Singapore has the most effective and efficient healthcare system in the world. It is quite a story. In 1965, Singapore was an illiterate and impoverished nation. They study best practice in all they do and have become one of the best educated and most prosperous countries in the world. The United States spends almost 20% of gross domestic production on health care. Singapore spends just under 5%, and they live longer.
Oddly enough, the Singapore story begins in United States in a most unlikely place. The best example of super capable primary care in America is the SouthCentral Foundation in Alaska. It is owned by Native Alaskans. The board members are Native Alaskans. The CEO is a Native Alaskan. The system is of, for, and by the people who use it, and it serves them incredibly well. It is the one system in the country that is truly patient-centered. Quality scores are in the 75th to 90th percentile. Medical costs are half of those charged by other providers in Alaska. Keep in mind that Native Alaskans are like other Native Americans. They are disadvantaged and they have a high burden of chronic illnesses. They should cost more.
This link goes to a podcast by Doug Eby, the Chief Medical Office at the SouthCentral Foundation who tells their story in his own words. Dr. Eby has played a large role in the improvements in this institution. The whole podcast is great but if your time is limited, here is a guide. The first two minutes are in Swedish so skip that. You can move around in the content. The section at 55 to 53 minutes left in the podcast describes the Singapore visit to the SouthCentral Foundation and how they used what they learned. The section from one hour and four minutes to 55 minutes describes their super capable primary care system. They spend about twice as other practices as much on super capable primary care and that results in a total cost reduction of 50%. Primary care usually consumes about 5% of healthcare revenue but directs 80% of the care. At SouthCentral it consumes twice as much but dramatically reduces total cost.
Singapore took the SouthCentral model and improved it. They applied it to the sickest 5% of the patients who generate half of the cost of care. By doing that, they cut the cost of care in half again. These patients have multiple chronic conditions. A typical patient might have diabetes, high blood pressure, high cholesterol, a heart attack, and congestive heart failure. Singapore has a system of super capable one-stop polyclinics scattered around their country. Within those polyclinics, are HDL teams of pharmacists that address patients with hypertension, diabetes, and lipid (cholesterol) problems. These teams can address all the complex but related problems in the patient that I described.
The Singapore-SouthCentral healthcare system could be even better. A marriage of the health system in Singapore and optimal medical therapy (OMT) would be a match made in heaven—super capable primary primary care and precision medicine aimed at the whole person! Our current system is a throwback to previous scientific understandings. It is arranged around organ systems, specialists, and risk factors like high blood pressure, diabetes. Now we have advanced our understanding so that super capable primary can precisely block oxidant production from genes that are inappropriately switched on to make us age faster and develop chronic diseases. Lisinopril, losartan, spironolactone, and eplerenone for hypertension, atorvastatin for high cholesterol, and metformin for diabetes all interfere with oxidant production to slow aging and delay chronic disease development. These medicines all activate the master metabolic switch AMPK directly or indirectly to slow aging and delay chronic disease onset.
Empagliflozin does the same thing. Here’s what the heart failure expert Milton Packer has to say about that drug: “it is now critical for physicians to reconceptualize SGLT2 inhibitors as organ-protective agents rather than glucose-lowering drugs.” That idea is important. It explains why empagliflozin cuts heart failure admissions by a third, whether the patient is diabetic or not. Reducing the sugar level is important, but interfering with the biology that damages cells and organs is more important. Lowering the risk factor is important. The way you lower the risk factor is equally important. Interfering with the biology that makes you age and get sick faster produces much better clinical and financial outcomes than the current system. We know what works. Let’s do it!
Love the summary; would be amazing to overlay this kind of system across the current one and begin moving care into it. Not as elegant as building from the ground up, but much faster than trying to simultaneously retrain the entire system.