WP’s Gerald Giam calls for measures to protect patients’ interests in Singapore healthcare system

SINGAPORE: Workers’ Party MP Gerald Giam called for fee benchmarks for medical procedures, an expanded panel of doctors and itemised hospital bills in an adjournment motion in Parliament on Monday (May 10). 

“The central theme of my speech today is to ensure that patients’ interests are protected within our healthcare system,” he said, adding that the Workers’ Party consulted insurers, hospital administrators, insurance agents, doctors in both private and public practice and constituents on the matter. 

Adding that healthcare costs have increased at “an unsustainable rate” over the past decade, Mr Giam noted that almost 70 per cent of Singaporeans have an Integrated Shield Plan and most premiums are funded by MediSave. 

“Because market failure is inherent in much of healthcare, a laissez-faire approach will not drive efficiency in the healthcare sector,” he added.

“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.”

This comes after Parliament debated the Integrated Shield Plans earlier on Monday during question time. Senior Minister of State for Health Koh Poh Koon had said that the Ministry of Health (MOH) will study whether Integrated Shield Plans can be made "fully portable", but this could result in higher premiums. 

Integrated Shield Plans offer private insurance coverage on top of MediShield Life, Singapore's national health insurance scheme. People may also purchase riders that typically cover the deductible and co-payment portion of the medical bill. 

Dr Koh was responding to a range of questions about Integrated Shield Plans, including the number of people who have given up their plans, the rate of premium increases and the issue of insurers' panel doctors.

This follows the recent debate between insurers and medical professionals, largely over the number of private specialists on insurers' panels and their selection criteria.

READ: Health Ministry to study if Integrated Shield Plan insurance can be made 'fully portable' 

FEE BENCHMARKS

Mr Giam suggested that MOH provide fee benchmarks for all the procedures in the Table of Surgical Procedures, to make the benchmarks a “more effective and authoritative reference” for patients, doctors and insurers. 

The Fee Benchmarks Advisory Committee (FBAC), appointed by MOH in 2018, could use data from “several more years” of MediSave and MediShield claims from private hospitals to set the fee benchmarks, said Mr Giam. 

“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,” he added.

Describing the brief history of fee guidelines in Singapore, Mr Giam noted that the Singapore Medical Association (SMA) first issued their Guideline on Fees in 1987. It was withdrawn in 2007 after being flagged as “potentially anti-competitive”. 

In 2010, the Competition Commission of Singapore (CCS) advised SMA that the guidelines would contravene the Section 34 prohibition of the Competition Act, he added. 

“While acknowledging that the GOF was an attempt to address information asymmetry in the medical sector, the 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.” 

There were also “other factors”, including a rapid increase in rents for private hospitals, that led to rising healthcare costs, said Mr Giam. Those factors combined could have created “a perfect storm”, which accounts for much of the “rapid growth” of the cost of private healthcare. 

But it was not until January 2018 that the Fee Benchmarks Advisory Committee was created, coming up with its first set of benchmarks in November the same year, Mr Giam noted. 

“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,” he added. 

Fee benchmarks have an “outsize influence” on the fees charged by doctors and the premiums, payouts and coverage of health insurance, said Mr Giam. 

“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 current fee benchmarks were developed from data from cases of Singaporean patients submitted by private healthcare providers in 2017, said Mr Giam. 

“The benchmarks align with the Table of Surgical Procedures, a comprehensive list of over 2,300 procedures categorised by their complexity. However, it is notable that only about 220, or 9 per cent, of these procedures are listed in the fee benchmarks,” he added. 

“The remaining 2,000-plus procedures do not yet have fee benchmarks. In comparison, the GOF contained over 1,500 surgical fee recommendations.”

READ: Government committee to be set up to look into management of Integrated Shield Plans, panel doctors

In his response, Dr Koh said that MOH had been publishing total hospital bill sizes for public and private hospitals since 2003, years before the GOF was withdrawn in 2007. 

According to Dr Koh, the bill publication started with 28 common conditions for the public sector and five-day surgery conditions for the public sector, using actual transacted charges. It was then “progressively expanded” to include more conditions and information. 

Today, the actual bill size publication for close to 300 procedures and medical conditions is available on MOH’s website, he said.

To further reduce the “information asymmetry” between healthcare providers and consumers, MOH in 2017 appointed an independent multi-stakeholder committee to develop and recommend fee benchmarks for the private sector, said Dr Koh.

EXPANDING PANEL OF DOCTORS 

Touching on the topic of doctors available to policyholders under Integrated Shield Plans, Mr Giam said the panels should be expanded to all doctors who wish to be on them, said Mr Giam.

This will ensure that patients do not feel pressured to switch away from their preferred doctor if the doctor is not on the panel, he said, adding that doctors with an adverse track record under the Singapore Medical Council can still be excluded.

Currently, policyholders under Integrated Shield Plan insurers have to choose from a panel of doctors to benefit from greater coverage and lower co-payment for procedures, he said.

To assure patients that their doctor’s fees will be covered by insurance, all insurers should use the fee benchmarks to determine their payouts, said Mr Giam.

He argued that the Government would have to lead the changes 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.”

Reiterating what he addressed in his earlier response to parliamentary questions, Dr Koh said pre-authorisation “is the way to go” to provide access to care by all doctors. 

“And in fact, panel sizes have increased by 40 per cent in the last six months to a year, up to 70 per cent of private specialists are already on at least one panel.” 

READ: COVID-19 spurs demand for some insurance products, but insurers watching long-term impact of pandemic

Greater certainty of fees would also reduce the need for pre-authorisation, said Mr Giam. In the pre-authorisation process, insurers give approval for medical costs beforehand.

Insurers require pre-authorisation to mitigate the risk of non-panel doctors overservicing and overcharging, he said.

“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.”

Instead, overcharging and overservicing should be dealt with through itemised bills. Doctors and hospitals should provide detailed itemisation of the charges on their bills by default, said Mr Giam.

The itemisation should be made consistent across all hospitals, based on a transparent, prescriptive template set by MOH, he said.

“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, he said. Rather, there should be a mechanism for them to register their concerns about overcharging or overservicing.

He welcomed MOH’s independent arbitration unit, adding that it must be accessible by patients, doctors and insurers to resolve disputes about fees and the necessity of medical procedures.

Providing an itemised hospital bill is “already required” under the existing Private Hospitals and Medical Clinics Act, said Dr Koh. This will be further enhanced under the new Healthcare Services Act to cover all licensable healthcare services, he added.

“MOH will prescribe the minimum level of granularity that must be reflected in patient’s bills, which include categories such as consultation, medication and investigations.” 

Licensed clinics and hospitals are also required to display common charges “prominently” at their premises or websites, or provide financial counselling for services that “tend to generate significant bills” before the service is provided, said Dr Koh.