Lam Pin Min
Singapore
“Mr Speaker, on behalf of the Minister for Transport, I beg to move, "That the Bill be now read a Second Time". This Bill, together with the Active Mobility (Amendment No.”
“It is timely for us to put in place a regulatory framework to ensure that active mobility devices being brought into and used in Singapore are safe. This is a key step in helping us put in place a safe and sustainable active mobility landscape in Singapore. Mr Speaker, I beg to move. [(proc text) Question proposed. (proc text)] 1.55 pm”
“Clause 6 facilitates the transfer to and vesting in the financial security provider of a seafarer's rights against a shipowner as a result of any liability arising from the shipowner's obligation to repatriate the seafarer. For example, the liability to pay the seafarer's wages and entitlements.”
“Mr Speaker, to ensure a safe and high-quality blood supply for our patients in Singapore, pre-donation interviews are conducted to screen blood donors for risk factors and blood donations are also tested for blood-borne infections. However, infections can only be detected some time after the blood donors have been infected.”
“I thank the Member for that clarification. As far as I know, not all mental conditions will be excluded from blood donation. In fact, we have checked with HSA. There is a wide spectrum of mental illnesses – from very mild mental conditions to very severe conditions.”
“I think we must be cognisant that the reason why they are inmates is because of certain things that have happened, prior to that. That actually pre-disposes them to some high-risk behaviours.”
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“I would like to thank Ms Tin for the supplementary question. We do not have any timelines currently. Having said that, we are quite encouraged by the take-up rate from GPs as well as dental practitioners over the past one to two years. MOH will continue to put in the effort to engage these practitioners so that we can increase the take-up rate as much as possible.”
“Based on current statistics, up to about 65% GP clinics are on CDMP and 55% of GPs are on CHAS.”
“I would like to thank the Member for the supplementary question. What is important is to find out the exact reasons from GPs on their reluctance to participate in CDMP and CHAS. Some of these reasons received from GPs include GPs being satisfied with their own current patient load; some GPs also perceive that the additional administrative burden that comes along with the schemes is quite onerous; some GPs are also quite concerned about the audit process, especially the amount of effort that is needed in the process, such as time needed to retrieve and photocopy relevant documents for the audit; and some GPs are not keen to take on a larger chronic caseload. Having engaged all these GPs, MOH will continue to streamline and simplify these processes so as to facilitate the GPs and dental practitioners in taking up both schemes.”
“Mdm Speaker, since the inception of the Chronic Disease Management Programme (CDMP) and Community Health Assist Scheme (CHAS), there has been a steady increase in the number of clinics participating in both schemes. There are currently about 1,000 CDMP clinics, and 850 general practitioners (GP) and 550 dental clinics participating in CHAS. These make up more than half of all private medical clinics providing primary care and more than three quarters of all private dental clinics island-wide. We acknowledge that some providers prefer not to participate in these schemes for various reasons. While the Ministry of Health (MOH) does not currently have plans to make it compulsory for primary care providers to enrol into CDMP or CHAS, we strongly encourage primary care providers to join the schemes. This enables Singaporeans to access subsidised care and tap on MediSave at more primary care providers, improving the accessibility of affordable primary care. It also enables our GPs and Family Physicians (FPs) to participate more actively in the management of chronic diseases. There are various ongoing publicity and outreach efforts, such as regular road shows and engagement sessions, where interested providers can find out more about the schemes. We will continue to work with the Agency for Integrated Care (AIC) to encourage more clinics to participate in CDMP and CHAS.”
“At the same time, efforts have been undertaken by our public healthcare institutions to improve the work environment for doctors, such as shorter rotating shifts, having protected time for structured learning and the adoption of IT Page: 29 to streamline and minimise administrative workload. I am glad to inform the Member that with the recent changes, the rate of our doctors leaving the public sector has decreased, from 6.5% in 2011 to 5.8% in 2014. The number of doctors working in the public healthcare clusters has also grown by 34%, to close to 6,500 over the same period. MOH will continue to review and enhance the value proposition of a public service career to attract and retain good doctors in the public sector.”
“MOH plans the training of healthcare manpower in tandem with the development of healthcare infrastructure nationally, including that of the private sector. As doctors are generally trained within the public sector, some of them will eventually join the private sector. Our aim is to retain sufficient good doctors within the public healthcare sector to ensure that we can continue to deliver good quality care to Singaporeans. To achieve this, we not only need to pay our doctors in the public sector competitively, but also provide them with challenging career opportunities spanning clinical service, education, research and leadership. MOH has worked with the public healthcare institutions to implement a new pay framework for doctors, in two phases in 2012 and 2014. The new pay framework provides better recognition of the important roles that public sector doctors play in the areas of clinical service, education, research and administration. Following the review, our public healthcare institutions are now more aligned in terms of principles and structures of doctors' remuneration while retaining some flexibility to manage individual packages for talent retention purposes. Beyond pay, the public healthcare sector aims to offer our doctors a fulfilling career that allows them to manage more challenging clinical cases, teach and nurture future generations of doctors, undertake research to improve quality of care and, for some, the opportunities to take up leadership positions in their organisations. Many of these roles are unique to the public sector which the private sector does not typically offer. To support professional and personal growth, public sector doctors also benefit from opportunities for continuing training and development.”
“Thank you, Mr Chairman. I would just like to thank Dr Chia for the clarifications. I think he has two clarifications for me – one on polyclinics and the other on overcharging. I do understand Dr Chia's concern and also that of many fellow Singaporeans. Indeed, polyclinic attendance and waiting times are important indicators that MOH is monitoring Page: 142 very closely. We acknowledge that we need to increase polyclinic capacity and thus, we have committed to building four more polyclinics by 2020 and a further six to eight polyclinics by 2030. In the meantime, there are existing 18 polyclinics across the island and they will continue to serve Singaporeans while these polyclinics are being built. At the same time, MOH is redeveloping Marine Parade, Bedok, Yishun and Ang Mo Mio polyclinics where the attendance at these places has been noted to be on the high side. In addition to that, MOH will continue to work actively with private GPs to explore new models of care including enhancing CHAS, developing more CHCs as well as FMCs. With this combined, polyclinic and CHAS GP network, in fact, nine in 10 HDB residents are within 15 minutes commute time from the polyclinic or any CHAS GP. MOH will continue to work with other non-CHAS GPs to see how we can encourage more of them to participate in the CHAS programme, thereby widening the primary care network.”
“Also, the new premiums per year after the change in insurance cover will be lower. Currently, there are adequate numbers of obstetricians, including those in training, to ensure availability of obstetric services to the general public. Page: 131 There will be 60 to 70 new obstetricians graduating over the next five years to ensure a continuing supply of obstetric services. Notably, we have sufficient trained and experienced midwives with the capacity to deliver more babies in our restructured hospitals. MOH is discussing with professional leaders and other stakeholders how best to address this issue. MOH will also consider ways to work with relevant parties to minimise impact on services and expectant mothers. In closing, MOH is committed to strengthening our primary care and residential ILTC services, deepening our infrastructural capacity, while raising our healthcare standards and ensuring affordability of care. Vaccinations for Children”
“In addition to raising standards of care at nursing homes, we have taken steps to ensure affordability of long-term care services for the elderly. Ms Lee Li Lian has asked if ElderShield and IDAPE will be reviewed. MOH is carefully studying options to enhance the current ElderShield product. We are mindful that we will be introducing MediShield Life at the end of 2015 and that it would not be best to introduce a new ElderShield insurance plan at the same time. We have taken other steps to ensure affordability of long-term care services for the elderly. For example, in 2012, we enhanced ILTC subsidies to raise subsidy levels and cover more middle-income households. We implemented the Pioneer Disability Assistance Scheme, or Pioneer DAS last year, where Pioneers with severe disability can receive $1,200 cash payouts a year. As Senior Minister of State Dr Amy Khor mentioned, we are growing our healthcare professional workforce to ensure that we can adequately support expansions in healthcare services. Ms Kuik Shiao-Yin was concerned about the potential impact of these changes in medical indemnity coverage for obstetricians on obstetrics services and has suggested that MOH provide post-retirement protection for these doctors as an assurance for them to continue their practice. There is also concern from the ground on whether this change will affect the supply of obstetricians. The insurer Medical Protection Society (MPS) is continuing to provide post-retirement protection for obstetricians by providing tail cover, which covers practitioners against any claims that may occur after the practitioner is no longer covered or has retired. This tail cover is available in five-year blocks for purchase.”
“We are on track to increase our nursing home capacity by 70%, to 17,000 beds by 2020. We have just opened a new nursing home in Bukit Batok run by Ren Ci, and will open another one in Yishun run by All Saints Home in April. By the end of the year, we hope to open three more nursing homes in Jurong West, Jurong East and Bishan. As our healthcare sector expands, along with an increase in Singaporeans' expectations, I agree with Ms Tin Pei Ling that we will need to ensure that the standards of care provision, whether in the hospitals, in the primary care or ILTC sector, continue to rise. One area that we have worked on is to establish appropriate standards of care in nursing homes. In 2013, we announced the development of a set of Enhanced Nursing Home Standards (ENHS) by an industry-led workgroup. The standards were finalised last year. To help nursing homes attain these standards, MOH has worked closely with the Agency for Integrated Care (AIC) to provide support, for example, a guide on the details of the standards. AIC has also developed new courses in Advanced Care Planning and falls prevention for nursing care staff and supervisors in nursing homes. The standards will take effect this year. Page: 130 5.30 pm Providers will be given a one-year grace period before the standards are enforced from 2016. With these standards in place, patients and their families can be more assured that their well-being will be taken care of. To maintain high standards of care across different settings, MOH has also developed evidence-based guidelines to improve clinical practice. These guidelines aim to support good care outcomes and recommend the use of clinically effective treatments and were developed by professionals.”
“We have made progress in strengthening primary care and will continue to plan ahead and do more. We are looking at fostering stronger public-private partnerships and further integrate GPs into the national healthcare system, so that, together, polyclinic doctors and private GPs play an important Page: 129 role in providing primary care to meet our population's changing health needs. Ideas and initiatives will not be developed by MOH alone. Over the next few months, we will consult our stakeholders, including primary care doctors and patients, on what they envision as the desired primary care landscape for Singapore. We can then move on to our next phase of primary care development. Mr Chairman, I will now touch on how MOH will strengthen residential Intermediate and Long-Term Care (ILTC) services. Minister Gan spoke on improvements in rehabilitative care. One of the ways we are doing this is by expanding capacity for community hospitals. By 2020, we will more than double our community hospital beds through the building of four new community hospitals in Jurong, Yishun, Sengkang and Outram. Last December, we opened the new Changi General Hospital's and St Andrew's Community Hospital's Integrated Building. The Integrated Building not only provides additional capacity but also enables both hospitals to collaborate and develop new ways to treat and rehabilitate patients. The new model of care at the Integrated Building will focus on optimising patients' recovery to prepare them to transit back to the home. Our hospitals are also working with their community partners to better integrate inpatient rehabilitation services with those in the community. MOH is also looking into addressing nursing home availability.”
“I would like to reassure Mr Ang that measures have been put in place to prevent overcharging of CHAS and PG patients. Prices charged by private GPs differ from clinic to clinic and from patient to patient, depending on the patient's condition, treatment provided, medications prescribed and length of consult. It also depends on the pricing structure of GPs. But we expect CHAS GPs to price reasonably, bearing in mind CHAS patients are expected to be lower- to middle-income. MOH closely monitors CHAS claims submitted by clinics and clinics will be called upon to account for any exceptional claims. CHAS GPs should make their charges transparent. We encourage patients to clarify charges and ask for itemised receipts if they are unclear. Together, the polyclinics, FMCs and CHAS clinics provide good quality, subsidised care to Singaporeans – close to their home. Today, over nine in 10 HDB dwellers live within 15 minutes, by public transport, of a polyclinic or CHAS clinic. To plan for future healthcare needs, quality manpower is also needed. We will do more to retain and train doctors within the primary care sector. We have been training more GPs with post-graduate qualifications, such as the Graduate Diploma of Family Medicine and Master of Medicine (Family Medicine). We need to better harness existing talents in the private sector. As part of our Family Physician (FP) development plan, we will offer funding support for selected candidates, to encourage more doctors to undergo post-graduate training in family medicine. This will allow us to raise the standards of Family Medicine training and ensure a consistent supply pipeline of capable family doctors. So, what is next for the primary care landscape?”
“With its pit stops at various Community Clubs and HDB car parks, patients are able to access services, such as diabetic foot screening nearer to their homes. Patients who have benefited include Mdm Sarasvathy d/o Rama Panickar, who has diabetes. With the Mobile CHC at Hougang Community Club, she can walk a short distance on her own to the CHC for her screening and feel more independent. As Minister Gan Kim Yong mentioned, besides building a new polyclinic in Bukit Panjang, we are also redeveloping Yishun and Marine Parade polyclinics. These expansions will allow us to meet expected demand even as the population in the estate grows and ages. Yishun Polyclinic will be redeveloped at a permanent site at the junction of Yishun Central and Yishun Avenue 9 by 2018, and expanded. Marine Parade Polyclinic at Marine Parade Central will be expanded from its current single storey to two storeys by 2016. Construction of Jurong West and Punggol polyclinics will begin later this year. Page: 128 Whilst polyclinics remain an important part of our primary care system, our private GPs still provide the majority of primary care in Singapore. We have regularly enhanced CHAS since 2012, enabling us to leverage on the capabilities of GPs to expand our primary care network. Most recently in 2014, we opened up CHAS to all ages and further raised the monthly household income per person to $1,800. With the Pioneer Generation Package, all Pioneers will benefit from CHAS. This means that there are now 1.2 million Singaporeans eligible for CHAS, more than double from a year ago. Similarly, the number of CHAS GP and dental clinics has also increased, from about 800 to over 1,300 over the last year.”
“For example, the National University Hospital (NUH) has been referring selected patients from its Specialist Outpatient Clinics Page: 127 (SOCs) to Frontier FMC. Linked up through a common Electronic Medical Record system, family physicians from Frontier FMC share and care these patients with their hospital colleagues, and meet regularly to jointly review their patients' care plans. Patients have benefited from this collaboration. One example is Mdm Ang Hwea Kee, an 86-year-old lady with multiple chronic conditions. Before her first visit at Frontier FMC in July 2013, she had been admitted four times in one year to NUH. The FMC primary care team has worked together with NUH specialists to care for her, including adjusting her medication doses when needed. Since her first visit to the FMC, she has not been re-admitted to NUH nor visited its emergency department. Mr Zainal Sapari and Mr Ang Wei Neng asked about our plans to enhance primary care services and work closely with the GP sector. We will continue to try out new care innovations to benefit patients. The FMC model is relatively new and we will continue to test it out. By the end of this year, we will open a seventh FMC at the upcoming Ci Yuan Community Club (CC) at Hougang Avenue 9. In addition, we have planned for a new primary care development at Sembawang. The Sembawang Primary Care Centre will be developed by a team from Alexandra Health System (AHS). It will be a test-bed for the introduction of new care models, innovative ideas and care processes. Among the CHCs, one of our CHCs adopts an innovative model of running on wheels and providing mobile services to residents living in Bishan-Toa Payoh, Hougang and Whampoa.”
“Since 2012, we have taken significant steps to make primary care more accessible and affordable to Singaporeans through our network of primary care facilities. Under the Healthcare 2020 Masterplan, MOH's key thrust for primary care was to better tap on GPs in the private sector to improve the access, quality and affordability of primary care. Part of the plans was to introduce new innovative care models such as our Family Medicine Clinics (FMCs) and Community Health Centres (CHCs). Since then, we have developed six FMCs and six CHCs. Patients, especially those requiring care for chronic conditions, now have more options for their medical follow-up. One example is Ang Mo Kio FMC, which has been serving patients in the Ang Mo Kio and Central areas since 2013. Care managers identify suitable patients who can be referred to the FMC, and share with them the services and benefits available there. Because patient volumes at the FMC are lower, waiting times are shorter. Moreover, patients visiting Ang Mo Kio FMC will get to see the same family doctor across visits, and are also assured of the same level of care as experienced at the polyclinic. One patient who has benefited from visiting Ang Mo Kio FMC is Mdm Betty Lee Oi Neay, aged 67 years old, who has both diabetes and hypertension. At the age of 38, Mdm Lee was referred by a heart specialist to Ang Mo Kio Polyclinic. In 2014, she moved to the FMC. She is happy to visit the FMC as she only waits 20 to 30 minutes to see the doctor. With her Pioneer CHAS benefits, she does not need to pay much for each visit. FMCs have also encouraged shared care programmes between hospitals and GPs, and reinforced the role of GPs as "first-line" doctors.”
“Mr Chairman, I would like to thank Members for the points raised earlier. Sir, if I may have your permission to show some slides during my speech.”
“I would like to thank Ms Chia Yong Yong for the clarification. As long as the policyholder has been assessed through the various databases that, indeed, he or she is suffering from a serious pre-existing condition, then Additional Premiums will be imposed on the policyholder. However, if the policyholder seriously feels that the imposition of the Additional Premium is not justified or for whatever reason or the condition would have changed for the better, then there would be an avenue for the policyholder to appeal for the imposition of the Additional Premiums to be re-looked at. 5.16 pm”
“I would like to thank the Member for the clarification. If the claim is under MediShield Life, then the CPF Board will undertake to pay for the medical report.”
“Madam, with universal MediShield Life, every citizen plays an important role in contributing to our national risk pool and benefiting from the lifelong coverage. This will further strengthen our social safety nets as we move towards building a more inclusive and compassionate society together. Mdm Speaker, I support the Bill. 4.51 pm”
“The Review Committee recommended that the Government allows private insurers to manage those with pre-existing conditions differently, including allowing for risk-loading. MOH will allow the insurers to risk-load policyholders with pre-existing conditions. We recognise that some policyholders may prefer to pay higher IP top-up premiums for the peace of mind that they are also covered for their pre-existing conditions by their IPs. We are working with the insurers to develop an appropriate framework. More details will be Page: 102 shared when they are ready. Er Dr Lee Bee Wah had a question on whether the insured have to pay for medical reports that are required for the submission of claims to the private insurance company. Most IPs absorb costs of medical reports needed to make claims. However, as the private insurers would have differing practices, we encourage members of the public to check back with their IP providers whether there is a need to pay for the medical reports. Many Singaporeans with IPs have sought our advice whether they should drop their higher coverage now that MediShield Life is available. This is a personal decision that each of you has to make for yourselves. However, I can offer three questions that can help to guide you in your decision-making. First, do you want to choose your own doctor or require an air-conditioned ward if you are hospitalised? If so, you may wish to consider an IP. Second, do you prefer to seek treatment at a private hospital or would a public hospital be sufficient? This would determine the type of plan you should buy. And thirdly, the consideration is that of affordability. Are you able to afford IP premiums in the long term, as IP premiums do rise significantly with age?”
“An IP is made up of two parts – the MediShield component run by the CPF Board and the top-up component run by private insurers. The top-up component provides the additional benefits and coverage, for example, for Class B1 or A and private hospitals' hospitalisation. There is no duplication between MediShield and the IP top-up components today. You do not need to pay double. An IP policyholder pays one total premiums payment to his private insurer and the insurer will pass the MediShield portion of the premiums to the CPF Board to manage. When MediShield Life is implemented, the MediShield tier in the IP will be replaced by MediShield Life. All IP policyholders will be covered by MediShield Life with no duplication with their current IP coverage. They will enjoy MediShield Life coverage for life as well as coverage for any pre-existing conditions, even if these conditions were excluded from their IP coverage. IP policyholders will therefore have greater peace of mind as they will continue to be fully covered by MediShield Life, even if they have exclusions on their IPs or decide to drop out from their IP plans later. To Ms Lee Li Lian's question, I wish to clarify that if IPs impose exclusion on an individual, this will not result in the imposition of Additional Premiums for MediShield Life if he had not been suffering from serious pre-existing conditions at the time that he joins MediShield Life. Assoc Prof Fatimah Lateef has asked specifically about IPs and when MOH will share more details about developments in the industry arising from the Review Committee's recommendations. MOH is working with the insurers on various initiatives and more details will be shared when they are ready.”
“However, as we will not be able to ascertain if such individuals have a pre-existing condition, therefore, to be fair to other policyholders, they will need to pay the Additional Premiums under MediShield Life. Should they change their mind, they can either allow access to their medical information, step forward to submit the necessary documentary proof like medical reports or submit statutory Health Declarations, as suggested by Mr Gerald Giam, for review and assessment. However, we also note that, as highlighted by Dr Lily Neo, some individuals could find it difficult to ensure that the relevant medical information is fully and correctly reflected within the Health Declarations. In response to Ms Chia Yong Yong's question, for those required to pay Additional Premiums and who wish to step forward to seek a review of their health condition and Additional Premiums, for example if their health has improved significantly, they do have the option to do so. These individuals may have to undergo additional checks or request for updated medical reports from their doctor. Page: 101 Madam, I will now speak briefly about Integrated Shield Plans. About 60% of Singaporeans today purchase additional benefits and coverage through Integrated Shield Plans (IPs). We understand that many IP policyholders are not clear about how MediShield Life will affect them. Some are concerned that they will need to pay "double premiums" when MediShield Life is introduced. We need to explain to IP policyholders that their Integrated Shield Plans today such as AIA HealthShield, Aviva MyShield, NTUC IncomeShield, Prudential PruShield or GE SupremeHealth already come with a MediShield component.”
“I also wish to provide the strong assurance to Er Dr Lee Bee Wah and her residents that Singaporeans who are currently insured under MediShield or an Integrated Shield Plan and developed medical conditions only after their insurance coverage started will not need to pay any Additional Premiums. For example, if you have been covered by MediShield since you were born and developed cancer this year, you will not have to pay Additional Premiums when MediShield Life starts. Many Members sought clarifications on the powers to access health records and financial information of patients. To minimise inconvenience to Singaporeans, the process of identifying individuals with pre-existing conditions will be made as convenient as possible so that Singaporeans need not undergo separate medical assessments or produce medical records. As shared by Minister Gan, the assessment will be carried out using existing medical information in Government administrative databases. These databases include the ones used to process various types of claims submitted by both private and public medical institutions. With these checks, the vast majority of Singaporeans will not have to step forward to undergo further health assessment or produce their own medical reports, as queried by Dr Lily Neo. For those whose medical records will be accessed under this approach, they will not need to undertake any statutory Health Declarations. For those who feel uncomfortable with the Government accessing their medical information, they may decline access to their medical information. More details on how to do so will be released at a later date.”
“On the other hand, less severe conditions such as pre-cancer, well-managed hypertension and diabetes with no complications will not be subjected to Additional Premiums as they generally have no long-term treatment impact. Ms Chia Yong Yong asked if the rate of the Additional Premiums would vary according to the type of pre-existing conditions. There is only one rate – 30% for 10 years, and this will apply to those with the identified serious pre-existing conditions so that we keep the approach simple. Those who are assessed to be without these conditions will not need to pay the Additional Premiums. Ms Denise Phua asked whether developmental disorders such as Down Syndrome and autism will incur Additional Premiums. I would like to reassure Ms Denise Phua that developmental disorders which do not result in higher risks of future complications or recurrence that require prolonged hospitalisation or expensive outpatient treatments will not attract Additional Premiums. In other words, the mere existence of autism on its own is not the basis for imposing Additional Premiums. However, if the person with autism also has a serious medical condition requiring prolonged hospitalisation or treatment such as dialysis, then Additional Premiums will apply on account of the serious medical condition. With regard to Assoc Prof Fatimah Lateef's question on whether HIV/AIDS patients will be covered under MediShield Life, these patients will be covered under MediShield Life, Page: 100 subject to the MediShield Life benefit coverage for hospitalisation and selected outpatient treatments. As with other serious pre-existing conditions, those who were diagnosed with HIV/AIDS prior to the start of their insurance coverage will have to pay Additional Premiums.”
“MOH is currently reviewing the list of serious pre-existing conditions, with specialist advice from clinicians. More details on the serious pre-existing conditions that will result in Additional Premiums will be made known at a later date. There will also be separate notifications to individual policyholders who are required to pay the Page: 99 Additional Premiums. I wish to emphasise Minister's point that we will take a fair and compassionate approach in the assessment for Additional Premiums. Our focus would be on the more serious conditions which require intensive medical intervention to treat or manage or have high risk of future complications or recurrence and therefore may require prolonged treatment. These conditions will result in much higher costs and risks to the scheme and should rightly incur Additional Premiums. We have heard the concerns of members of public on whether they will be required to pay Additional Premiums even if their medical conditions are minor. These concerns could have arisen due to their previous experiences in purchasing private insurance plans. I would like to highlight again that the MediShield Life approach for identifying serious pre-existing conditions will be different from and more compassionate than the approach used by private insurance schemes. For example, under MediShield Life, serious pre-existing conditions that may be subjected to Additional Premiums include stroke, cancer, kidney failure and heart diseases, just to name a few. Today, Singaporeans with these conditions will not even be accepted for coverage by a private insurer.”
“With MediShield Life, they can now be covered for life and receive help with their large medical bills. Many of them have told us how relieved they are that they can finally be protected and that they do not mind paying the Additional Premiums for the assurance of the peace of mind for life. Likewise, Assoc Prof Fatimah Lateef has also shared that her patients are looking forward to MediShield Life as they can now receive help with some of their large medical bills. Let me share an example with the House. Mr Ong, 48 years old, suffers from end-stage renal disease. He does not have any insurance coverage. Currently, he pays about $700 every month for his dialysis treatment using Medisave and cash, which is a significant drain on his Medisave and cash savings. With MediShield Life, he will be able to claim up to $1,200 per month for his dialysis treatments and related drugs, or up to $14,400 per year. In comparison, the Additional Premiums that Mr Ong will need to pay for the year, before taking into account any Government subsidies that he is eligible for, is about $130 per year. Mr Ong will also benefit from MediShield Life coverage should he be hospitalised in future. For Singaporeans who need help with their MediShield Life premiums, including the Additional Premiums, they can benefit from the MediShield Life subsidies that the Government will provide. These include Transitional Subsidies for all Singapore Citizens, Pioneer Generation Subsidies and Premium Subsidies for the low-to-middle income. For the needy who face difficulties in paying premiums even after subsidies, the Government will provide Additional Premium Support. A few Members have raised questions about which serious pre-existing conditions will require Additional Premiums.”
“This is in line with the philosophy of greater collective responsibility and reflects each person's contributions towards an inclusive society. This approach that we will be taking to move towards universal coverage under MediShield Life strikes a balance between shared responsibility and inclusivity while keeping premiums manageable. Some Members, including Mr Zaqy Mohamad, have asked whether the Additional Premiums of 30% over a 10-year period for those with serious pre-existing conditions would impose too heavy a burden on these individuals. I would like to explain that the MediShield Life Review Committee had made their recommendation on this issue only after serious and in-depth consideration of the extensive feedback from members of the public. The Additional Premiums strike a balance between reflecting the higher risks of those with pre-existing conditions while at the same time avoiding placing too much financial burden on Page: 98 them. In fact, to fully reflect the costs of their higher risks, individuals with serious pre-existing conditions would have to pay a lot more than 30% if it were not for the Government bearing the bulk of these costs. Ms Denise Phua and Ms Lee Li Lian have asked if the Additional Premiums would continue to be required after 10 years. I wish to confirm that individuals, subject to Additional Premiums, will only need to pay these for 10 years. Following which, they will pay the same standard premiums as the rest in their age group regardless of their health condition at that time. Most of these individuals with pre-existing conditions would not be able to purchase insurance from private insurers and would have been bearing high medical costs without any insurance protection over the past years.”
“Mdm Speaker, I am happy to hear the warm support from Members for the universal coverage and protection that MediShield Life will provide to all Singaporeans. Universal coverage is a key feature of MediShield Life and is a big step forward in providing greater assurance and coverage for all, for life, including those with pre-existing conditions. Let me elaborate on Ministry of Health's (MOH) approach to this. When MediShield Life is introduced at the end of this year, universal coverage for all Singaporeans will become a reality. Under MediShield Life, insurance coverage will be extended to those who are currently uninsured or are excluded from coverage today due to pre-existing conditions. No Singaporean will be left out of MediShield Life. With universal coverage, there will be higher costs for MediShield Life due to the higher expected claims from those with pre-existing conditions. This is estimated to a total of $1.1 billion over the first five years of MediShield Life. The MediShield Life Review Committee had recommended the following approach towards bringing in those with pre-existing conditions under MediShield Life which was accepted by the Government. First, to ease the shift to MediShield Life and ensure that the premiums impact is manageable for all other Singaporeans, the Government will bear the bulk of the higher costs of universal coverage at an estimated $850 million over the next five years. Individuals with pre-existing conditions will also bear part of the costs by paying Additional Premiums of 30% over 10 years to reflect their higher risks. Lastly, all Singaporeans will co-share a small part of the costs as part of their premiums.”
“Mdm Speaker, I would like to thank Assoc Prof Fatimah Lateef for the suggestion. At this point in time, Flexi-Medisave is only limited to the patients' as well as the spouses' Medisave account. We will take into consideration her suggestion in subsequent reviews.”
“MOH will continue to review Flexi-Medisave and Medisave use regularly, together with other healthcare financing policies, to ensure that outpatient care remains affordable to all Singaporeans. Assoc Prof Fatimah Lateef (Marine Parade): One supplementary question, Madam. The Flexi-Medisave scheme can be used by an individual from his own account and it is also mentioned that it can be used from the spouse's account. I would like to ask the Minister of State if the Ministry can consider, in the review that is going to be continuously carried out, if they can use that $200 from their children's account or other family members' account because, sometimes, the spouses already have got depleted Medisave accounts and they themselves have medical problems.”
“Mdm Speaker, from 1 April 2015, we are introducing a new outpatient Flexi-Medisave scheme for the elderly aged 65 and above. This allows them to use up to $200 of Medisave a year for outpatient medical treatment at the public sector Specialist Outpatient Clinics (SOCs), polyclinics and GP clinics participating in the Community Health Assist Scheme (CHAS). Together with the enhanced outpatient and drug subsidies for SOC, polyclinics and CHAS that were rolled out since 1 September last year, this means that the elderly will pay even less cash for their outpatient medical care. Page: 28 The $200 of Flexi-Medisave can also be used over and above other outpatient Medisave limits, such as the $400 annual limit for the Chronic Disease Management Programme, and the newly implemented $300 limit for outpatient scans. Flexi-Medisave is meant to allow the elderly more flexibility in using Medisave for outpatient medical treatment. It is, thus, not restricted to a prescribed list. It will generally cover consultation fees, tests, drugs and other medical services needed to diagnose or treat a medical condition. However, to ensure prudent use of Medisave, Flexi-Medisave cannot be used for non-medical treatments, such as those for cosmetic or lifestyle purposes, or for non-essential items, such as retail skincare products. This helps to ensure that the elderly have enough Medisave for their healthcare needs during retirement. Medisave is what Singaporeans have carefully saved up during their working years. Even as we continue to expand the use of Medisave, I would like to encourage all Singaporeans to use it wisely so that it is enough for their healthcare needs over a lifetime.”
“I would like to thank the Member for the supplementary questions. I do not have the figures at hand but I would like to highlight that there are currently about 4,500 specialist doctors registered with SMC, of which only about 5%, a very small percentage, are under conditional registration. Within this group, there are only about six in the private sector and the rest are in the public sector. With regard to whether such foreign doctors do go out into the private sector after they have fulfilled the mandatory period of conditional registration, I believe we have the figure but I hope that the Member can file a separate Parliamentary Question so that we can give him a more complete answer.”
“I would like to thank the Member for the supplementary questions. I understand Dr Tan's concerns. There are certain specialties where the specialised training programmes are not standardised internationally and the training quality as well as the duration of the training may vary between countries, thus making it very difficult to establish equivalence. However, such applicants can practise as non-specialist doctors, for example, as staff physicians, and application for specialist accreditation can be re-assessed after a period of working in Singapore. For other substantive applications where a specialist training committee's support is strong, the Specialists Accreditation Board can review the appeal on a case-by-case basis. I would like to thank Dr Tan for the comments as well as the suggestions and I would appreciate if Dr Tan can highlight any such cases worthy of consideration to MOH and we will be happy to look at them.”
“Mdm Speaker, the Specialists Accreditation Board and the Singapore Medical Council already have such a scheme in place. Foreign medical specialists who are recruited by the public sector hospitals must first be accredited by the Specialists Accreditation Board before they are conditionally registered with the Singapore Medical Council. Conditional registration requires such specialists to fulfil a supervision period in an approved institution. All the public hospitals are approved institutions to hire such specialists and they can make use of this scheme to manage their medical manpower requirements. Majority of these specialists can be fully registered upon satisfactorily completing the conditions of their conditional registration. However, a small minority will have other restrictions or conditions imposed on their registration and these will remain conditionally Page: 33 registered. This scheme is applicable to all specialties.”
“I would like to thank the Member for the supplementary questions. From what I understand, we do share information with other civil aviation authorities from the different countries on some of the protocols and measures they have taken. In fact, even in the affected countries in West Africa, they do have exit screening of travellers out of the country to make sure that they are asymptomatic before they are allowed to board the plane. What is important is that Singapore has actually taken a more discriminate, stratified kind of approach to monitor the health of arrivals from affected West African countries. We divide them into both symptomatic as well as asymptomatic travellers. If they are found to be symptomatic when they arrive in Singapore, then they will be managed accordingly by being brought to TTSH for further assessment. But if they are asymptomatic, then we will have to probe further with regard to the risk of exposure. If they have high-risk exposure, meaning they have been managing patients who are affected by the Ebola virus without any personal protection, then they will be put on very close surveillance, either being quarantined in Government quarantine facilities or even in home quarantine. But if the exposure is assessed to be low-risk, then we will put them on phone surveillance for 21 days to make sure that they are asymptomatic during this period Page: 20 before they are allowed to continue with their unrestricted activities.”
“However, I understand that the situation is very dynamic and we will continue to review our measures as the Ebola situation evolves.”
“I would like to thank Dr Chia for the supplementary questions. That is a very relevant question, with regard to the imposition of a travel ban. I would like to highlight to Members of the House that the decision to impose travel restrictions cannot be taken lightly. It is based on certain principles: (a) the extent of the epidemic in the affected countries, that is, whether there has been widespread and intense community transmission as seen in the three West African countries; (b) the state of the healthcare and public health infrastructure in those affected countries; (c) the ability of the affected country to contain further spread; and last but not least (d) the recommendations from the World Health Organization, as well as expert inputs from our local agencies, including the National Infection Prevention and Control Committee. Imposing a visa requirement, which we are doing from 5 November, will allow us to have better oversight of these travellers entering Singapore. We will be able to collect information, such as local contact details, local sponsor as well as their exact dates of travel, Page: 19 and this will facilitate the process of contact tracing, should the need later arise. In addition, it will also allow Singapore to inform the applicants at the point of visa issuance about our Ebola health advisory and the actions that they should take should they develop symptoms while enroute to and during their stay in Singapore. So, currently, we will not be imposing any travel ban on the affected countries in West Africa and this is also in line with WHO’s recommendation that there should not be any travel ban imposed on these countries.”
“We will continue to monitor the situation very closely and to step up our preparedness as well as necessary measures, as and when necessary.”
“I would like to thank the Member for the many supplementary questions. First, I would like to reassure the Member as well as Members of the House that MOH takes the training of our healthcare workers in the handling of Ebola very seriously. We have done regular audits and checks on the training as well as the preparedness of our healthcare workers, especially those in the frontline, for example, in the Emergency Department. We make sure they adopt and practise the right protocols and procedures that have been stipulated by the National Infection Prevention and Control Committee. At the same time, we do send circulars to all our healthcare professionals, including private general practitioners, to update them on the situation of Ebola in affected countries, as well as the measures that we are taking in Singapore. In that aspect, I would like to reassure the Member that we are doing all we can to prevent a possible imported case to Singapore. Nonetheless, we understand that it is impossible to prevent subsequent cases that may appear on our doorstep. The important thing is that we have to be well-prepared for that eventuality. Page: 18 With regard to the possibility of fear-mongering among the people, it is important that MOH continue to update the public on the epidemiology, the situation in West Africa and also to educate people that Ebola, although it is a fatal disease, is not easily spread from one person to another person because of the way that the disease is. It is spread through close contact with people who are infected with the disease and it is not through the respiratory route. I thank the Member for those supplementary questions.”
“MOH will continue to monitor developments in these areas. Of the five Ebola cases that were diagnosed in Spain and the US, three involved healthcare workers who had provided care to patients who were infected with Ebola in West Africa. Investigations of these cases suggested possible breaches in infection control measures, such as improper removal of Personal Protective Equipment (PPE). Although our hospitals and healthcare workers have been trained on the proper use of PPE, we have not been complacent. Our hospitals have been reminded on the need for strict infection control measures and adherence to stringent protocols when managing suspected and confirmed cases of Ebola. Even with proper equipment, protocols and training, human error can occur, as was observed in the cases of secondary transmission in Spain and the US. MOH will continue to work with the National Infection Prevention and Control Committee (NIPC) and other experts to review our guidelines and protocols to ensure a high degree of competency and preparedness in our hospitals. Page: 17 In response to appeals for aid, Singapore has contributed an aid package consisting of medicines, medical supplies and personal protective equipment to WHO. In addition, Singapore also contributed US$150,000 in cash to the WHO to support the WHO Ebola Response Roadmap. Singapore will continue to work with WHO on how to further assist in the global effort against the Ebola outbreak in Africa based on our capability and available resources, including the possibility of seconding one of our experts to assist WHO Headquarters in Geneva in their relief effort.”
“This move will allow for better oversight and control of entry of nationals from these countries and facilitate possible contact tracing. MOH will Page: 16 continue to monitor the Ebola situation closely and calibrate our preparedness measures. To keep our healthcare institutions in a high state of vigilance, we have given regular updates to all hospitals, polyclinics and primary care doctors on the Ebola situation. We have also provided them with guidance and protocols on the criteria for identifying suspected Ebola cases, how to refer such cases for further assessment and the subsequent management of suspected and confirmed cases of Ebola. MOH has also conducted preparedness exercises and visited our public hospitals to ensure that they are well-prepared and adequately resourced to manage cases of Ebola. Suspected and confirmed cases of Ebola will be centrally managed in TTSH, which has been designated as the national disease outbreak centre. Meanwhile, Ebola virus testing will be centrally conducted by the National Public Health Laboratory's designated testing facilities at Defence Science Organisation (DSO) National Laboratories. Currently, testing for the Ebola virus is done using the polymerase chain reaction (PCR) method. This is the most sensitive method and the mainstay of diagnosis in all reference laboratories. Rapid diagnostic test kits to diagnose Ebola are being developed and tested but none has yet been approved for use. MOH will evaluate the performance of such rapid kits to determine their suitability for use in our environment when they become available. The standard treatment for Ebola is supportive therapy. While there are experimental treatments and vaccines being developed and tested, none has been proven to be clinically safe or effective.”
“Nationals and travellers from countries with significant or potentially significant Ebola transmission – currently seen in Guinea, Liberia, Sierra Leone, DRC and Mali – arriving at our air checkpoints will be directed to a screening station where they will be screened for fever, requested to complete a Health Declaration Card which will include their contact details in Singapore and assessed for the risk of exposure to Ebola through a questionnaire. Travellers who are found to have a fever will be sent to Tan Tock Seng Hospital (TTSH) for further assessment and testing. Those who are well but assessed to have a risk of exposure to Ebola will be kept under phone surveillance or quarantined for up to 21 days, depending on the nature of their potential exposure. Screening of travellers from countries with significant Ebola transmission is also conducted at land and sea checkpoints using Health Declaration Cards and questionnaire assessment. The border health measures are part of a multi-layer defence against Ebola. While they alone will not be able to identify persons who are still in the incubation period and are not symptomatic or are not truthful in answering the screening questionnaire, they complement our overall efforts in looking out for travellers who may have Ebola infection. MOH is concerned by the widespread and intense community transmission of Ebola in West Africa. As such, MOH is working with MFA, MHA, the Immigration & Checkpoints Authority (ICA) and the Civil Aviation Authority of Singapore (CAAS) to impose temporary visa requirements for nationals from Guinea, Liberia and Sierra Leone for entry into Singapore, starting from 5 November.”
“As of 31 October 2014, the World Health Organization (WHO) reported a total of 13,567 cases of Ebola, including 4,951 deaths. There continues to be widespread and intense transmission of Ebola in Guinea, Liberia and Sierra Leone. Nigeria, Senegal, Spain, the US and Mali have reported imported cases, some with limited transmission. WHO has Page: 15 since declared Nigeria and Senegal to be free of Ebola. In addition, a separate Ebola outbreak is ongoing in the remote areas of the Democratic Republic of the Congo (DRC) involving 66 cases and 49 deaths. No new cases of Ebola have been reported in DRC since 4 October. WHO has stated that DRC will be declared free of Ebola on 21 November, if there are no further cases. Since 7 August 2014, MOH has instituted several border control measures. Travellers are provided with a Health Advisory on Ebola through the deployment of Health Advisory Posters and the distribution of Health Advisory Notices (HANs) to nationals from Ebola-affected African countries at all air, land and sea checkpoints, as well as other travellers who self-declare their history of travel to Ebola-affected countries. The Advisory tells them about Ebola symptoms and advises them to seek medical attention immediately and inform the medical staff of their travel history if they develop such symptoms. MOH has stepped up screening measures against Ebola at our checkpoints.”
“I would like to thank the Member for that question. Currently, we do not have any volunteers that are working in the affected areas, but we also do not prohibit or discourage volunteers from taking part in relief efforts in these affected countries. As a precautionary measure, MOH will keep very close track of these volunteers. Volunteers who have direct contact with patients will be monitored and put on phone surveillance for at least 21 days upon their return.”
“Mdm Speaker, I would like to thank the Member for the supplementary questions. On the question about the premature reporting of a suspected case in Singapore, I think, MOH is concerned about it. We have also written to the media to clarify with them and to ensure that in future reporting, they do check with the Ministry to prevent such false alarms. With regard to the use of some of the unproven medications that have been reported in the media, one of which that has been widely reported in the media is the experimental drug ZMapp. It consists of three monoclonal antibodies produced in a plant and it is developed by Mapp Biopharmaceutical. It was first reported to be used in infected humans very recently in July 2014. It was administered to two American health workers who had been infected with Ebola, and both appeared to have positive results and have recovered. However, ZMapp was also administered to a 75-year-old Spanish priest with Ebola, who died eventually and three other Liberian health workers, who showed improvement, although Page: 19 one of them eventually succumbed to the disease. We have been informed by the manufacturer that there is a shortage of ZMapp at this point in time. We want to let Singaporeans know that while we monitor the situation very closely, ZMapp is not the mainstay of treatment for any patient infected with Ebola. Intensive supportive treatment is still the mainstay. We will continue to monitor the research that has been going on in ZMapp and we will use it when appropriate.”
“Medical clinics and hospitals have been alerted, through professional circulars, to exercise vigilance and ensure early detection of possible suspect Ebola cases. Laboratories have also been advised of the testing procedures for Ebola. Management of suspect Ebola cases will be centralised in Tan Tock Seng Hospital, at a dedicated facility at the Communicable Diseases Centre 2 (CDC 2). All suspect cases will be triaged at the emergency departments, and as a precaution, isolated from other patients to minimise any risk of transmission. A case that has been admitted in another hospital will continue to be managed there to minimise risk of infection during transfer. All hospitals have put in place procedures for strict infection control measures when managing a suspect or Page: 18 confirmed case of Ebola. In the event of a confirmed case of Ebola in Singapore, MOH will carry out contact tracing and all close contacts of the confirmed case will be quarantined for 21 days from the time of last exposure. As there are no proven anti-viral drug treatments or vaccines yet available, a patient with Ebola will be given intensive supportive treatment. Healthcare workers attending to the patient will use appropriate Personal Protective Equipment in addition to the strict infection control measures that have been put in place. Our healthcare system will continue to remain alert and prepared to manage any potential outbreaks of infectious diseases in Singapore and our hospitals have dedicated response plans, which include plans to ramp-up resources and re-deploy staff to respond to disease outbreak situations. They have also carried out regular exercise to familiarise our healthcare workers with the contingency response plans.”
“To minimise the risk of infection to Singaporeans travelling to or residing in affected countries, the Ministry of Health (MOH) has advised Singaporeans against non-essential travel to the affected countries in Africa. For those who need to travel there, we have advised them on the precautionary measures to take, such as frequent hand washing and avoiding direct contact with blood and secretions or other body fluids of dead persons or animals. This information is available on the MOH website. In addition, health advisory posters are also displayed at our Changi Airport Departure Halls. We have also worked with the Ministry of Foreign Affairs and International Enterprise Singapore to disseminate this information through their networks. MOH has worked with the Civil Aviation Authority of Singapore (CAAS), Changi Airport Group (CAG), Maritime and Ports Authority (MPA) and the Immigration and Checkpoints Authority (ICA) to display health advisory posters at all air, land and sea checkpoints, and to distribute Health Advisory Notices (HANs) at our immigration counters to inbound nationals and travellers from Guinea, Liberia, Sierra Leone, and Nigeria. These passengers are advised to seek medical attention early if they develop symptoms within 21 days of arrival and to inform their doctor of their travel history. Contingency plans are in place at Changi Airport to manage passengers with signs of Ebola Virus Disease (EVD). Such passengers will be isolated and transferred using a Portable Medical Isolation Unit to Tan Tock Seng Hospital for further management. MOH will also extend these measures to Senegal and the DRC to ensure early detection of suspect cases. Healthcare staff are a key line of defence.”
“The ongoing Ebola outbreak is limited to the African region of Guinea, Liberia, Sierra Leone, Nigeria and, most recently, in Senegal, where an isolated imported case has been reported. A separate Ebola outbreak has been confirmed in a remote region in the Democratic Republic of Congo (DRC), which is not related to the outbreak in West Africa. Our current assessment is that the risk of Ebola spreading to Singapore is low due to the limited travel connectivity between Singapore and Africa. Prior to the Ebola outbreak, the number of travellers from these countries arriving in Singapore is small, with an average of about 30 travellers a month collectively from Guinea, Liberia and Sierra Leone, and between 200 and 300 travellers a month from Nigeria. Since WHO declared the Ebola outbreak in West Africa as a Public Health Emergency of International Concern on 8 August 2014, many airlines have stopped flying to Guinea, Liberia, Sierra Leone, the three countries with widespread active community transmission. The numbers of travellers from these countries to Singapore are even fewer now. In addition, Page: 17 transmission of Ebola requires direct contact with the blood and/or fluids of an infected person. It does not spread through the air like influenza. Nevertheless, while the risk is low, we cannot rule out the possibility of an imported case to Singapore. Hence, we have put in place measures to reduce the risk of infection to Singaporeans who travel to or are residing in affected countries, ensure early detection of cases and prevent spread in the event that we have an imported case of Ebola in Singapore.”
“In conclusion, the 3M framework has served Singapore well and, moving forward, we need to continuously review and tweak the system to make it more relevant to Page: 117 commensurate with the needs and expectations of Singaporeans. The universal coverage provided by Medishield Life is an important move to provide peace of mind and ensure that all Singaporeans are protected. I am sure the Government will continue to provide strong support to achieve universal coverage and enhance benefits, while ensuring affordable premiums for Singaporeans. With that, I pledge my support and endorse the recommendations of the MLRC. Page: 118”
“It is important for MOH to look at these social care aspects and see how they can influence health outcomes. After the rollout of MediShield Life, we need to ensure that social care is sufficiently funded for Singaporeans. Perhaps, we can take a leaf from the UK, where the government is undertaking the Care Act 2014, which promises to integrate health and social care services. Mr Deputy Speaker, Members in the House had spoken about Obamacare previously and how Singapore can learn from this initiative. MediShield Life offers Singaporeans many similar promises that Obamacare does. But at the same time, Obamacare has been criticised for the "broken promises" by its critics, and the Republicans are talking about repealing and changing Obamacare. One of the main things that I will be particularly concerned about is the implementation of MediShield Life. Like what many married couples and new parents will tell you – having a child is a lifelong journey. The story does not just end with the delivery of the child. We need to ensure that the benefits and the promises of the new plan filter down to all Singaporeans. Several things we need to be aware of: (a) we need to ensure its delivery is what it promises; (b) the scheme needs to be adaptable to changes according to the needs of Singaporeans; and, lastly, (c) we need to ensure that all Singaporeans know and understand what benefits MediShield Life brings. For this, I am particularly pleased by the communication materials that have been published, and I hope, in the subsequent roll-outs, it can be simple and easy to understand by all.”