Martin Lee @ Sg
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Suggestions for a Better Singapore Healthcare System

The Government Parliamentary Committee (GPC) for Health has made several suggestions to the government to revamp our existing healthcare system. The suggestions cover the use of Medisave, Medishield and the amount of subsidies that we get.

The announcement of the suggestions is a way for the government to test out the ground reaction to the proposed changes.

While I find some of the ideas good, there are some others that I am not so comfortable with.

Below are some of the proposed changes and my comments.

Setting the same Medisave withdrawal limits for inpatient and stepped down care

This is good as the current situation is such that some people choose to extend their stay in the hospital when they could be transferred to a community hospital as the hospital allows them to utilize more of Medisave daily.

Allow older people to withdraw more from their Medisave and introduce tiered withdrawal

As old people would have more Medisave savings and also have a higher chance to be hospitalized, it is good to allow them to utilize more of Medisave to pay for their bills.

Expanding the scope of Medisave to include more treatments such as health screening

Prevention is always better and cheaper than cure. This move might encourage more people to go for health screening. On the flip side, some health screening providers could take the opportunity to increase their prices.

Getting people to pay more in Medishield premiums when they are younger so that the premiums at the older age can be reduced

I am not too sure about this. If the premiums are increased too much, some young people might drop out of the scheme. When they realize that they need the coverage later on in life, it might be difficult for them to get coverage due to pre-existing conditions.

I would rather that the government continue with the existing system of topping up Medisave accounts of seniors. Another better way is for the government to top up the Medishield pool directly, to ensure that it stays solvent and adequate.

Increase the coverage of Medishield

I don’t know what’s the exact proposal given by GPC but I don’t like the current deductible levels. Having a lower deductible will help people appreciate the usefulness of Medishield and make it less likely for them to drop out of the scheme. If they are always unable to claim due to the bill size being less than the deductible, they will find Medishield useless.

Given that the deductible level was only recently raised this year, I’m not sure that the government will want to backtrack so soon.

Remove the age limit of 90 for Medshield

Generally, this is a good idea but one wonders how much the premiums is going to be when you hit 90.

Ensure Medisave top-ups from the Government are used only to pay premiums

I am neutral about this suggestion. It might be difficult to implement as you will then need to create some tracking for it, perhaps via the use of a Medisave sub-account. As it is now, our system is already complex enough and there will be a cost to implement this tracking.

For ease of administration, I would rather the government make top-ups directly to the Medishield pool. Of course, topping up Medisave accounts directly will make people more positive towards the government so this approach is more likely to happen.

Remove lower age limit of 40 for Community Health Assist Scheme (CHAS) programme

The CHAS is a very good programme for those who are not earning much. If they can reduce the entry age limit or even remove it altogether, it will be wonderful. Not only old and poor people need help. Young and poor people can do with some assistance too.

You may find out more about CHAS in another article that I wrote.

Allow patients who are referred by a GP to enjoy subsidies so they don’t need to be referred by a polyclinic

The current policy is that if you are referred to the outpatient specialist of a government hospital by the polyclinic, you are considered a subsidized patient. If you are referred by a private GP or are a walk-in patient, you are considered a non-subsidized patient.

In my opinion, this is a dinosaur policy that should be abolished immediately. It creates an unnecessary additional step for people to visit the polyclinic to get a referral letter. As it is now, all my polyclinics are already quite stretched and they can do without this additional workload.

Whether a person should be subsidized or not should depend on his residency status and wealth/income, and not how he was referred to the hospital.

Subsidize more essential medicine and publish private sector fees (including GP) online

Good ideas.

Means-test patients only once and apply results to all schemes that enjoy subsidy

This is another system that needs a serious overhaul.

Currently, when you are warded, you will get a subsidy that is a percentage of your bill. This percentage will vary depending on which ward you go to, and how much income you earn.  This can range from 50-80% . The B2 and C wards are subsidized, while the B1 and A wards are not.

For outpatient specialist treatment, you are either subsidized or non-subsidized.

Here’s the thing. If you stay in a B1 or A ward, you will be seen as a non-subsidized patient for all your follow-up outpatient visits for that condition. You will need to pass the means testing for your entire family before you can revert back to subsidized rate.

So even if you don’t mind paying a bit more during your hospital stay to stay in a B1 ward, (note that B2 wards and C wards do not have air-con), you may hesitate to do so because you do not want to jeopardize your subsidy for your follow-up treatments. You also end up not getting any subsidy for your hospital stay, no matter how poor (or rich) you are.

The unfair thing is that should you happen to upgrade from a B2 to B1 ward midway through your hospital stay, you will lose all your subsidies for your treatment from day one! However, you will still be subsidized for the earlier ward charges.

As I pointed out earlier, the amount of subsidy that a person receives should really be only dependent on his residency status and wealth/income.

This suggestion by GPC is consistent with my thinking and I hope it gets looked into.

My ideal system would be one where a person will get categorized based on his income.

The basic idea goes like this : you will fall into two categories, either subsidized or non-subsidized.

For the subsidized group, there can be many sub-categories for greater differentiation. For each sub-category, you will be given a different maximum subsidy level for each day you are hospitalized. For example, one category may get $50 a day, another might get $200 a day. There will also be a surgical subsidy cap for the different groups.

There will be another table for permanent residents.

It will be relatively easy to categorize people as the information can be pulled from IRAS. For those who are not working, they can be categorized by the annual value of their house (as what the government always use to determine growth dividends, etc).

When you are admitted to hospital, there is no need to calculate subsidies based on percentages or ward type.

No matter which ward you go to, be it A or C, your total bill will simply be offset by your subsidy amount. In this way, the patient can still have a choice of ward, and enjoy his or her subsidy benefit. The follow-up outpatient subsidy should of course be de-linked from the type of ward which was stayed in.

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4 comments
abc says 5 years ago

Looks like medishield premiums will go up 3X across the board by 2014.

The main issue is increasing the wages of the lower income group. 40% of sinkies earn below $2K per month.

No point having medishield with all kinds of features but people cannot afford to pay premiums, and with high deductibles such that 90% medishield claims are unsuccessful.

It is statistically proven that people with low wages tend to be sicker, unhealthier, have more chronic and acute health problems, and become long-term sick at an earlier age. Majority of wealthy people are still healthy at 75 yrs old. Poor people will become diabetic, high blood pressure, high cholesterol in their 40s.

Just look at s’pore hospitals overall. Majority of in-patients are the lower-income with chronic problems. People with comfortable wages will be able to have regular full-body checkups, catch any health problems early, and go for out-patient day-surgery if necessary to correct problems.

Reply
    Martin Lee says 5 years ago

    Dear ABC,

    According to PM Lee’s speech today:

    “We will revamp MediShield, to become MediShield Life because it will cover for life, not stop at 90. MediShield Life will give better protection for very large bills so patients will pay less out-of-pocket.”

    I do not like what is coming because we can expect higher premiums and perhaps the enhancement would be higher annual claim limits (not applicable for most people).

    Reply
      abc says 5 years ago

      The key phrase is “very large bills”.

      How large? Don’t tell me must be over $10,000 in order to have successful claim.

      Plus with the daily limits, ward limits, procedure limits, yearly limits, types of coverage, etc etc, I can always come out with a medical insurance that advertises coverage of $100 million each & every year.

      What are the specific terms & conditions, the fine print?? The devil is really in the details.

      Anyway do you know that all govt hospitals in s’pore follows SOPs for all the health problems e.g. heart attack, stroke, diabetes, bone fracture, pneumonia, cancer, organ transplant, etc etc??? These SOPs are known as Clinical Pathways and they are use to provide a minimal cost & procedure regime to tackle the various health problems. In order not to waste hospital resources. They are particularly followed in C class and B2 class wards. The political correct explanation is to save costs for patients. Hence often these patients may not be able to claim insurance coz the resulting bill amounts is too low. Good for those without medical insurance but bad for those with medical insurance.

      Reply
        Martin Lee says 5 years ago

        Dear ABC,

        The clinical pathway thing is something new to me. I am not surprised they have some protocol but shouldn’t their protocols be based on the best care/treatment for patients?

        Reply
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