Pricing out Patients: In Hong Kong, fast, effective treatment comes at a cost

Nic Tinworth is a digital design consultant, trail runner and father. In the summer of 2018, the 44-year-old, who lives with his partner and two children in Mid-Levels, was diagnosed with glioblastoma multiforme (a highly aggressive form of brain cancer).

After receiving the shocking news, Tinworth quickly sought treatment. He visited private Hong Kong Adventist Hospital for surgery and public Queen Mary Hospital for therapy, leaning on his health insurance to cover the lion’s share of his HK$1 million-plus medical bills.

“The advantages of going private are immeasurable if you are covered by insurance,” says Tinworth. “It’s so much quicker and easier. Public hospitals are under-resourced and overburdened, but you save a lot of money.”

During his ongoing recovery, Tinworth had to re-learn to walk. After just seven months, he is already back running on Hong Kong’s trails, completing the 12-kilometre QNET Gurkha Trailblazer race in January this year. Tinworth considers himself lucky. For those without a health insurance plan, access to the same treatments so quickly might have been impossible in Hong Kong.

That has been the case for Pong*, an unemployed mother of two who has been fighting stage 4 lung cancer since November 2017. Without an insurance plan, she’s endured serious financial burdens to cover the cost of her treatments. “Neither my husband [who is also a cancer patient] nor I have any income. My children are still studying [so they can’t help],” says Pong.

The family turned to the Community Care Fund, a financial assistance programme that supports those who fall outside the social safety net. In addition, they’ve raised money with help from the Apple Daily Charitable Foundation, the publication’s fundraising platform, which has helped cover some expenses. But it is still not enough.

“The hospital didn’t schedule my first treatment until January [two months after the diagnosis]. By that time, I already couldn’t walk. My condition is very bad,” says Pong. After five months of targeted therapy and chemotherapy, Pong’s condition continues to deteriorate. “The doctors [at Queen Mary Hospital] said there was no medicine suitable for me and told me to go home.”

The Cost of Cancer

According to a 500-person survey released last July by Hong Kong-based’s Charity Foundation, the average cost for cancer treatment at the city’s public hospitals can easily exceed HK$270,000.

That number doesn’t include targeted therapy or immunotherapy, as some of these treatments are not subsidised by the Hospital Authority (HA). As a comparison, private cancer care is estimated to cost HK$1.3 million on average. To put that into perspective, the city’s median wage was just HK$16,800 a month, or roughly HK$200,000 a year, in 2017.

Furthermore, 11 per cent of survey respondents said they would have to sell their apartments to raise funds for their treatments, while 56 per cent said they had heard stories about fellow cancer patients forced to terminate therapies because they could no longer afford them.

Legislative Assembly member Fernando Cheung Chiu-Hung says such situations are common in Hong Kong – and the root of the issue lies with the HA. As the statutory body managing all the government hospitals and institutes in Hong Kong, the HA handles the vast and varied needs of patients while operating on a limited budget granted by the government.

“HA values cost-effectiveness, meaning they need to make sure they can help as many people as possible with a limited budget,” Cheung explains, noting that the HA tends to prioritise younger and more hopeful patients. “[That’s] because when a patient is old, [the HA] thinks the return is insignificant, even when the treatment is hopeful. This is really cruel.”

The government has taken some steps to alleviate the financial burden on low-income households. For instance, the Voluntary Healthcare Insurance Scheme programme, which launched in 2018, enables cancer patients to claim up to HK$80,000 per policy year for non-surgical cancer treatments and an overall limit of $420,000 in claims per year.

Looking ahead, Hong Kong Cancer Registry Director Dr Wong Kam-hung, a clinical oncologist, has projected the number of new diagnosed cancer cases could rise 30 to 40 per cent by 2030 due to the city’s ageing population.

Within the next two decades, one in every four residents will be 65 or older, according to a Hong Kong Polytechnic University study. Since the incidence of cancer is most common in the elderly, this poses a challenge for the already overburdened public healthcare system.

“As Hong Kong people are living longer and getting older, the chances of dependency on medical, welfare and other services will be greater,” said Teresa Tsien, co-director of the school’s Institute of Active Ageing, in an interview with the university in 2018.

Get in line

The public system currently treats about 90 per cent of patients while only employing an estimated 40 per cent of the city’s doctors. There were an estimated 100 practicing clinical oncology specialists working under the HA in the entire city last year. This indicates a doctor-patient ratio of about 1 to 2,172, as Jeffrey Pong Chiu-fai of the Hong Kong Practicing Specialists Association told the Hong Kong Standard in 2018.

Speaking at a meeting of cancer charities, lawmakers and civil servants in October last year, Chief Secretary for Hong Kong Matthew Cheung Kin-chung conceded the issue was an “uphill battle.”

“We are mindful that both the high mortality rate and the number of new cancer cases are on the rise, mainly because of the ageing population and changes in lifestyle,” he said. “The adverse implications of this growing trend on the healthcare system and economic development should not be underrated.”

For patients, it will likely result in even longer wait times. Data published in 2015 by the HA revealed that public hospital patients can wait up to 2.5 years to see a specialist. Back in 2013, colorectal cancer patients faced a 67-day wait on average between their diagnosis and first treatment, according to a study by auditing firm KPMG published in September 2016. For breast cancer patients, the wait was about 50 days. That’s nearly double the wait time in the UK, where cancer patients in the public system waited 31 days on average in 2014-2015, the same study showed.

In cases where a patient is suffering from an aggressive tumour, such as pancreatic cancer, this delay could be a death sentence. In other cases, it could significantly affect the patient’s length of treatment, recovery period and overall life expectancy. As well as contributing to appointment delays, this means cancer patients in public hospitals are likely to receive treatment and consultations with more than one oncologist during their illness, and may not receive particularly personalised service.

To avoid delay, patients with the financial means will turn to private healthcare, where they’ll pay 10 or 20 times more for their treatments. By contrast to the public system, private hospitals generally provide a faster and more efficient treatment schedule with a dedicated physician. They also tend to provide more comfortable facilities, such as private or semi-private rooms with amenities including television and WiFi, and sometimes have more advanced cancer treating equipment.

But despite the higher costs, the expertise of private hospital doctors is no different to those in the public system, according to Dr Stephen Yau, an oncologist at Premier Medical Centre. “There should be the same standards of treatment [from doctors],” he says. Rather, it is the medical service and treatment mode in the private system that might be regarded as “superior” to the public one, according to a 2015 study published in the Journal of the Chinese Medical Association comparing the referential significance of Hong Kong’s healthcare system to that of mainland China.  

A ‘schizophrenic’ pricing system

Ultimately, Hong Kong remains a city of ‘haves and have nots’. Estimated costs of cancer treatment vary significantly depending on whether you go public or private. In the private sector, colorectal cancer patients could spend as much as HK$417,764 on treatments, including a colonoscopy and a colectomy, according to figures compiled by HSBC based on Hong Kong Adventist Hospital fees. The same treatment in a public hospital may only cost the patient about HK$200 depending on the convalescence time.

Meanwhile, lung cancer patients at private Union Hospital may have to spend HK$136,050 for a lobectomy (removing a lobe from one of the lungs) plus HK$14,000 to HK$16,000 per month for targeted therapy drugs. In a public hospital, it would cost about HK$200 for the lobectomy, HK$80 for each round of chemotherapy or radiotherapy, and possible extra costs for certain publicly available targeted therapy drugs.

“It’s a schizophrenic system,” says Dr Raymond Chang, a Hong Kong-born, New York-based cancer specialist and author of Beyond the Magic Bullet: The Anti-Cancer Cocktail. “There is no middle ground … Private hospitals are very expensive – they can be as expensive as in the US. Doctors can charge whatever they like. If I’m a renowned medical practitioner, like some doctors in Central, then I can charge more. But if I’m a doctor in Kwun Tong, then I’ll probably charge a lot less.”

While there is no specific data on how much patients in private hospitals might be ‘overpaying’ for their treatments, Chang says private facilities tend to suggest therapies that are not strictly necessary, adding to their overall cost.

“It’s a common scenario,” he explains. “Patients have the idealistic view that doctors will not be making suggestions based on financial gain; but that is only the case in the public sector. Of course [doctors] will deny it, but Hong Kong society is very commercial.” He says it reminds him of an old joke: If you ask your barber if you need a haircut, of course he’ll say yes.

Private hospital doctors maintain they always work within the best interests of a patient. Dr Yau says “the majority” of private hospital doctors are following the same treatment guidelines as their counterparts in the public system. “I do not think [prescribing unnecessary treatments] is a big issue,” he says. “There should be the same standards of treatment across private and public hospitals. It is whatever is best for the patient.”

In some cases, doctors suggest the most effective treatments but, in the end, the patient might not be able to afford it. “Twenty to 30 years ago, we didn’t discuss costs of treatment; we just prescribed what was appropriate,” Chang says. “Nowadays, we have to consider if the patient will [be able to] pay for it.”   

The drug factor

Aside from surgery, the cost of anti-cancer drugs can be a significant expense for patients in Hong Kong. Due to delays in making new drugs available in the public healthcare system, some patients resort to paying higher fees at more expensive private clinics. Across the city, both doctors and patient advocate groups are pushing for better access to timely, effective and affordable medications.

In fact, it’s one of the government’s most pressing issues. According to a 2016 report by Hong Kong-based insurance company Swiss Re, the HA reviews about 10 to 20 drugs per quarter for all conditions, and approves just 40 per cent on average. It can take between 18 to 24 months for the authority to formally approve a drug, compared to just 60 days in Singapore, according to a 2013 study by the University of Hong Kong.

“It’s all about money,” says Cheung. “As the HA is facing a big collective [the public], the [HA] often opts for cheaper medicine, and avoids using the most advanced and expensive medicines which are more effective and have fewer side effects.”

But when it comes to cancer patients, this practice is problematic. Since cancer medicine typically develops at a faster rate and costs more than other drugs, Cheung says the HA often excludes expensive targeted therapies and immunotherapy from the subsidised system, categorising them as self-paid medicines.

“Our government is always trying to [decrease their] commitment, and let the citizens be responsible for their own needs,” he criticises. “They are like: If you have a problem, please look for a solution in the market, don’t come to me.”

Cheung says that HA doctors may find it challenging to suggest expensive drugs to less affluent patients, even if the drugs could potentially be useful to cure their diseases. “Some doctors told me that they choose not to tell patients about expensive drugs because they don’t think patients can afford it,” he adds.

Alex Lam, the chairman of campaign group Hong Kong Patients’ Voices (HKPV), says those with the financial flexibility will seek drugs within the private healthcare system, which increasingly makes them a ‘luxury’ only afforded by the well-off. “Drugs are accessible only when you have the necessary funds to pay for them,” he says. “Cancer drugs are expensive and new drugs will take a long time to get into Hong Kong.”

Lam suggests that while there are some government subsidies available to patients who cannot afford certain drugs, in general, the current system means that many Hongkongers are priced out of the drugs market if they want to access the latest treatments. “The private hospitals are meant for middle-class and rich people, or those who are covered with medical insurance,” he says.

A big business

Cancer-fighting drugs are big business. Global spending on cancer medicines will exceed US$150 billion by 2020, marking an annual growth rate of 7.5 to 10.5 per cent through 2020, according to a report from healthcare information company IMS Health Holdings.  

There are no estimates for overall annual spending on cancer medicines in Hong Kong, but the 2016 KPMG report found cancer drug expenses per incidence of cancer patient across the public and private sector was US$7,210 (HK$56,569) in 2012. One course of cancer drugs can cost between HK$100,000 and HK$400,000, depending on whether a patient is treated by a public or private doctor, the same report found.

Critics argue that Hong Kong is constricted by outdated laws, dictating that drugs should be pre-approved by both the US Food and Drug Administration (FDA) and the European Union before being approved here. Writing as a supervisor of the 2013 University of Hong Kong study, Professor Thach Thuan-Quoc, suggests that Hong Kong should update its regulations to authorise drugs if they are approved by just one international authority.

Meanwhile, Premier Medical Centre’s Dr Yau suggests there is always “room for speeding up” the approval process, but suggests the delay is sometimes the fault of pharmaceutical companies rather than the Hong Kong government.

“Most of the drugs are being tested outside of Hong Kong, so ultimately the timeline is being dictated by the drugs companies,” he says. By contrast, there is an “extremely light touch” approach in the private healthcare system, where pharmaceutical companies do not always require FDA approval to distribute their products in the city, the 2016 Swiss Re report details.  

The government has pledged to address the problem. In June last year, Secretary for Food and Health Professor Sophia Chan, said the HA promised to “facilitate patients’ early access to drug treatments” by “setting up … risk sharing programmes for specific cancer drugs” with pharmaceutical companies.

But she remained cautious, adding: “More scientific evidence is required to confirm the clinical efficacy and cost-effectiveness of most newly developed drugs for cancer treatment and the actual benefits to patients.” It’s unlikely that Hongkongers will see a significant change, at least in the short-term.

Rising cancer costs

New York’s Chang believes that as more people seek cancer treatments in Hong Kong, the costs of drugs and treatment in public hospitals will increase as the government attempts to foot the bill.

Simultaneously, he says, growing numbers of public hospital doctors will be lured by private hospitals, where they can work in relatively comfortable conditions. “This is the issue for the government to solve,” says Chang. One way of doing so, he says, would be to increase the official investment in cancer care at the city’s public hospitals.

Currently, the government subsidises about 90 per cent of healthcare treatment costs, accounting for 17.5 per cent of its annual budget. Total healthcare expenditure reached HK$71.2 billion for the 2018-19
budget. Meanwhile the government announced an overall surplus of HK$138 billion in 2018. The government set about 40 per cent of that surplus aside for relief measures and invested a further 40 per cent to promote innovation and technological development.  

In 2017, Cheung proposed that the government establish “a life-saving drug fund” without financial thresholds that would allocate HK$20 billion to cover up to 10 years of medication for patients suffering from cancer and rare diseases. “Once you set up a separate budget for cancer and rare diseases, then it doesn’t have to compete with other needs,” he says.

Lam of HKPV echoes Chang’s concerns. “We are seeing an increasing number of patients with little increase in public hospitals’ resources,” he says. “There is an imbalance of quantity and quality, and [Hong Kong] cannot achieve both.”

Hongkongers are feeling the pinch. The latest statistics from the Hong Kong Federation of Insurers, released in 2017, showed that the number of those with private or group medical insurance policies rose to 4.4 million in 2016, compared with 4.1 million the previous year.

If their financial situation allows, many residents opt to pay more for their insurance premiums to be able to access private wards, rather than public centres. Premium health insurance, however, remains accessible only to the wealthy; Pacific Prime estimates the average annual cost of international health insurance in Hong Kong was roughly HK$98,00 (US$12,585) on average per year.  

For Lam, the future looks bleak for the average Hong Kong patient unless the government invests more in its public healthcare system: “The rise in cancer could mean escalation of healthcare costs and thus insurance premiums.”

Which bring us back to two very different cancer experiences in Hong Kong. Over the coming months, Tinworth faces more chemotherapy, after which he will have MRI scans to ensure he is cancer-free. But he anticipates there could be further hurdles along the road to recovery. “Cancer is not something which completely disappears,” he says. “It is something you have to embrace as the new normal.”

Pong, whose condition continues to escalate, says she has lost hope in the medical system – and any hope of recovery. “Due to the poor time management by the hospital, my treatments have been delayed,” she says. “I thought about seeing a private doctor, but it is so expensive. I have not made any appointments.”

*Name has been changed to protect identity.