged services would damage clinical autonomy. 'Doctors should be able to give the best treatment and drugs to their patients, but if all the costs are fixed, their hands are tied, they can't deliver good quality care,' Choi said. The private Union Hospital in Sha Tin is among the most aggressive providers of packaged operations. Over seven years, the number of packaged operations available at the hospital rose from a few to more than 80. They cover procedures including heart surgery, gynaecological operations, endoscopic examinations and anti-obesity procedures. For instance, the hospital charges HK$19,100 for excision of a breast lump and HK$40,350 for laparoscopic removal of an ovarian cyst. More than half of the patients at the hospital who are not covered by medical insurance pick packaged services at prices set by agreement with doctors, according to the hospital's medical director, Dr Anthony Lee Kai-yiu. Those covered by insurance still prefer so-called ? la carte charges because most insurance companies do not accept lump sum claims. Lee called on the government to allow flexibility in designing the health protection scheme, saying that there should be different coverage for patients of different risk levels. The hospital does not apply packaged services to high-risk patients, such as those with pre-existing conditions including heart or kidney diseases, and diabetics, as they have a higher chance of complications and a longer stay. 'If we mark a flat price for all, the charge will be high and those of low risk have to subsidise the high-risk group. The government scheme should provide more reimbursement to high-risk patients to cover the higher cost of operation, otherwise it is difficult to market the product,' Lee said. 'Private hospitals can market several levels of packaged operations according to patients' risk level - for example, 10 per cent higher fees for diabetic or heart patients.' Lee admitted the package fees would not be the cheapest, as the charges are set at the average of the high and low end of the real cost. The Hong Kong Sanatorium and Hospital in Happy Valley plans to provide packaged services for the government scheme, but this will not be its core business. Its medical superintendent, Dr Walton Li Wai-tat, said the hospital had a full house on 77 per cent of days in the past 10 months and had to turn away patients. 'Packaged services will never be our core business, as we do not even have the capacity to deal with the current demand because of limited space for expansion,' Li said. 'We are not geared towards providing cheap services in order to take those patients.' Patients' Rights Association spokesman Tim Pang Hung-cheong welcomed packaged services. 'It reassures patients that any unexpected complications from operations will be covered. But doctors are resistant as they don't want to take the risk or have their charges controlled.'