Fees charged for transit wards in hospitals

Mr Gerald Giam Yean Song asked the Minister for Health (a) which public hospitals charge patients for (i) temporary beds in tents; (ii) beds in the corridors outside the wards; or (iii) beds in the ward corridors but not in ward rooms; (b) how all these rates differ from beds in the ward room; and (c) whether stays in temporary beds in tents and in the corridors, outside and inside the ward, qualify for Medisave use or MediShield Life claims.

Parliamentary Question on 8 October 2014

USE OF MEDISAVE FOR PATIENTS IN TRANSIT WARDS OF ACCIDENT AND EMERGENCY DEPARTMENTS IN HOSPITALS

The following question stood in the name of Mr Zainal Sapari —
10 To ask the Minister for Health (a) what is the average length of time that a person will be in the transit ward of the Accident and Emergency Department of a public hospital before getting a bed at the subsidised wards; and (b) whether the Ministry can allow patients who are in transit wards to use their Medisave for payment during their stay there.

11 Mr Gerald Giam Yean Song asked the Minister for Health (a) which public hospitals charge patients for (i) temporary beds in tents; (ii) beds in the corridors outside the wards; or (iii) beds in the ward corridors but not in ward rooms; (b) how all these rates differ from beds in the ward room; and (c) whether stays in temporary beds in tents and in the corridors, outside and inside the ward, qualify for Medisave use or MediShield Life claims.

Mr Zainudin Nordin (Bishan-Toa Payoh): Question No 10.

The Minister for Health (Mr Gan Kim Yong): Madam, may I take both Question Nos 10 and 11 together.

Mdm Speaker: Yes, please.

Mr Gan Kim Yong: Madam, for 2013, the median time for admission to a ward from the Emergency Department was about 2.5 hours.

Patients at the Emergency Departments are prioritised and attended to based on the severity of their conditions. While patients wait to be admitted to an inpatient bed, they will continue to receive medical treatment, nursing care, clinical monitoring and other services, as well as meals that they may require during this transit period. Their safety and care remain the focus of our care teams at the Emergency Departments.

During the transit period, patients would be charged for services that have been rendered. Medisave and MediShield can be used for these charges if the patients are subsequently warded, subject to the prevailing daily and other limits, and the number of inpatient days of stay.

We have received appeals and queries earlier about the computation of Medisave and MediShield claims for patients who received treatment before their inpatient beds were ready. Some hospitals commence inpatient charges only when the patients are transferred to a ward and taken care of by the inpatient team. Ward charges are not imposed during the transit period at the Emergency Department and, consequently, the transit period does not count towards the inpatient days in the computation of Medisave and MediShield claims. Other hospitals consider patients as inpatient once they are taken care of by the inpatient team, even during the transit period. The time during this period contributes towards the length of stay and patients will benefit from higher claims for Medisave and MediShield.

We are reviewing these two ways of computation to see how we can streamline the practices across public hospitals to minimise confusion.

Mr Gerald Giam Yean Song (Non-Constituency Member): A few supplementary questions. I think the Minister basically has said that different hospitals have different practices right now. Can the Minister clarify which are the hospitals that do charge for the temporary beds and which are those that do not?

For the hospitals that charge for the temporary beds, do they charge at the same rate as for beds inside the wards or do they have a discounted rate? The patients on temporary beds are already putting up with a fair degree of discomfort and inconvenience. Would the Minister agree that as long as the bed is not inside the ward, and inside a room, that they should be eligible for a lower rate, and should be allowed to use their Medisave and MediShield where eligible, as well as receive all the C Class ward subsidies? Thank you.

Mr Gan Kim Yong: Madam, I thank the Member for the questions. Firstly, he asked which are the hospitals that charge for temporary beds in the transit area. The Changi General Hospital and the Singapore General Hospital consider the patients as inpatients once they are taken over by the inpatient team and, therefore, their stay during the Emergency Department after they have been taken over by the inpatient team will be charged according to the wards.

He also asked whether there are different rates charged. When the patients are transferred to the ward, they receive the same level of care and treatment as all other patients. So, generally, they will be subjected to the same charges that are imposed at the respective wards, whether they are B2 or C Classes. But some hospitals do exercise some flexibility, taking into account the environment and whether there is a need to help the patients. So some hospitals do offer reduced charges for some of these wards, taking into account various factors.

—-

Source: Singapore Parliament Reports

Supper Club interview with the Straits Times

I did a two-hour long interview with the Straits Times for its “Supper Club” series, which was published on 18 January 2014. I shared my thoughts on a range of issues, including healthcare financing, public transport, media regulation, education and the Workers’ Party’s approach to political engagement. I also shared about my work as a Non-constituency MP and about my family.

I did a two-hour long interview with the Straits Times for its “Supper Club” series, which was published on 18 January 2014. I shared my thoughts on a range of issues, including healthcare financing, public transport, media regulation, education and the Workers’ Party’s approach to political engagement. I also shared about my work as a Non-constituency MP and about my family.

Click the two links below to read the interview and watch the video.

Part 1:

Gerald Giam: ‘Rethink health-care financing philosophy’
Non-Constituency MP Gerald Giam is the Workers’ Party’s point man on health care issues. In Part 1 of this Supper Club interview, he speaks about what he thinks should be changed in health-care financing and public transport.

Gerald Giam: ‘Rethink health-care financing philosophy’

Non-Constituency MP Gerald Giam is the Workers’ Party’s point man on health care issues. In Part 1 of this Supper Club interview, he speaks about what he thinks should be changed in health-care financing and public transport.

Part 2:

Gerald Giam: ‘We’re a moderate party, not fence-sitters’

In Part 2 of this Supper Club interview, Non-Constituency MP Gerald Giam of the Workers’ Party talks about whether he sees a shift in the Government’s policy approach, the difference between being moderate and sitting on the fence, and his personal life.

Severe bed crunch in hospitals

During Question Time in Parliament on 20 January 2014, several MPs asked the Health Minister what was being done to alleviate the severe bed crunch in public hospitals, which has forced some hospitals to house their patients in tents or on corridors. I asked the Minister if public hospitals had considered converting their higher class (A and B1) wards to C class wards. I also asked whether public hospitals were still marketing their international patient services to foreigners residing abroad.

During Question Time in Parliament on 20 January 2014, several MPs asked the Health Minister what was being done to alleviate the severe bed crunch in public hospitals, which has forced some hospitals to house their patients in tents or on corridors.

I asked the Minister if public hospitals had considered converting their higher class (A and B1) wards to C class wards. This was a suggestion I had made during the Committee of Supply debate in 2012. Back then, I had pointed out that 22% of beds in public hospitals were non-subsidised (i.e., A and B1 class). My assessment is that since A and B1 class wards use up more space per bed, if they can be converted (permanently) to C class wards, hospitals would be able to free up more bed space for patients and this will help alleviate the bed crunch.

The Minister responded that this could not be done because of the re-wiring and re-piping that would need to be done. I am not convinced. If hospitals are willing to permanently convert their A and B1 class wards to C-class wards to maximise space for more beds, the necessary renovation works can be done.

On a related issue, I asked whether public hospitals were still marketing their international patient services to foreigners. Note that this had nothing to do with public hospitals treating foreigners who are already living and working in Singapore. (Of course we cannot deny medical treatment to these foreigners.) I was asking if the hospitals are still pro-actively marketing their premium healthcare services to foreigners residing outside Singapore. The Minister’s response was that these patients “only” take up 2% of hospital beds. But with many hospitals hitting 100% capacity during certain peak periods, wouldn’t this 2% make a difference?

Below is the relevant section of the debate. The full transcript can be found here.

———-

Mr Gerald Giam Yean Song: I have two supplementary questions. First, have the hospitals considered converting the A and B1 class wards to C class wards, especially in this period of bed crunch so as to free up more space for the patients? And, secondly, are the public hospitals still marketing their international patient services to foreigners because these would naturally add to the bed crunch as well?

Mr Gan Kim Yong: Madam, first, let me explain that for the wards in the hospitals, the conversion has to take into account the infrastructure design. It also needs to take into account the manpower capacity as well. Some of the wards in B1 may not be able to be converted into C class wards by simply adding beds because we need to ensure that the pipes are there, the wiring is there, and the system is capable of accommodating more than the number of beds that are currently in B1. But in the hospitals, what they have done is they have taken a very practical approach for patients when the bed capacity is tight. When they need more hospital beds to cater to the demand of the patients, they would allow the patients to be uplodged. Even if they are C class patients, we allow them to be uplodged to B2 or B1 wards. So I think all the private wards are being used as a potential capacity to cater to the need of the patient when the bed demand is high.

On the second point of foreign patients, I think I have replied in one of the PQs earlier. Foreign visitors form a very small component of our hospital beds. Some of them come for day surgeries, some of them are in the emergency and treated as outpatients and they go off. From my recollection, I remember that foreign visitors in our hospitals take up less than 2% of our hospital beds and these are sometimes urgent cases and some of them are already here in the emergency department. From the hospital’s point of view, these foreign visitors do not pose a significant stress on our hospital beds. If you look at the historical trends, as I mentioned earlier, I think extension of the length of stay and rising of proportion of patients aged 65 and above are key drivers of hospital bed demand. Of course, hospital bed occupancy is also a very dynamic number. It varies from day to day as you can imagine. It also varies from hospital to hospital. It depends to a very large extent on the number of emergency admissions and the number of discharges the hospital is able to undertake on each day. So it depends on how many patients arrive at the A&E, how many patients we plan to discharge and, therefore, in certain days, when we plan for a certain number of discharges but there could be a significant number of emergency cases that arrive at the emergency departments, and we have to address them and we may have to hospitalise them. If that situation happens, you tend to see a high bed occupancy rate for that particular day of that particular hospital. Once you admit a patient into a hospital ward, it is not just for one day. Sometimes it takes two or three days. For an elderly, it may take a bit longer. So even for that particular day, the occupancy rate is high because of high admissions. It will take a few days for the occupancy rate to come down even if you have low admissions because the patients will take up the bed for a couple of days, or three-four days, depending on the situation. So it is not just a simple factor. That is why I explained in my answer that a combination of factors will contribute towards a high bed occupancy.

[Source: Singapore Parliament Reports]

Adjournment motion: Easing the cost of healthcare for Singaporeans

While we are all at risk of falling ill, unaffordable medical costs are not inevitable. The Government must reform the way that healthcare is financed in Singapore, so as to ease the healthcare burden on all Singaporeans. This will give all our people peace of mind, knowing that they will be able to afford all necessary treatment if they fall ill.

I filed an adjournment motion on healthcare financing in Parliament on 12 November 2013. This was my speech.

———————-

Madam Speaker,

Thank you for the opportunity to speak on this adjournment motion.

Many Singaporeans are worried about falling ill and not being able to afford their medical expenses. A survey conducted last year by Mindshare, a global media and marketing services firm, found that 72% of Singaporeans felt they “cannot afford to get sick due to high medical costs.”[1]

This echoes the sentiments of many Singaporeans I have spoken to, many of whom are elderly or have sick family members to care for. In particular, the high out-of-pocket payments at the point of treatment are a great source of worry for many.

It is not uncommon to hear accounts of older folks ignoring health problems and delaying visits to the doctor because they fear that medical expenses will be a financial burden to themselves and their families.

Medical inflation in Singapore was almost 9% in 2011 – much higher than general inflation.[2] Our people should not have to face these increasing medical costs alone. The structure of our healthcare financing system is a critical factor in determining whether healthcare is truly affordable for all Singaporeans.

In Singapore, less than one-third of all healthcare costs are paid by the Government.[3] More than 60% of costs are paid by patients out-of-pocket, which includes cash and Medisave. This is much higher than the average of 14% in high income countries, according to data from the World Health Organization.[4]

Is it any wonder then, that Singaporeans are feeling the strain of healthcare costs? High out-of-pocket spending can create barriers to healthcare access and use, because people who have difficulties paying medical bills may delay or forgo treatment even though they need it.

It is a fundamental responsibility of the Government to ensure that all our citizens have access to high quality healthcare based on their medical needs, and regardless of their income.

The healthcare burden cannot continue to be borne so heavily by individuals and their families. Singapore’s population is ageing and healthcare costs are expected to continue rising.

The Government must be prepared to shoulder a much larger proportion of healthcare costs than it currently does. We need to shift away from seeing healthcare as primarily an individual responsibility, and emphasise more government intervention, risk sharing and fairness in financing.

We need to change the way healthcare is financed, so that Singaporeans who fall ill can focus on seeking the most appropriate medical treatment, without worrying about whether they will be able to afford it.

*****

I would like to make a few proposals on healthcare financing to reduce the financial burden on Singaporeans when they fall ill, to improve the efficiency of the healthcare system and contain medical inflation.

MediShield premiums

First, on MediShield.

MediShield is an insurance scheme intended to help cover large hospital bills. However, it does not provide full coverage. Patients need to make hefty co-payments[5], in addition to other claim limits like caps on hospital ward charges, and annual and lifetime claim limits.[6] As a result, MediShield claims covered only 2.1% of total healthcare expenditure in 2011.[7]

In August this year, the Government announced plans to provide expanded insurance coverage under a new “MediShield Life” scheme. These changes to cover all Singapore residents, without exclusions for old age or pre-existing conditions, are certainly welcome. They are consistent with what many Singaporeans and the Workers’ Party have been calling for.

However, I remain concerned about the rising premiums. The Government has already warned that premiums will go up.[8] While I accept that increased coverage will come at a cost, there are two questions we must consider: Should all of these cost increases be borne by policyholders? And will some groups of Singaporeans find the premiums unaffordable?

MediShield premiums rise with age. An 86-year old pays a premium rate that is more than 23 times that of a 20-year old.[9] The elderly shoulder a disproportionate premium burden. Policyholders over age 60 contribute about 36% of total premiums, even though they make up just over 12% of policyholders.[10]

Most of the elderly are retired with little or no income. It is unfortunate that many of those who are least able to afford the premiums are paying the most.

Many of our senior citizens have exhausted their Medisave accounts and have difficulty coming up with money to pay their premiums. Every year, an average of 650 elderly policyholders opt out of MediShield coverage completely.[11] This leaves them vulnerable and without insurance protection, putting them at risk of financial catastrophe if they fall ill.

The Government does not directly subsidise MediShield premiums, although it does give ad hoc Medisave top-ups to the elderly and a Medisave grant to newborns.

I would like to propose that the Government introduce a MediShield premium subsidy programme for all vulnerable groups of Singaporeans. These would include elderly persons with no income and limited savings; people with disabilities; patients who have exhausted their Medisave; low income families; and those who already qualify for Medifund, Public Assistance, ComCare and the Community Health Assist Scheme (CHAS).

The appropriate level of premium subsidies should be automatically extended to them, without a need for them to apply separately. This could help many more Singaporeans to cope with the rising premiums, while ensuring that the MediShield Fund remains solvent.

Annual cap on out-of-pocket payments

While MediShield is intended to help cover the costs of large medical bills, policyholders still have to make co-payments in the form of deductibles and up to 20% in co-insurance. Last year, over 2,400 MediShield policyholders made co-payments of over $10,000 each.[12]

These co-payments can be financially crippling on their own. Would MOH explore the introduction of an annual cap on out-of-pocket co-payments made by each patient. Any medical bills above the cap would be borne by the Government.

Such schemes are a feature in most developed countries, including Japan, South Korea and New Zealand.[13] It is also one of the key consumer protections in the Affordable Care Act in the US.

An annual cap on out-of-pocket payments will limit the financial risk that individual patients are exposed to, and help allay the anxiety of many Singaporeans about uncertain medical expenses.

Co-payments

From the Government’s perspective, co-payments are necessary to discourage over-consumption. The Government’s fear is that “free” healthcare will escalate costs, and become fiscally unsustainable.

However, people do not consume healthcare like they do other goods and services. Most people visit doctors rather grudgingly – usually when they fall sick and have obvious symptoms. Demand for healthcare is therefore not unlimited.

A health insurance experiment conducted by the RAND Corporation, involving over 7,000 patients in the US, found that indeed, higher co-payments reduced the consumption of healthcare. However, the experiment also found that co-payments caused patients, especially the poorer ones, to reduce the use of medically necessary care. The experiment found that poor patients with hypertension tended to avoid treatment, leading to significantly higher mortality rates.

High co-payments have also been shown to have an effect on patients adhering to their prescriptions. In another experiment by researchers from Harvard Medical School, nearly 6,000 patients who had just suffered a heart attack were prescribed drugs that reduced the chance of another attack. Half of them had their co-payments for these drugs waived, while the other half paid the usual fee. The result showed that more patients in the zero co-pay group took their medication regularly. They saw their health improve, with lower incidences of stroke and repeat heart attacks than the patients who had to co-pay. Interestingly, the elimination of co-payments did not increase total spending by patients and insurers, and even reduced spending in some areas.[14]

The lesson from these two experiments, is that if co-payments are too high, poorer patients may be deterred from seeking necessary treatment. Similarly, it is difficult enough to get patients to adhere to their prescriptions, and high co-payments could make it even harder. This could have knock on effects like higher rates of hospital re-admissions, which will cost both the patient and the system more in the long run.

Means-testing

The Government’s claim that no one will be denied healthcare because of inability to pay is cold comfort for some Singaporeans who regularly forego medical appointments or cut back on prescribed medication because of the high costs and the difficulty in obtaining financial assistance.

A few weeks ago, I met an elderly resident at his home in Bedok, who suffers from COPD[15], a chronic lung disease. He is unable to work and has no children to support him. When I asked him how he was coping with his medical expenses, he told me that he was using his Medisave but had almost exhausted it. I was disturbed to learn that he often skipped medical appointments and cut back on his medication just to save money. I told him that there was financial assistance available, and that he should not compromise on his health. But he told me that he had given up applying for assistance because of all the documents that he had to submit, and interviews he had to attend, for the purpose of means-testing.

Recently, a colleague sent me a photo of a large banner at the counter of a pharmacy at a government restructured hospital that read: “Please inform our staff if you do not want to take the full supply and/or if you need to know the total cost of your medication”.

These two situations illustrate how many Singaporeans find themselves making hard choices between getting the necessary treatment and saving money, and how the onerous process of means-testing may be deterring some needy patients from obtaining financial assistance, and therefore treatment.

I have spoken in this House before about how all means-testing should be done without the need for patients to physically submit income documents. The patients and their families should only need to give their consent for the provider to assess their income records with the relevant government agencies like CPF Board and IRAS.

This facility should be available at all institutions, whether private or public. The providers of all assistance schemes, including Medifund, hospital endowment funds and other charity schemes, should be able to access these records. This will better ensure that patients receive all the financial assistance that they qualify for.

Better still, can vulnerable groups of patients be pre-qualified so that they don’t even have to submit any applications before receiving financial assistance? Currently this is already being done for the CHAS cardholders receiving outpatient treatment. MOH should consider extending the same for inpatient financial assistance schemes.

*****

Containing healthcare costs

As I call for an expansion of the role of the Government in easing the healthcare burden on Singaporeans, I am also aware of the many challenges that our healthcare system faces in containing ever-increasing costs. We need to look into ways to contain healthcare costs while still improving patient outcomes.

Integrated healthcare

Many of the current measures to contain healthcare costs focus on curbing consumption by patients. However, most patients do not have sufficient knowledge to decide on the type of treatment they need. These decisions are usually entrusted to healthcare providers, which include doctors and hospitals.

Providers therefore drive the bulk of healthcare spending through their decisions to admit patients to hospital, order medical tests, prescribe drugs and charge fees.[16] Therefore, if we seek to control costs, we need to actively engage providers.

To achieve this, all providers – including GPs, hospitals and preventive care providers – must be made collectively responsible for providing a full spectrum of care for patients. These providers should cooperate and share patient information with each other, in order to make more accurate diagnoses and coordinate patient care.

They should focus on keeping patients healthy and ensuring they take their medication regularly. This will minimise hospital re-admissions, investigations and treatment, all of which are much more expensive. Providers should be paid based on their achievement of measured quality improvements, not simply the volume of patients they see or the level of fees their patients pay.

All this could lead to healthier patients and lower costs for both patients and the system.

Health technology

Technology should be used as a “force multiplier” in the face of limited manpower in our healthcare system. While Singapore is no laggard in healthcare technology, its potential is not being fully realised. Often, the problem lies not with the lack of technical expertise, but a lack of adoption.

One example of this is the National Electronic Health Records system (NEHR). The NEHR enables patient health records to be shared across the healthcare system. It can reduce medical errors, and improve productivity and coordination between providers. This will lead to better diagnoses and treatment, and reduced medical costs.

The NEHR has been rolled out to all public hospitals, polyclinics and long-term care providers. However, while over 5,000 clinical users have access to the system[17], what percentage of these users are fully utilising the functionality of the system? Is usage lower than it should be, due to usability issues or some providers still preferring to use handwritten clinical notes? How is MOH ironing out these issues to increase usage of the system?

The usage of NEHR in the primary care sector is lagging even further behind. As at March this year, it had been rolled out to only about 50 out of the 2,000 private GP and dental clinics.[18]

The Government has already invested $172 million to develop Phase 1 of the NEHR, and is paying about $20 million each year in maintenance costs.[19] The subsequent phases are expected to cost more. While the Government deems it important to recover the cost of developing and maintaining the NEHR, the goal of cost-recovery must not impose a roadblock to the full adoption of the system by all healthcare providers in Singapore. It is important to ensure that all providers, including GPs and specialist outpatient clinics, enter the necessary clinical data into the system, so that the full benefits of having electronic health records can be realised.

*****

Madam, healthcare is an issue that is close to the heart of every Singaporean. While we are all at risk of falling ill, unaffordable medical costs are not inevitable. The Government must reform the way that healthcare is financed in Singapore, so as to ease the healthcare burden on all Singaporeans. This will give all our people peace of mind, knowing that they will be able to afford all necessary treatment if they fall ill.


*****

[1] Mindshare “3D” Survey 2012, quoted in Hooi, Joyce, “Singapore’s emigration conundrum”, Business Times, 6 October 2012.

[2] Towers Watson, “2012 Global Medical Trends Survey”.

[3] Singapore Parliament Reports (Hansard), 13 May 2013, “Healthcare spending and funding sources”.

[4] World Health Organization, “World Health Statistics 2013”, p.138 (“Health Expenditure”).

[5] The MediShield deductible is $1,500 for Class C wards and $2,000 for Class B2 and above wards. Co-insurance is between 10% and 20% of bills.

[6] Claim limits include a cap on normal hospital ward charges of $450 per day, a lifetime claim limit of $300,000 and a maximum coverage age of 90 years.

[7] Singapore Parliament Reports (Hansard), 13 May 2013, “Healthcare spending and funding sources”.

[8] AsiaOne, 26 September 2013, “’We have made significant progress’: PM Lee”.

[9] Ministry of Health, MediShield Premiums. A 20-year old pays a premium rate of $50 per year, while an 86-year old pays $1,190 per year.

[10] Singapore Parliament Reports (Hansard), 21 October 2013, “Age Profile of MediShield Policyholders”; and MediShield Premiums (Ministry of Health).

[11] From 2010 to 2012, an average of 650 MediShield policyholders aged 60 and above opted out of MediShield coverage each year. Source: Singapore Parliament Reports (Hansard), 13 May 2013.

[12] Singapore Parliament Reports (Hansard), 21 October 2013, “Payments made by MediShield policyholders for cumulative MediShield Basic co-insurance”.

[13] Paris, Valérie, et. al (2010), “Health Systems Institutional Characteristics: A Survey of 29 OECD Countries”, Table 10 (Exemptions from copayments), p.24.

[14] Niteesh K. Choudhry (2011), “Full Coverage for Preventive Medications after Myocardial Infarction”, New England Journal of Medicine, 1 December 2011. Mentioned in Mullianathan, Sendhil, “When a Co-Pay Gets in the Way of Health”, New York Times, 10 August 2013.

[15] Chronic obstructive pulmonary disease.

[16] Rand Corporation (2013). “Solving the Health Care Cost Challenge: Leveraging RAND Expertise”. Retrieved from: http://www.rand.org/health/feature/health-care-cost.html.

[17] Singapore Parliament Reports (Hansard), 12 March 2013.

[18] Ibid.

[19] Singapore Parliament Reports (Hansard), 13 May 2013.

Health screening

We know that health screening is useful for early detection of chronic diseases and other illnesses like cancer. This can enable early treatment which means a better chance of recovery. The Health Promotion Board has been sending out letters to all Singapore residents aged 40 and older to attend health screening, yet from the Minister’s reply to my parliamentary question on 21 October 2013, it appears that the participation rate is quite low, and even MOH agrees that there is room for improvement. Here is my PQ and the Minister’s answer.

We know that health screening is useful for early detection of chronic diseases and other illnesses like cancer. This can enable early treatment which means a better chance of recovery. The Health Promotion Board has been sending out letters to all Singapore residents aged 40 and older to attend health screening, yet from the Minister’s reply to my parliamentary question on 21 October 2013, it appears that the participation rate is quite low, and even MOH agrees that there is room for improvement. Here is my PQ and the Minister’s answer.

What can we do to increase the participation rate?

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Mr Gerald Giam Yean Song asked the Minister for Health from 2011 to 2013 to-date (a) how many invitations have been sent annually to residents of 40 years old and older to go for health screening under HPB’s Integrated Screening Programme (ISP); (b) how many residents took up those invitations in each of those years; (c) what are the charges for such screenings; (d) what is the rationale for charging such screenings; (e) what are the KPIs the Ministry uses to measure the success of the ISP; and (f) how does the Ministry rate the success of the ISP.

Mr Gan Kim Yong (Minister for Health):

The nationwide Integrated Screening Programme (ISP) offers affordable and convenient screening for high blood pressure, high blood cholesterol and diabetes, as well as breast, cervical and colorectal cancers to Singapore residents for the recommended age-groups. Under the ISP, Singapore residents who reach 40 years of age receive invitation letters to go for the various ISP screening tests at GP clinics. Those who are screened receive rescreen invitations according to the recommended intervals in subsequent years for the various screening tests. To enhance accessibility, the Health Promotion Board (HPB) collaborates with partners such as People’s Association as well as companies, to bring subsidised health screening to residents in the community and workplaces.

The total number of residents aged 40 years and older who received 1st invitation letters and rescreen invitations were 490,000 in 2011 and 200,000 in 2012. In 2011, 36,000 people attended health screening under the ISP and 19,000 people in 2012. The total number of invitations and residents who attended health screening was higher in 2011 because 365,000 invitation letters were sent to women aged 50 and above who were due for their mammogram screening in conjunction with the launch of the Celebrate Wellness (CW) programme, a HPB partnership initiative with WINGS and Toteboard.

Costs for screening services under the ISP have been kept affordable. For example, the cost of the blood tests in the GP clinics to screen for diabetes and high blood cholesterol is $8, the cost of Pap smear to screen for cervical cancer is $15, and the cost of the Faecal Immunochemical Test (FIT) which screens for colorectal cancer is $30. This is in addition to the GP consultation fees. Lower-income Singaporeans receive all these tests for free and only need to pay GP consultation fees. For community based screening, the cost of blood tests to screen for chronic diseases is $2 to $5.

Under the ISP, GPs can refer women for mammography for breast cancer screening at Breast Screen Singapore (BSS) centres at 16 polyclinics, at a subsidised cost of $50 for citizens. Women aged 50 and above can use Medisave to pay for mammograms at all Medisave-approved screening centres, including the BSS centres.

Patients are charged for screening under the ISP as the health of an individual is a shared responsibility. We have also targeted government subsidies at those who need help most. To make screening even more affordable and accessible, the Community Health Assist Scheme (CHAS) has been enhanced to increase the coverage of subsidies for screening tests under the ISP. From 1 January 2014, the recommended tests will be fully subsidised by the government for CHAS patients at accredited GP clinics. They will also enjoy subsidies for GP consultation charges of up to $18.50 per visit, for their screening and subsequent follow-up consultations, up to two times a year.

The results have been encouraging. In the National Health Survey 2010, among Singaporeans aged 40 to 69 years, 71% had been screened for high blood pressure in the past year; and 61% and 64% had been screened for high blood cholesterol and diabetes respectively in the past three years, in accordance with the recommended frequency of screening. In terms of cancer screening, 48% of women aged 25-69 years had undergone the Pap smear test within the past three years; and 10.3% of Singapore residents aged 50-69 years had a Faecal Occult Blood Test (FOBT) within the past one year.

Nevertheless, there is room to further improve the screening participation rate. My Ministry will continue to look into how we can encourage more Singaporeans to undergo appropriate screening, and make screening even more convenient and affordable.

Age profile of MediShield policyholders

I asked the Minister for Health on 21 October 2013 for the number of MediShield policyholders in each age group. Here was his written reply to my parliamentary question.

I asked the Minister for Health on 21 October 2013 for the number of MediShield policyholders in each age group. Here was his written reply to my parliamentary question.

————————————

Mr Gerald Giam Yean Song asked the Minister for Health how many MediShield policyholders are currently in age ranges of (i) 0-20 years (ii) 21-30 years (iii) 31-40 years (iv) 41-50 years (v) 51-60 years (vi) 61-65 years (vii) 66-70 years (viii) 71-73 years (ix) 74-75 years (x) 76-80 years (xi) 81-83 years (xii) 84-85 years and (xiii) 86-90 years.

Mr Gan Kim Yong (Minister for Health):

As at June 2013, 3.6 million members, or 93% of the resident population, were covered under MediShield. The breakdown of MediShield policyholders by age group is presented below.

Age Group

MediShield Policyholders

0-20

881,800

21-30

505,100

31-40

598,500

41-50

598,200

51-60

537,800

61-65

189,200

66-70

106,300

71-73

51,500

74-75

29,700

76-80

46,800

81-83

16,500

84-85

6,300

86-90

2,600

Total

3,570,200

The maximum coverage age for MediShield was recently raised from 85 to 90 years in March 2013, in view of the increasing life expectancy of Singaporeans. As a next step, with the proposed move to MediShield Life, we will be studying enhancements to provide universal, lifetime coverage for all Singaporeans, including the most elderly.

Compulsory vaccination for children

Parliament sitting date: 16 September 2013

Mr Gerald Giam Yean Song asked the Minister for Health (a) what is the rationale for some vaccinations, including the pneumococcal disease vaccination, under the National Childhood and Adolescent Immunisation Schedule which are required for Primary 1 registration being chargeable for Singaporeans at polyclinics; and (b) whether the Ministry will consider making all vaccinations under the Immunisation Schedule free for Singaporeans.
Mr Gan Kim Yong : To help parents defray the cost of childhood vaccinations, the use of Medisave was extended to cover the cost of all vaccinations in the National Childhood Immunisation Schedule (NCIS), up to $400 per account per year from June 2013. The Government has also provided a Medisave Grant of $3,000 for all newborn Singaporeans which can be used to pay for these vaccinations.

In addition, vaccinations under the NCIS that confer strong herd immunity against the respective diseases for the whole population are offered free for citizens at the polyclinics. In doing so, we hope to encourage higher up-take of these vaccinations and achieve adequate coverage for the population.

Parents are required to produce records of their child’s immunisation certificates at Primary One registration, for BCG, diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella and hepatitis B, all of which are free for citizens at the polyclinics.

MOH will continue to regularly review the financing framework of the NCIS to ensure its relevance and affordability to Singaporeans.

Source: Singapore Parliament Reports (Hansard)

Projected increase in MediShield payouts under MediShield Life

I asked this question during the 16 September 2013 sitting of Parliament. I wanted to find out how much more in claims MediShield is expected to bear under the proposed MediShield Life scheme, which is going to cover all Singaporeans, including those above the age of 90 and those with pre-existing health conditions.

I asked this question during the 16 September 2013 sitting of Parliament. I wanted to find out how much more in claims MediShield is expected to bear under the proposed MediShield Life scheme, which is going to cover all Singaporeans, including those above the age of 90 and those with pre-existing health conditions. I was expecting the Government to have already done its actuarial calculations to arrive at an answer. However, the Minister was not ready to reveal the numbers yet (or perhaps the full calculations had not been done yet).Singaporeans will need to wait until at least next March (i.e., the Committee of Supply debate) to find out the details of the MediShield Life scheme.

One thing is clear: Claims are going to go up. The question therefore will be: How much more will premiums rise, and will the Government be prepared to step in the reduce the premium burden on Singaporeans?

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Mr Gerald Giam Yean Song asked the Minister for Health what is the projected annual increase in MediShield payouts if (i) all Singaporeans and Permanent Residents are enrolled (ii) all pre-existing, congenital and neonatal conditions are covered and (iii) the maximum coverage age is removed.

Mr Gan Kim Yong (Minister for Health): Mdm Speaker, as part of the overall healthcare financing review to ensure that healthcare remains affordable for all Singaporeans, MOH is studying the introduction of better coverage for large bills and moving to life-long MediShield coverage for all Singaporeans.

As the move to MediShield Life is a major policy shift, we will have a public consultation exercise later this year to seek Singaporeans’ views on the proposed MediShield Life. The details and costs of the MediShield Life, including the likely impact on the payouts from MediShield Life if all pre-existing conditions and all residents are covered for life, are currently under study. More details will be shared during the public consultation exercise.

Mr Gerald Giam Yean Song (Non-Constituency Member): Madam, I have three supplementary questions. First, my concern is that the increased coverage will also come with higher premiums. While I support the increased coverage, my concern is that these higher premiums will be a financial burden on some members, especially the elderly and the low income. So, my questions are: Is the Government planning to subsidise MediShield Life premiums as part of its overall plan to increase the healthcare budget, because currently MediShield is completely self-funding and receives no Government subsidies? Secondly, can the Government provide more details about the Pioneer Generation Package that was announced during the National Day Rally? Would it be means tested and what is the cut-off age? Lastly, when will the full details of MediShield Life be announced?

Mr Gan Kim Yong : Mdm Speaker, first let me explain that today, the Government already indirectly subsidises MediShield because the Government provides top-ups into Medisave, and Medisave is being used to pay for the premium for MediShield. So, indirectly there is Government subsidy for MediSheild, particularly for the lower income. Going forward, with MediShield Life, as the Member has rightly pointed out, with enhanced benefits, the pay-outs will increase and that is the objective of enhancing the benefits, and therefore the premium has to go up as well.

The Government is very conscious about the impact of higher premiums and therefore we have already made the commitment that we will make sure that the lower income as well as the older Singaporeans who may not have sufficient savings will be looked after. We will make sure that the premiums, with Government subsidies, will be affordable for them. That is the first question.

The Member also asked about the Pioneer Generation Package. The details are being worked out now. In due course, we will reveal more details on who will qualify for Pioneer Generation Package, and what is provided for in the Pioneer Generation Package. I urge the Member to be patient and we will reveal that in time.

Last question is about the details of MediShield Life. We will have a public consultation. We are still working on MediShield Life and what form it will take. But the key parameter is that we want to make sure that all Singaporeans will be included and they will also be included throughout their lives. Therefore, we will remove the age limit on MediShield Life.

As for the other features, for example, how we can enhance the payouts, how we can help to reduce the co-payment especially for the larger bills, these are the details that the Ministry is working on now. During the public consultation, we will share more details. And we hope to be able to give even more details, and the broad shape of the scheme by the next Committee of Supply (COS) debate.

Source: Singapore Parliament Reports (Hansard)

Means testing for family income (MOH)

I hope MOH will review its means-testing process to ensure that it does not burden patients or their family members, so that patients receive all the subsidies that they are eligible for. To reduce the hassle for patients, can means-testing be conducted without the need for the patient or his family to submit their income documentation? The process should be automated so that the patient and his family only need to give their consent for the hospital to access their income records with CPF Board or IRAS. This is much more convenient for the patient, and it better preserves their confidentiality.

This was my speech at the Ministry of Health Committee of Supply debate in Parliament on 12 March 2013.

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Currently, all hospitals and nursing homes conduct means-testing to determine a patient’s eligibility for government subsidies. Patients have to submit documentation to prove their income and that of their family members. These include up to three months’ of payslips, CPF contribution statements or income tax returns.

Obtaining salary documentation is onerous for some patients, including those who are not IT-literate, who do not have a SingPass to retrieve their CPF statements, or are odd job workers who are not issued payslips. Some need to contact their employers to request for letters to prove their income. Others may have difficulty obtaining the documentation from family members, who may not want to reveal their income or may be estranged from the patient.

All these present administrative and emotional burdens to patients, at a time when they are already saddled with worry and pain from their illnesses. As a result, many of them do not complete their applications and lose out on receiving subsidies that could ease the cost of their treatment.

I hope MOH will review its means-testing process to ensure that it does not burden patients or their family members, so that patients receive all the subsidies that they are eligible for.

To reduce the hassle for patients, can means-testing be conducted without the need for the patient or his family to submit their income documentation? The process should be automated so that the patient and his family only need to give their consent for the hospital to access their income records with CPF Board or IRAS. This is much more convenient for the patient, and it better preserves their confidentiality.

I note that this is already being done for CHAS (Community Health Assist Scheme) applications. Can the same be done for all hospital and nursing home means-testing?

Parliamentary Questions: Rental housing, MRT overcrowding and healthcare expenditure

During Question Time in Parliament on Monday (21 November 2011), I asked five questions on the issues of rental housing, MRT overcrowding, MediShield insurance premiums and claims, Medifund claims and healthcare costs vis-a-vis Singaporeans’ household expenditure. Here are the salient points from the ministers’ answers and debate.

During Question Time in Parliament on Monday (21 November 2011), I asked five questions on the issues of rental housing, MRT overcrowding, MediShield insurance premiums and claims, Medifund claims and healthcare costs vis-a-vis Singaporeans’ household expenditure. Here are the salient points from the ministers’ answers and debate.

Rental housing

I asked National Development Minister Khaw Boon Wan if his ministry would consider allowing those earning more than $1,500 a month to still rent flats from the HDB, but pay higher rental rates.

Currently HDB rules prohibit households earning more than $1,500 a month from renting from HDB, where they enjoy significant rental subsidies. The minister had said individual appeals from those earning slightly more than the threshold are allowed on a case-by-case basis. He said that the government preferred to encourage people to buy flats rather than rent. Citing statistics from recent sales of Built-to-Order (BTO), or new, HDB flats, he pointed out that new three-room flats were within the purchasing power of even households earning less than $1,500 per month, taking into account the housing grants available.

However, from my meetings with residents during meet-the-people sessions (MPS), I have encountered many who earn slightly more than $1,500 a month yet cannot afford to buy BTO flats. Some had just sold their flats, due to divorce or financial difficulty, and could not afford to pay the resale levy on the profits of their sale. Others needed housing urgently and could not wait for two to three years for the BTO flat to be built. In short, many of these residents are shut out of the BTO market and had no choice but to bunk in with friends or family in very crowded conditions. They would usually come to MPS when their friends or family members were threatening to evict them. Rental from the open market is not really an option, since they would need to pay over $800 just for a single room.

Hence my suggestion was to have a middle tier of public rental rates, somewhere in between the $200 or so that HDB currently charges and the $800 open market rental rate, for those who earn beyond the $1,500 income threshold but are not able to buy BTO flats.

The minister said his ministry will look into this suggestion and that he belongs to the “school of thought” which agrees that exceptions can be made for these families.

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