Ongoing Efforts to Ensure Patients’ Interest in Healthcare

NOTICE PAPER NO. 436
NOTICE OF ADJOURNMENT MOTION
FOR THE SITTING OF PARLIAMENT ON 10 MAY 2021

Answer

“Ongoing Efforts to Ensure Patients’ Interest in Healthcare”

1       Mr Speaker, ensuring patients’ interests has been and will always be a priority of the Ministry of Health (MOH).  We have put in place many measures over the years and will continue to work on ensuring that all patients have access to good quality and affordable healthcare. We have enhanced the safety net through universal coverage for life, of all Singaporeans and Permanent Residents with no disease exclusions under MediShield Life. Expanded CHAS also allows subsidies for outpatient care and CareShield Life further supports long-term care for those with severe disability especially in old age. The Government spending on healthcare has in fact tripled within a decade, from $3.7 billion in FY2010 to $11.3 billion in FY2019. To ensure healthcare remains affordable and cost-effective is an area that requires collective effort by patients, providers and insurers alike, and the ministry works collectively with all stakeholders to achieve this. 

(A) Bill size publication and Fee Benchmarks 

2       Mr Gerald Giam asked why it took MOH more than 10 years to replace the Guideline on Fees (GOF) with the Fee Benchmarks.  To increase the transparency of healthcare charges, MOH had already started publishing ‘Total Hospital Bill’ sizes for both public and private healthcare institutions in year 2003, five years before the GOF was withdrawn in 2007 due to anti-competition concerns. Such transparency encourages providers to charge more competitively and enables consumers to make better informed choices about their provider.  

32       The ‘Total Hospital Bill’ size publication started in 2003 with 28 conditions for the public sector and 5 day surgery conditions for the private sector, using actual transacted charges.  It was then progressively expanded to include more conditions and information. For instance, the ‘Total Operation Fees’ for common surgeries was published in the year 2014 for the public sector and in 2016 for the private sector. A further breakdown of ‘Facility Fees’, ‘Surgeon Fees’, and ‘Anaesthetist Fees’ for the private sector was also made available to facilitate the comparison of private professional fees. Today, the actual bill size publication for close to 300 procedures and medical conditions is available on MOH’s website.  

4       While publications on bill sizes provided a form of benchmarks on charges, we decided to further reduce the information asymmetry between healthcare providers and consumers.  Therefore in 2017, MOH appointed an independent, multi-stakeholder committee to develop and recommend Fee Benchmarks for the private sector. It is not, as if, when we withdrew the GOF there was a huge vacuum. There was actually a process that preceded that, but it was enhanced and strengthened even after the GOF was removed, and culminated in the fee benchmarks being promulgated. The Fee Benchmarks serve as references for (i) the public to assess whether the fees charged by a healthcare professional are reasonable; (ii) for medical providers and professionals to set appropriate charges; and (iii) for insurers to take an active approach in their claims assessment and panel design. 

5       As a start, MOH published Surgeon Fee Benchmarks for about 200 common surgical procedures in 2018. Although Fee Benchmarks have been published for only 8% of the 2,300 procedures listed in the Table of Surgical Procedures (TOSP), these 200 procedures were selected as they accounted for more than 85% of the cases involving procedures and 75% of professional fees for procedures in the private sector. The TOSP lists all procedures from Table 1 to Table 7 based on the level of complexity. For example, a Table 1 procedure will be something simpler, like taking out a small lump on your arm, and a Table 7 procedure would be where there is the highest level of complexity and surgical risk, involving multi-organ resection, for example. So even without direct information on the less commonly performed procedures and less available datasets, doctors will generally be able to benchmark the fees based on the equivalent level of complexity for procedures codes within the same Table level. This approach we have taken allows us to set the Fee Benchmarks for the most common procedures to achieve the intended outcome without the unnecessary administrative burden and costs of curating limited data for less commonly performed procedures. This is also a point that Mr Giam has acknowledged, and I would like to say that our approach is far more efficient in achieving the same outcome that we want without imposing unnecessary burden on the clinicians who are busy doing their work. In fact, when the dataset is scarce, what you have is a lot of outliers in the extreme ends, which makes the range more spread, and the outliers may sometimes predominate and make the benchmarks actually inaccurate. Indeed, our early data showed that doctors have been taking reference from this benchmarks, with more than 80% of fees in 2019 within the upper limit of the benchmarks.  This was also 4% higher than in 2018.  In 2020, MOH further introduced new benchmarks for anaesthetist and inpatient attendance fees, and will continue to review and develop new areas of fee benchmarking with the Fee Benchmarks Advisory Committee. 

(B)  Ongoing measures to address over-servicing and over-charging

6       Mr Gerald Giam suggested that doctors and hospitals should be required to provide detailed itemisation of charges on their bills, to address over-servicing and over-charging. This is in fact already required under the existing Private Hospitals and Medical Clinics Act (PHMCA) for hospital bills, and will be further enhanced under the new Healthcare Services Act (HCSA) to cover all licensable healthcare services. MOH will prescribe the minimum level of granularity that must be reflected in patients’ bills, which include categories such as consultation, medication, and investigations. Just as importantly, licensees are required to display common charges prominently at their premises or on their websites, and provide financial counselling for services which tend to generate significant bills prior to service provision, to ensure greater price transparency upfront and to help patients make much more informed choices. 

7       On the issues surrounding Integrated Shield Plans (IP), MOH has already implemented several measures and are continuing to explore and work on much more, which I have taken quite a bit of time earlier today in my to elaborate my response to PQs. The work by the Multilateral Health Insurance Committee is already ongoing on the areas that Mr Giam has raised, amongst others. So I shall not elaborate further and the member can refer to my earlier PQ reply. But I would just want to highlight a couple of points which he has brought up. 

8       One is on expanding the panel to more doctors, or in fact, all doctors, and I have explained in my PQ reply that pre-authorisation is the way to go to provide access to care by all doctors. In fact, panel sizes have increased by 40% in the last six months to a year. Up to 70% of private specialists are already on at least one panel.

9       On taking a hands-on approach to regulating Integrated Shield Plans, MOH already exercises close oversight of IP plans, due to their direct association with MediShield Life and also as MediSave can be used for IP premium payments. Any changes to IP premiums or terms and conditions requires approval from MOH. In approving any changes, MOH considers the interests of the policyholders, as well as the need for healthcare costs and premiums to be sustainable. 

10       As I had outlined in my earlier reply, riders are fully private insurance products going being MediShield Life, and IP plans, and MOH will typically not intervene in this space. Such riders are regulated by MAS, who exercises regulatory oversight on the financial viability of insurance products. 

(D)  Conclusion

11       Mr Speaker, we thank the member for his suggestions and would like to assure him that the issues brought up are already being looked into. MOH will continue to work closely and facilitate close collaboration between stakeholders to ensure that measures and solutions are put in place to uphold patients’ interests in healthcare. The WP Member’s Adjournment Motion on ensuring patients’ interest in healthcare focusses largely on the financial aspects of healthcare. Lest it be construed that good healthcare is only about finances and dollars and cents, I think it is useful to remind all of us that good healthcare, is ultimately delivered by our healthcare workers (HCWs). Many of our HCWs are currently on the frontlines of the fight against the COVID-19 pandemic 24/7, putting themselves and their families at significant risk of infection and even mortality. I want to thank them and salute their sacrifices, and their bravery and their courage, and call on all Singaporeans to give them our fullest support. Let us not shun them for the work and the job they have to do in this challenging and difficult time. But support them, so that they can better help us.  To our HCWs on the frontline, let us remember the aphorism of Sir William Osler in the way we care for our patients: “To cure sometimes, to relieve often, to comfort always.”