Yeo Cheow Tong
Singapore
“Mdm Ho Geok Choo asked the Minister for Health in light of the recent report on fungal corneal infections (a) whether those who contracted the contact lens related fungal corneal infections will suffer permanent damage to their eyes; and (b) how long will his Ministry take to conclude its investigations into the causes of these contact le…”
“My Ministry performs a regulatory role and what we do is that we try to ensure that we have a conducive regulatory environment for the growth of this industry in Singapore. Let me tell him what we are doing in some areas.”
“Sir, on her two questions, whether we are satisfied that the school buses are collecting fares during the school holidays, as I mentioned just now, the school bus service is a contractual service between the parents and the service provider. It is therefore up to them to work out the terms and to abide by the terms.”
“Sir, on the first question, whether there is any abuse by owners of buses while using the 50% rebate, the answer is no, because LTA monitors very closely.”
“Sir, I have to repeat my answer. We are not responsible for regulating school buses and therefore will not be involved. SCHOOL BUSES (Installation of seat belts) 5. Assoc. Prof.”
“Ong Soh Khim asked the Minister for Community Development, Youth and Sports (a) if his Ministry will increase the cap of $10,000 per disabled person over their lifetime for the Assistive Technology Fund scheme; and (b) if not, whether there will be a flexibility to adjust the funding cap for this scheme based on the applicant's need, as j…”
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“Only in this way can we ensure quality because of better pay. ii) a fixed salary structure be adopted for all doctors in Government and restructured hospitals, salaries and salary increments and promotions should be based on competence, meritocracy, professionalism and teaching and research work, and the doctors must have a holistic approach and be mature in terms of medical speciality practice. The doctors should be subject to tests of their ability. They should be tested and their ability proven. They should teach and help junior doctors to gain their skills. This is the quality of a good doctor. iii) Cost review committees are present in all hospitals, whether private, restructured or Government. If possible, the report of these committees be published so that we can make comparisons. Sir, I support the motion.”
“Cost comparisons can be made between the supposedly better and more expensive hospitals, such as NUH and SGH, and others like Alexandra Hospital. Data for such cost comparisons can be obtained from the authorities concerned. What we should ask ourselves is, who will benefit? The patient, the doctor or the hospital? If all existing hospitals now already have subsidised C class beds, do we need one specially set aside as a Government hospital, for the less well-off? The "no frills" hospital gives the public the wrong impression. They tend to think that: a) since it is meant for the less well-off, the quality of medical care will be less; b) the medicine given will be of lower quality; c) the doctors are of lesser "quality" and that only "quality" doctors are available in the restructured hospitals. Probably 95% of patients are already adequately treated in any hospital in Singapore and maybe only 5% really requires special care and special equipment to maznage them. This cannot be a valid reason for charging high fees, money which is then spent on advertisements and high-tech equipment and medicine. Unnecessarily allowing doctors in public institutions built with public funds to generate income for themselves and for their institutions may not be proper. Are we afraid that our doctors would leave these institutions to work in truly private hospitals such as Mount Elizabeth and Gleneagles? Singapore has a ratio of 1 doctor to 850 population. Not so much work is available in private hospitals. People with higher incomes prefer to be treated by specialists in Mount Elizabeth and Gleneagles. Even our neighbours have opened their own specialist hospitals. We should change our system of doctor payment to a fixed salary income.”
“Equipment only assist a good doctor in his performance but does not make a brilliant doctor, whether in medicine or surgery. Advertisement on the presence of high-tech equipment attracts patients' attention to the hospitals concerned but they would not necessarily benefit from them. ii) requests by patients themselves. Patients nowadays tend to ask for what they want and not what is advised by the doctor. CT scan, for example, is very useful. Its effectiveness has been accepted in the medical field but the patient only thinks of the brouhaha over its wonders and would press for its use even if it might not be necessary. Doctors would normally accede to the patient's request for various reasons. One of which is that it is income generating. iii) operations and procedures conducted by junior doctors or housemen under a senior staff are usually less expensive. iv) excessive research, laboratory studies and X-ray ultrasound, MRI and CT scans. v) over prescriptions in quantity and use of new and expensive pharmaceuticals. Rectifying the mistakes caused by such excessive services is difficult. This depends on: i) a sense of responsibility to contain cost. All doctors serving in medical institutions must be educated on cost calculations. We must ask ourselves if there really are two standards of health care for our citizens or two standards of treatment of patients. This question must be carefully examined. If we say there are two standards of care, we are putting the less well-off section of our population at a disadvantage. If we say there are two standards of cost, then we must ask why this is necessary. Does a higher cost of care mean better care or is it due to excessive services, unnecessary services, expensive equipment, etc.?”
“Alternative medical therapy should be looked at in view of the high cost of present pharmaceuticals. However, before alternative medical therapy can be introduced, research has to be conducted to determine the benefits and the problems that might arise with such therapies. Of course, we need to evaluate the benefits and the cost-effectiveness. The National Institute of Health in America will introduce programmes to evaluate alternative medical therapies and it will be exciting to see the direction they will take in the selection in alternative therapies to assess, methods of assessment and what benefits to expect. Curbing of Over-servicing Payment for services might, and again I stress "might", lead to misuse because we cannot teach doctors not to work towards acquiring more money. The over-servicing of patients is the way through which doctors generate an income for themselves. Over-servicing includes extra investigations, surgical procedures that might not be necessary or the use of high-tech equipment, such as surgical microscope for surgery. Indications can be made for the use of high tech equipment for surgery but the doctor must ask himself honestly whether his application will benefit the patient more than it does himself financially. I think the question of over-servicing can be resolved by paying doctors in Government and restructured hospitals fixed salaries. The pay should be increased but let it be "fixed" salary. There are still good doctors and within a fixed salary structure the temptation for more money can be eliminated. Doctors should not take advantage of a patient's situation and profit from him. Furthermore, high-tech procedures are generated by: i) doctors seeking to promote themselves as better than their colleagues.”
“As noted in the White Paper, we have to carry out clinical research if we want to maintain our status as the leader in the medical field in South-East Asia. Clinical research helps us to better understand the patterns of diseases in our population and with better understanding, health improvement measures can be taken and we can even thereby reduce costs - this has also been dealt with by the Minister of State for Health earlier. For example, we know that 8.6% - this is the figure for 1992 - of Singaporeans suffer from diabetes. But we also know that, within the population, the incidence is highest among Indians and Malays - the rates are 8% for Chinese, 9.3% for Malays and 12.9% for Indians. Alternative Medical Therapy The costs for pharmaceuticals have continued to rise. This is due to the marketing of new drugs and claims by pharmaceutical companies that their new drugs are better, more potent, etc. Not all such claims are necessarily correct. Again, there is a possibility, and I stress "possibility", that some doctors are inclined to believe that the "new is better and the old is to be discarded". This might not be completely valid. If it was so, then many of the old drugs that are still being used today would not have stood the test of time. For instance, Penicillin V, which was discovered in 1945, is still useful today. The notion that new must mean better is apparent in the use of antibiotics. For instance, Augmentin, which is quite as good as Amoxycillin in many clinical situations. A course of Augmentin costs $20 whereas Amoxycillin is only $1. The difference is just too much. Also, ordinary, cheaper drugs might not necessarily be less effective than patented medicine.”
“What the public must be concerned with is: i) gaining more information on health care - this has just been dealt with by the Minister of State for Health; ii) practising a healthy lifestyle such as refraining from smoking, over-eating or high consumption of alcohol; iii) getting proper information about chronic diseases such as diabetes, hypertension, stroke, heart disease, occur or are hereditable in his family that he could prevent or those that can be delayed by adopting a healthy lifestyle; iv) going for regular medical check-ups with the family doctor or at outpatient clinics, discussing medical problems with the doctors and getting advice on how to maintain one's health and prevent illness; The patient can be referred to a specialist at a hospital for evaluation, if necessary, only after he has been advised and examined by the family doctor or the outpatient clinic doctor. Parents are willing to follow the procedures for immunization and medical examination of their children, so they should be prepared to do the same for themselves. These are the measures the public can take if health cost is to be reduced. The public are the consumers of health cost. The public make demands on the system of health care, the public expects the system to rectify the damage caused to their bodies by their own adverse lifestyles. The public has the responsibility to educate themselves on self-care, consulting their family doctors and not immediately seeing a specialist to get advice on how to maintain their health or to redeem it when it fails on account of their poor lifestyles. We are prepared to spend on the maintenance of our car and on life insurance, but we neglect our own medical examination every year. Research Mr Speaker, research is expensive but it is also necessary.”
“Firstly, the expectations and the education of the public seeking medical attention; secondly, provision of additional care through excessive services by doctors, general practitioners, specialists, surgeons, for example, through the use of CT scan, ultrasound and scopes. Education - Expectations of the Public The advancement in knowledge and equipment for diagnosis and the patient management is described in newspapers and periodicals. News about a new medical equipment is usually accompanied by descriptions of how conveniently the patient can be managed with the new equipment. Usually these descriptions are true, but improper use of such equipment would increase costs with no definite benefit to the patient. For example, the use of ultrasound for normal pregnancies. CT scan is useful for diagnosis of stroke and stroke management but certainly not for diagnosis of chest infections, where a simple chest X-ray would help in such cases. Members of the public is familiar with descriptions and explanations of the use of such equipment, but the specific use of the instrument may not be known. Conducting a head scan or using ultrasound or scope without first being explained the use of such procedure is improper, because all this would increase costs.”
“Sir, I am glad he clarified about the B2 and C class and about his thoughts on special preferences being given to doctors. In the White Paper, we have already stated very clearly that the basic package would contain the services that are already available in the existing class B2 and C and the quality will be maintained. Dr Toh has just mentioned that people who are rich can get services, but children of workers will be left with a very poor level of service. I think that is trying to cause unnecessary alarm and trying to misinterpret what has been very clearly stated in the White Paper. Secondly, the same scenario about HDB shops can apply to provision shops, that is, there could be 50 provision shops in one estate and zero in another estate. Surely, we must leave it to market forces to ensure that there is a good distribution of shops and that if there is a good distribution of shops, there will be enough competition and that the services will be available and affordable to everybody, rather than putting the medical profession on a separate pedestal and giving them special treatment. Encik Harun bin A. Ghani (Hong Kah GRC)( In Malay): Mr Speaker, Sir, we have read in the newspapers of the many comments and praises about the White Paper on Affordable Health Care. I share the public pleasure with the findings of the Committee as presented in the White Paper and I fully support them. At the same time, though I do not belong to the medical community, I would like to offer some views. Affordable Medical Care This topic is dealt with under two headings.”
“Sir, he has asked that medical services be given priority, that we should put medical services on a pedestal and ensure that in all our estates, shops be specifically set aside only for doctors. If we have to set aside shops on the basis of importance, should we not set aside shops for the most basic item, which is food, and therefore we should call on HDB to ensure that certain shops in every HDB estate be set aside only for provision shops, so that the people can have access to shops which have very low rentals and therefore the food items will be even cheaper?”
“You mean when food becomes so expensive, people cannot afford them and in the end we should still give priority to medical services rather than ensuring that Singaporeans have a full stomach?”
“Sir, would he also agree that food items are more essential than medical services?”
“Sir, may I ask the Member how would he rate the B2 and class C medical services being delivered in the subsidised hospitals now?”
“Sir, if Mr Low had read the White Paper carefully, it is inside there.”
“Sir, we do provide kidney dialysis and it is also provided through the National Kidney Foundation (NKF). And because this is considered to be in the package, that is why MediShield also covers kidney dialysis, and which is why we encourage Singaporeans to ensure that they do not opt out from MediShield, so that when they get kidney problems they can get the support from MediShield which covers the bulk of their dialysis cost.”
“Sir, the CPI plus X formula applies to the whole revenue. The subsidy will be based on the revenue cap. So it depends on the class of ward. If it is Class C, the hospital will get 80% of that new revenue cap. Of course, if the cost goes up, then we expect the hospitals will also increase their fees to cover the cost increase in that portion which is not subsidised. Sir, as for the balance billing, we are still working out the details, and I think those are implementation details which we will take up with the private sector later.”
“My answer is exactly the same. If he had listened carefully, what I told him the last time was when a patient goes into a Class B2 ward, he will be billed at Class B2 rate. But if that patient cannot afford the Class B2 bill, he can request to be reclassified as a Class C patient, and the bill size will be reclassified accordingly. This is exactly what I have just said also.”
“Or even B2. If they have some difficulties meeting the hospital bills, they should go for the ward with the lowest bill size. And that is why I only quoted the Class C ward charges.”
“Sir, I will be very happy to supply the data when Mr Low tables a question, because I do not have the data now. But when he was talking about affordability, I would imagine that people who have difficulties paying their bills, who are from the lower-income group, would be people who are using the Class C wards. They will not be people who will be using the Class A wards.”
“Sir, he also questioned whether the Ministerial Committee consulted the private medical sector before coming out with the White Paper, since they are the ones who are the experts. He seems to get the feeling that we are blaming the doctors. Sir, nowhere in the White Paper have we blamed doctors for our situation. In fact, we have been praising our medical professionals that they are some of the best brains and they are well trained. Because of that, we have a good health care system. But the White Paper goes beyond pure medical professional matters. The White Paper actually deals with economics, the relationship between demand and supply and financing, and the influence of financing systems on behaviour. In terms of medical professional inputs, my Ministry has got ample supply of people in this area and we have taken their advice in terms of the medical professional factors. But we will definitely consult with the private medical sector in areas where they have an active role. It is right that we consult them and get their inputs because we will be implementing systems and procedures which will apply to them. Sir, Mr Chia also made a very sweeping remark that the hospitals charge drugs at five to seven times the cost. Unfortunately, he is not here. I asked him for a clarification as to whether he was referring to the private hospitals or the subsidised hospitals. His answer was both. I will get my officials to contact Mr Chia to substantiate his allegation. But I can state categorically here in this House that the subsidised hospitals have a formula for charging drugs, and the formula is a very simple one.”
“I think we better stick to what we have now, which is, stipulate a maximum, allow the excess to be paid into the Ordinary Account and, if there are special circumstances, we even allow the person to return those excess payments back to the Medisave account if the account holder suffers a serious illness that he now needs these additional funds. Mr Chia Shi Teck feels that we should be giving Singaporeans more incentives to keep healthy. He mentioned that we should give everybody $1,000 contribution if he does not use medical services each year, give him a certificate of fitness, and pay for MediShield. When I was toting up the numbers, it means we will be giving to everyone much more than what we are spending in the whole health care system each year. But the key point is that he has misinterpreted the whole intent behind the statement that we should give Singaporeans the incentives to remain healthy. What is the biggest incentive for a person to remain healthy? Surely, it must be that by being healthy he will be able to enjoy a higher quality of life. He can live life to the fullest, he can spend quality time with his family and, best of all, he will not have to spend unnecessarily on medical care. That must be the biggest incentive. We will continue to promote the healthy lifestyle message to impress on Singaporeans that it is for their own benefit that they put in the effort to have a healthy lifestyle and to remain healthy, and not by giving them more money. But, of course, for employers, since they are giving medical benefits, a healthier worker means lower medical cost, it may be worth their while to look into how to link workers' efforts at remaining healthy with some motivational tools.”
“The question is, what is the right number. We have used other countries as models, studying what is their make-up, what is their proportion. We feel that the ratio of 650 to 670 population to one doctor by the year 2000 will be adequate. Yes, there may be a need for some more or a few less. But, by and large, our system will still remain a system that is able to deliver quality care at affordable prices. But we will continue to review. Every five years, we review our situation and, if need be, we will make additional amendment. Sir, he does not feel that it is wise for us to increase the Medisave contribution rate further and to build up larger Medisave balances. Sir, I think the key point is that at the end of the day what is the average Medisave balance of our Singaporeans. We already have a mechanism limiting the maximum amount to be kept in the Medisave account. We will adjust the maximum balance over time to ensure that the sum is enough but not excessive. Excess contributions are then transferred to the Ordinary Account of the account holder so that he can use those contributions to either purchase his home or for investment. This is as Dr Low Seow Chay has proposed. But I think he has gone one step further. He has proposed that we treat the whole CPF account as a Medisave account so that whenever they need they can transfer from their Ordinary Account to the Medisave account for use. Sir, in that case, he contradicts what he has been talking about because instead of stipulating a definite Medisave balance quantum, he is now extending it to the full CPF. For certain account holders, you are talking of hundreds of thousands of dollars.”
“Mr Othman Haron Eusofe this afternoon mentioned that many people do not use Class C wards because they are not sure about the quality and requests that we assure patients that the quality of Class C treatment is good. Sir, we have been assuring patients all the time and we will continue to assure patients that Class C treatment is of a high quality. The outcomes of treatment are no different from the outcomes of patients in other wards. Dr John Chen asks whether we will allow workers to purchase insurance to cover the co-payment section. Sir, I had earlier explained why it is important that we do not rely on third-party systems because it is a prepaid scheme. The buffet syndrome automatically comes in. We will therefore not allow insurance to be purchased for the co-payment for him. It is good for the patient or the worker to pay a portion of the bill from either his own savings or his Medisave. He has also requested that the Ministry discuss with NTUC on its proposed MHS system. Sir, we are definitely willing to discuss with the NTUC and to see how we can be of assistance. Dr Low Seow Chay also talked about the need to reduce demand for health care and to also have cost containment measures. Sir, he has asked whether we are training excessive numbers of doctors. He feels that even with the reduced number that has been recommended by the Singapore Medical Council, we will still end up with more doctors than necessary. Sir, the need for doctors will continue to increase in the coming years for two reasons. Firstly, our population is still increasing. It is growing every year. Secondly, our population is ageing. As we all know, when we get older, the need for health services increases. So we are going to continue needing more doctors.”
“Sir, many of the Members and Mr Loh have touched on the proposal to allow employers to pay some contributions into the Medisave account in lieu of the medical benefits. Sir, the White Paper now makes this option available. Whereas in the past, that option was never available. There are some advantages. Firstly, most workers do not really use acute medical services. Most of them use outpatient services. The money that is being used to either purchase insurance for hospitalisation coverage, or being borne directly by the company, can then be paid into the Medisave account of the patients and that money can be utilised by that worker after he has retired. So that is one advantage. Secondly, it gives that worker the flexibility to decide on what to use with Medisave, ie, whether to purchase coverage that entitles him to a C class bed and therefore save the rest of the premiums or to purchase a higher class coverage. Thirdly, it allows him the flexibility to purchase medical insurance and thereby safeguard coverage for himself, especially when he suffers from serious illnesses. For example, if he suffers from kidney problems and he cannot work and the company boards him out, he will be without coverage. By the time he goes to get an insurance coverage, the insurance company will not cover his pre-existing condition. But if he had already purchased that coverage under his own name, even if he is jobless or when he joins another company, that coverage is still active. Sir, the medical benefits of most companies now come to less than 1% of the salaries. We will leave it to the employers and the unions to negotiate. Government will encourage, but not compel. So in the end how fast this proceeds will be determined by the employers and the unions.”
“He cited the recent news about the AIDS-tainted blood in Germany and how it has caused irreparable harm to people's confidence as well as to the image of Germany. Sir, I can assure Mr Loh that stringent measures have been taken to ensure that the safeguards on our blood supply remain. We will audit and we will make sure that the system is maintained and that the health of Singaporeans continues to be protected. Sir, we have certain measures in place, eg, our donor selection. Unlike many countries, we do not pay for the blood that we collect. So no one comes forward to sell blood. They come forward voluntarily to donate blood. But, nonetheless, we take measures to ensure that the donors are healthy donors. Not only that, we also have a very stringent screening process for the blood supplies. We test 100%. Every unit collected is tested. We test for sexually transmitted diseases, for hepatitis and we test for AIDS as well. And if any sample is shown to be even mildly positive, the sample is rejected and the donor is advised not to donate blood again in the future. So we do have the necessary measures in place to ensure that the blood is safeguarded. We will ensure that the other safety measures in the health care system, not just with regard to blood supply, are also maintained. Mr Loh requested that my Ministry regularly reviews the list of standard drugs. He also requested the drugs for conditions like cancer and heart diseases and other common and complicated conditions be included in the standard drugs list. Sir, I would like to assure him that the drugs for cancer, heart diseases and other common conditions are indeed within the drugs list, and that my Ministry reviews that list every year to make sure that the drugs there remain relevant.”
“Sir, I would like to assure Members that it is an established hospital procedure that if patients have difficulties making payments, the hospital provides the necessary treatment in class C wards first. After the treatment has been given, it will make the payment arrangements. So no one is deprived of treatment just because he or she could not make the payment upon admission. Sir, Singapore has healthy national reserves because the Government has exercised great prudence in spending the people's money. As a result, we have been able to invest in education, health and a superb infrastructure for the economy. The welfare system that Mr Cheo is still arguing for has been proven to be a failure. The European and Scandinavian countries, Australia, New Zealand and others are now trying desperately to unwind their welfare systems. Unfortunately, they are finding great difficulties. But unless they succeed, their economies will continue to be crippled by their welfare systems and the dependency mentality that it breeds. Sir, our system of focusing help only where help is needed is the most appropriate and effective one. It promotes responsible behaviour. People get to keep more of their money and decide on how to use it. The Government and community organisations provide a safety net for the few who genuinely need help. The alternative of the Government taking most of a person's salary through taxes and then deciding on how to put the money to use is one that we must avoid at all costs. Sir, Mr Loh Meng See has asked that we ensure that the cost containment measures do not end up jeopardising or compromising the quality of our health care or the safety measures that we have in place in our health care system.”
“These include AIDS, gynaecological problems such as infertility and impotence, sexual deviations such as lesbianism and homosexuality, and disorders of the breast such as unusually large or small breasts. Of the 3,000 procedures in this book, only 14 are not included. These include heart, liver and bone marrow transplants, cosmetic dental work, sex change operations, IVF, cosmetic surgery such as face lift and breast enlargement or reduction. Only 23 of the items in these two large volumes are not in our basic package. And because these excluded items are mainly uncommon conditions, our basic package basically covers well over 99.9% of patients. Our basic package is therefore more than generous. Mr Cheo Chai Chen touched on two issues - the health care costs of the elderly and those with chronic conditions. Mr Cheo was concerned about the indigent elderly singles. I would like to assure him that such persons would be eligible for public assistance and will receive free health care. Elderly persons facing financial difficulties in any case qualify for generous help from Medifund since they were born before 1940. Senior citizens who fall ill or suffer from chronic illnesses can obtain medical treatment in our polyclinics. There, they pay only half the regular fees and the fees can also be waived if they are facing financial difficulties. Mr Cheo worries that if elderly patients need to apply for fee waiver, it will result in delayed medical treatment. He proposes that since we have plenty of national reserves, the Government should provide more subsidies and, in fact, subsidise all elderly, without their having to resort to apply for a fee waiver.”
“Sir, Mr Low also touched on the five sub-specialities in the Singapore General Hospital without C class wards. Mrs Yu-Foo also mentioned this topic. Let me explain again. These five sub-specialities require well-trained staff and they are high cost disciplines. We have grouped them under B2 as a minimum so that we can better contain costs and therefore make it even more affordable for the low income earners. Patients who cannot afford the B2 rates can appeal for their bills to be reclassified to a class C bill. If this is still too high, they can also appeal for those bills to be waived. The hospitals will definitely consider them carefully and if they are genuine cases, they will be obliged. Sir, low income patients who normally would have stayed in a class C ward therefore have the advantage of staying in a B2 ward while paying class C fees. So they are really given the best of both worlds. [Mr Deputy Speaker in the Chair] 3.52 pm Let me move on to the topic of basic health care. Mr Low has questioned the need to limit subsidised medical services to a basic medical package. Most people that we have talked to so far accept that it is not possible to offer medical services without any limit and at the same time keep health care costs under control, but there are concerns as to whether the basic package will be too limited. Sir, let me show Members these two volumes [indicating]. These two volumes contain the international classifications of about 5,000 disease conditions and about 3,000 surgical and non-surgical procedures. Of the 5,000 disease conditions in this book, only nine are not in our basic package.”
“I am glad that he subsequently clarified, a bit reluctantly I thought, that actually what we heard was not what he had meant to say. He had meant to say that the Government should only intervene to subsidise those who cannot afford to pay the full cost of medical services. I am indeed glad that Mr Low agrees with the Government's approach to health care subsidies. Mr Low also claimed that the restructuring of hospitals has resulted in higher hospital fees and consequently the poor now cannot afford medical care. At the same time, low income earners are unable to obtain help from Medifund. Perhaps he also did not mean what he said. Sir, let me throw some light on the matter again. Firstly, 75% of all class C bills in our hospitals are below $420. Three-quarters of all the class C bills are below $420. For a person earning $800 a month, this represents only seven months of Medisave contributions. And those who cannot afford to pay even this heavily subsidised bill size, maybe because they have been sick for a long time and therefore unable to work or because of their prolonged sickness they have depleted their Medisave, these people can still apply for a waiver of hospital fees. The waiver process extends not just to the poor but also to the low income earners. With Medifund, the process is even simpler. Each hospital has its own Medifund committee and therefore can process the appeals and applications quickly. Medifund also extends special treatment to those who were born before 1940. It is a very generous scheme. If Mr Low is aware of any person who is not receiving medical treatment because he cannot afford it, I hope he will not hesitate to give me the details and we will definitely arrange for treatment to be extended to that person.”
“In trying to help, doctors and family members may actually be prolonging and increasing the patient's suffering. This is something which we all should strive not to do. Doctors are trained to make professional judgment in the best interest of patients. In deciding on treatment, doctors are guided by treatment protocols which set out the standard practice which, of course, vary from patient to patient according to the circumstances. These are the everyday decisions that all doctors have to make, when and how to treat, when to intervene and when not to. When junior doctors are uncertain, they refer to their senior specialist for a second opinion and advice before coming to a joint decision. Medical undergraduates receive lectures on medical ethics. My Ministry also organises a seminar on medical ethics and responsibilities of medical practice for all newly qualified doctors. To assist doctors in borderline cases, all hospitals now have their own ethics committee. My Ministry is now looking into the establishment of a national ethics committee to identify the ethical issues relating to medical practice and to develop guidelines on the ethical code of conduct for doctors. Sir, let me move on to the points raised by Mr Low Thia Khiang. I was truly astonished yesterday when I heard Mr Low speaking in this House. I thought he wanted Singaporeans to be the last of the Mohicans. Every country in the world with a system of socialised medicine is sorely regretting it. And Mr Low was standing there in front of us preaching that the Government should be responsible for an individual's medical costs because no one wants to be sick. Sir, even China has openly declared that free medical care for the masses is now history.”
“We now have financial counselling for all patients upon admission to hospitals. They are told what is the cost if they go to A Class, which is the full cost, and what it will cost them in the other wards. Similarly, the private hospitals are also required to do financial counselling. And in the Government hospitals, every patient receives a bill which shows the full cost of the services received. At the end of the bill, he will also get a statement that he has received so much in subsidies and the actual bill size to him is the full cost minus the subsidy. This tells him two things. Firstly, what it costs the hospital to deliver that service to him. Secondly, if he is in the subsidised classes, it tells him how much of that cost has been borne by the Government. I think these two facts are important for him to appreciate. Dr Lim also mentioned about the difficulties of deciding borderline situations, whether to withhold treatment for a patient who is critically ill, especially one who is terminally ill and especially if the family insists that treatment should be continued. Mr Loh Meng See has also mentioned some concerns about people interpreting the basic health care package as a first step towards euthanasia. Let me strongly stress that we do not practise euthanasia. Euthanasia is the deliberate action of a physician to terminate the life of a patient so as to relieve him of his suffering, eg, by giving him a lethal injection. But we must recognise that death is a part of life, and dealing with death has always been a part of medical practice. Modern medicine has made it more of a dilemma now for doctors, of course. However, the process of death in terminally ill patients should not be unnecessarily prolonged through futile intervention.”
“Sir, Dr Lim also requested for Medisave to be extended to more outpatient treatments. Mdm Yu-Foo has also made the same request. We are already extending the use of Medisave for outpatient treatments and these apply to those services or procedures that are more expensive and they apply to day surgery cases as well because we want to encourage patients not to be hospitalised if they can. This will help to keep their health care costs down. The guiding principle is that Medisave will be extended to outpatient treatment where the indications for treatment and procedure are clear and there is little risk of a doctor generating unnecessary demand for those services just because Medisave is available. We have to avoid extending the use of Medisave to outpatient treatment too liberally because, firstly, the administrative costs will rise exponentially because there are many outpatient treatments and, secondly, the patient-load can be substantial. Thirdly, it will create demand for more of these services unnecessarily. However, I am prepared to take suggestions from Dr Lim. If he has any item that he wishes to propose, we would definitely review and consider it carefully. Sir, Dr Lim also stressed the importance of educating the public on the true cost of health care. I agree with him. Health care costs are expensive. There is no doubt about that. We cannot hide from that fact. It is better that every Singaporean knows it so that he would take the effort to practise a healthy lifestyle, live a healthy lifestyle, and increase his chances of remaining fit and healthy. Also, when he needs to use the medical services, because he knows that it is costly, hopefully it will make him to be more prudent in the usage. Sir, the education process is a continuing process.”
“We also ensure that there is a co-payment element because there is nothing worse than free treatment. It will just generate more demand and cause the standard of health care to decline, as we have seen in countries with free treatment. Of course, for those who are indigent and poor, they will receive free treatment, but after we have ensured that they are genuinely indigent and poor. Dr Lim had stated that some of the tests in his Cardiac Department appear to be too inexpensive, too over-subsidised. Sir, I am not too familiar with the details in his Department but I will ask the CEO in NUH to review what he is talking about and to apply the appropriate subsidy level to those that have been inappropriately priced. Perhaps, Dr Lim may wish to inform the CEO which of those items are involved. Sir, because of the variety of medical conditions, certain patients may occasionally require expensive tests, whether they are in Class A, B2 or C. Our system of subsidy also ensures that for the more expensive tests, we have a cap on the price that we charge for that test. So for those expensive tests, they are only ordered when they are needed and the patient actually receives a higher subsidy rate so that he is not deprived of that needed test. It is up to the doctors to exercise their professional judgment and order those tests only when they are needed. They should not order those tests because the patients demand for them, or because we have heavily subsidised that test and is now so cheap. Tests must never be generated upon patients' demands. They must be generated only upon the professional judgment of the doctors concerned. And if the tests are warranted and helpful, I think the subsidies would have been well spent.”
“Sir, the key is to ensure that there are enough subsidised beds for those who cannot afford to pay the full cost of their medical treatment. My Ministry regularly monitors the occupancy rates of the various ward classes and we adjust the bed composition, when necessary, in line with patient demands. If demand for B2 and C Class beds increases, we will make available more beds. But on the other hand, if demand for Class C beds declines, as has been happening in the past few years, we would also have to adjust the numbers accordingly. In the case of the Ang Mo Kio Community Hospital, only 7% of the beds are A Class beds. The number has been reduced to the bare minimum and there is no need to reduce further. Mr Peter Sung expressed concerns about an over-supply of specialists in the private sector and public sector as well. Sir, my Ministry controls the supply of specialists through the provision of specialist training positions in our subsidised hospitals. We closely monitor the supply and demand for specialist treatment and we allocate trainees according to the need for such specialists. Our aim is to train no more than 40% of each cohort as specialists. The remaining 60% will work as primary health care doctors. I can assure Mr Sung that we share his concerns and we will make sure that we avoid an over-supply of specialists. Sir, Dr Michael Lim stated that the subsidies distort usage patterns. He suggested that we avoid over-subsidising the patients and to educate the public on the true cost of health care. Sir, Dr Lim is correct. It is important that we focus the heavier subsidies on those who genuinely need financial help and that is why we have the different classes of wards - A, B1, B2 and C. This allows us to focus on the subsidies.”
“The private sector must continue to compete effectively or they will lose their patients to the subsidised hospitals. The Ministry of Health will work with representatives of the private sector hospitals and doctors to come up with the balance billing limits. In working out the caps, we will consider the existing private sector costs as well as the fees charged by the Government and restructured hospitals. We will be fair to all parties concerned. Sir, let me move on to the points raised by Members. Mr Lau Ping Sum has suggested that we should reduce the number of Class A beds, as those who can afford such beds should be encouraged to use the private hospitals. He also proposed that the community hospitals should only have subsidised beds and not Class A beds. Sir, we should ask ourselves whether the removal or the reduction of Class A beds from our hospitals will be in the interest of the subsidised patients. Non-subsidised patients play an important role as quality controllers. Yes, they can afford to use private hospitals. But by choosing to use the non-subsidised services in a subsidised hospital, they confirm that the medical care in that hospital is of an acceptable quality. The Class A beds also serve as a benchmark for the private sector and help to restrain the cost of private medical care. This, in turn, helps to keep costs down in subsidised hospitals. There is no need for us to force those who are able to pay the full cost of the A Class beds into the subsidised wards. If they cannot get the Class A beds, some of them will actually just move into the subsidised wards. If they do that, this will only reduce the subsidies available to those who truly need these subsidies.”
“We expect to implement Stage One by the end of 1994, and Stage Two for the hospitals, by the end of 1995. There are some concerns that the setting of cap on private sector charges may actually result in doctors and hospitals all charging at the maximum allowable rate. Sir, that may happen. But I think what is more likely to happen is that the doctors who are already well-established will charge at the maximum allowable rate and doctors who are junior and who are still trying to establish themselves, will have to compete by charging at a lower rate and also compete by ensuring that they are able to give better service. Some others are also concerned that the quality of medical care may be compromised if charges are controlled. I want to assure Members of this House that the rates set will be fair to both the patients as well as to the doctors and hospitals. Private hospitals and doctors are likely to see a drop in income initially but it will still be a decent income. On the other hand, because their charges will be more reasonable, they may in fact attract more patients who would otherwise have gone to the subsidised hospitals. There will be no need for providers to compromise on the quality of medical care. We expect the doctors and hospitals to compete on price as well as quality within the caps. If a doctor or hospital decides to cut corners, he will risk losing his patients, or, worse, he may even lose the licence to practise. We will step up our medical audits to ensure that the quality of medical care is not compromised. In any case, Sir, the subsidised hospitals will continue to maintain the service quality and remain as a benchmark for medical service.”
“There are, therefore, adequate incentives for hospitals to innovate and to improve their efficiency while maintaining a high quality of medical care. Otherwise, they are going to lose all their patients. The revenue cap mechanism will help to restrain cost increases and ensure that patients will continue to receive affordable quality health care in the subsidised hospitals. Sir, but it is not sufficient to have cost containment in only the subsidised hospitals. The public and the private health care sectors are closely linked. If the private sector doctors and other health care workers enjoy a significant increase in income, the public sector cannot afford to lag far behind. Otherwise, they will lose their key staff and jeopardise the care they are providing to the majority of Singaporeans. We must, therefore, apply similar cost containment mechanisms to private sector hospitals and doctors. We propose to do this through the Medisave mechanism. The Government is, in fact, the custodian of the Medisave funds. We have the responsibility to act as a purchaser of medical services for our Medisave account holders. MOH will set limits on balance billing for patients using Medisave in the private hospitals and doctors. Health care providers, who are willing to accept the stipulated rates, will be registered by Medisave and be allowed to take on Medisave patients. However, the providers are free to set their own charges for patients who do not use Medisave and this will include foreign patients. Sir, the limit on balance billing will be implemented in two stages. Stage One will cover operation charges and doctor's daily hospital attendance fee. Stage Two will cover the fees charged by the private hospitals.”
“Sir, if the hospital's actual revenue is higher than the revenue cap, the subsidy from Government will be reduced by the same extent, that means, if hospitals increase their charges by, let us say, in total, $1 million annually, above the revenue cap, an equivalent sum of $1 million will be reduced from the subsidy. So, therefore, there is no incentive at all for hospitals to increase charges more than what they are allowed to under the cap, because any extra charges that they collect will be given back to the Government. The hospitals are also expected at the same time to operate within their revenue collections. With their revenues capped, the hospitals will be constrained to service their patients within a fixed amount of resources and to conform to reasonable service norms. This would discourage the hospitals from ordering unnecessary tests and investigations because all those unnecessary tests and investigations cannot be charged to the patients. It will just be additional costs which the hospitals will have to bear. They will have to be very careful to ensure that whatever they order are necessary and not wasteful. The subsidised hospitals will have to strive to improve the quality of their medical care within the resources available. If they are efficient they will be able to generate cost savings and therefore generate surpluses. They will be able to keep their surplus. It will be an incentive for them to do better. And they can use these surpluses to improve their services or to upgrade essential equipment. Sir, those hospitals which attract more patients, whether they are subsidised or non-subsidised, will generate more revenue from fees as well as from subsidies.”
“Sir, some people have time and again suggested that MediShield should extend its coverage to those beyond 70. MediShield has in fact gone beyond the conventional practice by extending its coverage limit from 65 years of age to 70. We will study the implications carefully before deciding whether to further extend the age limit in the future. Sir, another key cost containment measure is the capping of patient revenue in subsidised hospitals. The patient revenue comprises fees collected from patients and, secondly, subsidies received by the hospitals from the Government. The patient revenue adjusted for workload changes will not be allowed to increase by more than the consumer price index (CPI) plus X percent. That means, it will not be allowed to increase by more than the inflation rate plus an X percent factor. For the next two years, we have fixed the X component at 2%. Sir, this formula of CPI plus X will constrain the rate of cost increases in the subsidised hospitals and, in turn, restrain the increases in the charges imposed on patients. At the same time, this formula will allow hospitals enough resources to maintain the quality of their medical services and to introduce new medical developments that have been proven to be cost effective. The X factor will take into consideration the cost of labour and wage increases. And this is an important factor because in the hospitals, between 60% and 70% of the cost actually are labour costs. So when Singaporeans enjoy a 10% increase in salary, they can expect that the hospitals would have incurred a cost increase of 6%, almost automatically. So, as long as all Singaporeans enjoy good salary increments, the hospital staff will likewise enjoy similar increments and health care costs will increase in proportionate quantum.”
“And if the measures to contain health care costs, as laid out in the White Paper, prove to be effective, the long-term Medisave contribution rate may not need to exceed 10%. Secondly, insurance. As the Minister for Trade and Industry had stated in his opening remarks, high Medisave balances also increase the temptation for patients to draw on these balances more than they absolutely need to. That is why we introduced the insurance component in MediShield. MediShield reduces the amount of personal savings needed. Sir, MediShield currently covers one-and-a-half million people or almost 90% of all eligible CPF members. As a catastrophic insurance scheme, MediShield has been able to keep its premiums very low, and each year about 10% of hospital patients, mainly those with serious medical conditions and who require prolonged hospitalisation, receive MediShield reimbursements. We will improve on the system by enhancing and extending MediShield. This will be done in two ways. First, MediShield will reduce the existing deductibles while retaining the current premium rate. This will enable 20% to 25% of hospital patients to benefit from MediShield, instead of the current 10%. Second, we will introduce MediShield II with higher benefits. It will come in two options. Option A covers patients who use A Class or private hospital beds. And Option B, which has lower premiums, will cover those using B1 wards. MediShield II, like the current MediShield, will have deductibles and a payment co-component. It will be a voluntary opt-in system, and Medisave can be used to pay for the premiums. The lowering of deductibles for MediShield and the introduction of MediShield II will take effect from 1st July 1994. The details will be announced in the next few months.”
“You know, under my insurance coverage, I am entitled to an annual check-up. This will involve three or four days' stay in the hospital. There is a nice park next to it. Between check-ups, I can go to the park, lie down and have a holiday." So he was entitled to his annual all-expenses paid holiday at the local hospital. I mentioned this story to several people recently, and I said, "Well, luckily, such things have not happened in Singapore yet." To my surprise, one of the people there said, "Well, you will be surprised. One of my managers is in fact already looking forward to his annual check-up in a private hospital, all-expenses paid." It is just as I have described. Sir, the buffet syndrome is not unique to any particular nationality. Already in Singapore, we see it in many of our restaurants when there is a pre-paid buffet available. People load up their plates, and have a good time. It is therefore important that we keep this nexus between the use of, and payment for, medical services utilised. Today, more than 80% of the patients use Medisave to pay for their hospital bills. Medisave balances have been increasing partly because most of the Medisave members are still young and their health care needs are still low. The average Medisave balance in 1984 when the scheme started was $1,750. This increased to $4,400 by the middle of this year. Currently, the Medisave contribution rates are between 6% and 8%, depending on the age group. As health care cost increases, which is inevitabe, the Medisave contribution rate will have to be increased as well. But we should try to delay this for as long as possible.”
“Mr Speaker, Sir, I will take this opportunity to elaborate on several of the key measures contained in the White Paper as well as address some of the points and concerns raised by Members. First, health care financing. Sir, a key element of the Government's health care philosophy is personal responsibility, and this includes each of us putting aside some money while we are economically active to meet our health care needs when we are elderly and after we have retired. Sir, the introduction of Medisave has enabled Singaporeans to save for the future. When patients directly pay for medical services, whether in full or with the help of Government subsidy, they become more aware of the cost of what they are using. They are then more likely to use such services prudently and judiciously. This approach has enabled us to avoid the problems faced by the developed countries. Over there, their health care financing systems are mainly tax-based or insurance-based. And as the medical expenses are paid for by a third party, the patient becomes desensitised from the cost of the services that he is receiving. What is worse is that very often, the patient feels entitled to use as much medical services as he wishes since he has already prepaid in the form of either taxes or insurance premiums. Sir, let me relate to you a personal experience. In the mid-1970s, I was working in the USA on a job training programme. One day an American colleague I was working with told me that he would be away for the next week on holiday. So I was quite surprised. I said, "Well, good. Where are you going?" To my surprise, he gave me the name of a very good hospital down the road. So I was taken aback. "You are going on holiday to a hospital?" He said, "Yes.”
“Just a clarification. Is Mr Chia referring to the subsidised hospitals or the private hospitals?”
“The Women's Welfare Unit was set up as a Unit under the Family and Social Support Branch of the Ministry on 1st April 1990. The Unit functions as a direct point of contact for women in distress or in need of assistance. They can either call at the Unit in person or use the Unit's toll-free hotline. Officers of the Unit discuss with the women their problems and help them to decide on appropriate solutions. Where necessary, they are referred to other government or welfare agencies for appropriate assistance. Between April 1990 and September 1993, more than 3,500 women called at the Unit seeking assistance for domestic and marital problems such as divorce and separation, assault, conflict with in-laws and spouse leaving marital home. In addition, for this year alone, about 2,000 calls were received from women on the Unit's hotline. They sought information and advice on personal and family problems. The Unit has also compiled and published a Directory of Services for Women. The Directory has been circulated to grassroots organisations and community and voluntary welfare organisations which come into contact with women who have problems or who are in need of a social service. Information pamphlets on socially relevant issues affecting women such as Violence at Home, Assistance for Single Parents and Services for Unwed Mothers have also been produced and distributed by the Unit.”
“Yes, he gets AIDS. But for those who fall ill for various reasons, whether self-imposed or otherwise, he agrees that if they can afford to pay, they should pay, but where they genuinely cannot afford to pay, Government should provide some form of assistance.”
“That statement, I accept. But, of course, if he gets sick because he smokes, drinks and does all kinds of things -- An hon. Member: He gets AIDS!”
“So what you are saying is that those who can afford to pay their bills, they should pay, but those who cannot afford, Government should intervene to assist them to bear their hospital bills if they deserve it.”
“When I was listening to Mr Low just now, I was also equally confused. I am glad that he has thrown a little bit of light. But I think there is still quite a bit of darkness in front of me. Is he saying that even when a person has taken all the necessary efforts, for example, he has paid attention to all our healthy lifestyle messages, exercise everyday, and he still falls sick, if that person can afford to pay his own medical bills, the Government should still intervene to pay his bills for him?”
“Sir, I beg to move, (1) In page 2, line 22, to leave out "shall not", and insert "may". Sir, the amendments being proposed to clause 3 are similar to those proposed for clause 2 and are being proposed for the same reasons. Amendment agreed to. Amendments made: (2) In page 2, line 24, to leave out "unless", and insert "if". - [Mr Yeo Cheow Tong]. (3) In page 2, lines 28 and 29, to leave out "the same offence", and insert "any such offence referred to in this proviso, and for this purpose section 11(1) shall not apply to any such previous conviction". - [Mr Yeo Cheow Tong]. Clause 3, as amended, ordered to stand part of the Bill. Bill reported with amendments, read a Third time and passed. Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.15 pm. Sitting accordingly suspended at 2.49 pm until 3.15 pm Sitting resumed at 3.15 pm [Mr Speaker in the Chair] FIRE SAFETY BILL Order for Second Reading read.”
“Sir, I beg to move, (1) In page 2, line 8, to leave out "shall not", and insert "may". Sir, this amendment, together with the next amendment, which I shall shortly move, is of a drafting nature. This is to make the section easier to read by avoiding the use of the double negatives "shall not" and "unless". Amendment agreed to. Amendment made: (2) In page 2, line 9, to leave out "unless", and insert "if". - [Mr Yeo Cheow Tong]. Mr Yeo Cheow Tong: Sir, I beg to move, (3) In page 2, lines 13 and 14, to leave out "the same offence", and insert "any such offence referred to in this proviso, and for this purpose section 11(1) shall not apply to any such previous conviction". Sir, the expression "same offence" is ambiguous and can give rise to various interpretations. This amendment will make it clear that to qualify for probation, the young offender must not have any previous conviction for an offence which carries a specified minimum sentence or mandatory minimum sentence. Sir, under section 11(1) of the Probation of Offenders Act, probation is not deemed a conviction. This amendment will make it clear that young offenders who have previously been convicted for an offence carrying a specified minimum sentence or mandatory minimum sentence and who have been granted probation shall not be eligible for probation should he or she commit a second offence carrying a specified minimum sentence or mandatory minimum sentence. Amendment agreed to. Clause 2, as amended, ordered to stand part of the Bill. Clause 3 -”
“Sir, as I stated just now, there must be a cut-off point somewhere. Yes, if he is a youngster, 16-17 years old, who is caught stealing a hubcap, he is entitled to probation. But, of course, if he goes into hiding, he may not be. But the point that Mr Chua made at that time also was that the prosecutor had the flexibility of charging that offender under a different legislation but he need not charge him if that person was really of good character with no previous delinquent traits. The prosecutor can charge an offender under a different provision which does not carry a mandatory minimum sentence. So the flexibility is still there. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong]. Bill considered in Committee. [Mr Speaker in the Chair] Clause 1 ordered to stand part of the Bill. Clause 2 -”