Summary

Primary care is a very important part of a good health care system. In Hong Kong, primary care is mostly in the realm of the private sector, and in recent years has come under the control of large medical insurance firms and Health Maintenance Organisations (HMOs).

The fragmentary and commercial nature of Hong Kong's primary care system has made it vulnerable to problems such as the variability of care, the lack of trained family physicians, and unrealistic insurance plans. Doctor-patient relations can also be difficult, due to the constraints that doctors are placed under by their contracts with HMOs and insurance companies.

This discussion paper raises these and other problems in local primary care, and suggests possible steps that can be made towards an effective solution.

摘要

基層醫療是一個良好醫療服務架構的重要部分。在香港，基層醫療服務主要是私家醫療的範疇。而近年亦受到大型醫療保險公司及醫療集團所控制。

香港基層醫療服務系統的不完整性及商業性皆容易產生問題，例如：服務質素參差，專科家庭醫生缺乏與及不符實際的保險計劃。由於醫生受到醫療集團和保險公司的合約所限制，醫生與病人間的關係亦可能出現困難。

本論文提出上述缺點，及其他醫療服務問題，並建議各項解決此等問題的有效方案。

---

Introduction

In Hong Kong, primary care is mainly catered for by the private sector. It is quite fragmented, unlike secondary care, which is mostly run by the Hospital Authority. Until recently, private primary care generally operated on a fee-for-service system.¹ Due to problems of escalating costs, various major medical insurance companies have started to organise the market by entering into contractual relations with Health Maintenance Organisations (HMOs) and local doctors, thus providing their funding. As a result, we are now getting care that is more 'managed', such that the purchase of health care services is usually based on capitation or other pricing mechanisms.²

Current models of primary health care insurance through HMOs include:^2,3

The staff model-The HMO owns most of the health care facilities, and employs doctors and other health care professionals directly on a fixed salary basis. Payments from users are generally made through a capitation system.
The group model-The HMO contracts with medical groups and hospitals to provide care exclusively for its plan members.
The Independent Practice Association (IPA) model- The HMO contracts with a large number of solo practitioners for the care of its plan members. The doctors provide a discounted service, and are free to take walk-in patients or even to work with other HMOs.
The Preferred Providers Organisation (PPO) model-As with IPAs, the HMO contracts with a panel of health care providers, who offer services following a preset fee schedule. Plan members are also allowed to use providers not on the preferred list, albeit with less generous coverage.
Even with the different care provision and financing models available, the fee-for-service system remains predominant amongst private practice in Hong Kong. Our local system is still a far cry from the highly managed health care systems found in other countries, such as the tax funded National Health Service (NHS) system in the UK, where the funding comes mainly from the government and not from insurance premiums or out-of-pocket payments. Whilst not necessarily advocating such an approach, it is interesting to note that in such models of health care funding, the health service providers know their annual budgets in advance and can adopt a planned approach to primary care service provision and secondary care referral. In Hong Kong, on the other hand, where money comes from patients and insurance clients, income reflects activity; so the insurers have to compete for business. They do so by offering premiums that are attractive to their clients, the employers. These premiums are, unfortunately, far too low to reflect the proper cost of medical services, particularly ones that take preventive medicine into account. This is where the problems start.

Problems with Hong Kong Primary Care

Many local doctors and group practices in the private primary care sector have contracts with insurance companies and HMOs. The practitioners are placed under many restrictions by these profit-making organisations, who attempt to control costs in order to minimise expenditure and achieve the unrealistically low premiums offered to their clients. The consultation fees and the length of each consultation are often, among other things, fixed by the insurers. Doctors thus have a limited capacity to perform to the best of their ability, which may strain doctor-patient relationships in the process.

In Hong Kong, newly qualified doctors can set up private practice even if they are not postgraduate trained. Their lack of experience and training poses a significant problem to quality and efficiency in primary care. By contrast, the greater part of primary care delivery in the UK is provided by postgraduate-trained physicians, working in partnership with teams of other health care professionals.⁴ Lessons may be learnt from their example.

Another key factor that affects health care utilisation in Hong Kong is the 'patient culture'.

Firstly, some patients go 'doctor-shopping' to get the results they want,1 changing from doctor to doctor until they find one who can provide them with the services or cures they need. Apart from showing an apparent lack of confidence and loyalty to any one doctor or practice, these patients also duplicate resource usage, perhaps unnecessarily. From the patients' point of view, however, they are entitled to choose who looks after their health, and they want the best quality of health care for themselves and their families. Today's well-informed patients would think it prudent to seek a second expert opinion when dealing with serious health matters,⁵ particularly when they feel that quality might be compromised by the excessive restrictions imposed on doctors. This scenario can cause tension in the relationships between insurers, doctors, and their patients.

Secondly, there are patients with primary care medical insurance who know exactly what they are entitled to, such as the number of visits or the provision of medication. They are keen to reap all the benefits of their entitlements wherever possible. Hence, their doctors must deal with all kinds of requests, from providing extra medicines, health supplements, and vitamins, to authorising unnecessary medical investigations. To grant such superfluous demands may not be ethical, but refusals may again impair doctor-patient relationships, and also cause the loss of custom if doctors in other practices are willing to concede.

Meanwhile, insurance companies face difficulties in calculating the risks and premiums for their primary care packages, because with clients who have highly acquisitive attitudes, there would be little spread of risk over the population. In controlling costs, the insurers will demand to know why seemingly unwarranted procedures or prescriptions have been carried out. Doctors are therefore under a lot of pressure from both sides.

Problems with Health Insurance in Hong Kong

Local health insurance policies often contain many limitations which some may find unfair. For example, many pre-existing diseases, congenital diseases, functional disorders, mental illnesses, and even cancers are not covered. These are excluded because they are common,serious health problems, and the actual insurance coverage comes down to the calculation of cost and risk. If insurers were to cover these diseases, the premiums would be sky-high, and the resultant products would not be competitive in the market. There need to be clearer guidelines for clients as to their insurance benefits, so that they are aware of the many exceptions and exclusions in their policies.

Another issue is that HMOs often accept unreasonable terms from insurance companies in order to make a profit. The clients of these insurers can thus buy insurance packages at attractive rates that do not reflect the true costs of health care.

Employers must also shoulder part of the blame. Many purchase insurance benefits for their employees, but some do so only for the sake of 'window dressing'. These employers would choose the cheapest packages available, providing only minimal benefits for their employees, who may not necessarily know this. Insurers have a responsibility not to sell such products in the first place. Furthermore, even with decent insurance coverage, generalised packages may not always be suitable for everyone.

Possible solutions

Co-payments are possible answers to some of our health care funding issues. Successful insurance schemes that require patients to pay the doctor generally show much less abuse of the system.¹

Because secondary care in Hong Kong is mainly provided by public hospitals, while frontline primary care services are mostly offered by the private sector, we need to adopt an organisational model whereby the two sectors can complement one another. Our reformed financing system should not specify whether the money contributed has to be used for hospital or for outpatient services. Otherwise, integration would be difficult. We need to pay attention to how the system will allocate its funding as a whole.⁶

There is a lack of transparency in the health care and insurance systems4 because much of the negotiation is based on employer-insurance company discussions. These discussions often centre on financial rather than clinical issues; the doctors are largely excluded. The range of benefits available to employees is variable, and depends on the deal their employers have made with insurers. Hence, one obvious recommendation for improvement would be to increase the openness and transparency. For one thing, it should be made clear how insurers are remunerating their medical professionals. Moreover, the insurance provider should clearly delineate the charges and benefits associated with each policy, so that their clients can understand exactly what their insurance covers. The more data and information is made available, the better the clarity.

Patients naturally get more benefits for higher premiums and fewer for lower ones. However, they should be allowed to pay out-of-pocket if they require any extras. This arrangement would be ideal for local medical professionals, as it dispenses with the 'managed care' components of medical insurance. 'Managed care' has often placed excessive constraints on doctors, which ultimately affect the quality of care.

One of the critical points we should consider is a quality framework in primary care. We need to look closely at the licensing or accreditation of primary care doctors, and promote or make mandatory some form of minimum postgraduate training and qualification for such practitioners. Insurers will gain too, by selling the benefits of the quality framework to the people who buy primary care. Once a quality system has been set up, we can review its outcomes on an ongoing basis.

Quality Framework 1. Set minimum standards 2. Train and accredit primary care physicians 3. Educate and inform the public

The quality framework has to be supported by knowledge. All partners-doctors, their patients, providers, and insurance agencies-ought to know what to expect from primary care, and understand the need for evidence-based quality care; thus, information has to be made available. Furthermore, minimum standards of service should be set within primary care.

The way forward

Primary care in Hong Kong must first become better organised. Currently, primary care practice is not regulated by any administrative system, and its provision is fragmented, unlike our structured secondary care system. Subsequently, the quality of primary care can be somewhat erratic. This needs to be rectified, by setting professional standards and developing a framework to ensure quality of practice. Performance indicators, developed to enable monitoring, should be made accessible to the public. These would help ensure transparency, which is particularly important if funding is to be provided through medical insurance. It should be made clear to everyone where the money is flowing within the health care system. More emphasis should also be placed on holistic care, prevention, and continuity. Finally, we have to increase the communication between all parties-insurers, doctors, and patients-because we are working in partnership, which will succeed only if we can cooperate effectively and make decisions together.

Recommendations for improving Primary Care 1. Get organised 2. Develop a quality framework 3. Make the system transparent 4. Place greater emphasis on holistic care 5. Increase communication between all parties

---

Note: This article is primarily a summary of the discussions at the first Public Forum on Health and Health Care in Hong Kong: An International Perspective on Health Insurance and Primary Care, held on 12 September 2006. The event was jointly organised by the School of Public Health at The Chinese University of Hong Kong, and The Hong Kong Federation of Insurers.

---

---

References