Koh Poh Koon
Singapore
“In 2025, for walk-in patients, the median and 95th percentile doctor consultation waiting times were eight minutes and 72 minutes respectively. However, the Ministry of Health (MOH) does not track waiting times by peak versus off-peak hours, but it is likely that 95th percentile waiting times happened during peak hours.”
“The offences and penalties for importing, supplying or abusing SPS products are similar to those in the MDA, to ensure similar level of deterrence. Mr Speaker, with your permission, may I ask the Clerks to distribute a handout that summarises the changes in legislative penalties for key offences.”
“So, if you are a Singaporean student, you will expect that there will be some subsidies to the fees. The third question on how can the public, who may want to seek psychological care, know who is legitimate.”
“Sir, I thank the Member for his question on audiologists. In general, a qualified audiologist in Singapore needs a higher level of certification because a diploma level may not be quite enough to perform the task. So, we will look and see whether there is a way to actually find an in-between.”
“We are starting with registration to give formal recognition to those who are practising in higher risk sub-sectors in psychology and making sure that the quality, the standards and the support is given to them to deliver the care that the clients and the patients need.”
“It takes a bit of, not just system change in the providers, in the doctors and the care teams, but also, a gradual shift in the mindset of our population as well. So, it is something that we have to continue to do. There is no magic bullet to this and it is not something we can achieve overnight. 12.15 pm”
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“Mr Deputy Speaker, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a second time". Sir, the practice of dentistry constantly evolves with changes in population demographics as well as advancement in technology and materials associated with dental treatment. With Singapore having one of the world's fastest ageing populations, one of its challenges is ensuring that the needs of a growing ageing population, including dental care needs, are well provided for. The Singapore Dental Council (SDC) ensures that there is a steady supply of dentists each year to meet the expected demand for dental services. In addition to local graduates from the Faculty of Dentistry of the National University of Singapore, the SDC also registers dental graduates from foreign universities. The proportion of foreign-trained dentists in Singapore has risen steadily from 20%, or about 302 out of 1,484 dentists in 2008, to 36%, or 900 out of 2,475 dentists in 2019. Against this backdrop, SDC undertook a review of the process for foreign-trained dental graduates to practise in Singapore, to ensure that they meet the same high competency standards as locally trained dental graduates. SDC assessed that two measures are needed to achieve this objective. First, the Dental Registration Act (DRA) will be amended by this Bill to require that foreign-trained dental graduates must pass a qualifying examination to be eligible for conditional registration; and second, the DRA Schedule will be revised to list the foreign universities whose dental degree holders are automatically eligible to take the qualifying examination. This Bill gives effect to the first measure, relating to the qualifying examination, which I will explain in more detail now.”
“Thank you, Madam, I just want to clarify on the answer I had given to Question No 12. I had misspoken about the fine. For work pass holders found to be engaged in illegal employment, they will face a fine of $20,000 or imprisonment of up to two years, or both; not $2,000. [Please refer to "Enforcement of Restrictions on Work Pass Holders Working for More Than One Employer", Official Report, 2 August 2021, Vol 95, Issue 35, Oral Answers to Questions section.]”
“And if we do have enforcement actions being taken, especially against companies who were egregious, we do publicise them on the mainstream media as well as online social media platforms because this raises awareness and serve as a deterrence to other would-be offenders – whether it is employers or employees.”
“Madam, as I said in my main reply, beyond the public tip-offs and complaints by perhaps a competing company, for example, we also conduct our own proactive data analytics to see if there are suspicious behaviour that we ought to take proactive action to verify and check. Beyond that, part of the work also involves educational efforts to make sure that foreign workers working in Singapore understand what constitutes illegal employment or violation of their work permit kind of conditions. So, first, when we give an in-principle approval to the work pass applicants prior to their departure for Singapore, that letter states quite clearly that the work pass applicant can only work for the specified employer in that letter. Engagement and education of the migrant workers are done through several other initiatives and platforms. For example, the mobile app, FWMOMCare, where MOM pushes out employment-related messages through the app. So, it really is to help foreign workers themselves know what is illegal and wrong. There is also the mandatory Settling-in Programme for first-time work permit holders, which educates the migrant workers on their responsibilities and employment rights as well as the laws and regulations for working in Singapore. Prior to COVID-19, we did conduct a lot of road shows as well, at dormitories, at recreation centres, in public areas, where MOM would engage these work pass holders on their rights and responsibilities. Of course, in the present day, we utilise a lot of social media platforms and the online medium to educate and raise awareness.”
“Madam, under the Employment of Foreign Manpower Act (EFMA) work pass holders are only allowed to work for the official employer specified in their work pass card. It is an offence for the work pass holder to perform work for any other person or business entity. The Ministry of Manpower (MOM) receives complaints, tip-offs and referrals from members of public as well as other public agencies on possible illegal employment of work pass holders. Based on the information received, MOM will conduct inspections and look into each and every allegation. At the same time, MOM also carries out proactive inspections based on our own analysis and triggers to detect possible illegal employment of work pass holders. Between 2016 and 2020, MOM issued at least a warning to an average of 160 work pass holders each year who were found to have engaged in illegal employment. All of them were debarred from working in Singapore. MOM takes a serious view of illegal employment. Work pass holders found to be engaged in illegal employment will face a fine of up to $2,000 or imprisonment of up to two years, or both. [Please refer to "Clarification by Senior Minister of State for Manpower", Official Report, 2 August 2021, Vol 95, Issue 35, Oral Answers to Questions section.] MOM will also debar them from working in Singapore. Likewise, employers who employ any foreigners without a valid work pass will face a fine of up to $30,000 or imprisonment of up to 12 months, or both. Their work pass privileges will also be suspended.”
“Sir, statutorily, annual leave entitlements vary across developed economies. Some, like the United Kingdom and Australia, have relatively more generous provisions while the United States does not have a federal law regulating paid annual leave. The minimum statutory annual leave entitlement in Singapore is comparable to that in jurisdictions, such as Hong Kong and Taiwan. Singapore's statutory annual leave entitlements should also, as I have said before, be viewed alongside other paid leave entitlements that are already provided for in our laws. Employees can use these other forms of leave over and above their annual leave entitlements. In fact, in many other jurisdictions, such leave may not be available or fully paid at all. So, I think it is a balance of different types of leave to cater to different needs and, as I have said in my main reply, MOM and our tripartite partners will continue to look at the evolving needs and adjust our legal requirements accordingly.”
“Sir, annual leave should be viewed in context alongside other entitlements that similarly support employees in balancing work and personal needs. These include paid public holidays, sick leave, childcare leave, maternity leave and paternity leave. There has also been a significant push to support the adoption of work-life initiatives and flexible work arrangements, such as through the Tripartite Standards on Work-Life Harmony and Flexible Work Arrangements. Any increase in annual leave entitlements entails business costs and must be carefully considered in a tripartite manner. This enables us to take into account business needs and ensure employees' employability. Bearing in mind the current economic conditions and the existing suite of other leave entitlements, there are currently no plans to review minimum annual leave entitlements. However, the Ministry of Manpower (MOM) and our tripartite partners will continue to monitor the labour market situation and the needs of our workforce.”
“Sir, the Member's suggestion is already implemented today. There is already on our website a list of accredited and registered employment agencies so that those who are not registered will be taken to task for illegal recruitment activities and would be punished by the full effects of the law.”
“Sir, I must first contextualise the extent of the problem because the Member believes that this is a very widespread problem. But in terms of kickback-related complaints, this forms only about 10% of all the complaints that MOM receives in a typical year. Instead of focusing on giving financial incentives for people who are, especially migrant workers who come forward and make that complaint, it is more likely important to help them understand what exactly a kickback is. The Settling-In Programme is very important in helping them be aware what constitutes a kickback and then, to explain to them that, actually, they would be protected from loss of jobs should they report the employer for collecting illegal kickbacks. I think that is something that we should work a lot to reassure our migrant workers so that they feel comfortable coming forward. But the other side of the equation is to impose strict penalties and make sure that we take a strong stance against employers who resort to such illegal activities, so that the deterrence should be on the side of the employers, not so much as incentivising through financial means, to induce our foreign workers to come forward. I think what they look for is more protection and job security and that is something that we want to provide. The financial disincentive for employers to do so is already enshrined in our Employment of Foreign Manpower Act, where if they are convicted for kickbacks, they will be liable to a maximum fine of $30,000 or imprisonment up to two years or both, per offence.”
“Sir, between 2016 and 2020, the Ministry of Manpower (MOM) looked into an average of 960 cases per year for kickback offences. Of these, about two-thirds are complaints lodged by migrant workers, one-third are referrals from members of the public, non-governmental organisations (NGOs) and other public agencies, while a small number are detected through MOM’s proactive inspections based on data analytics. To encourage migrant workers to come forward to report kickbacks early without fear of reprisal from their employers, MOM will facilitate a change of employment for those who wish to continue to work here in Singapore. MOM will also refer affected migrant workers to selected employment agencies, which are committed not to charge these workers any fees for the job placement. MOM also educates first-time migrant workers on kickback offences and ways to seek help through the mandatory Settling-In Programme. We have stepped up our engagement and education efforts by tapping on the network of migrant worker volunteers being developed by the Assurance, Care and Engagement (ACE) group and Migrant Workers' Centre (MWC) ambassadors to disseminate key employment messages. MOM will continue to work with community partners, leverage technology, such as the FWMOMCare app, and tap on social media channels to amplify these messages and reach out to more migrant workers.”
“Members may remember that, earlier this year, in the Budget, we announced several measures to increase attraction of our locals to join the nursing profession. One is in the salary review, which was announced in the Budget this year. Public sector healthcare nurses will have an increase of about 5% to 14% in their monthly base salaries from July this year. It just kicked in this month and this will be phased in over the next two years. For publicly-funded community care organisations which require nurses, MOH will also increase funding support for wages to ensure that salaries in the community care settings are also competitive to attract locals to join this sector. We also encourage more flexible work arrangements. So, all healthcare clusters now have flexible work arrangements to help their workers strike a balance between their work and personal demands. These include part-time employment, compressed work week, flexible work schedules and hours. To facilitate the scheduling of work shifts, e-rostering will be scaled across the public health clusters by the end of 2021. There are also efforts to enhance professional development, such as through the launch of the Skills Framework for Healthcare and the National Nursing Academy, so that nurses can continue to upskill themselves and advance in their careers. It is through a multi-pronged approach. First, making sure that the work environment is much more conducive, much more flexible, but also creating different skill pathways for different entrants into different care roles to progressively go up into taking more advanced nursing roles. In that way, we create a more attractive environment for different people of different capabilities to join the healthcare sector and, especially, to attract the mid-career entrants.”
“Sir, I thank the Member Ms Foo Mee Har for raising these two clarifications. On how we would want to deploy our medical manpower should there be more cases during the endemic phase that requires community care monitoring, I think it is important to understand the differences between acute hospital care requiring more intensive nursing care and community care that does not require the intensiveness of care monitoring. We have a few options. One is, of course, we do have a ramped-up plan for nurses to be deployed into some of these Community Care Facilities (CCFs). We experienced that during the earlier phase of the COVID-19 crisis last year, when we had a lot more foreign workers who were being cared for in the CCFs. There, we have a complement of nurses providing more medical supervision as well as doctors, but there is also a series of other care providers, volunteers, who are trained to actually use technology, for example, automatic blood pressure reading machines and oximeters, to also help to monitor the health status of those in those community care facilities. In that way, we actually stretched the role of the nurses through partnership with other care partners. For the second question on how we can ramp up our local supply of nurses, Singapore's stock of registered nurses increased by about 19% from 36,000 in 2013, to more than 42,000 in 2019. This translates to almost 7.5 registered nurses per 1,000 population, which is a good number compared to many other Asian economies like Hong Kong and Taiwan. But as the Member said correctly, as our population ages, there will be an increased demand for healthcare services and the manpower will have to increase commensurately.”
“Sir, according to the Singapore Nursing Board’s 2019 report, about 7,600, or 18%, of our nursing workforce are Filipino. The Ministry of Health (MOH) is closely monitoring the impact of the Philippines’ suspension of permits. We are working with healthcare employers to ensure the adequacy and sustainability of our nursing workforce. Healthcare employers should also diversify their recruitment sources. Meanwhile, our local supply of nurses has grown. In 2020, there were around 1,400 new registrations from locals, compared to around 1,200 in 2019. This is a result of our past efforts to grow the nursing intake in our Institutes of Higher Learning. We will continue to enhance the attractiveness of the nursing profession and I hope more Singaporeans will join this noble profession, especially those who are considering a mid-career switch.”
“Okay. The panel only makes sense, if you have fee arrangements. But, the key to ensure all patients have access to care is to enhance the pre-authorisation process, so all patients regardless of whether the doctors are on panel or not can have access to the doctor for continuity of treatment.”
“But, on the whole, for common procedures, there are enough data sets for insurers to get a certain sense of what the general ballpark is, and then use that to get an extrapolation of something that is not actually having a benchmark, but should fall somewhere in between. So, that is how it is done. For panels, I think I have explained previously that it is difficult to ensure that all doctors get on panels because doctors can choose not to be on panels.”
“Mr Speaker, let me just take the first question, which is how do we ensure that insurers know how to price the cost of different procedures. Mr Gerald Giam may not be aware how the surgeons grade surgical procedures. Table 7 procedures, for example, would be usually grouped together in similar level of complexity. And in the private sector, when we charge a Table 7 procedure, we usually kind of put the cost around the same ballpark for other Table 7 procedures. You can have a certain variation above and below a certain range to account for some complexity but on the whole, generally, that is the approach taken. Even if the insurers were to try and see how each procedure can have a certain range, the fact is that the ranges will overlap, because they are all Table 7 procedures. But if in this Table 7 codes, there are 10 procedures, of which you may have information for five, the other four may be rare and uncommon, so you generally try and place it somewhere in between one of the five. For example, in terms of level of complexity. Table 7, 7A, 7B and 7C. So, if this is a 7B procedure, it will be charged somewhere between a Table 7A and a Table 7C procedure. That is how you kind of get a gauge, a rough gauge. It cannot be absolute because sometimes even a Table 5 operation can cost a bit more than a Table 7. If it takes longer to perform that procedure, intraoperatively there are challenges, a Table 5 procedure can cost more than a Table 7. So, it is not something that is easily hardcoded because it can vary from case to case.”
“MOH will continue to work closely and facilitate close collaboration between stakeholders to ensure that measures and solutions are put in place to uphold patients' interests in healthcare. The Workers' Party Member's Adjournment Motion on ensuring patients' interest in healthcare focuses largely on the financial aspects of healthcare. Lest it be construed that good healthcare is only about finances and dollars and cents, I think it is useful to remind us, all of us here, that good healthcare, is ultimately delivered by our healthcare workers. Many of our healthcare workers are currently on the frontlines of this fight against the COVID-19 pandemic 24/7, putting themselves and their families at significant risk of infection and perhaps even mortality. I want to thank them and salute their sacrifices and their bravery and their courage, and call on all Singaporeans to give them our fullest support during this period. Let us not shun them for the job they do in this challenging and difficult time, but support them, so they can better help us. To all our healthcare workers on the frontline, let us remember the aphorism of Sir William Osler in the way we care for our patients: "To cure sometimes, to relieve often and to comfort always." [Applause.]”
“The work by the Multilateral Health Insurance Committee, or MHIC, is already on-going on areas that Mr Giam has raised, amongst others. So, I shall not elaborate further and the Member can refer to my earlier Parliamentary Question (PQ) reply. But I would just want to highlight a couple of points which he has brought up. One is on the issue of expanding the panel to more doctors or in fact, to all doctors, and I have explained in the PQ reply that pre-authorisation is the way to go, to provide access to care by all doctors through the pre-authorisation route. And in fact, panel sizes have increased by 40% in the last six months to a year, up to 70% of private specialists are already on at least one panel. On taking a hands-on approach to regulating Integrated Shield Plans (IPs), MOH already exercises close oversight of IPs, due to their direct association with MediShield Life and also, as MediSave can be used for IP premium payments. Any changes to IP premiums or terms and conditions, requires approval from MOH. In approving any changes, MOH considers the interests of the policyholders, as well as the need for healthcare costs and premiums to remain sustainable. As I had outlined in my earlier reply, riders are fully private insurance products, going beyond MediShield Life and IP plans. MOH will typically not intervene in this space. Such riders are regulated by MAS who exercises regulatory oversight on the financial viability of insurance products. Mr Speaker, we thank the Member for his suggestions and would like to assure him that the issues brought up are already being looked into.”
“Indeed, our early data showed that doctors have been taking reference from the benchmarks, with more than 80% of fees in 2019 within the upper limit of the benchmarks. This was also 4% higher than in the year before in 2018. In 2020, MOH further introduced new benchmarks for anaesthetist and inpatient attendance fees, and will continue to review and develop new areas of fee benchmarking with the Fee Benchmarks Advisory Committee. Mr Gerald Giam suggested that doctors and hospitals should be required to provide detailed itemisation of charges on their bills, to address over-servicing and overcharging. This is in fact already required under the current existing Private Hospitals and Medical Clinics Act, or PHMCA, for hospital bills, and will be further enhanced under the new Healthcare Services Act to cover all licensable healthcare services. MOH will prescribe the minimum level of granularity that must be reflected in patients' bills, which include categories such as consultation, medication and investigations. Just as importantly, licensees are required to display common charges prominently at their premises or on their websites and provide financial counselling for services which tend to generate significant bills prior to service provision, to ensure greater price transparency upfront and help patients make much more informed choices. On the issues surrounding Integrated Shield Plans, MOH has already implemented several measures and are continuing to explore and work on much more, which I have taken quite a bit of time earlier today during Question Time to elaborate in my response. And in fact, many of the questions and measures that were suggested were also brought up by the Government Parliamentary Committee (GPC) Chair and many of our GPC members and backbenchers.”
“Although Fee Benchmarks have been published for only 8% of the 2,300 procedures listed in the Table of Surgical Procedures, or TOSP, these 200 procedures were selected as they accounted for more than 85% of the cases involving procedures and 75% of professional fees for procedures in the private sector. The TOSP lists all procedures from Table 1 to Table 7 based on the level of complexity. So, for example, a Table 1 procedure will be something much more simpler like taking out a small lump on your arm, but a Table 7 procedure will be where there is the highest level of complexity and surgical risk, involving multi-organ resections, for example. So, even without direct information on the less commonly performed procedures and less available datasets, doctors will generally be able to benchmark the fees based on the equivalent level of complexity for procedures codes within the same Table level. This approach we have taken allows us to set the Fee Benchmarks for the most common procedures to achieve the intended outcome without the unnecessary administrative burden and costs of curating very limited data sets for less commonly performed procedures. This is also a point that Mr Giam has acknowledged. And I would like to say that our approach is far more efficient in achieving the same outcome that we want without imposing unnecessary burden on the clinicians who are busy doing their work. And in fact, when the data set is scarce, what you have is a lot of outliers at the extreme ends which makes the range much more spread and the outliers may sometimes predominate and make the benchmarks actually inaccurate.”
“The "Total Hospital Bill" size publication started in 2003 with 28 common conditions for the public sector and five-day surgery conditions for the private sector, using actual transacted charges. It was then progressively expanded to include more conditions and information. For instance, the "Total Operation Fees" for common surgeries was published by 2014 for the public sector and in 2016 for the private sector. A further breakdown of "Facility Fees", "Surgeon Fees" and "Anaesthetist Fees" for the private sector was also made available to facilitate the comparison of private professional fees. Today, the actual bill size publication for close to 300 procedures and medical conditions is available on MOH's website. While publications on bill sizes provided a form of benchmarks on charges, we decided to further reduce the information asymmetry between healthcare providers and consumers. Therefore, in 2017, MOH appointed an independent, multi-stakeholder committee to develop and recommend Fee Benchmarks for the private sector. So, it is not as if when we withdrew the Guidelines on Fees, there was a huge vacuum, there was actually a process that already preceded that, but it was enhanced and strengthened even after the Guidelines on Fees was removed and culminated in the Fee Benchmarks being promulgated. The Fee Benchmarks serve as references for the public to assess whether the fees charged by a healthcare professional are reasonable; for medical providers and professionals to set appropriate charges; and thirdly, for insurers to take an active approach in their claims assessment and panel design. As a start, MOH published Surgeon Fee Benchmarks for about 200 common surgical procedures in 2018.”
“Mr Speaker, I thank Mr Gerald Giam for his impassioned speech asking for more efforts to help in ensuring patient's interest in healthcare. Indeed, ensuring patients' interests has been and will always be a priority of MOH. We have put in place many measures over the years and will continue to work on ensuring that all patients have access to good quality and affordable healthcare. We have enhanced the safety net through universal coverage for life, of all Singaporeans and Permanent Residents with no disease exclusions under MediShield Life. Expanded CHAS allows subsidies for outpatient care and CareShield Life further supports long-term care for those with severe disability especially in old age. The Government spending on healthcare has tripled within a decade, from $3.7 billion in FY2010 to $11.3 billion in FY2019. To ensure healthcare remains affordable and cost-effective, is an area that requires collective effort by patients, providers and insurers alike, and the Ministry works collaboratively with all stakeholders to achieve this. Mr Gerald Giam asked why it took MOH more than 10 years to replace the Guideline on Fees, or GOF, with the Fee Benchmarks. It is understandable, as Mr Giam is not a practising doctor, so he may not be fully aware. And Mr Giam has spoken to some doctors, so, I am quite surprised that he does not know, that to increase the transparency of healthcare charges, MOH had already started publishing "Total Hospital Bill" sizes for both public and private healthcare institutions in the year 2003, four years before the Guideline on Fees was withdrawn in 2007 due to anti-competition concerns. Such transparency encourages providers to charge more competitively and enables consumers to make better informed choices about their provider.”
“Sir, I thank the Member for his questions. I think the second question is easier to answer. We will just put as much information as possible, whether it is on MOH website, whether it is on the LIA website. And of course, CASE can play a stronger role in patient and policyholder education as well. But I think, for his first question, he is conflicting two different numbers together which do not quite necessarily gel. Just because there are only 17% of hospital beds, it does not mean 40% of people cannot buy insurance for private sector. It does not mean that everybody who buys a policy, gets sick and gets admitted to the hospital all at the same time. So, it is a choice to buy, it does not necessarily mean that they will necessarily have to consume. It does not necessarily mean that the size of the number of beds we have should then limit the amount of policy coverage a particular segment of population goes for. I hope that helps him to understand why the numbers should not necessarily be conflicted together.”
“Sir, I think this is also in the same vein as expanding the panel of doctors. Which is why in one of the work streams that the MHIC endeavours to do, as one of their earliest priorities, is to look at how they can further expand and streamline the pre-authorisation process. Once we can get a more seamless and streamlined, pre-authorisation process, it effectively opens up access to care by all doctors. And the patient, then do not have to really worry so much about whether doctors are panelled or non-panelled. The difference, of course, is in some of the benefits of panel and non-panel doctors. But today, any IP-insured patient can actually have access to non-panel doctors through pre-authorisation. So, at the moment, there is actually no restriction of care, but there is some friction in the process. With pre-authorisation, hopefully we can make this much more seamless and reduce a lot more anxiety for patients going for treatment, when they have to go beyond a panel to access a specialist outside the panel. So, I hope that will help Members understand that the MHIC will prioritise this as one of the key streams they want to work at.”
“This would include accident and health policies such as IP plans, which will be fully covered under the PPF scheme, in an event that the insurer fails. The PPF Scheme does not merely provide compensation of crystallised claims when an insurer fails, but also seeks to ensure continuity where possible for the effective policyholders in the event of an insurance failure. For example, you could also fund a transfer or run-off of the IP portfolio business to another IP insurer to ensure continuity of coverage for the affected policyholders, if necessary. In Singapore, what is useful for Singaporean citizens, is to always know at the back of their minds that they have a safety net called MediShield Life. Should all else fail, MediShield Life will be here to cover you universally with no exclusion on all your pre-existing conditions for life.”
“Sir, I thank Dr Tan for his clarifications and questions. His first question pertains to patient voices should there be a dispute by the policyholder against the insurer and what mechanisms are there today to address some of these grievances. Actually today, FIDReC, the Financial Industry Disputes Resolution Centre already has a mechanism in place to address any policyholder's concerns pertaining to whether it is policy terms or unfair treatment by an insurer. So, FIDReC is a mechanism that is already available. But we do feel that with better patient and public education, that will raise the awareness of consumers' rights and when they think that their rights, under the policy terms, have been violated. So better patient education, better policyholder education is another important thrust to get this done. We welcome the fact that CASE will be forming a sub-committee under the MHIC to further study this issue, and also to look at how they can better represent the voices of consumers, policyholders and patients. The second issue is about what would happen if the insurers were to exit the financial sector. If an insurer fails and undergoes winding up processes under the Insurance Act, the appointed liquidator is required to endeavour as far as possible, and reasonably practicable to sell, or transfer the whole or part of the insurance business to another insurer before considering other options. The Policyowners' Protection Scheme, or PPF Scheme, is also in place which aims to provide coverage for policies which are commonly purchased by consumers, and/or cause significant impact of destruction to policyholders should the insurer fail.”
“It is very hard to say which insurer ranks number one or which is ranked at the bottom because they may have product differentiation that meets different persons' needs. And for a person where the product meets his needs, it could be number one, as an insurer, but if the other product meets the other person's needs better, that could be number one in the other person's eyes. I think it is very hard for MOH to decide from one person to the next which is the best product to suit the person's needs. What we should do is to put more information so that patients and policyholders can make the right informed choices.”
“Sir, I thank Dr Lim Wee Kiak for his questions. The issue of whether the limited size of panels of certain insurers, as I have said in my reply, it will be very difficult to say that we make the panels include 100% of all doctors, because doctors have a choice not to be on panels as well. I think the more important way to look at this is how can we make sure that care is accessible to our patients, whether the mechanism is empanelment or otherwise? I think the key is to make sure patients have access to any doctor they want to see, which is why I think the better way to go for is to look at pre-authorisation. With pre-authorisation, the doctor puts in his diagnosis, gives a certain quote on the treatment cost that is needed and the insurer has a chance to see whether this cost is fair and whether the type of treatment that is proposed is reasonable for the kind of diagnosis that is being put forth. In that sense, the patient can then have access to any doctor, subject to a pre-authorisation, if they are not on the panel. This is a mechanism that is already available today. But, what we need to do is to make sure that the process is much more streamlined and seamless, so that there is not too much administrative burden on the clinics and the patient does not have to wait too long for this process to be completed before they can have access to care by a different doctor, by a different specialist. In terms of ranking of insurers, I think what is important is to have information on how each insurer price its policies and what benefits it has transparently so that patients or policyholders themselves can make a comparison and take a look.”
“Sir, I thank Mr Pritam Singh for his questions. In fact, these two items are already being done. The first, on the database for bill sizes, when we have the Fee Benchmarks Advisory Committee, in fact, the database on fees that are charged across a diverse range of procedures across various institutions are already available for the Committee, which comprises practitioners and insurers, to collectively deliberate on what the kind of benchmarking ought to be. So, yes, the database is available and I think that will provide some scrutiny by the relative stakeholders to ensure that, whether it is payouts or benchmarking, they are considered fair to the policyholders and to the payers as well. The second issue on independent assessment, as Members have heard from my reply earlier, we will be setting up a Claims Complaints Panel that comprises the insurers plus also the Academy of Medicine of Singapore who are specialists in the respective fields. So, that provides some degree of independence from the professional side or of both the stakeholders to really look at any areas, whether it is insurers or doctors, which have got some unhappiness over the way payments are done or the way a certain case is being assessed by either party. So, yes, there will be an independent panel that is going to be in the works.”
“On this particular last issue, CASE will be leading a sub-committee to the MHIC to deal with the matter comprehensively. As these issues are complex, some time will be required for the Committee to develop and agree on practical solutions. Processes within the institutions, hospitals and clinics may also have to be adjusted to make it more seamless and streamlined. The Committee has already begun its work with the first meeting held on 27 April. MHIC will share its recommendations progressively as they are ready and is working towards a first round of recommendations in the next few months. The issues surrounding IPs are multi-faceted and require thorough discussions as well as careful balancing of various considerations, to find solutions that best benefit policyholders and patients. With continued healthy dialogue through the MHIC, MOH will work together with all stakeholders towards developing sustainable solutions for policyholders, payers and providers alike.”
“However, we are confident that these measures will help to keep healthcare costs more sustainable. Looking ahead, the refinement of various IP features will continue to be a multilateral effort between MOH, hospitals, doctors and the insurers. To support these efforts, MOH appointed a 12-member Multilateral Healthcare Insurance Committee (MHIC) in April this year to provide a platform for healthcare providers, payers, consumer representatives and the Government to work on these issues related to health insurance. The MHIC comprises representatives from the Academy of Medicine, Singapore (AMS), the Consumers Association of Singapore (CASE), the Fee Benchmarks Advisory Committee (FBAC), the Life Insurance Association (LIA), the Singapore Medical Association (SMA), private hospital representatives and with MAS as an observer. For a start, the Committee will prioritise four specific workstreams. First, panels and pre-authorisation, including streamlining the processes I spoke about earlier; second, issues pertaining to improving transparency across the board, including providing more detailed and itemised information about healthcare bills and publishing data on claims and premiums, so that insurers, providers and policyholders can make better informed decisions; third, establishing a claims complaints process supported by AMS and LIA so that stakeholders have an avenue for recourse should they feel unfairly treated, such as where insurers or patients may wish to raise concerns about over-servicing or over-charging, or if doctors have concerns about certain insurer practices; and, fourth, examining the issues from a patient and consumer-centric viewpoint to ensure that the patient and public interests are best safeguarded.”
“It is, nonetheless, important that the process be handled professionally and efficiently by each insurer. Insurers should not make the process onerous and ask for unnecessary information unrelated to the claims, imposing a heavy administrative burden on the doctors. The questions and information sought for common conditions can be standardised and streamlined so it will not be perceived as questioning the decisions and judgement of the doctors. If a particular claim is justified, insurers should pay according to the policy benefits. We will be looking more into this issue. Dr Tan Wu Meng has raised concerns with the risk of IP insurers exiting the market. To ensure that insurers remain financially sound and are able to meet their obligations to policyholders, MAS exercises regulatory oversight over the insurers' financial standing, risk management and governance. This is accomplished through measures, such as establishing regulatory capital requirements and setting corporate governance and risk management requirements and guidance, which are, in turn, reinforced by regular onsite inspections and close engagement with the boards and senior management of insurers. MAS also takes action against insurers whose practices are found to be wanting or where there are breaches of MAS' regulations. An insurer may decide to exit the IP market because of commercial reasons or due to insolvency. In the event that an insurer exits the IP market, the insurer or the liquidator will seek to arrange for the IP policies to be transferred to another insurer for continuity of coverage. MAS will ensure that the existing insurer and the insurer taking over the IP policies properly account for policyholders' interests. The various initiatives covered above will take time to bear fruit.”
“Insurers offer policyholders enhanced policy benefits, such as the co-payment cap, lower deductibles or a longer period of pre- and post-hospitalisation coverage for panel treatments. All this must be made known to the policyholder prior to policy purchase and at least 30 days before any changes in policyholders' benefits. Policyholders must be properly advised at the point of purchase or renewal about their coverage, so they can make informed choices about their IP and choice of doctors and care setting. Some have asked if insurers can simply use MOH's Fee Benchmarks to determine all insurance payouts. As Fee Benchmarks are designed to be reasonable ranges of fees for the large majority of cases, insurers can, generally, take reference from the benchmarks for most payouts. Doctors do charge below and above the benchmarks, depending on the nature and the complexity of the cases. However, insurers also need to take into account the medical complexity and specific clinical circumstances, and deviate from the benchmarks for justified and exceptional cases. According to LIA, between 5% and 15% of IP claims for surgeon fees were approved above the upper bound of the Fee Benchmarks, depending on the insurer. Claims scrutiny by insurers may have been perceived as challenging a doctor's professional judgement. Insurers scrutinise claims to ascertain whether treatments were medically necessary and charged appropriately. This actually protects the interests of policyholders who may otherwise see their insurance premiums rise should claims be paid out indiscriminately. MOH recognises that this is an important process for the integrity of the healthcare system and is a common practice internationally.”
“While policyholder benefits may differ, depending on whether they see a panel doctor or a non-panel doctor who is pre-authorised, these benefits should not differ to the extent of prohibiting patients from seeing non-panel doctors or influence patient choices in an undesirable way. MOH recognises that some policyholders may wish to switch insurers, whether for more competitive premiums or for better benefits, such as access to more panel doctors, but are unable to do so because of pre-existing conditions. IPs are commercial products, and their features and pricing are, ultimately, determined by private insurers. MOH will study whether IP insurance can be made fully portable, including looking at examples abroad. However, insurers may potentially need to increase the premiums significantly for all policyholders to price in the increased risk they assume for portable IP that covers pre-existing conditions. This is why MediShield Life is designed as a scheme to cover all Singaporeans for life with no exclusions and covers all pre-existing conditions to give reassurance to all Singaporeans should they choose to relinquish their private IP plans, for whatever reasons. Over the last five years, about 5% of IP policyholders relinquished their IP per year on average. This could be because they may have opted for different coverage, after considering the cost of the premiums, their financial resources and their different healthcare needs. Their average age was 34. Data on the number of policyholders who did not subsequently purchase a new IP or were later admitted to public hospitals is not available. Consumers should understand their IP terms and conditions when choosing their IPs.”
“Patients have also raised concerns that the doctor they are comfortable with, or are familiar with, is not on the panel of their IP insurer and they may not enjoy the additional panel benefits such as the $3,000 co-payment cap. To address this, MOH has encouraged all insurers to grow the size of their panels and some have already increased the number of specialists on their panels by more than 40% since August 2019. Today, more than 70% of private specialists are on at least one IP panel. Some have asked insurance panels to be expanded to include all doctors, so long as they do not have a poor track record with the Singapore Medical Council, or SMC. However, some doctors may choose not to be empanelled as they may already have a sufficient pool of patients. So, the doctors do have a choice to not be on panels. This is especially the case for areas where there are very few specialists locally. Hence, MOH encourages IP insurers to enhance their pre-authorisation processes, to give approval for hospitalisation or treatments and their associated costs beforehand. With pre-authorisation, insurers are able to assess treatments for medical necessity and fee arrangements and appropriateness, including for doctors who are not on their panel. And patients can also have greater peace of mind knowing that at least a significant portion of their bill will be covered by their IP. With pre-authorisation, the risk of runaway bill sizes would then be minimised. Hence, some insurers have extended the co-payment cap to pre-authorised claims for treatment by non-panel doctors to provide policyholders with greater assurance, and we certainly encourage more to do so.”
“These practices do not contravene the Competition Act as any decision to empanel doctors is made by individual insurers independently with the doctors, on mutually acceptable terms. Such practices do not restrict insurers from competing with one another on their prices, insurance products, or choice of doctors. Nevertheless, MOH has encouraged insurers to make their panel selection criteria more transparent, a move which is also supported by LIA in its "Panel Good Practices Guide" to all insurers. On the issue of medical ethics, the Singapore Medical Council's Ethical Code and Ethical Guidelines stipulates that doctors should have the best interests of their patient at heart when treating them. This includes prescribing appropriate and cost-effective care that best meets the needs of their patients. Access to medical care and clinical judgement should therefore not be influenced by empanelment nor any other financial constraints or pressures inherent in any health system. Should doctors find that the conditions of being on a panel would impose constraints on their ability to care for patients, they may decide for medical ethical reasons to not participate in such panels. We want to emphasise that patients can make claims for all treatments covered under their IP, regardless of whether the specialist is on the panel or not. Nonetheless, some doctors have expressed concerns that IP panels do not have an adequate number of specialists, restricting referrals to the appropriate specialist who may not be on the panel, and therefore, limiting the continuity of care.”
“To provide some assurance to policyholders who were concerned with potentially large co-payments, MOH therefore allowed insurers to apply a $3,000 co-payment cap for treatment from panelled doctors with negotiated fee arrangements with insurers. This would mean that bills above $60,000 are capped at $3,000 co-payment. To put things in perspective, less than 3% of inpatient bills in private hospitals today exceed $60,000. So, the vast majority of inpatients bills do not actually hit the $3,000 co-payment cap. This co-payment cap could not be applied to all claims, as it would negate the effect of co-payment once the $3,000 cap was reached. Let me explain. Take for example, if the co-payment applies to all claims, policyholders may choose a treatment which costs $100,000 instead of another equally effective treatment at $70,000. This is because the policyholder would pay the same amount of $3,000 for either option once they breach the $60,000 limit, where the $3,000 co-payment cap has been reached. The additional costs would then be borne by the insurer and this eventually translates to higher premiums for other policyholders. Therefore, the cap was applied to panelled doctors, where there are established fee arrangements to ensure that appropriate and cost-effective treatment is provided. Some have raised concerns with regard to the use of panels. Questions have been raised on whether limited panel sizes are in the best interest of the patients and whether such practices are anti-competitive in nature or if there are medical ethical concerns around such practices. The use of panels was recommended by the HITF. Internationally, panels have been used by some countries to keep healthcare costs more predictable, to reduce variation in practices and charging.”
“Between 2007 and 2019, private hospital bills among IP cases grew at 4%, twice as fast as unsubsidised bills in public healthcare institutions. In both private and public hospitals, investigations, surgeon fees, treatment services and operating theatre facility fees were key drivers of cost growth for private patients. In 2016, the Health Insurance Task Force (HITF) comprising members from the Singapore Medical Association (SMA), Life Insurance Association (LIA) Consumers Association of Singapore (CASE), MOH and MAS had recommended various measures, such as panelling and Fee Benchmarks, to help contain claims and healthcare cost escalation. MOH has been working to implement the HITF recommendations. Fee Benchmarks have been rolled out since 2018, along with appropriate care guidelines. One of the recommendations from the HITF was to introduce a minimum co-payment requirement, as IP riders that fully covered deductibles and co-payment had contributed to rising private healthcare cost. The co-payment ensures what we call "skin in the game", to encourage patients and their doctors to make careful and deliberate decisions on the choice of treatment and the type of care they need. MOH, therefore, introduced a minimum 5% co-payment for all new private riders in 2018. The IP insurers have also extended this requirement or alternative claims-based pricing from April 2021 to their existing policyholders with riders. While this is not a requirement imposed by MOH, the Ministry supports the move as it will help to encourage appropriate care.”
“If I may continue, Sir, MediShield Life can be used in both public and private healthcare institutions, and coverage is sized to be sufficient for subsidised care. The Government provides means-tested subsidies for MediShield Life premiums and MediSave can be used to pay for premiums to keep them affordable. Individuals may choose to purchase an Integrated Shield Plan, or IP plan, which provides additional benefits beyond MediShield Life to provide more coverage for private healthcare services. MediSave can be used to pay for IP premiums, subject to withdrawal limits, to help defray the cost of private insurance. Currently, less than 1% of Singapore residents have a Standard IP plan, 10% have a class B1 IP, 20% have a class A IP and 40% have a private hospital IP. In addition, some individuals may also purchase riders on top of their IP plans, if they prefer additional coverage and can afford the premiums. Riders commonly cover the deductible and co-payments portion of the bill. Riders are fully private insurance products that must be paid by cash and MediSave withdrawals are not allowed for rider premiums. Less than half of Singapore residents have riders. Let me just summarise this part. In essence, MediShield Life is universal, it is sized to cover the bulk of the large hospital bills for subsidised care. IP plans stay right on top of this, to provide for private hospital bills. And riders go even further on top of the IP plans, to cover for the deductibles and the co-payments. So, you can see it as a three-tier thing. MOH does track and monitor the bills from both public and private healthcare institutions. Private healthcare costs have been rising rapidly in Singapore.”
“I beg your pardon, Sir, yes. Can I take Questions Nos 24 to 31 together?”
“Sir, all Singaporeans and Permanent Residents are covered under our national MediShield Life (MSHL) health insurance scheme. MediShield Life is universal, covers pre-existing conditions and provides basic protection against large healthcare bills.”
“Mr Chairman, I thank the Member for asking the clarifications. Yes, indeed, for PCHI, it is based on residents with the same household address, so that we know that they are staying in close proximity and they can mutually support each other. In terms of MediSave usage for mutual support, in fact, you can designate a next-of-kin, for example, You can have your spouse or even the children, who may not necessarily be staying at the same address, can also add support with their MediSave to contribute to the care of their aged parents, who may not reside in the same address but they can use the MediSave from their children, and vice versa. 5.45 pm In terms of liberalising MediSave usage, we have through the years, allowed more and more uses for MediSave. You will remember that when we first started with the Chronic Disease Management (CDMP), there were only a few conditions that were in it. In the last few years, more and more conditions were added with considerations such as disease prevalence, whether they are effective treatment and whether there is clear treatment protocol, that can translate to a good outcome. We are open to review the list of diseases that will be added on overtime as the science and the medical understanding develops as well, and in consultation with a panel of medical experts who can advise us on what they feel is useful to include in the CDMP list. We are always opening further opportunity to use MediSave, and as the Member pointed out, they could well be situations in which we could liberalise some more and we will continue to do so.”
“Mr Chairman, I will attempt to explain the MediShield Life premium issue. I have actually done an extensive explanation when I gave an update to this House late last year. I think the answer still applies. Mr Leong should check the Hansard. I think his point that the MediShield Life premium is unaffordable, the older the Singaporean gets, is not correct. Because if he checks my speech in the Hansard, he would have understood the fact that, for the Pioneer Generation, who are the older Singaporeans in Singapore, they get MediSave top-ups to pay for their premiums. In fact, for many of the oldest in the Pioneer Generation, they get virtually free MediShield Life because they virtually pay no premium at all. So, I do not think he understood what was said in the House last year and I urge him to read my speech all over again in Hansard.”
“Mr Chairman, I thank Dr Tan for his clarification. I would agree with him that as needs evolve over time, and certainly COVID-19 is a very challenging time, for us to also take stock post-COVID-19, what kind of healthcare model will we have, and in that case, to build resilience within maybe certain critical parts of our healthcare system; do we need to review the current structure in which we engage with outsourcing of our staff? 5.30 pm So, I do not think we are ideological here but we will take an open-minded approach to review the needs and maybe talk to our healthcare institutions as well to see during this period, whether they have made useful insights and observations to warrant a change in the current approach. But I also must caution that in insourcing back certain levels of staff within the system, we need to make sure that there is still a meaningful career progression and prospects for them as well. Because if they are a small number, for which there is little career progression, we need to also bear that in mind to balance out the needs of the organisation versus the aspirations of the person.”
“With deeper partnerships with our private sector providers, innovative, value-based healthcare delivery, a strong healthcare financing framework, and a resilient healthcare workforce, we will be better placed to provide all Singaporeans with good quality, affordable, and accessible healthcare. [Applause.]”
“Finally, we are cognisant that salaries play a key role in the attraction and retention of staff. Our healthcare workforce is the lifeblood of our healthcare system and the work that they do is critical in protecting the health and safety of our society. We must maintain the salary competitiveness of healthcare staff against the overall market to attract and retain quality talent. For doctors and dentists, we recently updated the salaries for junior House Officers, Medical and Dental Officers, Consultant Family Physicians and newly-promoted Associate Consultants within our public healthcare institutions in 2019. So, I am pleased to announce that nurses in the public healthcare sector can look forward to an increase of 5 to 14% in their monthly base salaries, phased over the next two years. Allied health professionals, pharmacists, and administrative and ancillary staff, including support care staff, in the public healthcare sector can also look forward to an increase of 3% to 7% in their monthly base salaries this year. We will also increase funding support to publicly-funded community care organisations to ensure that salaries of their staff also remain competitive. The changes to both sectors will be implemented from July this year. MOH will regularly monitor the salary competitiveness of our public healthcare workforce. Aside from salaries, we will also work with healthcare providers and union partners to make healthcare a progressive and fulfilling career. Sir, COVID-19 has posed a major challenge to our healthcare system, but we have learned valuable lessons and we will emerge stronger.”
“Second, we have built pathways for progression, and continue to expand mid-career conversion pipelines. We introduced new pathways for Enrolled Nurses to move from Nitec to Diploma-level qualifications within a shorter time and progress as a Registered Nurse. In line with the recommendations of the Future Nursing Career Review Committee (FNCRC), we enhanced nursing career tracks and job scopes. Nurses can now perform a wider breadth of care tasks and make clinical decisions. We are seeing increased interest in our Professional Conversion Programmes (PCPs). Between 2018 and 2020, an average of 160 mid-career locals enrolled each year, about double our average annual PCP intake in the preceding three years. This year, Ngee Ann Polytechnic (NP) will join Nanyang Polytechnic (NYP) in offering the two-year accelerated PCP for diploma-level registered nurses. We will also explore more pathways for mid-career entrants to complete their training in a shorter time. The Singapore Institute of Technology (SIT) is introducing an accelerated PCP in Occupational Therapy for those who have already got a degree in a science-related field. They can complete their training in slightly under three years instead of four years. Third, we actively partner healthcare employers in re-designing jobs for staff working in healthcare support and operations support roles. For example, the Care Support Associate (CSA) role in SGH, and AIC’s sectoral job redesign project relook processes and blend clinical support, administrative and operations responsibilities into new roles. These initiatives encourage cross-deployment and multi-skilling of staff, create new career pathways, and provide interesting development opportunities for them.”
“I know many staff in our public healthcare institutions suspended their annual leave to meet the surge in manpower demands during the height of the COVID-19 crisis. Many have played a critical role in the battle against COVID-19 and I would like to express our heartfelt thanks to all of them for their dedication and contributions, and their families for supporting them through this very tough period. We also recognise and appreciate the contributions of our outsourced workers in the healthcare sector. We agree with Dr Tan Wu Meng that their work is intrinsic to the hospital as many of them, such as cleaners and health attendants, work alongside our healthcare staff in the wards. The intent of outsourcing is to leverage economies of scale and enable our public healthcare institutions to focus on the core mission of delivery of healthcare services. While our public healthcare institutions are not their direct employers, they have also extended support and tokens of appreciation to these outsourced workers. We will continue to work closely with the outsourced companies to improve the work conditions of their staff. To strengthen our healthcare workforce, I agree with Ms Mariam Jaafar that we need to attract more talent to healthcare and to build a strong local core. First, we have strengthened our pipeline of fresh graduates. Since 2012, we have increased intakes and retained a strong local core of doctors, dentists, pharmacists and therapists. We have also strengthened the attractiveness of nursing, increasing intakes by about 45%, from about 1,500 in 2014 to about 2,200 in 2020. At steady state, we will be training about 3,300 students annually in our Institutes of Higher Learning to become healthcare professionals.”
“We also agree with Ms Ng Ling Ling that funding mechanisms can drive greater value through influencing providers’ behaviour. We, in fact, implemented some of the ideas that she has shared. One financing innovation which MOH has started to adopt is bundled payments, where funding is based on a patient’s entire care episode, even across multiple healthcare settings or attendances. This gives providers the opportunity to optimise care, reduce costs, and pass on savings to patients. MOH has also implemented a Pay For Performance (P4P) framework which financially incentivises clusters to perform well in key priority areas and the Value-Driven Care (VDC) Programme which tracks clinical performance and cost of care for medical conditions. We will expand these positive efforts and study other financing solutions and innovations that encourage healthcare providers to optimise care and improve outcomes. Beyond technology and care models, healthcare is ultimately a high touch and people-centric sector. Healthcare professionals are key in improving patient care and outcomes. COVID-19 has shown us the importance of maintaining a resilient core of healthcare workers. Following the launch of the SG Healthcare Corps (SHC) in April last year, over 5,000 workers and volunteers have been trained, and provided support in areas such as the care of elderly in nursing homes, swab operations, laboratory testing and vaccination operations. Going forward, we plan to develop the Corps into a platform for citizen engagement and volunteerism in healthcare during peacetime, and serve as a reserve pool in times of crisis. COVID-19 has been a trying time for all our healthcare staff and volunteers.”
“We also agree with Dr Tan Wu Meng that patient navigators can improve patient convenience, and our public healthcare institutions have increased the number of staff trained in such roles by 3% annually between 2018 and 2020. But beyond this, we have also improved scheduling services and offer telehealth follow-ups for suitable patients, helping to reduce the need for multiple hospital visits. Second, innovative care models have been introduced to improve right-siting of care in the community. Examples include the Urgent Care Centre (UCC) pilot concept and the GPFirst Pilot Programme which support patients with non-emergency conditions, helping them avoid unnecessary emergency department visits. 4.30 pm MOH will review the performance of such technology-enabled services and innovative care models, and explore how we can scale up the promising ones. We also strive for greater value and better services in our healthcare system. The Agency for Care Effectiveness (ACE) helps us to ensure that the prices we pay for subsidised treatments and vaccines are fair and commensurate with the healthcare outcomes they confer. This is done through health technology assessments and value-based pricing (VBP) negotiations. ACE will continue to ensure that subsidised medicines and medical technologies are both clinically and cost-effective. We also established ALPS in 2018 to aggregate demand and achieve economies of scale in procurement and supply chain management. In 2019, ALPS’s Central Warehouse Distribution (CWD) pilot for polyclinics saved an estimated $1.7 million through advanced warehouse and logistics technology. ALPS will study how this CWD concept can be expanded to the whole of public healthcare boosting efficiency, resilience, and value in our healthcare supply chain.”