3 October 2023
Professor Chung-mau LO, BBS, JP
Secretary for Health
18/F, East Wing, Central Government Offices,
2 Tim Mei Avenue, Tamar, Hong Kong
Dear Prof. Lo,
RE: Profession’s Feedback and Recommendations for the CDCC Pilot Scheme
I am writing to make recommendations to refine the Chronic Disease Co-Care (CDCC) Pilot Scheme, based on comments from the medical profession.
First and foremost, I pledge my full support for Primary Healthcare Development in Hong Kong. Primary Healthcare Development has been the key element of my election platform back in late 2021. Sound and effective Primary Healthcare is key to a sustainable, comprehensive, and high-quality healthcare for Hong Kong.
No doubt the CDCC Pilot Scheme is a breakthrough. It deserves the most careful planning. Feedback from the profession has been flowing in abundantly since the first briefing by the Health Bureau. After delving into the wealth of information received, three areas of specific concerns are identified together with a number of principles.
The 3 areas of specific concerns are data, professionalism and financing.
A. DATA
1. One Medical Record for Each Member of the Public
The aim is one medical record for each member of the public. The only reasonable choice is eHRSS, the maintenance and security of which remains with the Government. This is not the same as having eHRSS as the only portal of data entry.
For decades, private doctors have been using commercially available systems of which major players numbered no more than a handful. Systems provide more than medical record keeping. These systems manage our billing, accounting, stock take and document issuing at the same time. We rely on the system to dispense drugs which, after automatic deduction, warns us of low drug stocks. We bill our patients using the system, through which we keep track of the amounts payable to laboratories and receivable from banks. These systems generate reports of our monthly income and expenditure.
No one expect the eHRSS to replace these functions, which are often tailormade to suit the need of individual practices. What eHRSS requires from doctors are medical records: diagnoses, allergies, drug and other treatment.
2. Minimize Duplicated Data Entries
Instead of entering the data multiple times into the doctors’ usual system and then eHRSS, we propose the Government should liaise with the handful of system vendors to upload the clinical data to eHRSS in the background. The eHRSS should be an integrated platform whereby medical records for the same patient entered from different sources are pooled together.
3. User Friendly, Uniform Administrative Protocol, Integrated Monthly Statement
The CDCC comes with an IT system, which should be a module of eHRSS. Understandably, specific administrative protocols such as submitting claims and other returns will be in place for CDCC-Participating Family Doctors to follow. These should be user-friendly. Restricting the submission of claims to certain days of each month is unnecessary.
We urge the Government to take reference to the Elderly Health Care Voucher system (HCV). With HCV, Claims can be submitted round the clock. Reimbursement, where undisputed are made the following month. Monthly statements are ready for doctors to download.
There is no good reason that different systems of public-private collaboration / strategic purchasing programs should follow wholly different protocols. We urge the Government to unify protocols across all PPP/strategic purchasing programs. We further propose that monthly statements of all the programs to be integrated into one.
4. Make Good Use of Information Technology
The eHRSS should be more than a medical record system. It should also be a platform of communication between Healthcare providers. It already has a patient portal which serves as a patient held record and hopefully enquiry and booking capabilities in the future. It should be an apps for standardized tele-consultation. I long to see in it an e-prescription for patients to purchase HA / Family Doctor prescribed drugs from Pharmacist in the community.
In its current design, the CDCC Pilot Scheme will not reimburse for tele-medicine consultations. The CDCC Pilot Scheme requires doctors to print or fax referral letters. The CDCC Pilot scheme requires doctors who wish to quit the program or cease a particular doctor-patient relationship to make requests in writing with a lengthy notice.
We do not see why these cannot be applied online. We do not understand why well-recorded tele-medicine consultations are prejudiced against in the CDCC Pilot Scheme, when HA is embracing and promoting the same.
We urge the Government to widen the usage of information technology in the CDCC Pilot Scheme, which will benefit both patients and service providers.
B. PROFESSIONALISM
To start with, we are glad to see the CDCC Pilot Scheme allows a fair scope for professional judgment by the individual doctor in terms of treatment.
1. One Family Doctor for Each Member of the Public – The Usual Doctor
We understand that by Q1 2024, patients can register their Family Doctors at the doctors’ clinic, a progress we fully support. Patients who register their doctors at DHC / DHCE will make their own choices, which again, we support.
We believe it is crucially important for DHC / DHCE colleagues to remind Scheme Participants that they should first consider choosing their usual doctor as their Family Doctor, and that the scheme in no way intends to remove a patient from his usual doctor and match him with another one, while of course, the patient is fully entitled to do so if he so wishes.
2. Mode of Consultation is a Professional Judgment
A doctor may decide that tele-medicine is appropriate for a particular encounter. This should be respected by the CDCC Pilot Scheme and duly reimbursed. As mentioned in section A, eHRSS should be equipped with a standardized system for tele-consultation, thus addressing concerns of system security and proper record keeping.
3. Respecting Overall Clinical Management of a Patient
Family Doctors and Specialists in Family Medicine who have a long-standing rapport with their patients are responsible for their overall clinical care. The doctors and patients often agree to focus on specified conditions at one encounter, leaving other usually less urgent conditions to later encounters. While available time is one factor to consider, focus of concern is another. The number of episodic illnesses to be addressed at a particular consultation should remain the decision of the doctor.
The CDCC Pilot Scheme, by allowing patients to consult a doctor for both the specified chronic illness and episodic illnesses, if unqualified, will inevitably encourage some patients to bring up all unrelated symptoms, making a consultation unfocused and overstretched.
We urge the Government to limit the diagnoses of episodic illnesses to 2 per subsidized consultation, beyond which subsidies do not cover.
4. Patient-centric Care Provider Team from a Vibrant Community Healthcare Network
The Family Doctor is the overall health manager for his patients. He refers his patients to appropriate care providers including allied healthcare professionals where necessary. We therefore need to build up a Community Healthcare Network where doctors, dentists, CMP, nurses, pharmacists, physiotherapists, dietitians, psychologists and others work hand-in-hand with one another.
The DHC/DHCE has roles in (a) ensuring the smooth running of such collaborations and (b) provide specific services especially those that are lacking in the community. It should not be the sole provider. It should not even be the major provider.
A vibrant community of private practitioners in all healthcare professions competing by quality allows for choice, reduces bureaucracy and prevent the morph of DHC into another HA.
C. FINANCING
1. Co-Payment for Treatment, but for Screening….
We respect the concept of co-payment, which reflects a person’s ownership of his health and a shared responsibility of one’s illnesses. It comes, however, with a downside of eclipsed attractiveness. Private doctors will witness that people who are health conscious regularly pay for their own health check. For the Scheme to be successful, we hope to mobilize all in the community from the health conscious to the couldn’t care less.
Free screening for HT and DM / Pre-DM, we believe, has much more attractiveness and is worth pondering again. Repeated BP monitoring by RN at DHC / DHCE should be good enough data for a doctor to make a diagnosis. I really do not see why protocol based blood tests for fasting blood sugar and HbA1c cannot be done by an RN at DCH / DHCE. The family doctor would then have before him a series of BP data or the blood tests results. Diagnosis can be made immediately and the patient enters the Treatment Phase.
Of course, the Scheme Participant may choose to have his BP checked and blood taken by his Family Doctor if he so chooses.
2. Regular Review of the Scheme and the Subsidy Level in Tandem with Inflation
Let us tackle a myth straightly.
I fully grasp the prevailing perception with regards a doctor’s income, but applying to a general practitioner (GP), the numbers are overblown. Rental, overhead, staff salary, disposable clinical items and drugs well exceeds HK$ 120,000 for a clinic in a Government managed public housing estate, and HK$ 200,000 – HK$ 250,000 for a street corner clinic in the city or a LINK shop. If the average consultation fee is HK$ 350, the GP must see 340 and 570 – 700 patients per month respectively, to break even, or 13 and 22 – 28 patients per day respectively for a 26 working day month. During the pandemic which lasted over 3 years, many doctors saw well below the minimum above. The average GP now sees 50 patients a day. The income can be estimated.
The current level of subsidy plus co-payment (as recommended by the Government) falls short of HK$ 320 per consultation. This is very affordable compared to economies of similar level of development.
The Government has a track record of not reviewing the reimbursement level of CRCSP and other programs for years (7 for CRCSP, in fact it has never been reviewed since its inception).
We believe there should be in place a regular review mechanism of the reimbursement level and the scheme itself.
3. Self-Financing of Non-Listed Drugs
The Scheme Drug List comes with basic drugs for hypertension (HT), diabetes mellitus (DM) and very limited options for other conditions. There are no Coxib, PPI, anti-diarrhoeals, hypnotics, throat lozenges or anti-spasmodics, whether injectables or oral formulations. There are no haemorrhoidal suppositories or ointment and there are no topical ointment or creams of antibiotics, NSAID, anti-fungal agents or steroids. There are no vitamin B, folate, probiotics or iron supplement.
The CDCC Pilot Scheme however, requires the doctor to prescribe any medication for episodic illness at no additional charge (for up to 3 days). This is far too unreasonable.
It is a common understanding among doctors and patients alike that additional medication especially expensive ones come at additional charges. To forbid doctors from charging is financially constraining doctors from offering optimal treatment, if not frank bullying.
Under the current design of the CDCC Pilot Scheme, the patient (Scheme Participant) cannot pay extra for better medication advised by the doctor. This goes beyond a purely financing issue. It is trespassing into the professional judgment of the doctor.
I strongly urge the Government to shelve this restriction of additional co-payment to allow doctors and patients to agree on the best treatment available at a mutually accepted price.
4. Pay for Work Done
The Doctor will receive a total of HK$ 316 for the Screening Phase of the CDCC Pilot Scheme. The sum is fixed irrespective of the number of consultations. We all understand HT cannot be diagnosed at one consultation. A patient coming for fasting blood sugar will necessarily return for follow up to see the results. Two consultations is therefore a minimum for proper screening, meaning the doctor will receive a maximum of HK$ 158 per consultation. One must realize that no additional co-payment is allowed at the Screening Phase.
Family doctors in private practice work generally well over 12 hours a day and 6 days a week. Lunches are either missed or consumed inside their office on most days. One must understand that doctors working on both sides of the line, public or private, have their own hard times to face, and private doctors must bear all the expenditures.
I strongly urge the Government to be reasonable (not generous) with the payment and allow doctors a second claim for a follow up consultation in the Screening Phase.
CLOSING
I hope the above discussion gives colleagues in the Bureau a better understanding of the life of a private family doctor and the hard times we face. We are not businessmen. We are not making millions a month as some alluded to. We are learned workers for the people. We are professionals.
Urges, suggestions, recommendations above share the same goal of making CDCC Pilot Scheme a successful one welcomed by patients and colleagues alike, to the benefit of the entire society. I sincerely hope it will be read with impartialness and mutual respect.
I am thankful that the Bureau has prepared a FAQ section for doctor colleagues. I have painstakingly gone through all the questions (as at 30 September 2023), and made comments to the answers in the annex. I too hope you will find it useful.
Yours faithfully,
Dr Hon David Lam Tzit Yuen