Ministry of Health Committee of Supply 2019 – Cuts by WP MPs and NCMPs

(Delivered on 6 Mar 2019)

Private Ambulance Services – Sylvia Lim

While SCDF ambulances attend to about 90% of emergency cases, consumers will call for private ambulances in emergency cases if they wish to send a patient to a preferred or private hospitals, or in non-emergency cases.

For the consumer, however, the current lack of regulation has meant that there is patchy information on available services, and vasty different consumer experiences. On the one hand, I have personally had good experiences with private ambulances. On the other hand, I hear less happy accounts from residents. Such feedback includes lack of advanced disclosure or transparency about the costs of various services and equipment, and asking the family to decide on whether certain equipment should be deployed en route, which lay people have little knowledge on. Another concern is that private ambulances attending cases at HDB flats may not have stretchers that can be manoeuvred into an incline position to fit the size of HDB lifts. The quality of the vehicles is also disparate, with some ambulances apparently retrofitted from cargo vans. Some businesses insist on taking cash payments only, which can be stressful if the charges come up to about a thousand dollars, to be paid by the family in the middle of the night.

It was recently reported that regulation is coming in the form of the proposed Healthcare Services Bill. While this is welcomed by consumers and industry players, there are concerns. One concern is There is the proposed distinction in licensing requirements between those operating emergency ambulance services, and those operating medical transport services. The current proposal is that those licensed to provide emergency ambulance services will have more stringent requirements e.g. they will need to employ a clinical director to maintain high standards of comprehensive emergency care, conduct audits, as do training and protocol development. In contrast, medical transport service vehicles do not need to meet the same standards but will have operational restrictions e.g. they will not be allowed to have blinkers and sirens. Operators have pointed out that initially stable cases can quickly deteriorate en route to hospital, which will turn a non-emergency situation into an emergency one. When this happens, time is of the essence, and blinkers and sirens may make all the difference. What is the status of MOH’s review of the regulation regime?

Finally, to better facilitate consumer choice, could MOH arrange for a one-stop portal for consumers where they can evaluate the offerings and customer feedback of private ambulance services? As for the reasonableness of their charges, would the government consider publishing fee benchmarks, so as to keep this essential service affordable?

Data security for National Electronic Health Record – Daniel Goh

Chair, the SingHealth cyber-attack and HIV registry leak have shaken confidence in the security of our personal and patient information in the health records. Learning from these events, how will the personal and patient data kept in NEHR be better secured and protected against hacks and also leaks by administrators, doctors, front-end staff and researchers?

In early 2018, a joint survey on the public sentiments towards the NEHR showed that over 11 percent of respondents said they would prefer to opt out of the NEHRand 56 percent said they would like to have their records maintained in the NEHR but do not want any healthcare provider to access it without their explicit consent except during emergencies.

This negative sentiment preceded the SingHealth cyber-attack and HIV registry leak, thus the government would need to get better buy-in for the NEHR from the public now. Should the NEHR be minimally covered by the PDPA and a data protection regime that provides for additional safeguards and is patient-centric? Such a move can improve public confidence as many are now familiar with the PDPA framework. Small private clinics would need extra help to secure their data.

Patient Electronic Health Records – Sylvia Lim

Singapore has been centralizing patients’ health records through the National Electronic Health Record System. The benefits of convenience are evident. Patients can go to any healthcare facility and receive treatment that takes account of their medical history. However, the recent MOH data leaks and the cyberattack on SingHealth, have shaken the public confidence in such centralised electronic health records. These incidents targeting patients’ personal records are reminders of the risks to privacy and security that accompany convenience, risks which we had not understood or taken seriously enough.

MOH has announced that primary care providers such as private GPs will be required to enter case notes into the NEHR, though this has been held in abeyance while MOH does a thorough review of cybersecurity. However, even before the recent breaches, some GPs in private practice told me that they have grave reservations about the impending requirement for them to key in confidential data about their patients into the NEHR. They cited that they had a duty of doctor-patient confidentiality and were not comfortable keying in the medical conditions and drugs prescribed to patients, for review by unknown persons down the line. In view of potential unauthorised access or leaks, they would also be reluctant to put in sensitive information, however relevant to treatment.

We must acknowledge that even with the best fortifications, cyber defence is an endeavour that pits us against potentially the most technically advanced and resourced hackers in the world. There is also the risk of disgruntled or rogue employees who can exploit legitimate access for improper purposes. As it is impossible to completely prevent hacks and data breaches, one key concern would be to limit damage in the event of breaches.

To mitigate the risks and fallout from data breaches, common and effective measures include improvements in ways to store and access information, such as data compartmentalisation and restrictions on authority. For instance, it would be odd for persons responsible for macro-level policy to access personally identifiable information. It would also be unnecessary for staff not attending to a particular patient to access the patient’s records. There may be particular sensitivities if certain information gets into the wrong hands. In view of all this, I would like to ask what the Ministry of Health has done, or is doing, to compartmentalise data and limit who can gain access to data stored at MOH and at the healthcare providers it regulates.

Value-based Healthcare – Leon Perera

Sir, Singaporeans are still concerned about the cost of healthcare, as a recent Reach survey concluded. Incidents like the recent furore over Medishield Life not covering much of certain bills do not help. Some Singaporeans go to JB to purchase medication. Other than out-of-pocket expenses, there is concern that premiums for Medishield Life and IPs may rise in the future thanks to healthcare inflation.

Going forward, can we find cheaper ways to deliver the same healthcare outcomes?
Value-based healthcare, which was conceptualized in the University of Utah in the US, is a healthcare delivery model in which providers, including hospitals and doctors, are paid based on patient health outcomes. Value-based care differs from paying providers based on the amount of healthcare services they deliver.

While it is hard to summarise how this works in practice in under two minutes, it involves practices like sharing of data across physicians to prevent redundant testing and adjusting payments to hospitals based on good care best practices.

While there have been trials by organizations, no national healthcare system has implemented VBH on a national level – yet. But I understand that many companies are developing solutions for VBH in anticipation of an eventual VBH revolution in healthcare. Amazon, Berkshire-Hathaway and JP Morgan chase have announced a joint venture to champion elements of VBH as a disruptive healthcare solution.

I understand that NUHS has adopted a Value-Driven Outcomes initiative or VDO. NUHS states that it drew ideas from the VBH concept from the University of Utah and has shared the concept with all public healthcare clusters in Singapore.

I would like to ask the government whether it would study the VBH approach, conduct pilots and move towards a comprehensive adoption of VBH across the entire healthcare system if results are positive. If so, when is the target date for a more broad-based adoption of VBH and would a roadmap be published?

MediSave Limits for Long-term Care – Daniel Goh

Chair, from 2020, severely disabled Singaporeans will be allowed to withdraw up to $200 a month from Medisave for long-term care needs. However, this is very limiting for those with more than $20,000 in their Medisave accounts. This is especially if the long-term care is the only medical cost that they have to deal with, and that which, if the care is effectiveand preventive, it would minimiseadditional medical expenses.

The current limit of $200 is primed for 100 months. However, the median duration of stay in a nursing home is 59 months. Why not peg the limit to the median duration instead? The government should consider increasing the maximum quantum to $600, scaled up accordingly to the amount in the members’ Medisave savings.

If the member has $20,000 in his or her Medisave account, he or she can withdraw up to $300 a month, as the $20,000 would cover 60 months of stay in a nursing home. If the member has $40,000, he or she can withdraw up to $600 a month.

This may be a more efficient and effective way for severely disabled Singaporeans to make use of their Medisave savings to meet their long-term medical needs.

MediSave Withdrawal Limit – Faisal Manap

Sir, as members of this house, I believe many of us may have been asked by residents, relatives, friends and acquaintances, who are unhappy with the use of Medisave, on why should there be a limit set for the use of our Medisave money and why is the allowable amount to be utilized annually is so minimal.

Sir, for the first question on the limit set for the use of medisave, I will share with them MOH’s explanation, that is the setting of the withdrawal limit is with the intention to ensure that Singaporeans have sufficient savings in their Medisave account for their basic healthcare needs in old age. For the second question, my reply would be – sorry, I do not have the answer.

Therefore, sir, I would like to ask the ministry the following questions pertain to Medisave Withdrawal Limits;

(i) How is the withdrawal limit amount as well as the increment amount (upon reviewing process) being tabulated and arrived at, is there any specific formula applied and, if yes, can the ministry share this formula,
(ii) How regular is the review on the withdrawal limit conducted, is there any specific cycle or is it on situational basis, for example, review will be conducted when there is an inflation in healthcare cost,
(iii) Who are involved in this reviewing process.

Sir, the answers to the above questions may not able to address or lessen the unhappiness of these questioners, however, it will provide some clarity and transparency on the matter.

Greater MediSave Flexibility – Pritam Singh

Sir, this cut seeks to explore whether the Ministry can grant Singaporeans greater flexibility to use more of their own Medisave to pay their hospital bills. This is particularly for bills which are not covered by Medishield Life or because the amount owing is within the deductible limit and hence must be settled solely by the patient in cash or Medisave. In such cases, Medishield Life does not kick in because it is meant for larger hospital bills. While Medisave can be used, it is subject to limits and in many cases, a few hundred dollars will still have to coughed up in cash. I believe there is scope for the Government to exercise some flexibility and give Singaporeans the choice of allowing the entire remaining amount after subsidies to be paid by a patient’s Medisave instead of cash bearing in mind the matter involves a hospitalisation.

For citizens with sufficient Medisave balances, and who are in their senior years from the age of 60 in particular, some additional flexibility in terms of choice would bring significant peace of mind and leaving cash in their pocket. I hope the Government can look into this to reduce the out of pocket expenses for this category of Singaporeans. For example, can the Government consider a tiered-withdrawal quantum for those above 60, not too dissimilar to the Medisave withdrawals for Long-Term Care announced in July last year to achieve a sustainable balance between the use of member’s Medisave savings for the immediate term and the future respectively.

Compulsory Insurance – Adequacy Ratios – Pritam Singh

Sir, Careshield Life and Medishield Life are both compulsory schemes with the former soon to become a central pillar of our healthcare system. The public cannot opt-out of either scheme and this fact alone brings into sharp focus the premiums of compulsory risk pooling schemes. It would follow that the adequacy ratios of such schemes and the Government’s reasons and assumptions behind premium pricing should be made more transparent so that the public can understand the factors behind premiums calculation.

One of the pain points that was manifested through public discussions prior to the debate on the Careshield Life White Paper last year surrounded the fact that from 2002-2016, Eldershield collected $2.6b in premiums only slightly in excess of $100m was paid out. The importance of pre-funding for such schemes aside, a general lack of understanding contributed to the public dissonance on the issue, as the numbers suggest over-collection of premiums. I appreciate that the actuarial models that determine how premiums are priced are complex and multi-faceted – some of factors include disability mortality, recovery rate, claims continuance rate, improvements to mortality as well as the risk profiles of various cohorts amongst others. However, complexity should not be a reason to avoid publishing these considerations and the weightage of the calculations behind them. With upcoming legislation of Careshield Life, I hope these assumptions and considerations can be meaningfully communicated to all Singaporeans.

On a similar note, I would like to enquire about the frequency with which Medishield Life’s adequacy ratio is reviewed by the Medishield Life Council and considered by the Ministry, so as to ensure that the greater transparency on reserve requirements called for in the Medishield Life Review Committee report are meaningfully operationalised. I understand the FAQ section on Medishield Life on the MOH website provides a helpful table setting out the incurred loss ratio of the scheme each year. Can the Minister share, in light of Medishield Life transitional subsidies ending this year and incurred loss ratios over the years exceeding 90% so far, does the Council foresees an increase in premiums in the near future.

Sir, I believe transparency can help control healthcare costs by widening debate and scrutiny. It also helps create the peace of mind that all is done to ensure the affordability of these compulsory insurance schemes. In the absence of such knowledge regarding spending, insurance may be inaccurately perceived by some as a pure tax, rather than a risk-pooling scheme that is closely tied to each participating cohorts’ expected benefits.

Singapore Medical Council Complaints Procedures – Leon Perera

Sir, on 2nd March, Senior Minister of State Mr Edwin Tong announced that MOH will be doing a very comprehensive review of the entire medical regulatory landscape as overseen by the SMC, including reviews of disciplinary processes.

I have several questions and suggestions on how those disciplinary processes currently operate and what would be the parameters governing the pending review.

Firstly, the current process allows complainants to appeal to the Minister should they be dissatisfied with the ruling of the Complaints Committee. I understand that MOH has signalled its intent to do away with this avenue of appeal in future. But that reform may take time to implement. For now, I would like to ask – how does this appeals review process operate within MOH? It would seem to be opaque to many in the profession. What expertise and skill sets are brought to bear in considering such appeals and what sorts of personnel are involved?

Next, once a complaint is escalated to an SMC Disciplinary Tribunal or DT, it is my understanding that lawyers begin to play a key role in the process. What measures are being taken to minimise the legal fees incurred by the SMC for DTs which are paid by insurers, since this has the potential to elevate medical indemnity insurance premiums borne by doctors?

Next, will the review process address the long time periods often associated with the CC and DT processes? And can the government consider if disciplinary action for more minor complaints can be addressed by a different form of committee than a DT, to reduce the considerable time and cost associated with the DT process.

Lastly, the government currently appoints the majority of members on the SMC. What is the government doing to correct any perception now or in the future that the SMC is insufficiently independent of the government? If any such perception took root, it may erode confidence among doctors of getting a fair hearing, which in turn could lead to things like defensive medicine, which can escalate costs and worsen efficiency.

More Singaporeans for Nursing – Dennis Tan

Demographics have only increased the demand for healthcare. In the Government’s Healthcare Manpower Plan 2020, released in October 2016, the healthcare services estimated an addition of 30,000 healthcare workers by 2020. With more hospitals and polyclinics coming online in the communities to establish the key infrastructure for delivering healthcare needs to our people, it is time to look at the manpower available to operate and manage both new and existing infrastructure.

A strong local core is important as healthcare needs are better served with cultural understanding. I would like to seek clarification from the Ministry on the plans to build a “strong local workforce” in accordance to the Healthcare Manpower Plan 2020; how is the Ministry monitoring and ensuring that enrollment figures and local graduate figures translate to reinforcements to the nursing manpower, and then retaining the local graduates to meet the long-term plan of building a strong local workforce?

I ask as the number of local nursing graduates have been gradually decreasing since a peak of 1,744 graduates in 2012, to 1,479 graduates in 2015. During the COS debate in 2017, Dr Amy Khor stated that the foreign workforce for nursing is 33%. Even as we have learnt that the reduction in services DRC will not impact healthcare operations, how has this percentage shifted with the introduction of conversion programmes available at the tertiary institutions (such as SIT) and the push to increase intakes to the healthcare courses?

The retention rate of new healthcare workers will also be a key measure of sustainability of our healthcare operations. What is the attrition rate and average tenure of nurses and other healthcare workers? Is the suite of measures to retain the local graduate healthcare workers in the industry sufficient, and what are common reasons for healthcare workers to leave the work force?

Engaging VWOs in Intermediate and Long-term Care – Leon Perera

Sir, I declare my interest as the CEO of a research consultancy that undertakes work in the silver industry, among other sectors.

Sir, Voluntary Welfare Organizations or VWOs figure prominently in the Intermediate and Long-Term Care or ILTC sector. It is in our interest to ensure that these VWOs flourish in the long-term and become sources of good quality care.

I have a few questions and suggestions for improving the intersection between the government and VWOs in ILTC, though some of these points may apply to private sector developers and/or operators of ILTC facilities as well.

Firstly, the tendering process takes into consideration a range of factors, but by virtue of convention, public tendering tends to create pressure on bidders to bid higher – or lower, if it is a tender for operating services and not land. And this is not a bad thing, value-for-money is an important consideration. Nevertheless the ILTC sector is a space where innovation and experimentation is important. There should be space for facilities in our ILTC sector which are unorthodox, and which may come with a higher price tag, as it were. What is the consideration given to striking the right balance between quality and innovation on the one hand and cost on the other?

Secondly, what steps are being taken by the government to further empower and help VWOs in the ILTC sector in terms of funding, manpower and organizational development? Capacity-building is one area where VWOs may face challenges.

Lastly, in growing the ILTC sector, the VWO sector may need to be augmented by the private sector, which has potentially a substantial capacity to invest financially, as well as, in some cases, to deploy relevant, cutting-edge technology. What is the government doing to engage and support good companies to invest in this sector and possibly to partner with VWOs?

Personalised Medicine – Low Thia Khiang

Chairman Sir, personalised medicine involves the customisation of medical treatments to specific patient groups based on genetic profiles.

At last year’s MOH COS, I asked the Minister whether the Ministry of Health was on track with drafting the code of practice for clinical genetic testing. Minister replied that the Ministry was developing an integrated national strategy for precision medicine research and implementation; and would provide a thorough update at an appropriate time. It has been a year since, hence I would like to ask for an update.

There have been reports that hundreds of patients have benefitted from personalised medicine treatments at our public hospitals. I would like to know how many Singaporeans have benefitted to date?

I have three concerns. First, precision medicine is a fast-developing field of clinical research and application. I am concerned that the longer we take in enforcing the code of practice and implementing the national strategy, developments in the field would have outpaced the code and strategy.

Second, if a substantial number of Singaporeans have already obtained personalised medical treatments, then the delay in enforcing the code of practice may expose these Singaporeans to the misuse of their personal and DNA data, medical risks associated with DNA-editing and other bio-ethical risks.

Third, last November a Chinese scientist used gene-editing technology in an experiment that led to the birth of the world’s first genetically modified babies. There was an international uproar and the Chinese Government is putting in a regulatory regime now in response. I am concerned that the longer we take, in regulating precision medicine and genetic testing, we run the risk of such an incident happening here that will damage our reputation as a biomedical R&D hub.