Comments on Bloomberg Most Efficient Health Care Ranking 2014

I refer to the 18 Sept 2014 Bloomberg News “Singapore beats Hong Kong in Health Efficiency: Southeast Asia” and the 19 Sept 2014 Straits Times report “S’pore’s health-care system tops efficiency ranking”.

Bloomberg’s data differs from source

Some of Bloomberg’s data for its Most Efficient Health Care Ranking 2014 differ from those of its sources WHO and World Bank.

Country Name 2012 WHO health cost / GDP (%) 2012 World Bank Health cost / GDP (%) 2012 Bloomberg health cost / GDP (%) Difference (%)
Argentina 8.5 8.5 6.8 1.7
Slovak Republic 7.8 7.8 6.2 1.6
Turkey 6.3 6.3 7.8 1.5
Iran, Islamic Rep. 6.7 6.7 7.5 0.8
United States 17.9 17.9 17.2 0.7
Korea, Rep. 7.5 7.5 7.0 0.5
Israel 7.5 7.5 7.0 0.5
Libya 3.9 3.9 4.3 0.4
United Arab Emirates 2.8 2.8 3.2 0.4
Ecuador 6.4 6.4 6.7 0.3
Germany 11.3 11.3 11.0 0.3
Spain 9.6 9.6 9.9 0.3
Peru 5.1 5.1 5.3 0.2
Greece 9.3 9.3 9.1 0.2
Italy 9.2 9.2 9.0 0.2
Singapore 4.7 4.7 4.5 0.2
Mexico 6.2 6.1 6.3 0.2
Finland 9.2 9.1 9.3 0.2

Countries that beat Singapore excluded

Bloomberg gave 90% weightage to life expectancy and health spending per GDP in its health efficiency rankings. Monaco’s life expectancy of 89.7 years is much higher than Singapore’s 82.1 while Monaco’s health spending per GDP of 4.4% is also lower than Singapore’s 4.7%. It’s clear that Monaco beat Singapore based on Bloomberg’s health efficiency definition but because Bloomberg restricted comparison to countries with more than 5 million population, Monaco was excluded and Singapore ended up tops. If Bloomberg had carried out its ranking just 5 years ago in 2009, Singapore would have been excluded too for our population then was less than 5 million.

Different calculation methods yield different results

Bloomberg’s description of its methodology is brief. Only the weightage of each category is given but not the precise calculation method. Without the calculation method, its methodology cannot be independently verified for correctness and appropriateness. Given minute differences in overall scores, a different calculation method in one, two categories could easily have turned Bloomberg’s table topsy turvy.

For example, the methodology below yields a completely different result from Bloomberg’s even though the weightages are the same:

• Life expectancy score = life expectancy (%)
• Health care cost as percentage GDP score = 100 – health care cost as % GDP (%)
• Health care cost per capita score = 1 – (health care cost per capita – lowest health care cost per capita) / (highest health care cost per capita – lowest health care cost per capita) * 100 (%)
• Overall score = (60% * Life expectancy score) + (30% * Health care cost as % GDP score) + (10% * Health care cost per capita score)

Country Alternative ranking Alternative scoring Bloomberg ranking Bloomberg’s scoring
Hong Kong 1 87% 2 77.5
Singapore 2 85% 1 78.6
Korea, Rep. 3 85% 5 67.4
Chile 4 85% 17 55.5
Israel 5 85% 7 65.4
United Arab Emirates 6 84% 9 64.1
Mexico 7 84% 12 59.1
Italy 8 84% 3 76.3
Saudi Arabia 9 84% 16 57.8
Greece 10 84% 24 49.9
Ecuador 11 84% 13 58.4
Spain 12 84% 14 58.1
Portugal 13 84% 28 47.2

There are probably a hundred different methods that can be used to come up with a hundred different rankings to suit whatever agenda one may have.

Bloomberg ignored old age dependency ratio

Bloomberg also failed to take into consideration differences in old age dependency ratios across nations. It is well known that the bulk of healthcare costs are incurred by old people so all else being the same; a more aged country will have higher health care costs compared to a less aged country. Singapore’s health expenditure is low primarily because our old age dependency ratio of 13.8% is low compared to many First World nations with old age dependency ratios in the 20+%, 30+% ranges.

A regression of health spending per GDP against old age dependency yields a P-value of 7.4 × 10-13 which translates to a 99.99999999993% confidence in the relationship between old age dependency and health care spending per GDP that must be accounted for.

The following is the regression plot for Bloomberg’s set of countries only. As can be seen, apart from the US, there are no significant outlier points which means that most nations’ healthcare costs aren’t so out of the ordinary after adjusting for old age dependency.

regression

Life expectancy not solely affected by health care

Bloomberg should have accounted for the fact that life expectancy is not solely a function of health care standards; it is also a function of natural disasters of which there are but few in Singapore. Japan for instance, experiences many natural disasters that Singapore doesn’t face.

• The Guardian, Japan quake death toll passes 18,000, 21 Mar 2011

• Straits Times, Japan’s snowstorm leaves 19 dead, causes transport chaos, 17 Feb 2014

• Straits Times, Heatstroke kills three in Japan, 24 Jul 2014

• Yahoo News, Japan volcano death toll hits 47 as new bodies found, 1 Oct 2014

• Reuters, Typhoon Vongfong leaves two dead, nearly 100 injured in Japan, 14 Oct 2014

For the same life expectancy, a nation that experiences more natural disasters ought to be considered having a higher standard of health care.

Under provision of health care

Singapore’s low health care costs may not necessarily reflect prudence but under provision of health care instead. For example, there was a surge in old folks visiting doctors and dentists after the implementation of a nationwide medical discount for them this year.

MANY seniors who have not seen a dentist in a long time are getting their teeth checked and fixed, now that they have the Pioneer Generation (PG) card which gives them a subsidy of up to $266.50. Dr Amy Khor, Senior Minister of State for Health and Manpower, said last night that 24,000 people have used their cards for dental care since the subsidies kicked in last month. Dentist Anthony Tay, who has a clinic in Geylang, has seen close to 30 patients with PG cards. “Two in three have not seen a dentist in many years,” he said, adding that they had problems ranging from gum disease to cavities and missing teeth. Dr Khor added that 85,000 people have used the PG card to see a general practitioner …

[Straits Times, 24,000 visit the dentist, armed with Pioneer card, 31 October 2014]

ABOUT 50,000 members of the pioneer generation visited general practitioner (GP) clinics in the first three weeks of last month, after special subsidies kicked in. The number of polyclinic visits also increased by 8 per cent in that time, said Health Minister Gan Kim Yong yesterday.

[Straits Times, 50,000 pioneers saw GPs after special subsidies took effect, 1 Oct 2014]

Older generation Singaporeans even resort to committing suicide so as not to incur hefty medical bills [http://www.theonlinecitizen.com/2013/11/unwilling-to-burden-family-95-year-old-samsui-woman-commits-suicide].

Bloomberg News, Singapore Beats Hong Kong in Health Efficiency: Southeast Asia, 18 Sept 2014

Singapore overtook Hong Kong to top a ranking of the most-efficient health-care systems, as the government boosts spending on medical services to support an aging population.
The Southeast Asian nation was rated first among 51 countries, according to an annual ranking compiled by Bloomberg that tracks factors including life expectancy, the cost of health care as a percentage of gross domestic product and total medical expenditure for each person. Hong Kong dropped to second place and Italy was ranked third, while the U.S. was 44th and Russia last.
Singapore has increased health-care spending in recent years as the workforce ages and the government faces political pressure to ease the burden of the country’s poor. The city-state subsidizes some medical expenses and patients are required to take on more of the costs if they choose premium services, with citizens using mandatory savings set aside for health-care needs.
“I describe Singapore’s system as the least imperfect in the world,” said Jeremy Lim, head of Oliver Wyman & Co.’s Asia-Pacific health and life sciences practice. “If Singapore can successfully balance the increased funding availability with prudent measures to curb inappropriate and over-consumption which society as a whole accepts and supports, the future would be very promising.”
Health-Care Spending
Prime Minister Lee Hsien Loong’s administration will spend close to S$4 billion ($3.2 billion) over the next five years to help Singaporeans benefit from a new universal health insurance plan calledMediShield Life to be implemented at the end of next year, according to the Ministry of Health. It has also set aside S$9 billion for health care and other benefits for the elderly as part of a Pioneer Generation Package.
Bloomberg’s ranking of the most-efficient health-care systems is based on countries with a population of at least 5 million, GDP per capita exceeding $5,000 and a minimum 70-year life expectancy. This year’s ranking took into account year-on-year changes to the criteria used.
Hong Kong’s health-care cost per capita increased 38 percent from a year earlier to $1,944, while Singapore’s rose 13 percent to $2,426, according to the ranking. Singapore’s life expectancy gained 0.4 years in the same period to 82.1 years, compared with Hong Kong’s 0.06 years rise to 83.5 years.
“The higher health expenditure is a result of the increase in both government spending as well as expenses of the private sector,” a representative for Hong Kong’s Secretary for Food and Health Ko Wing-man wrote in an e-mail. Singapore’s Ministry of Health declined to comment on the ranking.
Targeted Spending
Singapore’s consumer prices rose 1.2 percent in July from a year earlier, the slowest pace since March, while Hong Kong’s inflation quickened to 4 percent from 3.6 percent in June.
Hong Kong has higher utilization rates and public medical expenditure, while Singapore’s health-care spending is more targeted, said Phua Kai Hong, an associate professor of health policy and management at the Lee Kuan Yew School of Public Policy in Singapore, citing preliminary findings from his comparative studies.
A photograph of patients housed in a tent outside Singapore’s Changi General Hospital in the Straits Times newspaper in January prompted concern that the nation’s hospitals may not be able to accommodate the aging population.
The number of elderly in Singapore, or those older than 65 years, will triple to 900,000 by 2030, according to the National Population and Talent Division. Based on the current birth rate and without opening its workforce to more foreigners, the median age in the city-state will rise to 47 years by 2030 from 39 in 2011, it said.
Chronic Illnesses
The average length of stay in hospitals for patients aged 65 years and above rose to 8.2 days in 2013 from 7.8 days in 2010, according to the Ministry of Health. About 1,200 beds will be added to the health-care sector this year, with 10,000 more by the end of 2020, according to the ministry.
In addition to eight public hospitals, private options on the island include IHH Healthcare Bhd.’s Mount Elizabeth and Raffles Medical Group Ltd.’s center.
“As the population of older people with chronic illnesses and disabilities and home requirements increases,” beds would get filled with more people who have difficulty getting out of the hospital, said David Matchar, director of health services and systems research at Duke-NUS Graduate Medical School in Singapore. “It only means that the bed crunch would get worse.”
Singapore topped a separate 2012 Bloomberg Ranking of the world’s healthiest countries, compared with Hong Kong at 17th and the U.S. at 33rd out of 145 countries. Singapore’s Health Promotion Board hosts free exercise programs in the central business district and schools run a program to help overweight and underweight children achieve an ideal weight.
“In terms of Singapore being very high in terms of rankings, I think largely it is attributable to preventative care,” said Tilak Abeysinghe, an associate professor of economics at National University of Singapore. “The government takes a very, very active role of telling people to live healthily.”
To contact the reporter on this story: Sharon Chen in Singapore at schen462@bloomberg.net
To contact the editors responsible for this story: Lars Klemming at lklemming@bloomberg.netLinus Chua, Rina Chandran

Straits Times, S’pore’s health-care system tops efficiency ranking, 19 Sept 2014

SINGAPORE overtook Hong Kong to top a ranking of the most efficient health-care systems, as the Government boosts spending on medical services to support an ageing population.

The South-east Asian nation was rated first among 51 economies, according to an annual ranking compiled by Bloomberg that tracks factors including life expectancy, the cost of health care as a percentage of gross domestic product and total medical expenditure for each person.

Hong Kong dropped to second place and Italy was ranked third, while the US was 44th and Russia last.

“I describe Singapore’s system as the least imperfect in the world,” said Dr Jeremy Lim, head of Oliver Wyman’s Asia-Pacific health and life sciences practice.

“If Singapore can successfully balance the increased funding availability with prudent measures to curb inappropriate and over-consumption which society as a whole accepts and supports, the future would be very promising.”

Singapore will spend close to $4 billion over the next five years to help Singaporeans benefit from MediShield Life, a new universal health insurance plan, to be implemented at the end of next year.

It has also set aside $9 billion as part of a Pioneer Generation Package.

Bloomberg’s ranking of the most efficient health-care systems took into account year-onyear changes to the criteria used.

Hong Kong’s health-care cost per capita increased 38 per cent from a year earlier to US$1,944, (S$2,455) while Singapore’s rose 13 per cent to US$2,426, according to the ranking published yesterday.

Singapore’s life expectancy gained 0.4 years in the same period to 82.1 years, compared with Hong Kong’s 0.06 years rise to 83.5 years.

Singapore’s consumer prices rose 1.2 per cent in July from a year earlier, while Hong Kong’s inflation quickened to 4 per cent from 3.6 per cent in June.

Hong Kong has higher utilisation rates and public medical expenditure, while Singapore’s health-care spending is more targeted, said Dr Phua Kai Hong, an associate professor of health policy and management at the Lee Kuan Yew School of Public Policy in Singapore.

The average length of stay in hospitals in Singapore for patients aged 65 years and above rose to 8.2 days last year from 7.8 days in 2010. More beds are being added, but as the population ages, the bed crunch may get worse, said Professor David Matchar, director of health services and systems research at Duke-NUS Graduate Medical School in Singapore.

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