Surgeries Commonly Carried Out in Hong Kong May Be Medically Unnecessary

Categories:Health Insurance, Healthcare, Hong Kong, News |Published on May 20, 2013

Hong Kong and its expatriate culture knows all about unnecessary spending. You only need to ask an expat family to compare their life here to the one they left behind at home, and they will no doubt reveal that they are leading a very different lifestyle now.

But surely this wanton disregard for money hasn’t spilled over into the healthcare sector of Hong Kong? If your doctor recommends you need a certain surgery, you are generally not going to argue with them – they are the ones that went to medical school after all. They are also supposed to be someone who you trust with your life and your health, especially if they are going to be performing surgery on you. So what happens if they may not be giving you completely honest advice?

The Hong Kong private medical scene is not as transparent as one would hope, and evaluative reports or figures from previous costs and surgeries are often very hard to come by. Normally, a patient may want to assess their doctor/hospital and their need for a surgery by analysing all the available information so they can make an informed and confident decision. However, with no such data currently available, patients do not have a benchmark to base their decisions on, and it would appear that many HK expatriates are resorting to other means to inform themselves or evaluate their doctor’s diagnosis.
Online social forums, such as Asia Expat, are a hot bed for discussion, and many peer-rated reviews on hospitals and doctors can be found on these sites. It is understandable then, that with no real data to go on, decisions may be formed purely based on how highly a doctor is recommended. As a result, patients may be subjecting themselves to unnecessary surgery mainly because of word of mouth, leading them to put all their trust in a highly recommended doctor and their professional opinion.

If this can happen in a place like Hong Kong, then other countries elsewhere in Asia (where similarly priced private healthcare sectors exist) could also fall victim to the same issue.
But what does all this mean for Hong Kong’s local and expatriate residents? This tendency to over-prescribe and regularly perform unnecessary surgeries among HK doctors could spell trouble for both you and your insurance provider.

Private medical procedures in Hong Kong do not come cheap and its private healthcare sector actually ranks as the second most expensive in the world so if insurance providers are having to cover claims increasing in frequency and in cost, general premium rates are likely to follow suit and increase as well. This is all the more concerning if you discover you may not have actually needed your surgery in the first place, and have just unnecessarily made your body, and your insurance premium, suffer as a result.

Hong Kong Health Insurance (HKHI) chose to investigate this issue further and the data acquired on behalf of HKHI suggests that; the most common surgeries and treatments which are being performed in Hong Kong are not always medically justifiable, and private doctors could actually be recommending and performing these unnecessary procedures purely to generate a higher income.

 

Caesarean births are a very controversial topic in Hong Kong and the number carried out here per year is steadily increasing. However, the driving factor behind the higher demand for this particular delivery method may be less about a patient’s personal preference and more about the fattening of your doctor’s wallet.

Yes, it can be said that the local Hong Kong culture is all for C-section births, with a firm belief in astrological and auspicious dates playing an important role for elective C-sections. However, these cultural beliefs do not transfer over into the expatriate population and yet 50% of the C-section births that occurred in the private sector (public hospitals do not allow medically unjustifiable C-sections) are believed to have been performed unnecessarily.

Caesarian section rates may actually be a reliable indicator of whether a health system suffers from over-operating. Typically, it is good practice for a country’s Caesarian section birth rate to total a conservative figure that reflects the percentage of medically justifiable Caesarian section births. However, Hong Kong’s Caesarian section rate is twice that of the UK’s, Australia’s and the US. So, based on this, if one uses Caesarian section rates as an indication of whether a health system is over-operating, would it be far-fetched to extrapolate higher surgical rates in other areas of medicine as well?

This over-prescription of caesarean births is all the more baffling when the risks of a birth by C-section are compared to those that may occur during a natural vaginal delivery. Infections, excessive blood loss, anaesthesia complications, blood clots and possible injury to surrounding organs all pose very real threats, not to mention the dangers that face the unborn baby.
Then of course, you have the fact that you will need to spend more time (and money) in hospital, you’ll have a longer recovery period and may need more post-natal check ups than you would need for a natural delivery.
Furthermore, how a first delivery occurs basically dictates the risks for all subsequent births and so women with a history of a caesarean birth are more prone to risks if their second birth is a natural delivery. In other words, for a young woman’s first birth, natural delivery should always be encouraged unless a C-section can be medically justified.

However, rates for hospitalisation and obstetric care typically fall between USD $15,000-20,000 for a normal vaginal delivery (for a standard shared room) but can cost an extra USD $5000-10,000 for a basic (without complication) C-section procedure. Take this, and the fact that doctors can actually book C-section births – meaning more flexibility, more procedures and ultimately more money, and you may have an idea as to why a doctor may encourage a woman to have a C-section, rather than talk her out of it.

Meniscal tear surgeries are another interesting one to consider. On the one hand, you may wonder how the repair of cartilage in your knee could be deemed unnecessary, but on the other, the basic cost of a meniscal tear surgery in a private hospital can total USD $7000 (for 2 days in a standard room) so there is a lot of money to be made here.

The medical justification of meniscal tear surgeries is very dependent on the personal circumstances of the patient in question and an individual’s need for surgical repair can differ depending on the location and type of tear present.
For example, as meniscal tissue is non-regenerative, it has very few mechanisms for repairing itself and meniscal tears are therefore generally more likely to occur as we age. A degenerative tear can simply be the result of the wear and tear inflicted over the years and typically, these types of tears may not require surgery as an individual can still maintain an active and healthy lifestyle for the majority of the time (symptoms may worsen in certain conditions such as the cooler months of the year).
Acute tears and flap tears on the other hand, tend to be more symptomatic and can be very painful so a surgery would often be required in this case to relieve the individual of painful symptoms and try and save as much of the meniscus as possible.

Obviously each patient leads a different lifestyle and a perfectly functioning knee may be more necessary to some than to others (depending on a patients state of health, age etc). For less symptomatic tears, there are alternatives to surgery and a comprehensive physical therapy plan can help to strengthen the surrounding muscles in the knee, allowing a patient to avoid surgery whilst maintaining a reasonably active lifestyle.

A meniscal tear surgery does not guarantee a full recovery and there is a chance that the knee will not return to its original functioning state. Yet doctors may not be as keen to suggest physiotherapy, particularly to a patient on an expatriate package, as they would be to suggest surgery, and up to 70% of the meniscal tear surgeries performed in Hong Kong might have actually been carried out unnecessarily.

A knee arthroscopy is the typical procedure for carrying out a meniscal tear surgery but it can also be performed for diagnostic purposes.
However, while it may be a common, low risk surgery, there are still small risks present and other, less invasive ways available to observe the knee. But if you consider the fact that a typical MRI scan at a private hospital will cost around USD $700 whereas a knee arthroscopy will set you back USD $3500, that could explain why up to 80% of knee arthroscopies may have been performed unnecessarily in Hong Kong.

A cholecystectomy refers to the surgical removal of the gall bladder via an open surgery or a more common (and less painful) laparoscopy, and in Hong Kong at least 30% of gall bladder removals were believed to be unnecessary. While this may not be a particularly shocking figure in itself, if you consider that the risks with this kind of surgery involve possible blood clots, infection, damage to surrounding organs, pancreatitis and bile leakage, you might wonder why a doctor may choose to suggest this surgery if there is no urgent need for it.

The most common cause behind cholecystectomies is gall stones, however, many experts disagree as to whether a cholecystectomy actually needs to take place if gallstones are present but symptoms are non-existent.

If symptoms do become apparent, typical advice from a medical expert may be to wait and see if symptoms go away on their own (known as watchful waiting). This is especially recommended if a patient is experiencing gall stones for the first time, if the pain is mild and if they are not at risk of future complications or planning on having children. However, considering it is a relatively straight-forward procedure and the cost of a basic cholecystectomy with one day in a standard room can cost a minimum of USD $700 (not including doctors fees), its easy money for your surgeon, and an unnecessary cholecystectomy for you.

Unnecessary treatments are worrisome enough when they only affect you for the short term, but imagine if you found out you underwent a life changing operation when you could have survived without it.

Hysterectomies are typically the suggested treatment when a female patient is suffering from uterine fibroids, endometriosis, heavy menstrual bleeding, chronic pelvic pain and cancer (of the cervix, uterus or ovaries) and typically involve the surgical removal of the uterus and in some cases, the ovaries.

Uterine fibroids are noncancerous growths that develop in or around the uterus and are usually the most common reason for a hysterectomy. However, many women rarely experience symptoms and if they do, they can be mild and manageable without such drastic action.

Of course, symptoms vary depending on how many fibroids are present, their location and their size, but a hysterectomy should still be considered as a last resort, or if a woman does not plan on having children and has considered all her options first.
In fact, non-symptom causing fibroids typically do not become cancerous and unless they are causing pain or heavy bleeding, procedures to remove them would not normally be contemplated “just in case”. However, it is believed that up to 50% of the hysterectomies carried out in Hong Kong could have been medically unnecessary, leaving women with an irreversible and permanent alteration to their body.

Fibroid growth is stimulated by oestrogen, a hormone which naturally dwindles as a woman approaches menopause, by which time a fibroid could naturally shrink by itself without the assistance of a surgeon’s knife. Consequently, other procedures are becoming more popular alternatives to a full removal of the uterus. However, with a bare minimum cost of USD $900 (1 day in a private hospital standard shared room, doctors fees not included), it would appear HK surgeons are tempted to opt for more drastic methods rather than partake in watchful waiting.

Staying on the subject of women’s health, ovarian cystectomies are another controversial topic amongst healthcare professionals.

Like fibroids, ovarian cysts are often affected by a woman’s hormone levels and are actually a very common occurrence among women, particularly those in their child bearing years.

In fact, during a woman’s menstrual cycle, when an egg is released from a fluid filled follicle in the ovaries, it is very common for this a follicle to take on more fluid and grow into what is termed a ‘functional cyst’. These are typically around 3 centimetres big, they rarely become larger than 6 centimetres and while they may cause some mild discomfort during menstruation, surgery is not normally the optimal solution. In fact, 90% of simple cysts occur in this form and will simply go away on their own after about 5 weeks.

Of course, there are cysts that are not functional and can continue to grow in size but 98% of these cysts in young women are normally benign and pose no cancerous threats. In younger women in particular, cysts are highly dependent on a woman’s hormonal balance, so simple changes such as taking birth control pills, or adjusting diet and lifestyle, can dramatically affect a patients prognosis. This is especially the case if a patient is only suffering from mild symptoms and a watchful eye is kept on the cyst to monitor growth.

Considering that surgery can bring about significant risks and offers no guarantee that cysts will not return, it is somewhat surprising that surgeries appear to be so frequently resorted to for ovarian cysts in Hong Kong. Although, when the total cost for an ovarian cystectomy and a night in a standard (shared) room can reach USD $1800, maybe it’s not so surprising that up to 60% of these procedures may have been performed without solid medical justification.

Unnecessary surgeries seem to occur in other areas too, but when it comes to surgery on your spine, you would definitely want your doctor to consider all other options first. In Hong Kong however, this may not always be the case and as many as 70% of spine-related surgeries carried out here could have been performed unnecessarily.
With a condition such as spinal stenosis, depending on the severity of a patient’s case, it is quite likely that only mild or moderate symptoms will be present, so it is often manageable for a patient to wait and try other non-surgical treatments first. Most medical experts will in fact recommend other options above surgery and even then, surgery should be as non-invasive as possible.
Obviously, when operating on something as delicate as the spine, open surgery makes the procedure a high risk one and therefore more expensive (around USD $8300 including doctors fees and standard accommodation). Unfortunately, some doctors may suggest an open surgery for this very reason and seeking a second or third opinion is highly recommended for sufferers of spinal conditions, especially when you consider some of the potential risks involved (infection, blood clots, nerve and tissue damage, to name a few).

So, where insurance is concerned, what could all this mean for you as a policyholder and a possible ‘unnecessary’ patient?
Firstly, if you have purchased a local Hong Kong insurance plan, your procedure in a private healthcare facility will most likely be covered. However, as many plans include sub-limits on benefits such as surgical or anaesthetist’s fees, unnecessary procedures may eat into these benefits and could leave you paying out of pocket for unplanned or emergency medical treatment. What’s more, given that local Hong Kong health insurance plans are typically experience rated; unnecessary surgeries are likely to greatly affect your premiums when it comes to renewing your plan.

International health plans play more of an important role in Hong Kong as typically, most expatriates will be part of an international plan when receiving coverage in Hong Kong. Where premiums are concerned, unnecessary treatments have more of an indirect impact on international health insurance.

Since international plan premiums are community rated, the effects of unnecessary treatments are not immediately seen in premium rises at renewal.
However, if doctors are insisting on carrying out medically unnecessary surgeries left right and centre, more claims (which tend to be quite expensive for surgeries) will be paid out and premiums will see a steady increase overall. Furthermore, as many of the surgeries mentioned tend to be performed on younger patients, especially procedures such as cystectomies, C-sections and knee operations, it could mean that even if you fall under a younger ‘low risk’ age group; your premiums could rise dramatically in the near future if this trend continues.

As previously mentioned, private healthcare in Hong Kong is the second most expensive in the world after the United States of America, and the overuse of medically unnecessary surgeries will not help resolve this issue.

Another unhelpful factor which appears to be adding fuel to the fire, is that of the transparency (or rather lack of it) problem. Hong Kong’s private healthcare sector could definitely benefit from being at least a bit more open with their evaluative data. If an online system were to be made available whereby patients could have an insight into a surgeon’s previous rates in order to, for example, compare how often they performed C-sections over normal deliveries, doctors could gain more trust and loyalty from their patients and still not miss out on making money. And loyalty is the key to maintaining a reputation in the expat community where, as previously noted, word of mouth is so very much relied on and if a doctor comes highly recommended, they will be highly sought after.

If this trend continues however, insurance plans and premiums will undoubtedly suffer the biggest impact and so the important thing to take away from this is that second opinions matter. At the end of the day, it is your body that is going under the knife so don’t hesitate to find out just how necessary your surgery might be – you (and your insurance policy) won’t regret it.