By Leong Sze Hian

This is part one of a three-parts chronological treatise on healthcare issues over the last 2 years or so, like means-testing, non-priority for subsidised rates healthcare, wards down-grading, medical fees competition, costs of medicines and alternatives, healthcare spending, MediShield, ElderShield, implications for foreigners, PRs and Singaporeans, etc.

What will the future of healthcare be like for Singaporeans? What are some issues that we may need to be concerned with? What are your fears? What sort of healthcare system do you want? How do we compare with other countries?

Here are the first 3 issues with our healthcare system.

F1. May 2007 – REVERSE MEANS-TESTING:

I went to the Travellers’ Health and Vaccination Clinic at Tan Tock Seng Hospital for a Yellow Fever vaccination recently. The charge was $130.20, compared to just $15 for the same vaccination I had at the same clinic 10 years ago. This is an increase of 768 per cent or a 24 per cent compounded increase per annum.

The clinic was furnished lavishly with leather sofas, leather chairs, paintings on the walls, flowers in vases, etc, like a five-star hotel. The same vaccination costs about HK$200 (S$39), A$50 (S$63) and 35 euros (S$72) in Hong Kong, Australia and Ireland, respectively.

Why has the cost of vaccination increased by so much over the last 10 years, when inflation in Singapore was less than 2 per cent per annum?

When I paid the $130.20 fee, the staff gave me a brochure and said that if I had a platinum credit card, I would receive a 12 per cent discount for health screening.

Why do the more affluent who qualify for a platinum card get a discount of 12 per cent, whereas the lower income have to pay 13.6 per cent more, in a government restructured hospital?

Is this not, in a way, like reverse means testing – the rich pay less, the poor pay more?

F2. April 2007 – ELDERSHIELD:

The MOH has announced that the two insurers of ElderShield will give a one-time rebate to policyholders because of low claims relative to the premiums collected, since the scheme started.

Why pay a rebate, and increase premiums at the same time? Why not just use the excess funding accumulated to reduce future premiums or increase benefits?

At the end of last year, there were about 750,000 policyholders, with a total of 2,366 successful claims. About 16 per cent of claims declined. The claims payout last year was about $8.5 million (2,366 claims x $300 monthly x 12 months).

Even if we assume all 750,000 policyholders paid the lowest premiums at age 40 of $169.74 (male $148.84 + female $190.63 divided by 2), premiums per year were $127.3 million ($169.74 x 750,000 policyholders).

This means the claims ratio was only about 6.7 per cent ($8.5 million in claims but $127.3 million in premiums).

As the 2,366 claims were the cumulative total for the four years since the scheme started, the claims payout over premiums per year is actually much lower.

What was the claims ratio for each of the four years of the scheme? I believe this may be the most profitable insurance scheme in the history of insurance in any country.

How much profit has been made since the scheme started?

Notwithstanding the proposal to increase the monthly payout by $100 and the payout period from five to six years, in view of the above, how is it possible that the proposal now is to have existing policyholders pay a one-off adjustment to make up for lower premiums paid in earlier years under the current ElderShield scheme, increase premiums of about $10 a month for the older age group, and have policyholders registered automatically for the new scheme after September pay premiums of $1 to $2 more a month?

As to the opt-out rate having gone down steadily from 38 per cent when the scheme was launched to 14 per cent last year, there are 1.26 million residents (Singaporeans and PRs) aged 40 to 64, according to the Department of Statistics’ ‘key statistics demography Singapore residents by age group end June 2006’.

So, isn’t the opt-out rate about 40 per cent (with about 750,000 policyholders among 1.26 million residents)?

Does the Ministry of Health’s study on the opt-out rate refer to the current opt-out rate of new entrants who reach age 40, or the overall opt-out rate of those eligible?

F3. April 2007 – HOSPITAL WARDS DOWNGRADING:

The Health Minister clarified in Parliament on April 10 that downgrading to subsidised wards is a two-day process and his plans to introduce means testing in hospitals within a year.

Some Singaporeans who can afford higher class wards might be reluctant to opt for them, fearing that their hospital stay might be prolonged due to unexpected complications and the charges incurred might exceed their Medisave account balance, medical insurance and cash reserves.

Thus, higher-income Singaporeans might opt for Class C or B2 subsidised wards if, for example, they believe that they could be required to stay in hospital for longer than, say, five days. The logic is that if it’s five days or less, they might think that they can afford the luxury of higher class ward facilities. But, since there is always the possibility of them staying for an indefinite period, they might think it is better not to risk opting for a higher class ward.

Now that this worry is being exacerbated by means testing, the problem of overcrowding in Class C wards may get worse.

In any case, when the Class C or B2 ward is full, one can go to a higher class ward and still pay the lower rates. So, why risk opting for a higher class ward in the first place?

In this regard, I would like to suggest that patients and their families be assured that if they opt for a higher class ward, and end up staying for much longer than expected, such as over three weeks, they will automatically be allowed to downgrade to C class or B2.

This may result in fewer people opting for C class or B2 on admission to the hospital.

Currently, those who opt for a higher class ward, and subsequently request for downgrading, are subject to means testing — this I believe is what Singaporeans fear most. Thus, this may be the root cause for many patients opting for subsidised wards.

It was clarified in Parliament that it takes two days or longer to process a ward-downgrading request, if patients are unable to produce the relevant documents to support their applications when means-testing is involved.

Only those with a per capita family income of $1,000 a month or lower can downgrade to Class B2, and $500 or lower to Class C. For outpatients applying to downgrade, it takes an average of two weeks to secure an appointment with a medical social worker to assess whether the patient qualifies.

So, for say a three-person family with a household income of just $1,501 a month, downgrading to Class C is not allowed. Only 1 per cent of patients in Class A or B1 wards who sought to downgrade were successful.

Judging from this, no wonder Singaporeans are opting for lower-class wards — due to the fear of not being able to downgrade.

In part 2, Sze Hian writes about healthcare costs, medical fees competition, licensing of medicines, etc