Increased coverage under Integrated Shield Plan riders might blunt government efforts to reduce cancer costs: Experts
The Ministry of Health is monitoring cancer drug claims and coverage closely, says Health Minister Ong Ye Kung.
SINGAPORE: Some insurers are offering huge additional coverage for cancer treatment and services through their rider policies – a move that experts say could potentially undermine the government’s efforts to reduce cancer costs.
It comes after recent changes to Integrated Shield Plans (IPs) in Singapore, which took effect on Apr 1, that allow only cancer drugs on a government-approved list to be covered.
CNA previously reported that some insurers had introduced or revised rider policies ahead of the changes, with most providing at least double the main IP policy for cancer drug treatment.
The highest offering was 18 times the MediShield Life claim limit, and this is on top of the main policy's limit.
What are the changes?
Since Apr 1, all new and renewed IPs from private insurers can only cover cancer treatments on a government-approved cancer drug list.
Previously, most policies covered outpatient cancer drug treatments "as charged", excluding the deductible and co-payments borne by patients.
The number of treatments in the cancer drug list has increased from 270 when it was first published in August 2021 to 340 as of February this year. This covers about 90 per cent of all cancer treatments approved by the Health Sciences Authority.
The remaining treatments are not on the MOH list because "the prices do not yet justify the effectiveness and suppliers are not willing to moderate their prices", Health Minister Ong Ye Kung said in a parliamentary reply on Feb 23.
"But we will continue to work with them in good faith and try to expand the list," he said.
The changes to IPs are part of efforts to slow the rising cost of cancer treatments in Singapore and obtain better drug prices, the government said in August 2021.
“The introduction of riders may blunt the effects of these efforts depending on how many Singapore residents purchase these riders and how these in turn affect overall sales,” said Associate Professor Jeremy Lim from the National University of Singapore’s (NUS) Saw Swee Hock School of Public Health.
Agreeing with this, Associate Professor Wee Hwee Lin highlighted that the “buffet syndrome” may also affect efforts to curb the increasing costs of cancer treatment in Singapore.
Previously cited as one of the causes of Singapore’s growing healthcare costs, the buffet syndrome refers to when patients claim unnecessary or overly expensive procedures using their full riders. This, in turn, drives up insurance premium costs for the general public.
“If the attitude towards healthcare spending does not change, (meaning) the buffet syndrome persists, then yes, such a move will undermine the government’s efforts,” said Assoc Prof Wee, who is also from the Saw Swee Hock School of Public Health.
In a parliamentary response last Friday (Apr 21), Health Minister Ong Ye Kung noted concerns raised by Members of Parliament (MPs) about high claim limits offered by IP riders and how it may push up cancer drug prices.
He said the Ministry of Health (MOH) will review how to improve the transparency of cancer drug prices to help patients make informed decisions and encourage providers to calibrate their mark-ups.
The annual number of citizens and permanent residents who received cancer drug treatment and services increased from 22,500 in 2017 to 31,500 in 2021 – a 40 per cent increase.
About 84 per cent received treatment in public healthcare institutions while the remaining 16 per cent were treated in private medical institutions. This proportion has remained stable over the past few years, the Health Minister said.
Mr Ong added that MOH is monitoring cancer drug claims and coverage closely, and will work with the Monetary Authority of Singapore (MAS) to take further steps to regulate IPs and riders if costs continue to escalate.
"In the meantime, we urge individuals to consider the long-term cost of the insurance products they purchase against the level of protection that they need," he said, adding that Singapore's cancer drug list is more extensive than similar listings in most developed countries, including South Korea, Australia, and the UK.
"MAS also requires insurance intermediaries to properly assess if a health insurance product is suitable for a customer’s needs and financial situation before recommending the product to the customer."
ENSURING GOOD OUTCOMES
While placing limits on IPs may prompt providers and patients to think twice about using unnecessary treatments and help to reduce spending, experts said it is important that treatment outcomes are not compromised.
“The increase in cancer drug spending through MediShield Life and the IPs will almost certainly be moderated through the Cancer Drug List (CDL) and the claim limits,” said Assoc Prof Lim.
“However, we have to ensure that this spend reduction is not accompanied by poorer outcomes and I hope the government is actively tracking cancer survival rates – for example, the quality of life – especially in lower income groups that may not have the means to afford riders.”
Oncologists who CNA spoke to said patients who do not have a rider would be most affected by the changes.
According to them, the maximum IP claim limit for cancer treatment – five times that of MediShield Life – is “too low” to cover the cost of most treatments in the private sector.
This is because the MediShield Life claim limit for cancer drug treatments is based on subsidised prices at public hospitals.
“The reimbursement rate is pegged at an unrealistically low level and the acquisition cost for drugs in the private sector remains as high as before," said one private oncologist.
Speaking to CNA on the condition of anonymity, he said most of his patients who are currently taking non-CDL drugs have either advanced or incurable cancer.
“It’s not a matter of being kiasu (the fear of losing out). Many of them will run out of options eventually because their disease can’t be cured, which is why those with incurable and advanced diseases are often the ones who are using all these very expensive drugs that could not get on the CDL.”
He added: "We must also remember that advanced cancer patients cannot be treated and so there is no end date to their treatment. All we can do is to try to retain control of the cancer and extend their life as much as possible until the disease becomes resistant, gets worse and the patient dies."
Mr Ong said that all insurers will maintain the current IP coverage of policyholders at least until Sep 30.
Beyond Sep 30, cancer patients whose treatments are not on the MOH list may still be covered by IP riders or other insurance plans they have. If not, they would have to shift to treatments that are on the list.
Those who require drug treatments not on the list and are unable to pay can opt for subsidised care at public healthcare institutions, where they may apply for financial assistance.
For some private healthcare providers, matching their cancer drug prices to public hospitals is simply “not possible”, they said.
“We have no leverage with the pharmaceutical companies in the private sector because we are not united,” said another oncologist.
“Even a group practice with 10 doctors – which is already considered quite big – won’t be able to get it at the same price as public hospitals because there’s no bargaining power.”
WAIT AND SEE
With Singapore’s spending on cancer drugs projected to reach S$2.7 billion (US$2 billion) by the end of this decade, experts said the country has to rein in healthcare spending as the current trajectory is unsustainable.
However, they stressed that efforts need to be based on data and guided by patient outcomes.
“There is a 'price to life' and we need to know as citizens the price we are paying as we trade off managing costs with restricting access to medicines outside the Cancer Drug List,” said Assoc Prof Lim.
He added that a wait-and-see approach might be needed so that the government can see how the situation evolves and make policy adjustments as needed.
Assoc Prof Wee said IP riders remain relevant as it is important that such coverage options are available.
“This will allow those with the means to seek care in the private sector to do so and relieve the patient load in the public sector,” she said.
“My greater concern is one of equity. It will be most unfortunate if only a small proportion of the population can afford higher coverage.”