Under Secretary for Health Dr Libby Lee Ha-yun is on the show this week. She talks about the logic behind the Hospital Authority's fees and charges reform, and gives us the perspective on where we are compared to other economies in the region. She also stresses the importance of strengthening primary care for Hong Kong people to prevent overburdening the secondary and tertiary healthcare services.
Check out the full transcript of TVB’s Straight Talk host Dr Eugene Chan’s interview with Dr Libby Lee:
Chan: Good evening! I'm Eugene Chan, and we are on Straight Talk, speaking with Dr Libby Lee, under secretary for health. Prior to her current appointment in July 2022, Dr Lee was the commissioner for Primary Healthcare, and she has been with the Hospital Authority since 2008 in other leadership roles, including director of Strategy and Planning, cluster chief executive and head of Patient Safety and Risk Management. As a specialist anesthetist, Dr Lee has served on various professional bodies, including the Hong Kong College of Community Medicine and the Hong Kong College of Anaesthetists. This evening, we will be talking about “Securing the Well-being of Hong Kong People”. Welcome, Libby!
Lee: Thank you. Thank you for inviting me here.
Chan: Dr Lee, we know that Hong Kong is renowned for its high-quality healthcare system. How will you describe the overall state of the Hong Kong public healthcare system as of today?
Lee: As a Hong Kong citizen, I'm very proud of our Hong Kong healthcare system in two ways. One is: actually, we are running a very efficient system in Hong Kong, like we're talking about ... we are the second or the first in, according to Bloomberg, the efficiency in the healthcare system in Asia. At the same time, we have a very good reputation among overseas ... basically because of our services and research as well as our education. So, we are proud of our healthcare system. And Hong Kong is actually running a model that is actually being envied by in many countries, because we have a very strong presence of the public healthcare system, or public hospital systems in the society so people can seek services either in the public systems or in the private sector. So, I would say we are doing pretty good in terms of healthcare services.
Chan: Dr Lee, as you said, as Hong Kong residents, we always pride on a high-quality and, most importantly, accessible sort of public healthcare system. But what do you see as our, sort of, major challenges right now?
Lee: There are plenty. First of all, some external factors, like aging population, we all talk about. In 2030, basically, one quarter of people will be more than 65 years old. And another one is actually the advancement of technology and medical services, it will add burden to our financial cost for the healthcare service provision. The third one is about the manpower resources, but this is a global issue. You know, in every kind of healthcare systems, doctors and nurses are really crucial … as the providers, but they're really running short of it, partly because of the low birth rate and partly because of the escalating healthcare services demand.
Chan: Right, Libby. We know that the Hospital Authority actually runs 43 public hospitals, and maybe you can give a sense of the scale of the services that the HA is providing, such as the number of hospital beds or even number of staff. How big is your, sort of, workforce in the Hospital Authority?
Lee: Okay. Hospital Authority is running around 90 percent of the total inpatient services Hong Kong and running about 30 percent of the general outpatient clinic and but we only have half of the doctors in the healthcare system, like 7,000, and we are also around 20-something, so 20-something thousands of nurses in the Hospital Authority. But each year, basically, we are running like two millions of A&E (Accident and Emergency) attendances. We are having around 26,000 beds, inpatient beds in the systems, and operating 24 hours per day.
Chan: Wow! I mean, we understand you just said earlier that 90 percent of the inpatient care is handled by the public sector. Say about 40 percent to 50 percent of doctors are within the public system. So, what kind of pressure will this, I mean it's an obvious imbalance, create?
Lee: Two things. One is the push factors. You know, you know this. This is the heavy workload in the inpatient service in the hospital will actually add additional burdens to the workloads, burdens to the healthcare providers, and pushing them might be the thing of, oh, life is so busy. Maybe we can actually go to private and also it's also creating challenges to the service seekers. You know the service users, the waiting time may be prolonged because of the heavy workload compared to the limited amount of manpower. And so, this is not an ideal situation to provide accessible and sustainable services.
Chan: Right, Libby. Since you mentioned all that … we are very lucky, we are blessed with one of the world's longest life expectancies. But as you just said, in a few more years’ time, one in four Hong Kong's adults will be over age 65. How would this sort of, will it put more pressure onto the system?
Lee: With people ... with more, you know, people more than 65 years old, we have looked into statistics internally aging people, elderly persons using the healthcare services much more than people less than 65 years old. This is actually quite obvious, right? And so the strategies of our bureau of the government is to actually maintain good health of our people. If you are healthy today, stay healthy and prevent having any diseases. If you have diseases, treat it as early as possible to minimize the effect of complications. And if you unfortunately have long term diseases or complication would want to make it sustainable for you. So, this is our strategies.
Chan: Maybe that's why we are also pushing our primary health care as well. So, let's look at sort of a recent reform that has been brought up by your bureau on the fees and charges reform. Before we go into any sort of details, look at the big picture, it says it sort of aligned the principle of targeted subsidies. And I'm sure a lot of people may not have realized 97.6 percent of the charges that's actually incurred in the hospital is being subsidized by the government, sometimes even 100 percent. Simple question is, can we afford it?
Lee: The short answer is, probably we are not going to afford it in the future. If we are doing things like this continuously, what would suffer is our next generation, maybe our children, or maybe when the young people getting old, they will suffer because this healthcare system is not sustainable. And then, basically, I would say, if we do not do something right now, the health of our people will be getting worse, and the system probably will collapse as well.
Chan: Libby, I'm sure you understand other healthcare systems as well. How fortunate are Hong Kong people, I mean, getting 97.6 percent even close to 100 percent except some medical devices or sort of those you have to pay for yourself? Would you say we are one of the very fortunate populations?
Lee: I say so, I think so. And that's why I say, as a Hong Kong person, I'm very proud of our healthcare system. Think about countries nearby, the maximum subsidization, they basically in their own country, the most underprivileged group, the government only subsidized at 80 percent. But here, we actually, for the most underprivileged group, we subsidize 100 percent and for normal people in other countries probably subsidized around 20 percent but in average, we are running, currently running 98 percent. So, mind you, we basically, we have a very low taxation system, actually, in Hong Kong. So, how to maintain a low tax and also a high-quality healthcare system? We need to think about it.
Chan: Libby, I mean, I was going to ask you about this reform. I mean, I've read under different principles you're trying to achieve, saying that, strengthen the healthcare protection, rationalize the public service subsidies, one very important thing catching my eyes, reduce wastage and misuse and also enhance sustainability. Can you explain to the viewers along those lines ... what are you trying to do?
Lee: Alright.
Chan: And why do we have to increase charges? I'm sure people will know that we have been subsidizing too much, but it looks like the underlying principles have gone much, much deeper than that.
Lee: Thank you, Eugene. Fees and charges is just a tool for us to make our healthcare system sustainable. In terms of sustainability, we also want the right people being treated in right place with right care. So, that's why we try to use different kind of tools to do that. Before fees and charges review, basically, we promote primary healthcare. We set up the primary healthcare commission. It’s one of our strategies to actually do the healthcare reform. The healthcare … the fees and charges restructuring, we want to focus or subsidize more on those who are really in need of it. For example, those who are underprivileged. Those who are very acute cases, in critical and serious condition. And about misuse, you know, wastage, that kind of stuff, I want to clarify one thing: resources allocation to healthcare system is not only about funding. It's also about manpower, and also for physical facilities, such as the hospitals, the beds, etc. If we focus on much one area, for example, we have a lot of A&E attendances, all the resources, including manpower, the beds, the places will all go to A&E. And resources, allocation is always, always a zero-sum game. That means we put people in A&E, there will be less people in other specialty. For example, people, unavoidably, will suffer from long waiting time from other specialties, like cataract, total joint replacement. So, we want to make it a balance and ask our people to help us to make it a balance so that we can provide timely services to our people.
Chan: Right. Thank you for explaining it. So, I think is … so this fees and charging reform is a lot more than just increases the actual fees. But actually, I've sort of look at the reform proposal, looks at over 1,000 charges have been reviewed. And for example, visiting the A&E department, as you mentioned, has doubled from HK$180 to HK$400. The specialist outpatient from, actually tripled from HK$80, which is very low, to HK$250 and the hospital inpatient charges will go up 2.5 times to HK$300 a day, compared to HK$120. While we understand that all this is needed to be done, we also have to face with increased energy charges, increased public transportation. I mean, our public housing estate is going up as sort of increase in rental, and with this sort of downturn in the economy is going to be pretty tough. Do you have any sort of fees waiving system in this?
Lee: Oh, yes, yes, yes. As I said, fees, charges and restructuring. We want to focus on the underprivileged, serious, critical and acute cases. So, at the same time, we will introduce a waiver system and also a capping system. The waiver system is, we assess, you know, the patient's monthly income as well as their asset, and we have a scales, and then we can basically have a total waving or partial waving at the same time, if a patient, unfortunately using a system, and then they have to pay more than HK$10,000, there will be a cap of that, of course, the patients need to apply for this waving system, and also the capping and the other things is quite different from other fees and charges, just adding the fees and charges, we try to restructure it in order to add, just adding the fees, we’re also doing itemized charge. That means when you need more, you need to pay more. But so that when unnecessary needs, you probably need to pay and people would tend not to pay for it and they will reduce the unnecessary needs. So, this is kind of concept at a behind, so to make well use of the limited resources.
Chan: Right Libby, let's take a short break now, but viewers, stay with us. We will be right back.
Chan: Welcome back. Dr Libby Lee, undersecretary for health, is with us discussing how the government is securing the wellbeing of Hong Kong residents with reforms to our public health system. Libby, you had very clearly explained to us the rationale behind. It is not just increasing the charges, but we are trying to reform the whole system, so that everything can be sustainable. But just looking at one of the reports from South China Morning Post, they said that, although you mentioned there will be a cap on the money spending on like HK$10,000, they use an example of somebody with chronic illness. Say, they might see a specialist every month – that is HK$250 per visit, that is already HK$3,000 a year, and occasionally go to A&E if they feel uncomfortable, have to stay in the hospital, and all the diagnostics. So, it is easily reaching that HK$10,000. So, if a person making like HK$30,000 to HK$40,000 a month by himself or with the family, that is, I am sure, above the ones that have all the subsidies, that is really stretching it, especially living in Hong Kong with a rental flat. And even worse so if he is a primary sort of income owner. So, how can you help this sort of missing out all the waiver systems’ patients? How shall they sort of face this increasing charges?
Lee: I would guess there are 3 points that are helping them. First of all, the waiver system. Under the current waiver system, we are having right now, we will try to extend all the criteria, so that the safety net will be much bigger to cover people, because people, if they really want to have a waiving system, they could apply and look at our income and also the asset management. The asset amount is actually much, much exceeding than the current one. And also we have changed the definition of family. Anyone who is single and more than 18 years old, basically we count it as one family, one person family. So, they can actually apply for the waiver individually without actually sticking to the family. And this is one point. The other point is actually about the capping. If a chronic disease patient basically comes in to use the services, and the fees and charges are more than HK$10,000, they are very welcome to apply for the capping. And so beyond the HK$10,000, they will not need to pay. Thirdly, it is also about waiver system. Our waiver system is not only looking at the financial terms, but also non-financial terms. If a patient really has needs and also because of the complexity of the disease, they can always access to our medical social worker to assess for non-financial terms waiver system. So, I hope that this group of people, basically our target group, we really want to help them.
Chan: Right. I mean, the Hospital Authority, Dr Ko, has said this public co-payment ratio will remain affordable even after the reform, not only looking after the underprivileged, but also the middle-income people. So, can we still maintain the concept that I always have, that in Hong Kong, nobody will be denied any medical care due to financial means. Is that underlying principle still applied after all this?
Lee: Of course, definitely. Talk about it, we look into our data, we look at our patients attending our general outpatient clinic. Normally, say average, they take 4 drugs a month. Even with the new system with itemized charge, drugs HK$5 per 4 weeks in general outpatient. That means that person will pay HK$20 a month.
Chan: Did you say HK$20?
Lee: Yep, yep, yep.
Chan: That is pretty low for 4 drugs.
Lee: Yes, think about this is less than HK$1 per day. So, this is the concept about what we want people to invest in their own health. Instead of spending that one dollar in anything else, maybe we can stop and think about it, could we actually invest it into our health? So, this is again a kind of reform that we want to do, that is changing this health-seeking behavior.
Chan: Libby, I have also looked up some of our government’s spending expenditures. It says that in public healthcare, it definitely has increased over, actually quite significantly, over the last decade, from HK$70 billion in 2015-2016, to now projecting to current financial year HK$141 billion, which is equivalent to 90 percent of the government recurring expenditure, only second to social welfare. But at the same time, our government reserves has depleted, I use the word depleted, from one-third … from HK$1.1 trillion before the pandemic to about HK$674 billion right now. So, is this initiative trying to attempt to cover some of that financial deficit? Or has this reform, it has just been overdue for too long because a lot of people say, even just now when we are in the make-up room, they say it is very cheap in Hong Kong for medical care, which… under what direction are we doing right now?
Lee: I would say it is definitely not for covering the deficit because the government committed whatever we actually earn from these fees and charges review, we put it back into the healthcare system, so to help more people, like people having self-finance drug etc. So, it is definitely not covering the deficit. Why we are doing this is just because earlier we say we are facing a lot of challenges in the healthcare system. If we do not try to intervene right now, basically in our next generation or like in 5 to 10 years ahead, basically our people will not be having a sustainable or affordable healthcare system anymore. So, that is why we think this is timely to do it. And again, the fees and charges review, we did it actually every 2 years, and so this is just a timely … a good time, an appropriate time to look at it, and we will review that in 2 years’ time again.
Chan: Right. Libby, now that you just mentioned the word “sustainable”, I think sustainability, I am sure that is a word that everybody sort of treasure, that what Hong Kong has ... So, with this sort of upcoming reform and all that, it is kind of affecting everybody in a way because everybody is eligible to go to a public system, how are you going to build support from the community? How are you going to engage the people? Because sometimes, especially the younger generation, they may not be as well informed. And having said that, we need them to support the system by looking after their own health. How would you sort of engage to the community in a more, even more efficient manner?
Lee: A very good question. I always think that healthcare systems or hospitals should not be situated top on a hill. They should be part of the community, and community are always our partners. So, there are different forefronts for doing this. First of all, we will try to basically work closer to the primary healthcare system because the primary healthcare system is a very good community network. If we can actually have a good relationship with primary healthcare, you know, the patient journey from the primary healthcare to secondary to tertiary will be much smoother. So, this is one point. The other point is actually … we try to engage a lot of community partners, including patient groups and also different NGOs, volunteer groups, to understand a bit more of our healthcare systems and policies, and try to work together for some specific targeted group. I think continuous engagement with our community partners is very essential, especially when we talk about a waiver system. It is a really complicated one, it is difficult to just explain one time. Probably we need to have an ongoing dialogue on that.
Chan: Libby, just now we mentioned about other neighboring cities or countries that are subsidizing 80 percent. Will other countries face similar problems like us?
Lee: I think we are facing the same problems. So, you will see that different countries also have initiatives promoting primary healthcare, preventive medicines like anti-smoking exercise, that kind of stuff, anti-alcoholic, that kind of stuff. We are all facing the same thing. What is actually fortunate for Hong Kong people is that we already have quite a robust mechanism over here. If we try hard together, I mean the healthcare system providers, as well as the users, and also the healthy people, if we work together, I think that is a bright future for all of us.
Chan: Right. Let me … as we mentioned earlier in our interview that we are now subsidizing like 97.6 percent to even up to 100 percent in terms of subsidies, and our plan now is trying to bring it down to like 94 percent, and hopefully in 5 years, down to 90 percent, because these fees and charges will be reviewed every 2 years, as I read. So, this is just the beginning. Can we still afford at 90 percent subsidies to the system? It is still very high compared to the 80 percent that you mentioned?
Lee: We always think Hong Kong people are clever and smart. Yes, you look at neighboring countries, it is actually, subsidization, the maximum would be 80 percent, most of them is around 20 percent to 50 percent. But we are still running a 90 percent subsidization with low taxation. At the same time, we try very hard to improve our efficiencies on top of our already very efficient service. We hope that we can actually, from that, we can grip a bit more, but apart from just changing the fees and charges.
Chan: Right.
Lee: And also introducing primary healthcare, working with the community, preventing preventable disease are very important. Hopefully in the future, we can decrease the healthcare burden by that.
Chan: Looking ahead, what gives you confidence that we can build a stronger and fairer healthcare system for all of us?
Lee: I think one factor is actually, you know, the human heart to our minds, both from the providers and also our patients, and also the citizens. We had SARS, we had COVID, we all understand health is an essential element, but just how to make this understanding, this belief, into exercise. So, I think we can work together to make it a healthy Hong Kong.
Chan: Thank you, Dr Lee, for sharing with us all the changes ahead, that with our population ageing and healthcare needs growing, these reforms are about future proofing the wellbeing of Hong Kong people, not just for today, but for the next generations.
Until next time, I am Eugene Chan, and thank you for watching Straight Talk.
