“This afternoon at the Prince of Wales Hospital, 10 doctors have to see 120-150 patients in the weekly diabetes clinic. A majority of the patients are insulin-treated and have multiple risk factors and/or complications. Even if we see these patients once a year, we can only see 7,500 of them in 50 weeks when we should be seeing them at least two to three times a year even if they are stable,” laments Professor Juliana Chan, Professor of Medicine and Therapeutics and Director of the Hong Kong Institute of Diabetes and Obesity at the Chinese University of Hong Kong (CUHK).

In this exclusive interview, Chan fills us in on how directives from the government on public private partnership (PPP) and inclusion of the private sector in the management of chronic disease like diabetes are urgently needed to make our health care sustainable which will also provide an ecosystem more conducive to the development of innovative health care and biotech industry in Hong Kong.

An imbalance between public and private sectors in Hong Kong

Note that there are at least 70,000 people with diabetes in our catchment area with a population of one million. Newly diagnosed patients or those with unstable condition need to be seen more often. Yet, we can’t. While we can’t discharge our patients to the busy public primary care clinic, unstable or high-risk patients attending the primary care clinic are also not finding their way to the specialist clinic in a timely manner,” says Chan.

“Meanwhile, many patients are attending the emergency room or queueing to be seen at the specialist clinic with an average waiting time of 1-2 years while their conditions silently deteriorate. These people are missing the golden period for early intervention and may suffer from critical illness which are preventable, only if they can be seen early and treated properly,” she notes.

“After all, these patients have few choices. It’s either waiting for months or years to be seen under the heavily-subsidised public sector or spending a lot more to seek private treatment, which they either cannot afford or are not willing to pay due to the huge price differences between the private and public sectors,” she adds.

Supposedly, one of the competitive edges of Hong Kong’s healthcare system is that patients can choose between the public and private sectors. Nevertheless, under the current system, people tend to see private doctors only for vaccination, minor ailments or one-off treatment or procedure. For chronic diseases like diabetes, they visit the public hospitals or clinics instead due to the recurring treatment costs in the private sector.

“If a patient is diagnosed with diabetes at the age of 40, unlike a one-off treatment for cold and cough, he would need to visit his doctor or care team for regular follow-up for the next 30 years, assuming he lives up to the age of 70,” says Chan.

Explanation of personalised diabetes report at the CUHK Yao Chung Kit Diabetes Assessment Centre
Explanation of personalised diabetes report at the CUHK Yao Chung Kit Diabetes Assessment Centre

Chan also points out the ramifications of the imbalance between the public and private sectors in Hong Kong. “There are just under 6,000 medical professionals hired full-time at various public hospitals or clinics in Hong Kong. Yet, we have similar number of private doctors, and many of them have expertise and experience in managing chronic diseases. It’s not because we don’t have sufficient manpower to manage this large volume of patients with chronic diseases. It is more of an issue of uneven resource distribution. Private doctors should be contracted to manage chronic diseases in order to stay current and competitive. The Hospital Authority (HA) is offering services which only charge a fraction of the real costs. The high demands mean long queues, inevitable rationing and few choices,” says Chan.

“In Hong Kong, 2.5% of GDP which accounts for 17% of the government’s revenue is used to support HA’s services. The scope and quality of services provided by HA are comparable to healthcare services in many high-income countries in Europe and North America. However, sustaining these services will require 5-8% GDP supported by a high tax system and a compulsory insurance system,” she suggests. “The HA now looks after the health care of nearly all citizens from cradle to grave. Unless there are new resources and major reforms, the system simply cannot cope.”

Challenges and opportunities for the Public Private Partnership (PPP) Programme

One of the initiatives to narrow the gap is the General Outpatient Clinic Public-Private Partnership Programme (GOPC PPP), which was launched by the HA in mid-2014. Currently, the programme offers HKD3,155 to each general practitioner per year for a maximum of 10 consultations. Meanwhile, at public hospitals, the HA’s Annual Report 2015 – 2016 showed that the costs per specialist outpatient attendance and general outpatient attendance are HKD1,190 and HKD445, respectively. On top of consultations, there are also costs for medications, education, laboratory tests and clinical assessments which have not been addressed adequately.

To increase the reach and impact of GOPC PPP, Chan emphasises the importance of aligning the interests of both patients and care providers. “On average, it costs around HKD8,000-12,000 per year to manage one patient with diabetes who often has co-existing high blood pressure and high blood cholesterol. The management includes consultations, lab tests, medications and assessments,” she said. “In patients with diabetic complications, the annual cost may go up to HKD20,000 or HKD30,000. Depending on their levels of control, these patients may need to be seen frequently until they are stable enough to be seen at longer intervals.”

“During the patients’ course of 30-40 years of diabetes, there are many events that can destabilise their condition. Investment for high quality outpatient care is value for money since it will prevent critical illnesses such as heart disease, stroke, kidney failure and cancer, which can easily cost half a million dollars per event. These serious illnesses now account for 50% of the HA’s hospitalisation costs, although 50% of them are preventable” she continues.

Whether working in the public or private sector, Chan emphasises that healthcare professionals bear the responsibility in looking after these vulnerable patients with silent risk factors and multiple needs. However, as Chan points out, the question is: Are these patients being seen at the right time by the right people and managed in the most cost-effective manner?

“Worldwide, all countries are struggling to make chronic disease care sustainable. This is an issue that concerns all of us – we all need health care at some stages in our life and all of us have to pay for health care either through tax or insurance or out of pocket. If we provide expensive but ineffective or suboptimal services, then we will all lose out in the end,” she says.

Currently, 50% of the medical workforce is providing health care to 90% of our population through HA. While a single healthcare provider has many merits, when it comes to chronic disease care, there are a lot to be said in capitalising both private and public resources to develop community-based services for addressing the many needs of people throughout their life journey.” says Chan.

“People in Hong Kong have few health care choices when many young and middle-class people especially those in full-time employment, are looking for more flexible and user-friendly service. Some of these individuals are willing to pay a bit more for convenient and personalised service, so that they can see their preferred doctors at a preferred time in a preferred clinic. Why are we not providing these choices so that we do not stress our public system further, which has the primary mandate of looking after the sick and poor and training staff?” questions Chan.

Taking the overall cost effectiveness into consideration

Apart from giving patients more choices, narrowing the gap between public and private care could also enhance the cost effectiveness of our health care in the long run.

“Every time, when patients visit their doctors in public hospitals or community clinics, they only have around 10 minutes to talk to them. Can they really remember the advice given to them? Are they really taking the 3-month medications as prescribed to them? As many as 50% of these patients are not taking their medications regularly or changing their lifestyle. The HA is using a lot of paramedical staff to address these service gaps, while this is laudable, medical expertise in making diagnosis and formulating a treatment plan is extremely important when it comes to chronic and complex care.” asks Chan.

“Perhaps five to ten years later, despite given free drugs aimed to prevent complications, these patients will still end up being hospitalised with critical illness. One of the reasons why so many patients are coming to HA is to have free medications. But, without quality consultations and reinforcements by a competent care team together with a stable patient-provider relationship, we cannot bring out the full benefits of these expensive medications. The frequent changes of doctors and insufficient integration between primary and hospital care teams are additional challenges in the over-burdened public care system. So, not until the government steps in and takes the lead to narrow the gap between the public and private sectors, we are not really using our finite resources in an effective manner.”

As Chan observes, patients tend to visit different doctors in both the primary and hospital care settings and often receive different instructions. However, patients with chronic disease like diabetes should be managed by a stable team consisting of doctors, nurses, dieticians, pharmacists depending on how complex the medical condition is. Here, a trusting relationship is crucial for modifying these biological and behavioral risk factors. Importantly, structured assessment at diagnosis and then every 1-2 years is essential for quality assurance, care triage and reinforcement.

“Each person with diabetes has a unique set of risk factors and complications and depending on their access to treatment, education and self-management, they will have different trajectories and outcomes ranging from good health to life threatening critical illness to premature death. Thus, tracking and monitoring of their conditions is essential for the care team to identify needs and individualise care,” highlights Chan.

“These risks do not appear to be urgent. However, prevention is the key. The earlier we identify the risks, the easier is the management. We shouldn’t wait until disaster happens. Even if it’s possible to provide treatment at late stages, it could be a lot more expensive —and this is not the most cost-effective way of using our finite resources.”

More healthcare choices will drive biotech industry in Hong Kong

The same philosophy of prevention, informed decision and team-based care is also deep-rooted in the first Hong Kong based genetic testing company specialised in diabetes founded by Chan.

Opening of the first diabetes genetic testing laboratory at the Hong Kong Science and Technology Park
Opening of the first diabetes genetic testing laboratory at the Hong Kong Science and Technology Park

“It’s not just a genetic testing service provider. We have been working closely with doctors and other healthcare professionals. In particular, those who are interested in diabetes and chronic disease, as well as those who believe in education and early intervention,” explains Chan.

“This network of healthcare professionals can use these genetic and other relevant information to educate and empower their clients or patients to manage and reduce their health risks through lifestyle changes, early use of drugs and personalised counselling,” says Chan. “This is precision medicine where we use the unique set of risk profile to raise awareness and help at-risk individuals take early actions in order to avoid critical illness and stay well and healthy.”

Chan has been witnessing the development of biotech industry in Hong Kong in the last two decades, although the sector has been lagging behind in terms of its competitiveness, she comments that there is now a silver lining with the new government fully committed to developing a long term and holistic plan to develop talents, build infrastructures and attract new investments.

“Until recently, there are very few job opportunities in biotech industry for PhD graduates and many have to join other industry while some return to China like Shenzhen to set up their companies,” points out Chan. “They can’t see their career prospect here. And we are losing our talents. The busy working environment in HA also makes clinical and applied research challenging. This is critically important if we want to translate results of basic research into service or technology.”

Hong Kong has many challenges, as Chan describes. “Even if we are physically and mentally healthy, we are not living in an optimal state if we are surrounded by a lot of social problems. Our social wellbeing is interlinked with our living condition, job opportunities, economic competitiveness etc. After all, we are part of a larger community which we collectively shape its norm and define its culture,” says Chan.

By embracing more health care professionals and reducing the price differences between the private and public sectors through government subsidy and health care reforms, we will give more healthcare choices and innovative technologies to our people. This will allow the public sector to focus on the sick and needy while researchers can continue to develop prototypes to address unmet needs. Despite the multiple challenges faced by Hong Kong’s healthcare and biotech industry, Chan remains optimistic.

“What I envision in the future is that people can use innovative technologies such as genetic tests and wearable devices, to learn about their risks for common critical illnesses which are preventable and treatable. Their healthcare team can use this information to engage their patients and families in a meaningful conversation and deliver a holistic care plan, putting the doctor-patient relationship back into action,” says Chan.

“If, unfortunately, when things go wrong, they have the choices to go to private hospitals with adequate insurance coverage or public hospitals, which I hope would not be too crowded by then. For their children, they can develop their careers in biotech, data science, healthcare along with financial, tourism and culture sectors. Through concerted efforts, our young generation will identify unmet needs in healthcare, brainstorm solutions and build their ideas into brands—and along the way, transform Hong Kong into a healthcare innovation hub and a more vibrant city,” she envisions.

“This is our home and we all have a role to make it work—so that one day, we can proudly say to ourselves: We have made Hong Kong a great city to live in,” echoes Chan. MIMS

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