Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
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“Our plan is to keep Alexandra Hospital temporarily for a few years while the new general hospital in the west is being built. The exact timing and location are being studied.”
“Mr Speaker, Sir, the supply of acute hospital beds must keep pace with increasing demand, as our resident population expands and ages. We try to match supply and demand, but it is quite a challenge to do so perfectly given the long lead time in putting up new hospitals. Our current bed situation is tight, particularly in the Tan Tock Seng Hospital as it is the only hospital serving the large population in the north besides its own large catchment area. The over-crowding in Tan Tock Seng Hospital in turn causes spill-over to the other hospitals, especially National University Hospital and Changi General Hospital. There will be relief when the new general hospital in Yishun opens in three years' time. Meanwhile, we are adding new beds to existing hospitals. Since the beginning of this year, we have added 81 beds in Tan Tock Seng Hospital and NUH. All are subsidised beds. Another 67 beds in NUH and Changi General Hospital will be opened in the second half of this year, ie, over the next few months, also in the subsidised wards. We will continue the incremental expansion wherever practical until the new general hospital in Yishun opens. As our resident population will continue to expand and age, demand for new hospital beds will continue to rise even after the new general hospital is fully opened with 550 beds around 2012. Our rough projections suggest that we will need 60-100 new beds per year until the population stabilises. A significant proportion of these beds will be in the subsidised wards. We are planning ahead. A new general hospital in the west will be built during the next few years. Otherwise, National University Hospital may become as over-crowded as Tan Tock Seng Hospital is today.”
“Yes, we work in a humane industry and we would try to be as compassionate as we can. I think hospitals do exercise flexibility. I did ask for some data from SGH, in particular, on applications and what is the success rate. By and large, they said that for outpatients, about two-thirds have a successful downgrading. For inpatients, about 1% of Class A and B1 patients have successfully been downgraded. By and large, the hospitals do try to assist as much as they can, but they really need the help of the family members to cooperate. Where children are not forthcoming in providing information, or worse, in helping to pay the bills for their parents, I think society as a whole must encourage the children to do so because the failure of them to do so means that you and I have to look after their parents, which I do not think is the right way society ought to be organised. GREEN CARS (Separate category of Certificates of Entitlement) 8. Dr Lim Wee Kiak asked the Minister for the Environment and Water Resources what is the long-term target for proportion of clean cars on our roads and whether his Ministry will push for a separate "green car" category of Certificates of Entitlement to increase the uptake of 'green cars'.”
“As I said earlier, we will try to streamline. But, sometimes, the difficulties are that patients are unable or unwilling to disclose the necessary information. Dr Fatimah works in SGH. So I specifically asked SGH's medical social workers about the processes for outpatient downgrading, and they said by and large they are able to do it smoothly. They make sure that the decision is made before the follow-up appointment. So if the follow-up appointment is in a few weeks' time and so long as it is done in time for the next appointment, I think that should be adequate. But if a patient is unable or unwilling to provide the information, I hope the doctor can help counsel the patient to do so. He has to cooperate with the medical social worker, and we will try to facilitate it as much as we can.”
“Mr Speaker, Sir, public hospitals offer different classes of ward at different levels of subsidy so that patients can choose according to their budget. While clinical care is the same, comfort and other non-clinical service levels do differ. Before admission, hospitals will advise the patients on the estimated bill sizes so that they can make an informed choice. There is no means-testing at this stage and patients are free to choose. Subsequently, a higher-ward class patient may seek a downgrading to a subsidised ward. At that stage, we will require means-testing. It takes about two days to process the application. But sometimes it takes longer, not because the procedures are cumbersome, but because the patients are unable to produce relevant documents to support their applications. We will continue to streamline the process. Unfortunately, the necessary step of getting income information and family particulars cannot be avoided in any means-testing process.”
“This gives me the opportunity to explain a little bit about ElderShield, and the difference with schemes like MediShield. ElderShield is more like life insurance. MediShield is based on reimbursement. So if you stay three days in hospital, you get so many dollars, if you stay five days, you get so many dollars, and you claim accordingly. But ElderShield is really like life insurance. The premium is a fixed rate for the rest of your life, depending on when you come in. If you come in earlier, your rate is cheaper. If you come in late, your premium rates are higher. Likewise, for life insurance, there are gender differences. There are differences between the tropics and temperate countries because life expectancy is shorter in the tropics than in the temperate countries. All these are actuarial computations of probabilities and so on. Women, being a stronger sex, live longer, so their premium rates are higher. I would like to be a woman in that regard.”
“I must admit that this is a level of details which I am not too familiar. But since the Member has mentioned it, I would take a look as we are at the stage of reforming ElderShield. We have two objectives. I want to keep the basic product as cheap as possible and, secondly, I want to allow payout as high as possible, so that more people can benefit. There is always a trade-off and we have to make that judgment call. That is why, at the end of the day, I still prefer my approach, which is, to keep the basic cheap and really basic, with no frills, and then let people who can afford, top it up. How do the mentally ill then come in? It is a tricky problem which we have to spend some time thinking about that. Assoc. Prof. Kalyani K Mehta: On the same subject of ElderShield, Sir, I would like to give a little feedback and seek some clarifications since the Minister is looking into ElderShield, to revising it. One of the feedback has been why are women asked to pay higher premiums than men for ElderShield? I know this is to do with actuarial figures and stuff like that, that women live longer, therefore, there is a higher chance that they are likely to use ElderShield. But it would be good if the Minister could look at this again and perhaps find a way to make it gender equitable.”
“Provided everybody comes in, buy a MediShield or ElderShield, it should be all right for maybe 90% of the cases. But still, there will be some who drop through the net. Then, we have Medifund. We will look at each case individually and the Medifund Committee of wise men and women will take a look, and I am sure they will assist them. I think this is a much better system than to have a very generous subsidy system that applies to all and sundry. When you do that, you will be over-subsidising many who actually do not need that level of subsidy. And because money is not unlimited, what it means is that the budget which is left to help the really needy, would be reduced and diminished. I do not think we should do that.”
“As to the question of what subsidised patients are paying, I monitor those carefully. Part of my reason for publishing many information is that it gets into the consciousness out there, both among the public, the referring GPs and also, very importantly, to the doctors and the hospitals. Once we allow diversity in management, we cannot be micro-managing every issue and decide on how much we should charge for Panadol or Lomotil. I think I would have no time to sleep and it is a wasteful way of doing things. It is better that we make sure we have the right people in charge and they make their individual decisions. My job as regulator is to collect relevant information and periodically analyse those data and publish them so that the doctors in hospitals can then learn from this collectively. If their fees go up ridiculously, there will be a restraint on them. I think the efforts have been, at least from my point of view, positive and we will continue to push along this line. The bottomline is the question that Mdm Halimah asked: are our services still good and reasonably affordable? My honest answer is: it is good and it is affordable. For a small number of cases, it is not affordable, sometimes, through their own fault, because we have always stressed that we have a good 3M system, but it is good only if you are in. If you work as a self-employed and refuse to pay Medisave, then of course, even a $100 bill may be unaffordable. But even if you earn $1,000, but provided you save in Medisave regularly for many years, a $2,000 bill is affordable. So that is the key, you must be in. Let us persuade our residents who are out to be in. I think Workfare this year is formulated to encourage the casual workers to come in.”
“Sir, I thank Mdm Halimah for her further elaboration. I spent some time yesterday in my speech talking about the diverse needs of the patient and, therefore, the need for diversity. From my point of view, that is a critical point. You can have a very uniform system which was what I grew up with when I was a young officer starting my career in Singapore. From the headquarters' point of view, it is the simplest - one circular and everybody follows, everybody wears the same uniform, etc. But I think that world is gone. And I gave some illustrations yesterday - different kinds of needs. It is very hard for us to group them into simple boxes. For general policies, we have no choice but to simplify. But reality requires us in each case, to try to be able to meet the unique needs. That is why we restructured the hospitals and we have clusters, and we continue to evolve. I do not see that the current structure will go on forever. I am sure we will continue to evolve. Even during my term as Health Minister, I am quite sure that it will continue to evolve. And yes, what it means is that, once you allow that kind of diversity, we are paying a price for it. We are paying some price for diversity. So the challenge in management is to know what we should standardise and centralise, and what we should allow diversity. There are always trade-offs and we will continue to make that kind of trade-offs and judgement calls. Sometimes, we miss something and when a feedback is received, we will take a look at them. That will be my general comments on this point about duplication and higher costs. I think it is inevitable, provided the price, compared to the benefits that we get out of diversity, is worthwhile.”
“If we are too strict in taking them in, then we are missing out on opportunities. So I would rather be a little bit loose in taking in, but be very prompt, firm and decisive in throwing them out. If you find that the fellow is just not up to our ethical standards and competence, we will be the first one to throw him out. So, yes, it is not chasing numbers. Numbers are important, but quality as well because, at the end of the day, it is the Singapore brand of medicine which is at stake here. Assoc. Prof. Kalyani K Mehta (Nominated Member): Mr Chairman, Sir, I have three points of clarification. The first one is very straightforward. In the step-down care system of health and social services, is the RAF form mentioned yesterday used across all the 20-odd services? Is there any system of seeking feedback from all the different professionals, such as doctors, nurses, social workers, etc? Is there any system of seeking feedback as to the adequacy of the form in order to improve it? Lastly, for means testing of MOH and MCYS services in the step-down care sector, are there steps being taken to make the two consistent, because I believe there is a little bit of inconsistency there?”
“On both points raised by Dr Neo, I totally subscribe to her views. One is that we must continue to train, because medical science continues to evolve and we cannot stand still. HMDP, which is a programme that we created many years ago to send doctors overseas and to attach them to some of the best centres of the world, continues to expand, and we are pumping in more money each year. More importantly, in recent years, we have extended it beyond doctors, because the medical system comprises - no doubt, doctors form a big part - also nurses and allied health workers who are very important. Each year, when I give away such scholarships to our staff, I am glad to see that besides a large number of doctors, also large numbers of pharmacists, radiographers, etc, and we should continue this way. The second point is about the quality of intake of foreign doctors. Yes, that is why we study the medical degrees very carefully before we put them on the approved schedule. I have progressively expanded it. My operating principle is a simple one: all the top medical schools of major countries ought to be on our approved list. There is no reason to exclude them. But it does not mean that once a degree is recognised, you can just come in and set up shop, because, first, we only give a conditional registration. So when you come in, you must have an employer and, practically all the time, it is the public hospitals. My point to the CEOs is this: yes, you can have a recognised degree, but you never know until the fellow appears and works for a few weeks or months. Please watch over him very carefully in the first few months because, whether it is medical competence, or more importantly, it is his ethos and values, and those are very hard to check on paper.”
“There are softwares that can pick up very quickly; if you have a hundred patients, why are you accessing 1,000 patients' records? There is no reason for you to do so. Unfortunately, it does happen. The system is able to pick it up. I remember there was a case where we have to terminate the service of the staff.”
“Sir, this is indeed a very important subject, and that is part of the reason why "one Singaporean, one EMR" will take some time to implement. Therefore, we will have to do it gingerly and carefully. Otherwise, once information starts going around in the virtual world, it is very troublesome. All countries are grappling with this problem. My approach is to take it step-by-step. That is why we focus on public hospitals first, because it is easier for us to manage our own doctors and nurses. Once we are confident - and we are reasonably confident - my next step is going down to step-down care, eg, nursing homes, VWOs, etc. The key point is that we will have to decide what are the critical data. Some data are so sensitive that they will never be shared. So it does not mean that "one Singapore, one EMR" means all the gory details are out in outer space. It cannot be. We have to decide. For example, issues like HIV and sexual diseases, these are data that we keep highly confidential. In any case, do not get the wrong impression that electronic medical records will worsen this problem. This problem exists even in paper form. When we run hospitals, we know that with medical records on paper, any hospital staff with a badge, can walk into the records office, in the name of checking out the medical records of their patients. You never know what happens in the office. Whereas now, with electronic medical records, we can actually audit them. So, let us say, we have a staff who, for various reasons, checks into the medical records of all kinds of patients who are not his patients, in the paper world, it is very hard to audit. But in an online world, it is so easy.”
“As for rich foreign patients crowding out the poor, I am very alive to this concern. The solution is to ramp up supply of doctors, nurses and bed, and this is what we are doing, as I outlined yesterday. The solution is not to say we do not treat rich or foreign patients in public hospitals. Remember that doctors are mobile. While they are mindful of their public duties, they also want to treat a range of patients, rich and poor. If we unduly restrict their practice, some will simply pack up and go, and the poor will then be denied of their expertise. But I agree fully with Mdm Halimah that our accounting should be clear and that we do not end up with subsidised patients subsidising the rich patients by unwittingly shouldering part of the cost of private care.”
“Mr Chairman, Sir, I will continue with my reply yesterday which was interrupted. Mdm Halimah's queries are related to two important subjects, ie, how best to subsidise the needy, and how to ensure that care for the rich does not affect care for the poor. We do not apply the subsidy formula mechanically, eg, every Class C bill, subsidise 80% or Class B2 bill subsidise 65%. This is because there are many ways to treat the same illness. For instance, we promote generic substitution, ie, the use of generic medicine which is cheaper but effective, instead of branded goods. This way, we save on healthcare costs. But sometimes, some subsidised patients insist on getting the more expensive branded medicine. We oblige, but we get them to pay more for the non-standard drugs or implants. Otherwise, the subvention budget would be depleted by such subsidised patients who obviously can afford better care and are demanding more. This will disadvantage the truly needy who accept the basic but adequate care that we prescribe. And there is an added reason. For very expensive care, such as in the intensive units, we actually subsidise much more than the standard 65% or 80%. The cost of running ICU is very, very high. And if we were to simply apply the standard subsidy rate, many such patients would not be able to cope. This is the reason why subsidy rates differ from nursing homes to expensive acute hospitals and why we apply a lower subsidy rate for outpatients than inpatients. After all the mathematics are done, what patients are really most concerned about is the dollar quantum they have to pay and not so much how many percent of the bill that they are paying. This way, we better ensure that the needy can afford their healthcare.”
“Madam, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2007/2008, and ask leave to sit again tomorrow.”
“So, some supplements could have two criteria, instead of three, but, of course, the premium will be higher. For some supplements, instead of paying just $300 or $400 a month, maybe they pay $800 a month or $1,000 a month, and some other supplements maybe, instead of just paying five years, they may pay six years or seven years, or even lifetime annuity, all at different pricing. I think that will make the whole ElderShield system much more diverse, which is really the theme of my speech this afternoon, ie, our needs are diverse, so we need a wide range of diversity. On SingaporeMedicine in public hospitals and separation of local patients from private patients. Actually, the separation right now, which we are doing, is by class - C, B2, B1, A - and foreign patients or Class "A" patients really is one category. In other words, we do not subsidise foreign patients, just like we do not subsidise the Class "A" patients. I am not very keen to have a special block for Arab, another block for Koreans, etc, because I doubt the numbers are of such big numbers to begin with.”
“I probably will only be able to respond to one or two points, but we have time tomorrow to continue. Let me take the easier ones first. On ElderShield - ElderShield reform is something I am committed to do and I want to do it, and I am glad that Mdm Halimah supports it in principle. The qualifying criteria are certainly one of the criticisms usually levied on ElderShield. For the information of the Members, right now, we require certain threshold. You have to cross the threshold and professionally what we do is we look for disability measurements, like inability to, say, bathe and feed yourself, and so on. There are six such criteria and the patient must not be able to do three things, then you qualify for ElderShield. What I plan to do, going forward, is, for the basic product, we keep these three disabilities criteria. The reason is this. If you start lowering the threshold, that means easier to get payout, then your premium, unfortunately, will be quite high. So there is a trade-off. My actuaries are still doing the computations. Most likely, I think we keep to the basic product - three qualifying thresholds but as I have already shared with the public a few weeks ago, what I plan to do is we allow "rider". I used the term "rider", which has confused NMP Ms Cham just now. "Rider" has a technical meaning and actually "rider" is the wrong word to use. The better word I can think of is "supplement". So I am asking my colleagues in the Ministry of Health not to use the word "rider", but use the words "ElderShield supplements". For the basic, it applies to everybody. But if you can afford and want better payout, you buy a supplement, like health supplements. So, basic ElderShield plus supplements. We leave it to the industry to develop different "supplements".”
“And I thank Members for their continuing support and advice. Health Promotion Programme”
“Ultimately, I agree fully with Mdm Halimah that SingaporeMedicine must benefit Singaporeans, and must not come at the expense of care for Singaporeans. Mdm Chair, I believe I have addressed all the queries by Members. I know Mr Low Thia Khiang spoke on the Human Organ Transplant Act (HOTA). He was not in this House last week when we had a full discussion on this when Dr Lim Wee Kiak raised the same issue. In the interest of time, I do not wish to repeat the points already made here last week, except to say that we will learn from the SGH incident and try to do a better job. We will certainly step up public education on organ donation and brain death and help Singaporeans think about the plight of those fellow Singaporeans on the waiting list. As I said in this House last week, it is the luck of the draw. We cannot be sure whether we may end up on the waiting list. Before HOTA, we could only save five lives in one year. After HOTA, we now save one life every week. So from five a year to one every week. HOTA is good both for the dead and the living, from the religious point of view. But we respect the wishes of those who want to opt out of HOTA. We will facilitate it. Every year, about 2,500 opt out of HOTA. The number went up soon after the SGH incident but has since come down to about 80 a day, which is high. But I respect the wishes of those who opted out but I worry for the poor patients on the organ waiting list. In conclusion, I acknowledge that our healthcare system is not perfect. But actually, it is not bad. My foreign counterparts told me so. And they would happily trade off their system for ours. But it can be better. Over the next few years, we will get the pieces together and be better ready for the challenges ahead.”
“Let us work to make it succeed. Finally, let me touch on SingaporeMedicine, the strategy to attract foreign patients to Singapore. This is an economic objective, not a strictly healthcare mission. In fact, my advice to the public hospitals' CEOs is that SingaporeMedicine is not our primary objective, but a secondary and consequential outcome. Our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices. That is our mission. But if our standard is high and our prices are reasonable, Singapore is bound to attract all sorts of foreign patients to come here. Our regional neighbours have raised their medical standards over the years. But we remain ahead of them and should always strive to stay ahead. If we do our job well in serving Singaporean patients, we will always attract foreign patients. It is a validation of the quality of our healthcare. We should therefore factor in this reality when we make projections of beds, doctors, nurses, and so on. If we do not do so, and since we cannot prevent foreigners from coming here for treatment, public hospitals and subsidised patients will get crowded out. If nothing else, costs will go up because private hospitals will poach public sector doctors and nurses, pushing up wages. This is the reason why we are stepping up foreign recruitment of foreign doctors and nurses, even as we ramp up local training. While we may see some foreign patients in public hospitals, the fact is that the majority of foreign patients go to private hospitals and clinics. 80% of foreign inpatients stay in the private hospitals. Foreign patients make up less than 2% of public hospital admissions.”
“What we are also hoping to achieve out of all this is that patients do not hop from doctor to doctor. For chronic diseases, it does not help the situation. It is best to stay faithful. You can shop around initially if you do not like this doctor for various reasons. Once you find he or she is good, then stick to one. I have another slogan for that, "One Singaporean, one family physician". I think that works best for Singapore, and for other people too. With the Medisave scheme for chronic disease management, now that we have gotten over the implementation phase, we will use this whole year to collect and analyse the outcomes. By next year, we should be better able to answer some of the questions, as posed by Mdm Halimah and Mr Low. How do the various clinics perform, in terms of managing their patients' chronic diseases? How much do they charge their patients and for what treatments? And very important, are their patients showing signs of improvement? Then I am going to publish them. Then you can see if you are diabetic, there are diabetes care at Ang Mo Kio, Sembawang or Hougang. Is there a difference? And then patients can make better informed decisions about which family physicians to be loyal to. Every patient should be given a personal health information folder by his doctor on his chronic disease and what he should do to improve his health. His health status should be regularly tracked and charted and explained to him by his doctor. If your doctor does not do this for you, ask him why not? Suitably empowered, I hope many patients would take their health more seriously and work to improve on it. If we do it well, the long-term impact will be significant. If we cut down unnecessary hospital care, it means major savings in dollars and human suffering.”
“The correct approach comprises three elements: early detection, regular ongoing low-tech, low-intensity treatment by family physicians, and good compliance by patients in changing their lifestyle and habits. I remember Dr Lily Neo reminding us about this frequently in this House. The wrong approach is to ignore the disease, persists with an unhealthy lifestyle and then when complications emerge, rush into hospitals for high-tech, high-intensity attention by multiple specialists, hoping for a cure and a quick return to the same lifestyle. But there is no such cure. When a chronic illness is still mild, that is the time to change your lifestyle and begin treatment. If you wait, the complications are a lot harder and much more costly to manage. With the Medisave scheme for chronic disease management, I hope to bring about a mindset change among our chronically ill. Through Medisave, we have eased the financial burden. It is now up to the patients to come forward and help themselves, to work with their doctors to actively manage their chronic diseases. If they do so, their health will improve. It can be done. In small-scale pilots, we have seen such improvements among participating patients. Through Medisave, we are scaling this across the nation. Mr Low asked about the cost of treatment for the chronic disease. I think he specifically asked about polyclinics. It depends on the state of the illness. If you neglect it, and it has become highly complicated, with all sorts of other problems, then of course, the treatment will be more complicated and the bill size is bigger. But the key point is, if you come in early, then the treatment is simpler, the cost is lower. So it really depends. It also depends on what type of chronic disease, say, diabetes or stroke.”
“Companies and unions should also chip in to ensure that their employees do not get short-changed. Seventh, we will release even more information to Singaporeans. We will measure and publish outcomes and performance indicators to increase market transparency and help patients make better choices - which doctors to consult, which clinics to go to. NUH, KKH and SGH have recently, just a few weeks ago, through their own initiative, begun to publish clinical outcome data selectively on their respective websites. This is the first for any hospital in Singapore. I applaud their public commitment to quality improvement and greater transparency. I will encourage all our hospitals - public or private - to publish outcomes and benchmark themselves with international outcomes. Maybe Raffles Hospital will do that too. This will similarly apply to step-down care providers. My Ministry is working with them to develop indicators to measure their performance in service development, utilisation and clinical quality. We will ensure that minimum care standards and patient safety are met. For those who do not perform well, we will help them improve their standards. Eighth, we need to further empower our patients by engaging them in their care and their care choices. Patient empowerment led me to introduce the Medisave scheme for chronic diseases last year. We know that chronic diseases account for the bulk of the workload in public hospitals and the polyclinics. And these diseases will not go away because today, there is still no cure, and if left unmanaged, they would only get worse, not suddenly, but gradually over time. Fortunately, medical science is now clearer on how to manage these chronic diseases to minimise future complications.”
“And this is one of the reasons why SingaporeMedicine has some benefits to Singaporeans because if more patients are coming in, then you can justify a higher level of care and you can allow this decentralisation to take place. But at the end of the day, organisational structures are merely the means to an end. Our mission is to serve patients, particularly those in the lower half of the population. When a person falls sick, what does he want out of our healthcare system? Talking to patients, I reduce it to just two basic questions: what is wrong with me? What can you do for me so that I can recover fully, if possible? These are the two basic questions. Our job is to provide accurate answers to these two questions and then to do so in a way which makes the total care experience for patients as smooth as possible and does not bankrupt him or society. But as I stressed just now, patients too have a big part to play, particularly, while they are healthy. So while you are healthy, ask yourself a different question. How do I maintain my health so that I do not fall sick and have to go and visit Dr Loo Choon Yong or Dr Fatimah? And we know the answer, that is, please adopt healthy lifestyle. Many do, but many still do not. Mr Sam Tan spoke about Health Maintenance Organisations (HMOs). They organise GPs and then they market their services to some company employees. It is an idea imported from the US a few years ago. I do not know how wide is their coverage today but while we do not regulate HMOs, we do regulate the doctors working for them. And I am sure any attempt by HMOs to cut corners will be resisted by our GPs as they have high ethical standards. Otherwise, the Singapore Medical Council will run after them.”
“Mr Low made an added point which is, for certain specialties, is it not better to centralise instead of mini-units spread out in the various hospitals? I think both solutions are relevant. It depends on the specialty. My preference is always to have at least two competing departments because competition will always push up standards and I have an added reason. Having run hospitals and dealt with doctors, I know they are highly individualistic and sometimes, for various reasons, you just cannot work for a particular Head of Department. So we must allow some space. There is a Chinese saying: "Yi shan bu neng cang er hu ". So sometimes, you need two mountains to hold the two tigers. But as far as possible, we try to decentralise it for the convenience of the patients. Of course, if decentralisation means one-man-team in a department, then it does not make sense. If you look at how we handle it, for example, neurosciences, neurology, it is centralised. But because accidents, like head injuries, can crop up anywhere, and if you centralise it, all ambulances will rush to SGH, we will have a mad-house there, and Dr Fatimah will have no time to attend Parliament. So the neurology services are decentralised, but the department running it is centralised. The department is the one who decides on staff deployment. That way, you can sub-specialise and you rotate staff accordingly. But once the specialty has reached a certain size where it is possible to have two very well-run departments, I encourage them to split up. I do not encourage families to break up though but for clinical departments, it is always better that way. Two, three, or four departments, so long as the volume can justify it.”
“For non-emergency cases, service standards vary and we publish such data so that patients can choose the less busy hospitals. All doctors who practise in the public sector will treat subsidised patients. This is part of the ethos of public service which our doctors feel very strongly about. As for physical provisions, the Ministry decides on the distribution of beds among classes. The fact is that 80% of beds in Singapore are in public hospitals and over 70% of public hospital beds are the heavily subsidised B2 or C. In other words, more than half of the patients treated in Singapore are subsidised by the Government to more than 65% of the cost at least. We also have guidelines in place to ensure that public hospitals do not spend on lavish fittings and renovations. But some renovation is inevitable to enhance efficiency and to meet public expectations. Nobody want to be admitted to a run-down hospital. Mr Low Thia Khiang asked if our hospital cluster system has led to wasteful duplication and if integration has led to better service level. One key objective of clustering is, in fact, to facilitate better integration of care between hospitals and polyclinics. This remains an important objective which I have discussed earlier. We have made some progress integrating public hospitals and polyclinics but full integration requires us to bring in the private GPs and the rest of step-down care providers. So our journey to restructure and bring about organisational change continues. Certainly, our hospital clusters will make a big push on this front this year but it will always be work-in-progress. We must never be fossilised into a concrete structure and become unresponsive to external changes and expectations.”
“It is a major boost to our researchers, although in the scheme of things, it is not really a huge pool of funds. So we will have to prioritise and focus on specific areas where Singapore-based researchers already are strong or in diseases where strong capabilities can best benefit Singaporeans. Because the greatest potential impact will come from areas where we are strong along the value chain from basic sciences to clinical treatments, we will encourage our doctors in the hospitals and the scientists in the laboratories to work very closely together. We will not be able to allocate research funds equally to each hospital. Hospitals and researchers will have to compete for them. Those who are able to better manage unnecessary overcrowding and free up manpower resources will have an advantage and that is why it is so important for hospital specialists to learn to work with the GPs, to co-manage or joint-manage the chronic patients and make right-siting of care a reality. Sixth, we should not shy away from organisational changes that can help us achieve our mission more effectively. That is why we restructured our hospitals more than 20 years ago. We moved from central planning by Ministry of Health Headquarters to a decentralised competitive model. This allows individual hospitals greater room to innovate. How else can we nurture experimentation and bring about improvements? Mr Sam Tan asked if our restructured hospitals are wasting resources on rich patients and foreign patients at the expense of subsidised patients. All patients, rich or poor, receive competent clinical care. Hence, all patients requiring urgent medical attention are promptly seen: three minutes for the critically ill, 30 minutes for other true emergency cases.”
“Increased competition has resulted in cheaper x-rays and improved turnaround times from local radiologists. Almost 60,000 patients can benefit from this per year. We are moving beyond simple x-rays now to CT scans and MRIs. I have no doubt this will bring further benefits and those cost savings will be even more significant. We will continue to study other applications of telemedicine and get it to work for our patients here. I have also encouraged our radiologists, wherever there is spare capacity, to sell their services to buyers in developed countries. We can sell tele-radiology services as well as buy tele-radiology services. Fifth, medical science here will continue to progress and we have reached a stage where Singapore should be part of the global search for faster diagnosis, better and more cost-sustainable care for patients. Our public sector doctors have always been bogged down with heavy patient loads. If we are able to recruit more doctors to improve our doctor-patient ratio, we can ease their burden somewhat. Through this process, we hope some doctors with special interest in clinical research will find more opportunities to do so. Every generation of doctors has always yielded a few outstanding researchers, for example, Professors Wong Hock Boon, the late SS Ratnam and more recently, Ng Soon Chye, Yap Hui Kim, Donald Tan, and so many others. With our latest emphasis on life sciences development, public hospitals will now be better supported with research funds to pursue this interest. Over the next five years, Ministry of Health, National Research Foundation and A*Star will jointly contribute $1.55 billion to support translational and clinical research.”
“This is commonly referred to as "right-siting" of healthcare services, and the logic is obvious. But the outcome is seldom the case. Today, many patients who choose to be treated at SGH or NUH, in fact, should not be there. They can be and should have been treated by their family physicians, less hassle and at a lower cost. For various reasons, they get wrongly-sited there. Wrong pricing, as observed by Mdm Halimah, is one factor. Mdm Halimah's proposal is for us to reduce prices at step-down care so that patients will have an incentive to leave the hospital. To achieve this, Mdm Halimah suggested that we exempt such patients to be transferred from hospitals from means testing at nursing homes. I am afraid I do not agree. The correct solution is to extend means testing at nursing homes to the hospitals so that we eliminate this policy anomaly. I have asked Ministry of Health to study how we can do so, at least for those patients who have exceeded the average length of hospital stay. Meanwhile, we will continue our push, through the Medisave scheme for chronic disease management, to shift chronic disease management to the primary care level by family physicians and in the community. If patients can be right-sited to family physicians and they feel confident that they will be well looked after, we can reduce overcrowding at hospital specialist clinics. Fourth, we must exploit technology to improve care and lower cost. Telemedicine is a good example and can potentially bring benefits to many areas of healthcare. As Dr Lam pointed out, we have started with tele-radiology in our polyclinics with very good results. Patients save time as they no longer need to make a return trip just to get their results.”
“We need to take a measured approach to pilot and then put together a comprehensive framework that takes care of these issues. This will begin with common data standards. We will do this within the public sector first, test it out, and extend this to the step-down facilities. We have started to build the linkages to the private sector GP clinics by helping them to set up their IT systems under the Medisave for Chronic Disease Management Programme. I am confident that we will get there. Second, we need to strengthen the collaboration between acute hospitals and community hospitals to achieve seamless care for patients when they move between these two types of institutions. For patients who no longer need medical treatment in acute hospitals and who should move into community-based care, we must ensure the continuity of patient care and eliminate barriers and bureaucracy. The handover must be smooth, as though it is from one ward to another in the same hospital. For a start, we need to enhance medical collaboration between the doctors in our hospitals and either their counterparts in the community hospitals or the family physicians who look after the patients over the long term. Patients at the end of the day must feel confident that they are getting seamless care. The same approach is needed for patients who require care and nursing homes. We are working with MCYS on this. We are also studying the longer term feasibility of integrating different residential and community-based healthcare and eldercare facilities so as to help the elderly to age in place and to continue using familiar facilities even as their care needs change with time. Third, we need to have patients treated in the most appropriate locations by medically-competent teams at the lowest possible cost.”
“We achieved a first but very important psychological step in 2004 when public hospitals began to electronically exchange their Hospital Inpatient Discharge Summaries. These are summaries that each time a patient is discharged, the consultant-in-charge will summarise it up - what exactly is the problem with the patient, what were the treatments made or given to the patient and what is to be expected in the future. And sharing this is crucial because when the patient appears again in another hospital, access to this summary immediately updates the doctor about this particular patient. Since then, we have made the EMRX more comprehensive by adding other patient records such as laboratory tests, radiology reports and medication information. The electronic volume of laboratory results exchange has grown seven times in two years. Thousands of patients benefit from EMRX every month. Our doctors' feedback is that EMRX has made their work easier. I am sure Dr Lam agrees with that. In particular, our Emergency Department doctors have said that the EMRX gives them greater reliability and confidence in treating patients, especially those with long and complicated medical histories. And I am glad to see Dr Fatimah nodding her head. Extending EMRX to private doctors would be a natural step and it is the objective. As Dr Lam pointed out, a national EMRX will minimise unnecessary medical investigations. More importantly, I see EMRX playing a critical role in the integrated delivery of care to patients. However, this is a very complex national project. Very few countries, if any, have successfully implemented a system that links up public, private and the charity sectors. This is because there are many issues such as data protection, regulation and audit to be addressed.”
“This requires a change in mindset on the part of the healthcare providers. In particular, hospital specialists will need to work more closely with family physicians and step-down care facilities as a team, with patients at the centre. Ideally, they will all share a common medical record for each patient, and they consult regularly and they function as one team whose sole purpose is to advance the health of the patient. This is challenging even when all the healthcare providers are from one single employer and serve patients with the best of intentions. Complications multiply many-fold as such a team often comprises members coming from all the three sectors - public, private and charity sectors. Coordination and trust take time to build. That is why true care integration has not yet happened, whether here in Singapore or in other countries. It will take us years, not months, to achieve such an optimal outcome. Many pieces have to fall in place. Let me highlight some of them. First, an important infrastructure is the Electronic Medical Record (EMR). I have coined the slogan, “One Singaporean, One EMR” to catalyse this initiative. Right now, it is one Singaporean, many medical records, stored away in different clinics and hospitals in different formats - some in papers, some in CDs - and not connected or consolidated. As a result, when patients visit different doctors, their tests have to be repeated, x-rays redone. This adds to unnecessary cost. 5.15 pm We are moving towards this target of “One Singaporean, One EMR”. Because of legacy systems, we cannot achieve it in one step. But we have made progress. As pointed out by Dr Lam Pin Min, public hospitals now have the EMR eXchange (EMRX).”
“An 80-year-old with advanced cancer may also need highly specialised care involving experts and sophisticated equipment. But the outcome may be a prolongation of life or postponement of death by a few weeks with pain and discomfort. Another patient in a similar condition may well choose a less aggressive treatment regime focusing mainly on palliative care and pain management. A young person with a broken bone needs a surgery and after a few weeks will be back to normal. The surgeon plays a key role and the patient plays only a very minor role in that treatment episode. On the other hand, an obese patient with diabetes will need life-long medical attention. The patient’s well-being is almost entirely dependent on his personal willingness to change his lifestyle and follow the treatment regime strictly. The healthcare team can, at best, play a supportive role, a coaching role. As Members can see, a patient’s treatment choice is often determined by a complex interplay of his understanding of likely outcomes, the advice he gets from his doctors and friends, his personal expectations, values and philosophy, and his ability and willingness to pay for treatment. Clearly, one size cannot fit all. Even a dozen sizes will still not fit many. There is a need for us in healthcare to segment patients more, clearly understand their needs by observing them closely and consulting them. We have to develop practical treatment strategies, innovate and continuously fine-tune approaches to improve outcome and to reduce cost. To transform healthcare to better meet the different needs of our patients, we must innovate. To innovate to meet diverse needs, we must have diversity in organisations, structures, models of care and pricing.”
“Madam, just now, we discussed how we must gear up Singapore for our healthcare needs of 2020. We discussed the three key resources that we will need - financial, physical and human resources. But having more resources alone will not necessarily lead to a better healthcare system. Witness the huge amount of resources some countries are pouring into their healthcare today and yet they deliver much poorer outcomes than other countries which spend much less. More of the same will not do. We need to have the courage and the wisdom to transform healthcare. Some analysts in the automobile industry compared General Motors with Toyota, and they criticised General Motors for being too product-focused. They praised Toyota for focusing on the changing needs of customers over their lifetime. Parents buy a small car for their child when he graduates from high school. A young adult buys a Corolla, then an MPV when his family grows, and when he gets a promotion, he buys a Camry, and later on, he upgrades to a Crown and perhaps a Lexus. Toyota made over a hundred models to meet the different needs of the different market segments. Healthcare, unfortunately, is more like General Motors than Toyota. We focus on buildings, equipment and skills. This is not wrong, but I think we are not paying enough attention on the varied needs of our patients. Let me give some examples. An infant with a hole in the heart needs a one-off highly specialised care involving a large team of specialists and other staff to fix the problem using highly sophisticated equipment. But once fixed, the infant will be, more or less, normal and well. Another infant born with severe brain damage will also require sophisticated care but the best outcome may still be a lifetime of pain, discomfort and total dependency.”
“My Ministry will do its best to expand our capacity and our service levels to meet up with the rising demand and rising expectations. That is why the Finance Minister, in his Budget Speech, talked about healthcare budget, rising from about $2 billion to $3 billion within five years. This is a very substantial expansion in the Government's commitment to healthcare. My job is to make sure that the funds are wisely spent. Management of Chronic Illnesses”
“This is good, but it means a longer consultation time. Such patients will not be satisfied with a 10-minute consultation. But if everyone demands a 20-minute consultation, we will have to double our doctor-patient ratio, double the number of doctors and, of course, double the unit cost of treatment. We will maintain our current subsidy policy of Class C patients paying 20% of cost, polyclinics, 50% of cost, and so on. But when unit cost goes up in line with a higher standard of care, the dollar co-payment by patients will have to go up accordingly. These are the types of adjustments that Singapore will need to make over the next 13 years, if we want the medical standard of Singapore at 2020 to match the expectations of Singaporeans and to stay ahead of our neighbours. In practice - let me assure Mdm Halimah and other Members - we will weave in such adjustments gradually, compassionately and pragmatically. 4.45 pm We will pace the adjustments according to what Singaporeans can afford. Maybe, a couple of hospitals can move ahead slightly faster than others. All hospitals will receive the same unit subvention from my Ministry for the same illnesses, and all patients will receive competent medical care. But the hospitals, which can offer shorter waiting time because they have a higher doctor-patient ratio, will need to cover their higher operating costs with slightly higher fees. My mission is to ensure that our healthcare services remain affordable to Singaporeans in general, particularly the lower half of the population. It requires careful planning and cooperation from all the stakeholders. It requires all of us to have realistic expectations.”
“This is good, but we remain particularly short of certain specialists who are also in huge global demand, like renal physicians, neurologists and cancer specialists. We have to devise more effective schemes to attract such specialists from abroad to augment our team. As I said earlier, we will also pay attention to the allied health professionals. The good news is that many more excellent students have been entering nursing, pharmacy, radiography, therapy and other courses in recent years. They are bringing up and changing the profile of our allied health workers. Many existing staff are also upgrading themselves. We encourage and facilitate this through many scholarships and overseas attachments. Our healthcare team is getting stronger. Students and mid-career Singaporeans are discovering the job satisfaction of a healthcare career. We must be doing something right in our hospitals. We will press on. Recently, I suggested to my parliamentary neighbour, NTUC Secretary-General Mr Lim Swee Say and also WDA’s CEO, that let us work together to get more mid-career workers to work in hospitals. We have a successful scheme for nurses. Let us now promote other professions like physiotherapists, speech therapists, podiatrists, and so on. At the same time, we will work hard to retain staff. This requires us to keep our wages competitive. This is also the reason why medical fees need to be raised periodically because manpower cost is a major component, more than half, of our medical cost. Sir, let me conclude. Gearing up for 2020 does not mean that we can simply do more of the same, because patients’ expectations are changing. Patients Google the latest information on their illnesses and treatment options, and want to engage the doctors in our treatment choices.”
“Beyond financial and physical resources, human resources are the key to a good healthcare system, as highlighted by Mdm Halimah and Mr Zainudin Nordin. Our doctors, nurses, allied health professionals and other support staff work very hard in public hospitals and polyclinics. To keep healthcare cost low, we run our facilities at very high occupancy rates. Our doctors and nurses see many more patients than their counterparts elsewhere. If not for their sense of public duty, many would have quit for an easier time. Yes, we may have service lapses at times. But most of the time, our healthcare workers do a competent job, and often go beyond the call of duty. They do not expect gratitude, although we do receive many complimentary letters that cheer them up and keep their morale high. So, please, give them your moral support. They are the unsung heroes and heroines of our excellent healthcare system. They deserve our appreciation and understanding. Medical specialists take a long time to train. It is especially difficult to get manpower planning right in Singapore because we have a significant foreign patient load which fluctuates from year to year. I have noted Mdm Halimah’s comment on SingaporeMedicine and foreign patients and their possible impact on local patients. I will address them in my next speech. Meanwhile, we are recognising more good medical degrees and we are recruiting more foreign-trained doctors. From about 85 a year in 2003, last year, we took in 180 foreign-trained doctors from very good medical schools, bearing in mind we ourselves produce only 230 last year. So it is almost one to one.”
“We will need more physiotherapists, speech therapists, occupational therapists, podiatrists, counsellors, psychologists and also doctors and nurses with skills in geriatric medicine, as highlighted by both Dr Lily Neo and Dr Fatimah Lateef. We will also push up the skills of our nurses so that they can take over those routine tasks from doctors, as advocated by Mr Zainudin Nordin. We call them Advanced Practice Nurses (APNs). I remember we discussed this in this House when I moved the Nurses and Midwives (Amendment) Bill two years ago. I have noted the point about liability issues and I will take a look. I am sure our cluster would have adequate coverage for them but I will take a look. Fourth, we need to address the financing of this sector. The needy will need some subsidy by Government or charities. But with healthy competition among providers, the majority of patients should be able to self-fund either through savings and/or long-term disability insurance, like ElderShield. ElderShield, as a product, is rather new to Singaporeans. I agree with Mr Yeo Guat Kwang that we should educate the public more on the different types of insurance products and their users. For example, there is still confusion between MediShield and ElderShield. MediShield is for acute hospitalisation, with payouts based on reimbursements. But ElderShield is a cash supplement for step-down care in the community, often at home or in a nursing home. I am reforming ElderShield to make it work better for Singaporeans with their needs in 2020 in mind. I shared my thoughts on this during my recent Ministerial walkabout. I will continue the public consultation and welcome feedback and suggestions. We will get the reform implemented this year.”
“To gear up for 2020, we have to ramp up supply and systems from now on. Briefly, we need to do four things for step-down care. First, we need to expand capacity. We are reviewing the requirements for community hospitals and nursing homes, and will facilitate investments at the appropriate time. Second, we need to widen participation by all providers in this sector because the needs of the elderly are diverse, from the higher-income to the indigent. Today, our step-down care facilities are largely run by charities and they do a reasonable job. But higher-quality nursing homes to serve the needs of the middle-class elderly are still in the early developmental stage. We must widen the range of choices, at different pricing levels and at different service standards. It costs much more to run Ritz-Carlton than Hotel 81. If Ritz-Carlton were to charge less than Hotel 81 or the same, there would be a long queue outside Ritz-Carlton and Hotel 81 will be empty. But because hotel pricing is sensible and undistorted by Government subsidies, both businesses are full with their respective clientele. I know some might not agree that the economics of healthcare should be the same as the economics of hotel services. But the reality is that healthcare services need to be financially viable in the long run, and there is no other way. Even if the Government pays for it, it is still taxpayers’ money. Third, we need to attract more allied health staff to this sector - and several Members talked about this - with better skills and higher education level, to service the rising demand for a higher level of care.”
“This brings good specialist services closer to their homes. The patients I spoke to were very happy with the change. The private hospitals will also need to expand to cope with rising demand. They are important partners, serving the middle and higher-income groups, or about 20% of the national patient load. They provide Singaporeans with more choices. As our medical standard is high and our fees internationally competitive, naturally we attract many foreign patients in the last few years, increasing by more than 20% a year. It could actually have been higher, but the private hospitals had under-invested in the past and they are now missing out on opportunities. EDB’s feedback is that private hospitals are now ready to invest and expand their capacity. There are also international investors who are interested in setting up in Singapore. The Government intends to launch two land sites for private hospital use in the second half of this year, so this will be quite soon: one near the Novena MRT Station by URA, another within One-North by JTC. Both sites can add about 400 beds to the private hospital bed capacity, which is quite significant. Meanwhile, we are also preparing other sites for possible release in the next few years. The beds described above are acute hospital beds. But healthcare is more than that. As emphasised by Mdm Halimah and Dr Lily Neo, with ageing, there will be increasing demand for longer-stay, lower-cost, lower-tech facilities in the step-down care sector. We will need more community hospitals, nursing homes, hospices and day-care facilities for rehabilitation and home-nursing services. We have not had to pay much attention to this sector as our population is still young. But by 2020, the needs for step-down care will be significant.”
“Some elderly patients are worried if their Medifund needs will be squeezed out by the needs of their younger applicants, and I get such feedback occasionally. We have reassured them that all cases will be assessed based on needs, and that we do not bias our decisions towards the young or the old. However, we will give our senior citizens added peace of mind. I am thinking about carving out a portion of Medifund, ringfence it as the Medifund for the elderly. We can call it Medifund-Silver, protected for the use of needy senior citizens above 65. It can have a capital sum of $500 million, about a third of the entire Medifund today. This way, we can address the needs of the elderly patients in a more targeted manner. With the financial resources through the 3M system, we can then work to match supply of physical resources with demand. Just to maintain this year's standard of care, in the year 2020, we will need more hospital beds, clinics, doctors and nurses than what we have today. That is why we are building a new general hospital of 550 beds in Yishun. When it fully opens in 2010, our acute hospital beds in the public sector will total 6,500. But between now and then, we will add beds, where there are opportunities to do so. This year, for instance, we will add 120 beds in Tan Tock Seng Hospital, Changi General Hospital and National University Hospital. In parallel, we will continue to expand day surgeries to reduce unnecessary hospitalisation. Last year, I remember discussing the Jurong Medical Centre idea. It has now materialised. I visited it not long ago and am very pleased with the development there. Alexandra Hospital, which runs it, has started to systematically transfer their day surgeries and outpatient follow-ups for their patients who live in Jurong.”
“But for the vast majority, MediShield coverage from young will give parents peace of mind that, should their children develop any illnesses as they grow up, they will have insurance coverage for such illnesses and the subsequent treatment. After I have brought the children into MediShield, I will see how best to bring in the 100,000 or so housewives who are still outside MediShield. I will study Mr Yeo Guat Kwang's suggestion for an opt-out scheme for husbands to sign on their wives. Actually this is already the case. At the time of marriage, there is this opt-out scheme in place. But for some couples, after marriage, somehow, some husbands decided to opt out their wives. We have to find some way to get them in. Medifund provides the ultimate safety net to catch anyone who drops through the Medisave and MediShield nets. We aim to build up Medifund to a capital sum of $2 billion. So this year, the Government has topped up with $200 million, making it now $1.5 billion. Every year, we make use of the interest income to help those who fall through the net. Our hospital Medifund committees work very hard to prevent any Singaporeans from falling through the cracks. These are good-hearted, busy and successful people who volunteer their time, expertise and wisdom to help us manage this piece of social welfare in a wise and compassionate manner. [Mdm Deputy Speaker (Ms Indranee Rajah) in the Chair] 4.31 pm Last year, Medifund handed out $40 million to 290,000 applications for financial assistance. About one-third of these beneficiaries are over the age of 65. With ageing, we know that such demand will only grow. We need to build up Medifund when our economy is doing well and whenever there are budget surpluses.”
“MediShield coverage among active workers is not bad, 90%, nine in 10 workers. But 390,000 Singaporeans below 20 years of age are still not insured. The premium at their age is inexpensive. It is only $30 a year. And young parents can use their Baby Bonus to pay for the premium in full. So cost is not an issue. Many parents already do so, in fact, about half of our youths are covered by the enhanced MediShield promoted by private insurers. Some parents who did not do so told me that they know MediShield is a good product, but inertia is the reason for their lack of participation. I will make it easier for these parents to sign on their children for basic MediShield coverage. We will introduce an opt-out scheme for infants to be automatically covered under MediShield from the time their births are registered. Premiums can be deducted from their fathers' Medisave Accounts or, alternatively, their mothers'. Parents who do not want such coverage can opt out any time by informing the CPF Board. We would get this done soon so that all babies born on Christmas can have MediShield. I would try to get it done hopefully in less than nine months so that some babies who are already conceived can also benefit from it. For those who are already born but below seven, we will work with the Ministry of Education to provide this opt-out service at the time of Primary 1 registration. For older students, we will work with MOE to see how we can get them in as a one-off exercise. I think this can happen next year. 4.30 pm I thank Mr Yeo Guat Kwang for his support of the measure, and I hope all parents will support it too. It will be good for their children. To keep basic premiums affordable for the majority, MediShield will continue to exclude coverage of congenital illnesses.”
“This will avoid future complications and save patients money and suffering. Mr Low Thia Khiang asked that we remove or reduce the cash co-payment; I think that will be unwise. Remember that Medisave was not designed for outpatient care. I make an exception here, and we must not unwittingly deplete it for purposes not originally planned. Because if you do, then the contribution rate will not be enough. You have to raise the contribution rate. Collectively, there are now $36 billion in our Medisave Accounts today, and this is still growing at more than $1 billion a year. This is healthy but only because we are still a very young society. Medisave is our savings for the future when we will all grow old. The only structural problem now is that some Singaporeans, a minority, are not saving. They are naturally worried about healthcare cost. The solution is not to make healthcare free but to get them to save. Workfare and Government top-ups will help them build up their Medisave for the future rainy day. But they must themselves make some effort. For larger medical expenses requiring intensive and prolonged hospitalisation, we have MediShield. After the reform in 2005, it is now working better. We will continue to refine it to reduce the co-payment by patients, but we must not make it a comprehensive medical insurance scheme without any need for co-payment. Some insurers sell MediShield riders to eliminate co-payment. This is not wise and we do not encourage this. That is why we do not allow Medisave to pay for the premiums of such riders, as proposed by NMP Cham Hui Fong. But if Singaporeans want to buy such riders out of their cash savings, I cannot stop them. I have a couple of ideas to enhance MediShield further.”
“The rational approach is therefore to require some co-payment by patients. Co-payment makes a dramatic difference to patient behaviour and even doctors' behaviour. For everyone to afford the co-payment, we have to get everyone to save through Medisave for a rainy day. And, on top of that, we pool the risks through a basic insurance plan, MediShield, as a backup. Finally, we provide sensible social welfare through Medifund as the ultimate safety net. This is how we tackle our financing challenge, with 3Ms providing multiple layers of safety nets. Each layer does not cover everybody, but together the multiple layers of safety net cover everyone. Dr Faishal asked that we explain our healthcare financing schemes more thoroughly and frequently to Singaporeans. I fully agree, and we will. We must keep the schemes easy to understand, because healthcare can sometimes be very complex. And we will improve our public communication efforts. Let me use this opportunity to reiterate our model. For minor treatment and healthcare needs at GPs and polyclinics, $20, $30, $40, or even $50, I think, preferably use cash. Our GP services are very competitive, inexpensive and affordable for most people. But for larger medical expenses that require hospitalisation, our Medisave scheme is working as designed, especially after we have fine-tuned it in recent years. Every year, some half a million transactions are funded through Medisave. I have now extended Medisave to cover outpatient treatment of four common chronic diseases. And the full impact will be felt over the years when the scheme matures. I am optimistic that, if participating chronic patients cooperate with their family physicians and actively change their lifestyle, comply with medication, their health would improve.”
“Many will be financially comfortable, but there will be a sizeable number who will be very tight financially. Scientific discoveries and medical technologies will accelerate and make available diagnostic and treatment modalities that we can only dream of today. But many of these will be costly and the companies are not going to give it away for free. Clearly, one size cannot fit all. As Health Minister, my duty is to put the big pieces in place so that, by 2020, we will have a healthcare system that offers a whole spectrum of care that meets the needs of the young and the old, the rich and the poor and the large numbers in between, and we have the financial resources to pay for them. So, let me start with funding. In the musical cabaret, Liza Minnelli had that popular line, "Money makes the world go round" and our Jack Neo made "Money no enough" part of our psyche. Money does not make the world go round, people do. And we will have money for healthcare if we save for it, have the right expectations and do not waste it. What are the realities of healthcare? Everyone will need it, most of them towards the latter part of life when they are not at their peak in earnings. Social welfare and comprehensive insurance are seductive ideas - no need for co-payment, make it free at the time of consumption, so that nobody needs to worry about healthcare cost. But we all know that both lead to the "buffet syndrome" of abuses, over-servicing and financial disaster. And when the healthcare system is overwhelmed, it is the poor who suffer because unlike the rich, they cannot afford the other alternatives. The truth is that healthcare demand is unlimited but supply is, because not many people are willing to pay more taxes or insurance premiums, which are needed to expand supply.”
“Sir, this is my 4th Health Budget. Having dealt with the more immediate issues for three years, I will from now on focus on gearing up Singapore for its 2020 healthcare needs. Sir, I will be 68 by then. My wife and I will be silver haired. What about you, Sir? Actually, I am already silver haired, except for the wonders of hair dye. My daughters should be married by then and, hopefully, we will have a hall full of grandchildren. My family and I would need much more healthcare than we do now. That is why I am most mindful that 2020 is only 13 years to go. We must not let it slip by casually. The questions posed by Mdm Halimah, Dr Lily Neo and Members are all pertinent ones. We must find answers to those questions over the next few months and continue to refine them over the next few years. The socio-demographic changes to come are well known. Still, it is worth highlighting what are the key factors that would significantly impact our future healthcare demands. Most Singaporeans would be better educated, have higher expectations and they want high-quality care and, I hope, they are able and also willing to pay for it. But for the bottom 20% or 30% striving to cope with global competition, money will always be tight and healthcare cost will be their key concern. The number of people above 65 will increase; fortunately, most will be healthy and well. Many will however be health conscious and will seek medical attention without hesitation to address any discomfort or just to get a reassurance. The number of "old-old", exceeding 80 years, will increase many-fold. By the time they hit this age, many will have some medical problems. Just now, over tea break, I remember discussing this particular problem of elderly patients with Mdm Cynthia Phua and Ms Denise Phua.”