Delivered in Parliament on 10 May 2021
Mr Speaker, I have tabled this adjournment motion to contribute to the ongoing 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 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 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 overservicing of healthare. In each of these areas, I will suggest policy changes which I believe will benefit patients over the long term.
Fee benchmarks
Let me begin with the fee benchmarks. In 1987, the Singapore Medical Association (SMA) first issued their Guideline on Fees (GOF). The GOF was issued in response to complaints of overcharging made by 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Unfortunately, the GOF was withdrawn in 2007 after being flagged as being potentially anti-competitive.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, the CCS said at that time 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 co-payment “full riders” for MediShield Integrated Shield Plans (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 of healthcare costs in the private sector.
It was not until January 2018 that the Fee Benchmarks Advisory Committee (FBAC) was appointed by the Ministry of Health (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 steep healthcare cost inflation over that decade.
Nevertheless, I am glad we now have the fee benchmarks to work with. According to the FBAC, 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 (TOSP), a comprehensive list of over 2,300 procedures categorised by their complexity. However, it is notable that only about 220 — 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, the 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 may 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 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.
Panels and pre-authorisation
Integrated Shield Plan (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.
The 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 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 overservicing 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 and 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-paced to determine if a particular treatment is appropriate for the patient. The risk of overcharging and overservicing should be dealt with through a different mechanism, which I will talk about next.
Overservicing and overcharging
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 in Dr Susan Lim v 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 (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 don’t view their practice of medicine as simply 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 overservicing 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 overservicing by instituting greater price transparency in billing. Doctors and hospitals should be required to provide detailed itemisation of the 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 overservicing.
I was glad to hear during Question Time earlier today that MOH is setting up an independent arbitration unit. This unit must be accessible by patients, doctors and insurers to resolve disputes about fees and the necessity of medical procedures. The arbitrators should 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. This could make this an effective mechanism against overservicing or overcharging, while ensuring that the quality of care provided to patients is not compromised.
Conclusion
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 are 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 the regulator of insurers, should also take a more proactive role in this process. It is notable that the 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 interests of patients ahead of ourselves, and contain the growth of healthcare costs in Singapore. Thank you.