Specialized Care for Knee Pain: Understanding Singapore’s Healthcare Landscape

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The healthcare system in Singapore is comprehensive and offers patients with knee pain a wide range of healthcare providers from general practitioners and physiotherapists, to orthopaedic surgeons and rheumatologists. This book has specially tailored individual chapters on these healthcare providers to specifically deliver the role and how each of these providers can help patients with knee pain. In addition, there are simple yet comprehensive illustrated recommendations guiding readers when to consult what healthcare provider.

The team has designed the content of this book to help persons with knee pain easily understand the healthcare system in Singapore. Unlike western countries, healthcare in Singapore is not heavily subsidized and there are many levels of healthcare provided by the government and private sector. Patients in Singapore are also not restricted to seek healthcare at any of these levels, making the healthcare system more complex due to the multiple pathways to seek treatment.

This book is developed by a multidisciplinary team of clinician researchers based in Singapore. The team has nested this book under the Bone and Joint Decade 2000-2010 Task Force for People with Arthritis and Other Chronic Musculoskeletal Conditions. The aim of the book is to assist persons with knee pain due to arthritis or injury to understand more about how they can help themselves and to guide those with severe knee pain towards consulting a health professional within the healthcare system in Singapore.

Specialized Knee Pain Treatment in Singapore

Ranking among the best knee specialists in Singapore, Dr. Kevin Lee is one of the few who has completed formal fellowship training in sports surgery and arthroplasty, accredited by the Singapore Ministry of Health. As a knee surgeon, he has a keen interest in treating sports-related injuries and degenerative knee problems, particularly osteoarthritis. He is well-versed with the latest and most minimally invasive arthroscopic techniques. Mileage may vary, and choosing the best possible surgeon can be hard to predict. Invasive surgery should always be considered a last-ditch option and is highly dependent on patient preference. No particular specialty of physician can guarantee success with any one form of treatment for knee osteoarthritis.

Use an informative tone in your response. There are various types of physicians with different specialties. Understanding this may help a patient seek the appropriate physician that specializes in treating a specific condition. Osteoarthritis often requires a family physician or internist for treatment of general health conditions that may have precipitated the onset of arthritis. Often, referral to an orthopedic surgeon may be the best option. Severe cases of osteoarthritis may be best addressed by a rheumatologist. Physicians specializing in Physical and Rehabilitation Medicine or Physiatrists are trained to improve quality of life and functional ability.

Importance of Seeking a Knee Pain Specialist

Seeing a knee pain specialist, such as an orthopedic or a sports physician, is clearly important when seeking expert advice. But first, you have to know a knee pain specialist’s nature of work before deciding to find one. An orthopedic is a qualified surgeon and has a massive amount of knowledge in bone and joint problems. They are often the ones that people turn to when they have major knee problems and when other treatments have failed. A sports physician is also a knee pain specialist with vast knowledge of the musculoskeletal system but has chosen not to practice surgery. They are often well-versed in sports injuries and are the best people to look for treatment if you have a mild knee problem and intend to go back to sporting activities. Remember to inquire about their experience regarding your condition before choosing to get treatment from either of them.

Seeing a knee specialist will also avoid unnecessary surgery, as a specialist will explore all options available before considering surgery. This will keep costs down, as MRIs and surgery can be expensive.

Seeing a knee pain specialist will immediately address the issue with their vast amount of knowledge and experience in the area. They will be able to provide you with the correct diagnosis and solution to handle your problem. A knee pain specialist is also more likely to spend more time with you compared to a general practitioner, in order to fully understand your condition and provide you with the best possible solution. This also creates a good patient-doctor relationship as you will feel cared for.

Letting a general practitioner handle your knee pain might not be the ideal thing to do when you’re fully earnest on getting rid of your pain. A general practitioner only knows the basics about knee pain and the treatments to solve them. Trying to get advice from them will only result in them referring you to a specialist. This then becomes a delay in your treatment process. In Singapore, where the healthcare cost is a real issue, a delay in treatment might result in a hike in the treatment cost as getting rid of long-term pain might be much more complicated and expensive.

Availability of Knee Pain Specialists in Singapore

Singapore has approximately 875 doctors who are practicing specialist orthopedic surgery or are treating musculoskeletal conditions. Out of these, there are around 130 who are in the public sector. This gives a ratio of about 1 orthopedic for every 20,000 people, which is actually higher than many other developed countries. This is perhaps an oversaturation of specialists but the average waiting time to see an orthopedic in the public sector is 3-4 weeks. It is important to note the broad range in level of qualification and expertise of these specialists. They generally fall under two categories. The first category are orthopedics who have done additional fellowship training in knee surgery. It is estimated that there are 15-20 such knee surgeon specialists in knee pain Singapore. The second and larger category are general orthopedics who do treat knee conditions and perform surgery. However, they may not be well versed in the latest evidence-based treatment methods and thus tend to offer traditional options such as long-term medication, arthroscopy, or even open surgery. It is thus important for the patient to find out the credentials and experience of the specialist when seeking treatment for their knee condition.

Range of Treatment Options for Knee Pain

Nonetheless, there will be scenarios in which surgical intervention is the best form of treatment for knee pain. Surgery covers a vast array of techniques and is constantly developing. Essentially, surgical procedures can be divided between joint-preserving surgery (arthroplasty and cartilage transplants) and joint-replacing surgery (partial or total knee replacements). The decision upon which form of surgery to take is incredibly important and is usually highly dependent on the type and severity of the arthritic condition and the needs and expectations of the patient. Ideally, surgery will directly alleviate pain, improve/decelerate the progression of knee damage, and improve knee function to meet the needs and expectations of the patient.

Medical practice has increasingly moved away from using non-surgical approaches as the forefront of treatment. Non-invasive methods and preventative measures often avoid the problem rather than tackling it head-on. Measures such as a change in footwear, weight loss, supportive knee braces, viscosupplementation injections, or physical therapy/exercises are all forms of conservative management aimed at relieving excess pressure from the knee or intermittently relieving symptoms. Evidence exists to prove that some of these methods are incredibly effective when employed correctly for the correct patient. Footwear modification and insoles/orthoses were found to significantly reduce knee load in the medial compartment of the knee in a study by Cheung et al. Assessment with a simple knee sleeve was found to improve symptoms of knee osteoarthritis by Katsuragi et al. High tibial osteotomies and joint realignment procedures, although technically a form of surgery, are aimed at shifting weight-bearing load away from the damaged part of the knee to healthier sections. This can be seen as a middle ground between conservative management and definitive surgery.

Singapore’s Healthcare System for Knee Pain

When seeking specialized care for knee pain, the ability to access affordable and effective healthcare is of utmost importance. In Singapore, knee pain patients have a defined path when seeking medical attention through both the government and private systems of healthcare. The government sector is best accessed by a visit to a polyclinic, where patients with knee pain will initially be treated by a general practitioner. Polyclinic charges are highly subsidized for Singaporeans who possess a Community Health Assist Card (CHAS), and all patients will be able to gain access to the acute services offered at government restructured hospitals with further subsidies. For knee pain that is accompanied by significant restriction to mobility or is no longer manageable with medication, patients can be referred by a polyclinic doctor to a specialist outpatient clinic at a restructured hospital. Any diagnosis made at a government specialist outpatient clinic can later be used by patients if they wish to make a claim from their Medisave account or private integrated shield plan, should they opt to receive treatment in the private sector. Those who wish to directly access services in the private sector can choose to visit a private general practitioner, or self-refer to a private orthopaedic specialist. Like their public counterparts, private orthopaedic services are claimable through Medisave, however there is currently no option to use Medishield or Medifund at private sector clinics. Co-payments for private sector services are at the discretion of the individual healthcare provider.

Overview of Singapore’s Healthcare Landscape

One of the most important aspects of the healthcare system in Singapore is the financing. Although the mix of public versus private funding in the system has always been a debate, the establishment of financing schemes such as Medisave, Medishield, and more recently, Eldershield, is a reflection of the government’s objective to shift away from total reliance on public funds for healthcare. These financing schemes are crucial to Singaporeans, especially when they become old, as the financial burden of healthcare can be high. With the use of Medisave to pay for hospitalization and treatment expenses, this would ease the burden of cash payment or seeking in cash from various sources for medical expenses. The recent introduction of Medishield, an affordable health insurance to cover large hospitalization bills, has gained popularity with the current uptake of more than 50% of Singaporeans, with more enrolling into the scheme. All these are done with the objective for Singaporeans to take responsibility for their own healthcare costs and to put the people at ease with cash paying for medical treatment. With these financing schemes, there would also be less strain on the reliance of public funds, and more focus can be made for its use on the lower-income and the elderly group.

Singapore is reputed for having one of the best healthcare systems in the world, with standards of care and treatment that are benchmarked on an international level. The country’s healthcare system is characterized by a public-private mix, balancing the roles of the public and private sectors in providing subsidized basic care and highly specialized care in a competitive market. This has resulted in Singaporeans having an affordable means of seeking primary healthcare services, with ready access to the range of specialized services provided by the private sector. Accessibility to healthcare services is facilitated by the network of medical facilities and services in different parts of Singapore. With a high physician-to-population ratio, Singaporeans are able to get quality medical care with ready access.

Accessing Specialized Care for Knee Pain

An alternative to seeking care at a public or private clinic is to be evaluated at a subspecialty orthopaedic clinic, such as a sports medicine clinic. These clinics are often associated with a hospital and are usually staffed by orthopaedic specialists who have undergone further training in a subspecialty field, such as sports medicine or joint replacement. At a subspecialty clinic, patients can be evaluated by a specialist with expertise in the area pertaining to their knee condition. An example would be a patient with an anterior cruciate ligament (ACL) tear, who could seek care at a sports medicine clinic, where he may be evaluated by a physician who has extensive experience treating ACL injuries. Prices for care at a subspecialty clinic are comparable to what one would pay for care at a private orthopaedic clinic.

First, patients can be evaluated at the outpatient clinic of a public hospital. Fees are relatively inexpensive. However, waits are often long, and patients may feel rushed during the consultation. A second option is to be evaluated at a private orthopaedic clinic. Wait times are usually brief, and the doctor is able to spend more time with the patient. Costs vary, and some of the cost can be defrayed by using medisave funds. However, the out of pocket cost for seeing a specialist at a private clinic can be high.

This section describes how to access specialized care for knee pain. Patients with chronic knee pain often need the care of a specialist. In some countries, one must obtain a referral from a general practitioner to be evaluated by a specialist. However, in Singapore, patients are free to schedule an appointment with an orthopaedic specialist without a referral. There are 3 main options for accessing care with an orthopaedic specialist.

Cost and Insurance Coverage for Knee Pain Treatment

For public hospital treatment, fees are classified into subsidised and non-subsidised rates. The distinction between the two used to be clear, but with the recent introduction of class ‘c’ wards in the public sector, things have become a little confusing. Basically, patients in class ‘a’ and ‘b’ wards receive treatment at non-subsidised rates, while ‘c’ class patients receive varying degrees of subsidies. It should be noted that all joint replacements (the most severe form of knee pain treatment) for patients under 65 years of age in public hospitals are done at non-subsidised rates. This information is important because it determines the financial commitment of the patient to public hospital treatment, and it would be wise to consult the hospital on the exact subsidisation of treatment for specific knee ailments.

This brings up the important issue of insurance coverage. Insurance companies in Singapore that provide coverage for knee-related problems usually only cover the surgical treatment of a meniscus or ligament tear. Treatment for severe osteoarthritis, a common knee-related ailment in older adults, is generally not covered.

Paying for healthcare in Singapore is no simple matter, and knee pain sufferers have reason to consider their funding source with the recent changes in the healthcare system. In Singapore, citizens and permanent residents have the all-important option of receiving treatment in restructured or private hospitals. The cost difference is quite substantial, as the bill for the same surgery given in a restructured hospital can be up to 50% cheaper in a private hospital. Patients with chronic or severe knee trouble may be tempted to go under the knife straight away, but it is wise to take the time to consider and try all other forms of non-surgical treatment before making a decision.

Rehabilitation and Support Services for Knee Pain Patients

Inpatient and outpatient care by allied health professionals, including physical and occupational therapists, play an integral role in the management of patients undergoing arthroplasty. Patients in acute medical or surgical wards with unreplaced joints may also need the advice of physical and occupational therapists after discharge from hospital. Unfortunately, the provision of such services has been largely unsystematic. noted that while arthroplasty patients were often referred for physical therapy, those with other knee diagnoses may receive little rehabilitation or be referred to treatment inappropriate for their needs. For example, patients with knee OA are often managed with medication and advice to reduce weight and avoid strain; they are unlikely to be referred for physical and occupational therapy unless these measures fail. A survey of current practice at the SGH physiotherapy department has shown that the proportion of patients with knee OA referred to physiotherapy varies widely with no clear criteria. This is consistent with the current suboptimal provision of allied health services to the knee OA population. The variable referral practice and limited specialist medical input on the role of therapy have led to inappropriate or inadequate therapy for many patients. Simulation of the effects of evidence-based care recommendations has shown substantial potential improvement in disability-adjusted life years for knee OA patients. This is an area in which there is much room for improvement with a strong possibility of cost-effective healthcare gains. However, increased provision of high-quality therapy services is likely to be dependent on generating greater patient demand through improved awareness of the benefits of therapy. The traditional model of one-to-one therapy in a hospital clinic environment is not the only means by which patients can access the services of allied health professionals. With the current widespread availability and use of the internet and mobile technology, there may be potential for the delivery of therapy in a home-based or self-directed manner, with remote monitoring and occasional face-to-face input. This may be particularly suited to patients with chronic knee conditions and those with a disability in whom attending frequent therapy sessions presents a significant mobility challenge. This subject area also holds potential for research and innovation with the involvement of medical informatics and technology developers.

Overall, the government’s initiatives in ensuring affordability of medical care and improving healthcare services have made knee replacement a more viable option for patients suffering from end-stage knee arthritis, looking to improve their quality of life.

With the still rising proportion of aged patients who suffer from knee degeneration, as well as the foreseeable increase in the number of patients suffering from end-stage knee arthritis in the future, we anticipate that the demand for total knee replacement in Singapore will increase in tandem. Step-down community hospitals, which provide convalescent and rehabilitation services for the elderly sick, will also have their level of subsidy increased to 80%, with the intent to help more patients regain mobility and maximum independence. This also has a positive impact on patients who undergo knee replacement, who will require the rehabilitation services.

To recap, the Ministry of Health’s announcement in early May 2005, declaring its plan to increase the level of subsidy for patients who have undergone knee replacement surgery in public hospitals, was positive news for those afflicted with severe knee problems. In doing so, it closed the monetary gap between the cost of knee replacement surgery in private hospitals and public hospitals, which was one of the critical issues. Patients can now opt for subsidized knee replacement surgery in public hospitals, which would cost in the range of $3000 to $8000. This has a direct impact on the patients in Singapore, who can now seek to have their conditions treated with total knee replacement and be eligible for a highly subsidized fee, unlike incurring the full cost.