26/03/2018

Is the Rise of Healthcare Cost Unsustainable?

Who Should Be Blamed For The Unsustainable Increase In Private Healthcare Cost?

Earlier this week, the Life Insurance Association (LIA) of Singapore shared some worrying trends about the cost of private healthcare in Singapore. Here are some extracts to consider. The above chart, obtained from the Ministry Of Health (MOH), shows that the median bill size for private hospitals have been increasing at a rate of about 15% per annum over the past two years. This is in contrast to public hospitals, which have seen a reasonable increase of about 2-3%.

Singapore long-term inflation rate is about 2-3% per annum. What this means is that while medical bills from public hospitals are in line with our inflation rate, the same cannot be said for bills from private hospitals.

When we look at the average bill sizes incurred by the five insurers that provide integrated shield plans, we observe a similar trend.

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How Much Do Hospitalisation Treatments In Singapore Cost?


In recent years, the rising cost of healthcare has been a major concern in Singapore. Aside from an increase in government spending on healthcare, both from an absolute amount ($7.5 billion in 2015) and as a proportion of overall GDP (2.1%), insurers have also been increasing their premiums for private integrated shield plans due to the rising and unsustainable increase in the cost of hospitalisation treatments.

Unless you are working in the finance department of a hospital, most of us do not realise just how expensive treatments in hospitals can be, until it happens to ourselves or our loved ones.

While bills for hospital treatments differ depending on where you get your treatments from (private hospitals tend to cost more), ward types and the complexities of the illness, the Ministry of Health (MOH) does keep track of the average hospital bill sizes across different types of conditions in Singapore.

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Doctors warned against overcharging, overtreating
The SMC also reminded doctors not to subject a patient to unnecessary test or procedures just because of the fees the doctor can charge, as this may be a breach of his ethical obligations. FOTO: ST FILE

Doctors in Singapore have been warned that they will face action from the body that regulates them, as well as the Ministry of Health (MOH), if they overcharge patients or put them through superfluous treatments.

This comes on the heels of recent moves to rein in ballooning healthcare costs, partly brought on by "hefty & questionable insurance claims" in which some doctors were said to have played a part.

Needless treatments & inflated medical charges were mentioned in Parliament earlier this month to explain the decision to stop further sale of full insurance riders that leave patients with nothing to pay for their treatment.

related:
Itemised bills can reduce ballooning of claims
SMC reminds doctors in wake of 'hefty and questionable insurance claims'

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MOH to probe alleged insurance fraud involving physios, doctors and others 
Some medical doctors are paid commission fees of 20% to 30% of the physiotherapy bill if they refer their patients – such as those who require rehabilitation due to injury or illness – to private physiotherapy clinics

Dodgy practices have emerged in the healthcare industry, involving doctors, physiotherapists, insurance agents & third-party administrators (TPAs) splitting money from inflated insurance claims among themselves via a referral and commission system, TODAY has learnt.

Responding to queries, the Ministry of Health (MOH) said it has received feedback on such practices, & will be looking into the matter.

“MOH takes a serious view of any attempts to defraud the healthcare system at the expense of Singaporeans,” a ministry spokesperson said. “Fraudulent behaviour such as unnecessary referrals & false claims for services not rendered raises the overall costs of healthcare in Singapore, and leads to Singaporeans paying more for their healthcare services and insurance plans.”

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DOCTORS HAVE AN IMPORTANT ROLE TO PLAY IN KEEPING HEALTHCARE COSTS AFFORDABLE AND SUSTAINABLE

We refer to the recent media coverage on rising healthcare costs (including medical insurance premiums) and hefty and questionable insurance claims.

The Singapore Medical Council (“SMC”) notes that to keep healthcare costs affordable and sustainable for patients, all stakeholders – healthcare professionals and providers, insurers and policyholders, employers, patients and caregivers, and the Government – have their roles and responsibilities. While the SMC acknowledges that there are various drivers of healthcare costs, many of which are beyond the control of doctors, doctors have a major role in managing healthcare costs, by advising patients on appropriate and cost-effective tests, medical procedures and treatments, and striving to keep fees fair and reasonable. In light of the recent scrutiny of healthcare insurance and unreasonable practices and fees, the SMC by way of reminder, wishes to bring to bear the ethical principles against complicity by doctors outlined in the 2016 edition of the SMC Ethical Code and Ethical Guidelines.

Where patients are covered by medical insurance that guarantee they pay little or nothing towards their medical bills, they may be less likely to contest the fees charged by the doctor. However, patients’ acquiescence to a doctor’s fees does not absolve the doctor of the responsibility of charging reasonable fees; the doctor’s ethical obligation to charge fair and reasonable fees for services rendered operates over and above contractual and market forces and is not superseded by any agreement between the doctor and his patients.

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SMC reminds doctors to help keep healthcare costs down
The SMC also reminded doctors not to subject a patient to unnecessary test or procedures. TNP FILE FOTO

The Singapore Medical Council (SMC) has sent a circular to doctors reminding them of their role in helping keep healthcare costs down.

The reminder, it said, comes in the wake of recent scrutiny of healthcare insurance and unreasonable practices & fees.

The SMC also alluded to media coverage of "hefty and questionable insurance claims".

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Doctors have ‘ethical obligation’ to charge reasonable fees: SMC in wake of insurance co-payment debate


Doctors have an important role to play in keeping healthcare costs “affordable & sustainable”, said the Singapore Medical Council (SMC) on Monday (Mar 19) in a circular to medical professionals.

It was issued in the wake of new rules announced in Parliament earlier this month, requiring patients to bear a minimum 5% co-payment for new Integrated Shield Plan riders. This means insurance companies can no longer sell full riders, which entitled policyholders to pay nothing for hospitalisation & treatment, regardless of the size of the bill.

The Health Ministry had said that the zero co-payment feature resulted in a “buffet syndrome”, leading to over-consumption & over-charging of healthcare services.

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SMC reminds doctors of ethical obligations amid concerns of ‘over-servicing’
The government body that regulates medical practitioners here on Monday (Mar 19) reminded doctors of their “ethical obligation” to charge fair & reasonable fees for services rendered. Reuters file foto

The government body that regulates medical practitioners here on Monday (Mar 19) reminded doctors of their “ethical obligation” to charge fair & reasonable fees for services rendered.

This is “over & above contractual and market forces and is not superseded by any agreement between the doctor and his patients”, the Singapore Medical Council (SMC) said in a circular put up on its website.

A doctor must always place his patient’s best interests above his personal interests & any business or financial considerations, stressed the SMC, which highlighted existing standards from the 2016 edition of its Ethical Code & Ethical Guidelines.

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Why is the Government Penalising Consumers while using Kid’s Gloves on Rogue Doctors and Insurance Firms?


At one point of time, the government was even touting the benefits of buying Integrated Shield plans with full riders so you don’t have to pay a cent if you need medical treatment. Today, it appears to have backtracked on that “don’t have to pay a cent” part and mandated that all new hospitalisation policies will have a 5 percent co-payment component, capped at S$3000.

The reason, according to the Health Ministry, is because policy-holders are indulging in “buffet syndrome” and abusing their health insurance policies by going for more expensive/more extensive treatments than they should, and hence pushing up healthcare costs. On the sidelines of that explanation, rogue doctors are getting off the hook by recommending more expensive/more extensive treatments than required (because you got insurance what, don’t need to pay a cent).

And, all 6 insurers offering rider policies are underwriting losses for 2016. So why is the government only penalising the public for this “buffet syndrome”?

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Impact of Full Riders on Healthcare Costs


22.     As highlighted in HITF’s report, the zero co-payment feature of these full riders has resulted in a “buffet syndrome”, leading to over-consumption, over-servicing and over-charging of healthcare services. In 2016, the average medical bill size for full rider policyholders was about 60% higher than the average bill size for those without riders, even though rider policyholders are younger and generally in better health.

23.     Some of the examples of over-consumption and over-servicing are – to put it plainly – disturbing:
  • In one case, a full rider policyholder made claims for 12 nose scopes in a year, without clear medical need.
  • We also have patients who were admitted for gastritis or piles, and then referred to many other specialities ranging from dermatology, ophthalmology, ear nose and throat, and orthopaedics, for additional scans and tests. The final bill?  Up to $25,000 for a hospital stay that was less than 24 hours!
  • There was also a full rider policyholder who underwent an expensive surgery for a small breast lump removal that costs $70,000 in doctor fees alone, when there was an equally effective alternative procedure which costs only $5,000.
24.     To be fair, not all doctors prescribe such expensive treatments and not all full rider policyholders submit such large claims.  But it is clear that full riders have a detrimental impact on overall healthcare costs in Singapore.  This is a key reason why rider premiums have increased by up to 225% over the past two years.

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FULL RIDERS HAVE “DETRIMENTAL IMPACT” ON OVERALL HEALTHCARE COSTS
He stressed that MOH is not issuing these requirements to “bail out” the insurers

The zero co-payment feature of these full riders has resulted in a “buffet syndrome”, leading to over-consumption, over-servicing & over-charging of healthcare services, he said. “Our objective is to address the concerns with over-consumption, over-servicing & over-charging, as these will lead to patients & policyholders paying rapidly escalating fees and premiums over time,” he said. Mr Chee gave some of the examples of over-consumption and over-servicing, which he described as “disturbing”.
  • In one case, a full rider policyholder made claims for 12 nose scopes in a year, without clear medical need, and another policyholder who underwent an expensive surgery for a small breast lump removal that cost S$70,000 in doctor fees alone, when there was an equally effective alternative procedure at S$5,000.
  • There have also been patients who were admitted for gastritis or piles, and then referred to many other specialities ranging from dermatology, ophthalmology and ear nose and throat, for additional scans and tests racking up to S$25,000 for a hospital stay in less than 24 hours, he said.
  • “It is clear that full riders have a detrimental impact on overall healthcare costs in Singapore.
This is a key reason why rider premiums have increased by up to 225% over the past 2 years,” he said.

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Co-payment mandated for new IP insurance riders in bid to curb 'buffet syndrome'

Speaking at the MOH’s Committee of Supply debate, he said some instances of over-consumption & over-servicing “are, to put it plainly, disturbing”.
  • “In one case, a full rider policyholder made claims for 12 nose scopes in a year, without clear medical need,” he said.
  • Another policyholder with a rider underwent a surgical procedure amounting to S$70,000 to remove a small lump from her breast, when there was an “equally effective” alternative which cost just S$5,000, he added.
  • “To be fair, not all doctors prescribe such expensive treatments and not all full rider policyholders submit such large claims. But it is clear that full riders have a detrimental impact on overall healthcare costs in Singapore. This is a key reason why rider premiums have increased by up to 225% over the past 2 years,” he said.
Such behaviours have had an indirect effect on premiums for IP policies across the board, said Mr Chee. IP premiums have risen by up to 80% over the same period, with older policyholders and those on private hospital plans experiencing higher increases. All insurers clocked underwriting losses — between S$5.1 million to S$29.2 million — in 2016 for the first time since IP full riders were first introduced in 1994.

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WHAT CAUSES COSTS TO SPIRAL

Doctors & consumers said they have encountered or heard of unnecessary tests or treatment being rendered, as a result of insurers footing the entire hospital bill.
  • An AIA full-rider policyholder, who only wanted to be known as Ms Xie, felt the MRI and CT scans ordered, after she suffered bruises from a car accident 2 years ago, were warranted.
  • But she was also advised to see an orthopaedic surgeon, do a general health screening and have a session to check for psychological trauma. Each session cost about S$100.
  • Ms Xie, 27, did not question the doctors’ advice at the time “because they are healthcare professionals”. But on hindsight, the sessions may have been unnecessary, she said.
  • A doctor who declined to be named said he has observed a case involving drainage of pus from a patient’s limb being billed 3 to 4 times what it would usually cost.
  • Full-rider policyholders may adopt a “safe than sorry” mindset and demand in-depth tests even for minor ailments, said infectious diseases specialist Leong Hoe Nam. Such investigations often lead to higher bills and overconsumption of services, he said.
  • The co-payment percentage of at least 5% would make patients think twice about healthcare spending, said the doctors.
“Currently, people with full riders are in the minority but are spending the majority’s money, hence it is not very fair,” said Dr Chia.

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SMC warns money-greedy doctors about immoral ethics of overcharging insured patients

The Singapore Medical Council (SMC) has sent a circular to doctors reminding them of their role in helping keep healthcare costs down.

The reminder, it said, comes in the wake of recent scrutiny of healthcare insurance and unreasonable practices and fees. The SMC also alluded to media coverage of "hefty and questionable insurance claims".

The SMC also reminded doctors not to subject a patient to unnecessary test or procedures just because of the fees the doctor can charge, as this may be a breach of his ethical obligations.

read more

Billing procedures by private doctors need closer scrutiny


It is wrong to penalise policyholders who want to buy riders for their insurance plans (“Co-payment mandated for new IP insurance riders in bid to curb ‘buffet syndrome’”; March 7).

In cases where private hospitals & doctors send patients for unnecessary tests or treatments knowing they can be claimed through insurance, shouldn’t the Singapore Medical Council act on them & implement a system of checks to scrutinise these bills & penalise the doctors or sanction the hospitals?

How did medical bills at private hospitals get to be so high in some cases? Do doctors have so much leeway to bill unnecessary procedures? Do drug companies offer any benefits to doctors for using their drugs?

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IP full riders the first things we sell, say some insurance agents


Integrated Shield plan (IP) full riders have come under the spotlight for promoting a “buffet syndrome” among healthcare consumers, & insurance agents whom TODAY spoke to readily admitted that they have been aggressively pushing such policies to young clients — not entirely out of self-interest, even though the higher premiums mean they get to pocket a larger commission.

The agents said they are looking out for their clients’ interest by doing so, because premiums are cheaper when they are young & they would not qualify for such policies when they are older & have pre-existing illness.

These policies are the “first things” they would pitch to prospective clients, especially if they are young, said the agents, adding that IP full riders are by some distance the most popular policies they have sold.

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4 ways to manage escalating medical premiums


With the end of the 12-month premium freeze, some Integrated Shield Plan (IP) insurers are set to raise their premiums for next year amid increasing medical costs and higher claims. Healthcare costs are expected to continue its uptrend for years to come. In fact, the pace of inflation for healthcare is one of the fastest across all items. This is due to demographics and longevity. Singapore ranks within the top five in the world for life expectancy.

Longevity does not mean good health however. Rich men's diseases such as diabetes, high blood pressure and high cholesterol levels are so common that they are touted as the new norm. According to Ministry of Health (MOH) statistics, hospital admission rate increases by more than 30% every five years from 55 years old onwards.

There are currently 6 insurers offering IPs in Singapore. Here are 4 ways to choose and keep your preferred coverage while taming the ever-increasing premiums:


  • Enter early
  • Hospital class and co-payment
  • Flexible structure
  • Other ways​

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Why change policy on co-payment for Integrated Shield riders only now?

Even with full-riders, you still pay for your medical treatments

If you are just about sign up for a new rider to your integrated shield plan, you will not be able to find a rider that covers the entire co-payment amount, so that you don’t have to pay anything regardless of the bill size. Instead, you will have to pay at least 5% of your medical bill. There will be a cap on the co-payment amount each year.

If you already have one of those “full riders”, you may or may not affected. It depends on whether your insurer changes the terms of your existing policies. So… if you already have one of those “full riders”, don’t get too worried… yet.

A lot of people who read that news got quite angry. They ask: Why is the government squeezing Singaporeans? Medical treatments can be very expensive. Without those full riders, Singaporeans might end up having to pay huge medical bills. Has the government no heart?

related: Healthcare in Singapore is a misnomer. We don’t have healthcare

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Co-payment mandated for new IP insurance riders in bid to curb 'buffet syndrome'

To curb the over-consumption over-servicing & overcharging of healthcare services, the Ministry of Health says IP riders must now incorporate a co-payment of 5% or more. Reuters File foto

To curb the “buffet syndrome” among healthcare consumers who do not have to pay out-of-pocket for their hospital bills, new Integrated Shield plan riders must feature co-payment of at least 5%, the Ministry of Health announced on Wednesday (March 7).

New riders incorporating co-payment of 5% or more will be available by April next year.

In the meantime, insurers can still sell existing rider plans, some of which are full riders that cover the entire co-payment sums for hospital bills. But the insurers must inform new policyholders that they will transit to new riders with co-payment from April 1, 2021, said Senior Minister of State for Health Chee Hong Tat in Parliament on Wednesday (March 7).

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"Buffet Syndrome” leading to rising healthcare costs
There are limits to the buffet syndrome metaphor when it comes to dealing with integrated shield plans with zero co-payment coverage, says one observer from the Lee Kuan Yew School of Public Policy

If someone pays S$100 for a buffet, would you be surprised if that person proceeds to load up on as much food as possible? Or empties the dishes with the most expensive or delicious items?

What about when he or she picks up that last piece of lobster on the table, depriving others behind in the queue?

In this metaphor, the restaurant copes by pricing the buffet to make a profit even if there are people who consume much more than usual. Some people are happy, some get angry & stressed, and others simply give up and skip the buffet.

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related:
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"Buffet Syndrome” leading to rising healthcare costs
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