Ensuring Patients' Interest in Healthcare

Mr Speaker, I have tabled this Adjournment Motion to contribute to the on-going discussion about healthcare and health insurance, and to give voice to the concerns of patients. I would, first and foremost, like to salute our healthcare workers for their immense contribution to our nation and for all the sacrifices they have made to help our country overcome the COVID-19 pandemic. We owe them a debt of gratitude for putting themselves out in the frontlines, and I hope that we, as a nation, will continue to appreciate their service.

Our healthcare system has delivered good outcomes overall to date. However, there is still further room for improvement. We owe it to our nation, our constituents, our families and indeed ourselves to continually seek ways to improve Singapore's healthcare system, because all of us may become patients at one time or another in our life.

The central theme of my speech today is to ensure that patients' interests are protected within our healthcare system. In preparing for this speech, my colleagues and I in the Workers' Party consulted insurers, hospital administrators, insurance agents, doctors in both private and public practice, and constituents to better understand their concerns and hear their perspectives on the issues.

I recognise that the cost of healthcare is an enormous topic, of which I will only be able to scratch the surface in the time I have today for my speech. I will, therefore, focus on just three areas: medical fee benchmarks, health insurance coverage and over-servicing of healthcare. In each of these areas, I will suggest policy changes which I believe will benefit patients over the long term.

Let me begin with fee benchmarks. In 1987, the Singapore Medical Association or SMA first issued their Guidelines on Fees or GOF. The GOF was issued in response to complaints of overcharging made by members of the public against doctors. SMA's stated objective was to provide greater transparency of medical fees and safeguard the interests of patients.

Unfortunately, the GOF was withdrawn in 2007 after being flagged as being potentially anti-competitive. In its 2010 decision on the matter, the Competition Commission of Singapore (CCS) advised SMA that the GOF would contravene the section 34 prohibition of the Competition Act. While acknowledging that the GOF was an attempt to address information asymmetry in the medical sector, CCS at that time said that there were "other more effective measures'' in place. However, with nothing to immediately supersede the GOF, the longer term impact of its revocation on medical costs may have been even worse than the initial problem the CCS was trying to correct.

To be clear, there were other factors beyond the removal of the GOF that led to rising healthcare costs. The removal of the GOF coincided with the expansion of zero payment "full riders" for MediShield Integrated Shield Plans or IPs and a rapid increase in rents in private hospitals. This trio of changes could have created a perfect storm which accounts for much of the rapid growth in healthcare costs in the private sector.

But it was not until January 2018 that the Fee Benchmarks Advisory Committee or FBAC was appointed by MOH to set reasonable Fee Benchmarks for surgical procedures and services. The FBAC came out with its first set of benchmarks in November 2018. Why did it take MOH more than 10 years to replace the GOF with its own Fee Benchmarks? Had the Fee Benchmarks been introduced soon after the revocation of the GOF, we might not have seen such a steep healthcare cost inflation over that decade.

Nevertheless, I am glad we now have the Fee Benchmarks to work with. According to the FBAC, the Fee Benchmarks are intended as a common reference for all stakeholders. Doctors can use them to set fair and appropriate fees. Insurers can use them to manage and assess claims. And patients can use the benchmarks to discuss with their doctors about their condition, available treatment options and fees.

Fee Benchmarks, therefore, have an outsize influence on the fees doctors charge, and the premiums, payouts and coverage of health insurance. By providing more transparency on doctors' fees, they can help narrow the perennial problem in healthcare: information asymmetry between patients, doctors and insurers. However, to be effective in helping stakeholders manage costs better, the Fee Benchmarks need to be more comprehensive.

The Fee Benchmarks were developed based on actual fee data derived from cases of Singaporean patients submitted by private healthcare providers in a single year – the year 2017. The benchmarks align with the Table of Surgical Procedures or TOSP, a comprehensive list of over 2,300 procedures categorised by their complexity. However, it is notable that only about 220 procedures or 9% of these procedures are listed in the Fee Benchmarks. The remaining 2,000-plus procedures do not yet have fee benchmarks. In comparison, GOF contained over 1,500 surgical fee recommendations.

To make the Fee Benchmarks a more effective and authoritative reference for patients, doctors and insurers, MOH should provide Fee Benchmarks for all the procedures in the Table of Surgical Procedures. To do this, the FBAC could use data from several more years of MediSave and MediShield claims from private hospitals. For procedures with insufficient transacted data, MOH could consult specialists, insurers and patients, before independently deciding on a reasonable range of fees.

Currently, the lower and upper bound of the fee range is set at around the 25th and 75th percentile respectively of the fees for that surgical procedure. Based on feedback I gathered from doctors and insurers, this might be too wide a range to take effective reference from. It may be more useful to set the Fee Benchmarks to a narrower 40th to 60th percentile of each fee range.

While coming up with the fee benchmarks for all surgical procedures will be a resource-intensive undertaking for the FBAC and its secretariat, it would be well worth the time and effort as it will reduce ambiguity in fees and claims for all stakeholders. It will also cut down administrative costs in the long run and reduce the need to have exclusive panels of doctors and pre-authorisation of medical procedures by insurers, which I will speak about next.

IP insurers currently have panels of doctors that their policyholders have to choose from in order to benefit from greater coverage and lower co-payments for procedures. One of my constituents likened panels to an umbrella she carries to prepare for a rainy day, but when it pours, she still gets wet because of the holes in the umbrella.

SMA has argued that panels should be expanded, while the Life Insurance Association has warned that if the number of doctors on panels is "recklessly" increased, premiums will "rise significantly". To provide patients with a wider choice of doctors, panels should be expanded to admit all doctors who wish to be on the panel, so that patients will not feel pressured to switch away from their preferred doctor just because that doctor is not on the panel. Doctors with an adverse track record with the Singapore Medical Council can still be excluded from the panels.

In order to give greater assurance to patients that fees charged by their doctors will be covered by insurance, all insurers should use the Fee Benchmarks to determine their payouts. They should not use their own panel doctors' fee schedules, which may tend towards the lower end of the Fee Benchmarks. If a doctor charges more than the upper end of the Fee Benchmarks for a procedure, he or she will need to provide written justification or inform their patient beforehand of potential out-of-pocket expenses.

The Government has to take the lead in introducing these changes across the board for all doctors and insurers. No insurer will be willing to be the first mover on this because of competitive pressures. Insurers also cannot coordinate these changes among themselves, lest it be deemed anti-competitive.

Greater certainty of fees may lessen the need for pre-authorisation by insurers. The main reason why insurers require pre-authorisation is to mitigate the risk of over-servicing and overcharging by non-panel doctors.

However, insurance companies are not in a position to decide on the medical necessity of a treatment, since they would not have personally examined the patient or understood their case history. These are professional decisions best made by the doctor. Even a doctor from a different specialty acting on behalf of insurers may not be sufficiently well-placed to determine if a particular treatment is appropriate for the patient. The risk of overcharging and over-servicing should be dealt with through a different mechanism, which I will talk about next.

Every doctor is under an ethical obligation to charge fair and reasonable fees for services rendered to their patient. The Court of Appeal, in its June 2013 verdict on Dr Susan Lim vs Singapore Medical Council, said that "overcharging would constitute an abuse of trust and confidence placed by a patient in his or her doctor and this would (in turn) constitute conduct that is dishonourable to the doctor as a person as well as in his or her profession, ie, it would constitute professional misconduct."

The SMC's Ethical Code and Ethical Guidelines or ECEG states that "profit motives must be subservient to treating patients in their best interests".

The vast majority of doctors are committed to patients' best interests. They do not view their practice of medicine simply as a trade but a labour of care and responsibility to their patients. For every doctor that overcharges, there are many more who routinely waive charges for patients who cannot afford their fees.

Often, what constitutes overcharging is not clear-cut. A doctor may order more investigations out of an abundance of caution, in line with their training. Certain patients may present a higher risk of complications and therefore require further tests before arriving at a diagnosis. In some cases, the doctor may fear being sued by their patient if they do not order sufficient tests, leading to a deterioration in their condition. It is important that we do not tar all doctors with the same brush when we accuse them of overcharging.

Nevertheless, overcharging and over-servicing are issues that must be addressed because they contribute to increasing healthcare costs. In doing so, we must not inadvertently create an administrative hassle for patients, insurers and doctors. This could lead to increased costs for all parties without improvement in health outcomes for patients.

We can address concerns about overcharging and over-servicing by instituting greater price transparency in billing. Doctors and hospitals should be required to provide detailed itemisation of charges on their bills by default. For example, surgeon’s fees could state the TOSP code and fee benchmark range for that procedure. Hospitals should list their base costs and mark-ups on drugs and consumables. This itemisation should be made consistent across all hospitals, based on a transparent, prescriptive template set by MOH. This added level of transparency will give payers and patients more confidence in the accuracy and reasonableness of bills and ensure a higher level of accountability by healthcare providers.

However, insurers should not unilaterally reject claims just because they deem a procedure medically unnecessary. Doing so risks saddling patients with higher bills that they are ill-equipped to contest. Instead, patients and insurers should be provided with a mechanism to register their concerns about overcharging or over-servicing.

I was glad to hear during Question Time earlier this morning that MOH is setting up an independent arbitration unit. This unit must be accessible by doctors, patients and insurers to resolve disputes about fees and the necessity of medical procedures.

The arbitrators could be empowered to call upon specialists in the same field as the doctor in question to give their professional opinions on the case. They can then decide whether to allow the charge or require it to be reversed.

Reputation is very important to doctors. No doctor wishes to be known among their peers or patients as someone who overcharges. The mere presence of this process will make doctors think twice before performing unnecessary procedures or overcharging. This could make this an effective mechanism against overcharging and over-servicing, while ensuring that the quality of care provided to patients is not compromised.

Mr Speaker, healthcare costs have increased at an unsustainable rate over the past decade. Almost 70% of Singaporeans possess an Integrated Shield Plan and most premiums funded by their MediSave. Because market failure is inherent in much of healthcare, a laissez-faire approach will not drive efficiency in the healthcare system.

The Government must step in and take a stronger regulatory role over the health insurance market to ensure optimal outcomes for the benefit of patients. The Monetary Authority of Singapore (MAS), as a regulator of insurers, should also take a more proactive role in this process. It is notable that MAS had two committee members on the Health Insurance Task Force in 2016, but has only observer status on the Multilateral Healthcare Insurance Committee (MHIC) that was just set up last month. Why not make them full committee members so that their inputs in the committee's deliberations will carry greater weight?

While I understand that there are often competing interests between doctors and insurers, I believe that these proposals can help to bridge the gulf between the two for the benefit of patients. I hope that the MHIC, MOH, MAS, insurers, doctors, hospitals and other stakeholders will consider these suggestions with due gravity. Ultimately, we should all share the same desire to place the interest of patients ahead of ourselves and contain the growth of healthcare costs in Singapore.

Mr Speaker, I thank Mr Gerald Giam for his impassioned speech asking for more efforts to help in ensuring patient's interest in healthcare. Indeed, ensuring patients' interests has been and will always be a priority of 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 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 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 collaboratively with all stakeholders to achieve this.

Mr Gerald Giam asked why it took MOH more than 10 years to replace the Guideline on Fees, or GOF, with the Fee Benchmarks. It is understandable, as Mr Giam is not a practising doctor, so he may not be fully aware. And Mr Giam has spoken to some doctors, so, I am quite surprised that he does not know, that to increase the transparency of healthcare charges, MOH had already started publishing "Total Hospital Bill" sizes for both public and private healthcare institutions in the year 2003, four years before the Guideline on Fees 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.

The "Total Hospital Bill" size publication started in 2003 with 28 common conditions for the public sector and five-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 by 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.

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.

So, it is not as if when we withdrew the Guidelines on Fees, there was a huge vacuum, there was actually a process that already preceded that, but it was enhanced and strengthened even after the Guidelines on Fees was removed and culminated in the Fee Benchmarks being promulgated.

The Fee Benchmarks serve as references for the public to assess whether the fees charged by a healthcare professional are reasonable; for medical providers and professionals to set appropriate charges; and thirdly, for insurers to take an active approach in their claims assessment and panel design.

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, or 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. So, for example, a Table 1 procedure will be something much more simpler like taking out a small lump on your arm, but a Table 7 procedure will be where there is the highest level of complexity and surgical risk, involving multi-organ resections, 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 very limited data sets 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.

And in fact, when the data set is scarce, what you have is a lot of outliers at the extreme ends which makes the range much 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 the benchmarks, with more than 80% of fees in 2019 within the upper limit of the benchmarks. This was also 4% higher than in the year before 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.

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 overcharging. This is in fact already required under the current existing Private Hospitals and Medical Clinics Act, or PHMCA, for hospital bills, and will be further enhanced under the new Healthcare Services Act 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 help patients make much more informed choices.

On the issues surrounding Integrated Shield Plans, 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 during Question Time to elaborate in my response. And in fact, many of the questions and measures that were suggested were also brought up by the Government Parliamentary Committee (GPC) Chair and many of our GPC members and backbenchers.

The work by the Multilateral Health Insurance Committee, or MHIC, is already on-going on areas that Mr Giam has raised, amongst others. So, I shall not elaborate further and the Member can refer to my earlier Parliamentary Question (PQ) reply.

But I would just want to highlight a couple of points which he has brought up. One is on the issue of expanding the panel to more doctors or in fact, to all doctors, and I have explained in the PQ reply that pre-authorisation is the way to go, to provide access to care by all doctors through the pre-authorisation route. And 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.

On taking a hands-on approach to regulating Integrated Shield Plans (IPs), MOH already exercises close oversight of IPs, 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 remain sustainable.

As I had outlined in my earlier reply, riders are fully private insurance products, going beyond MediShield Life and IP plans. 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.

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 Workers' Party Member's Adjournment Motion on ensuring patients' interest in healthcare focuses 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 us, all of us here, that good healthcare, is ultimately delivered by our healthcare workers. Many of our healthcare workers are currently on the frontlines of this fight against the COVID-19 pandemic 24/7, putting themselves and their families at significant risk of infection and perhaps 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 during this period. Let us not shun them for the job they do in this challenging and difficult time, but support them, so they can better help us.

To all our healthcare workers 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 and to comfort always." [Applause.]

I thank the Senior Minister of State for his response. I have got two clarification questions. First, regarding the issue of the Fee Benchmarks, not containing all the TOSP procedures, for the remaining TOSP procedures which are not in the Fee Benchmarks, can the Senior Minister of State explain how are insurers who are not medical professionals expected to determine what is a reasonable fee if it is not found in the Benchmarks? My concern is that if they cannot find it in the Fee Benchmarks, they might either just reject the claim, or they might just take some other Fee Benchmark which may not be accurate. I can understand that doctors may be able to find some equivalent Fee Benchmark, but I am not sure if insurers can.

Secondly, he mentioned that and tied in with that earlier point, that is why I feel that it is important to ensure that there is sufficient information inside the Fee Benchmarks, so that insurers would not be left hanging and will be just making educated guesses.

On the second point of the number of specialists on the panels, yes, I noted that he said up to 70% of specialists are already on at least one panel. But, if you take it from the patients' perspective, they only care about what percentage of specialists are on their own insurers' panels. So, can the Senior Minister of State share, for the different insurers, does he have the data on what percentage of all the specialists are on each insurance panel?

Mr Speaker, let me just take the first question, which is how do we ensure that insurers know how to price the cost of different procedures. Mr Gerald Giam may not be aware how the surgeons grade surgical procedures. Table 7 procedures, for example, would be usually grouped together in similar level of complexity. And in the private sector, when we charge a Table 7 procedure, we usually kind of put the cost around the same ballpark for other Table 7 procedures. You can have a certain variation above and below a certain range to account for some complexity but on the whole, generally, that is the approach taken.

Even if the insurers were to try and see how each procedure can have a certain range, the fact is that the ranges will overlap, because they are all Table 7 procedures. But if in this Table 7 codes, there are 10 procedures, of which you may have information for five, the other four may be rare and uncommon, so you generally try and place it somewhere in between one of the five. For example, in terms of level of complexity. Table 7, 7A, 7B and 7C. So, if this is a 7B procedure, it will be charged somewhere between a Table 7A and a Table 7C procedure. That is how you kind of get a gauge, a rough gauge.

It cannot be absolute because sometimes even a Table 5 operation can cost a bit more than a Table 7. If it takes longer to perform that procedure, intraoperatively there are challenges, a Table 5 procedure can cost more than a Table 7. So, it is not something that is easily hardcoded because it can vary from case to case. But, on the whole, for common procedures, there are enough data sets for insurers to get a certain sense of what the general ballpark is, and then use that to get an extrapolation of something that is not actually having a benchmark, but should fall somewhere in between. So, that is how it is done.

For panels, I think I have explained previously that it is difficult to ensure that all doctors get on panels because doctors can choose not to be on panels.

Okay. The panel only makes sense, if you have fee arrangements. But, the key to ensure all patients have access to care is to enhance the pre-authorisation process, so all patients regardless of whether the doctors are on panel or not can have access to the doctor for continuity of treatment.