Healthier SG is a welcome new initiative, even though focusing more on preventive healthcare is something that has been advocated for over the years.
In February this year, the Member for Aljunied GRC, Mr Leon Perera, made a very comprehensive adjournment motion speech on rethinking preventive health to generate better outcomes. Among his policy recommendations were for the Government to set short- and medium-term targets for reducing the incidence of chronic diseases; encouraging more people to go for health screening by providing additional subsidies for MediShield Life premiums; and nudging people to buy healthier food products by providing a digital currency earmarked for their purchases.
To its credit, the Ministry of Health is now bringing preventive healthcare to the forefront of healthcare policy, through the Healthier SG programme.
My speech today will focus on managing the cost of healthcare under Healthier SG and measuring and improving the desired health outcomes of the programme.
Costs – Out-of-pocket payments
Under Healthier SG, MOH will waive the requirement for residents to co-pay part of their bills in cash when using MediSave for chronic care management at their family doctor under the Chronic Disease Management Programme (CDMP).
Can I ask the Minister if there will still be an annual MediSave withdrawal limit for chronic disease management?
According to an answer to my PQ, in 2019, some 15% of patients reached the $500 withdrawal limit, most of whom had complex conditions.
Fifteen percent of patients in 2019 translates to about 20,000 patients in absolute numbers.
These patients were restricted in the use of their own medical savings for chronic disease treatment. It could discourage them from seeking treatment for their conditions and lead to a further deterioration of their health.
This could necessitate more expensive interventions down the road like hospitalisations or amputations, which will drastically reduce their quality of life.
Given the direction of Healthier SG towards waiving cash co-payment requirements for chronic care management, I would like to call for the annual MediSave withdrawal limits for chronic disease management to be completely lifted, especially for those over 60. This will encourage residents with chronic diseases to see their doctor early and stay on their disease management plan.
In an answer to another PQ I filed, in 2018 about 563,500 local patients were seen at polyclinics for non-CDMP conditions. These patients were not eligible for the full subsidies and MediSave withdrawal allowances under the CDMP.
Moving forward, under Healthier SG, can the CDMP be expanded to all chronic conditions so that more patients can benefit from it?
The Future of Polyclinics
Next, on polyclinics.
Polyclinic attendance has increased from under 410,000 ten years ago to more than 550,000 in July 2022. The White Paper acknowledged that many residents, especially retirees who no longer have company health plans, have been switching away from private family doctor clinics to polyclinics for their medical treatment. Cost is a factor in these decisions, with drug prices a key reason why medical treatment is often more expensive at GP clinics.
Under Healthier SG, drug prices at participating private family doctor clinics will be made “more comparable” to those at polyclinics through a combination of enhanced drug subsidies and drug price limits. I also note that a new subsidy tier to CHAS for common chronic drugs will be introduced. Singapore Citizens who are CHAS, Pioneer Generation or Merdeka Generation cardholders can opt to obtain these drugs at the private family doctor clinic which they have enrolled with.
These are welcome changes. However, the words “more comparable” suggest that CHAS, PG and MG cardholders will not necessarily enjoy the same low prices for drugs and medical consultations at private family doctor clinics as they do at polyclinics, let alone the other patients who are not eligible for these additional subsidies. The Minister mentioned just now in his speech that the basis for computing subsidies for polyclinics and GPs is different, so the prices cannot be equalised to the last cent. However, can the Minister confirm that the differences will only be in cents, and not dollars or tens of dollars for each prescription?
I’m asking for these details because any price differentials will be a disincentive for Singaporeans from switching from polyclinics to family doctors.
I note that Healthier SG aims to encourage residents to enrol with a family doctor by “narrowing the difference” in drug subsidies across polyclinics and private clinics.
Can the Minister confirm that the “narrowing” of the difference will be brought about only by lowering the price of drugs for patients of family doctors, and not by increasing polyclinic prices to achieve parity?
Furthermore, how much can drug costs be brought down, without subsidising private GPs’ profits, given that GPs also make a margin from the sale of prescription medication?
With all this in mind, it is my recommendation that residents who currently prefer seeking outpatient medical treatment at polyclinics should not be compelled to enrol with a private family doctor.
They should, however, remain with a polyclinic in the same healthcare cluster, so that their medical records can be shared with whichever doctor is attending to them.
If eventually most residents enrol with private family doctors, can the Minister elaborate on what will be the role of polyclinics under Healthier SG? Will the Government continue to build more polyclinics or will there be a reduction in polyclinic capacity as Healthier SG gets implemented?
Maternal and child health
Another area that can potentially reduce healthcare costs in the long term but was given relatively less attention in the White Paper is maternal and child preventive healthcare.
A research study on childhood obesity published in the International Journal of Obesity found that early-life risk factors increased childhood obesity. These risk factors included the father’s obesity at 24 months after the child was born, the mother’s pre-pregnancy obesity and excessive weight gain during pregnancy, short duration of breastfeeding and early introduction of solid foods.
The study found that early-life and preconception intervention programmes may be more effective in preventing obesity if they concurrently address these risk factors.
Another study by local researchers published in BMC Pregnancy and Childbirth found that women interviewed had poor knowledge of the child health consequences of maternal obesity and were often unaware of reliable sources for health information.
Is MOH looking to take a more preventive approach to maternal and child health? For example, family doctors could take a more proactive approach in advising expectant mothers and young parents on healthy dietary habits for themselves and children. The Healthy 365 app could also be used to provide more continuous guidance from healthcare professionals to women who are planning, undergoing and recovering from pregnancy.
Many habits are developed from a very young age and persist for the rest of our lives. The benefits in terms of cost savings and health outcomes of preventive health initiatives for expectant mothers and children could thus be tremendous in the long term.
KPIs and Targets
I would now like to discuss more about the health outcomes under Healthier SG.
What gets measured gets done. Both performance metrics and targets should be set before embarking on Healthier SG.
I am glad to see that the White Paper has listed some short term and long term metrics. However, it does not provide their targets. Without targets, these metrics hold much less meaning.
I have filed PQs to be answered by the Minister tomorrow on the targets for various short and long term preventive health metrics. These include the target screening rates for chronic diseases, the proportion of residents actively using the Healthy 365 app, the obesity rate and the avoidable emergency department attendance rate.
I look forward to the Minister’s reply to these questions. The achievement of these targets should be closely monitored, so that adjustments can be made to better achieve them.
Given the huge investment in Healthier SG, the public should expect an improvement in both the short and long term metrics.
Family doctors that accept enrolment should also be held to a high standard of quality and transparency. They should publish their prices, bill sizes and clinical outcomes. This will allow residents to make informed decisions when choosing or switching their enrolled family doctor.
Other non-clinical metrics should also be used to gauge them. These include the adoption of IT systems that make it easier for patients to make and change appointments, reducing waiting time and sharing of clinical data with other healthcare institutions.
Good service quality would encourage patients to more regularly seek preventive health services.
Conclusion
Last week, I received a phone call from a market research firm doing a survey on behalf of the Government. The pollster asked me to state the extent of my agreement — strongly agree to strongly disagree — to statements like “Singapore is heading in the right direction”, “the Government is managing Singapore well” and “I approve the way the Prime Minister is running the country”.
This was not the first time I was surveyed this way. But this time I was also asked a series of questions about healthcare financing, which was an uncanny coincidence given that it was only a week before today’s Parliament debate on healthcare.
The questions revolved around whether I was worried about being able to pay for my family’s healthcare needs currently and in the future.
I must admit that the questions made me ponder about my own family’s healthcare expenses. Individual healthcare expenses are unpredictable and a large chunk of the costs are likely to come in the final years of life as a result of chronic conditions, many of which are preventable.
Given that this survey was funded by taxpayers, the Government should release the survey results, so as to better inform the public on issues regarding future healthcare spending, and prompt them — as is the objective of Healthier SG — to make the necessary adjustments to their lifestyles and preparations to avert preventable chronic illnesses in the future.
Sir, I support the motion.