Reforming MediShield to be truly national ― Jeremy Lim
MARCH 27 ― Every now and then, Singaporeans come across a media report of a medical bill in the hundreds of thousands of dollars, and everyone seems to know someone struggling financially after a prolonged illness.
In fact, the late Dr Balaji Sadasivan, previously a junior minister in the Health Ministry, while undergoing treatment for cancer commented: “Cancer treatment can be very, very expensive. This is something our health system will have to deal with. It is not surprising if some patients have to sell their house (sic).”
In dealing with the financials of catastrophic illness, Singaporeans are likely most concerned about two issues: The uncertainty of illness severity with an attendant massive hospital bill, and their share of the bill.
On the former, Health Minister Gan Kim Yong has correctly identified that expanding risk pooling is fundamental.
It does not make sense for every Singaporean to try and save for a hospitalisation episode that may never materialise (half of all heart-related deaths are sudden); and besides, most Singaporeans will never be able to save enough to pay fully for a complex and long-drawn illness.
MediShield is the bedrock insurance programme intended to protect against the financial consequences of medical catastrophes. It is the only health insurance scheme created by an Act of Parliament and must be national.
However, MediShield has three limitations that prevent it from being truly national: Exclusion of pre-existing conditions from coverage, non-eligibility upon reaching 90 years of age; and sharp premium increases with age.
How can we revamp MediShield to assure that it is truly inclusive or national and covers every Singaporean?
Three changes are worth exploring. Firstly, expand MediShield to include all Singaporeans regardless of age or pre-existing illnesses.
This is a monumental decision and truly fundamental as it reframes MediShield from being a scheme run on commercial principles (albeit as a non-profit scheme), to one that is founded on social principles.
The current premium calculations are in age bands, excluding Singaporeans with pre-existing illnesses. For a national programme, it is preferable to spread risk across all age groups and all risk groups.
This would result in younger and healthier policy holders paying more, but would prevent premiums for the elderly (who have healthcare bills four times larger than their younger counterparts) from skyrocketing — and, just as importantly, enabling those with prior cancer, heart disease and the like to have affordable insurance.
Secondly, ensure all Singaporeans can afford to pay the premiums. Premiums may still be higher for the very elderly or those with substantial pre-existing illnesses, and government funding for those who cannot afford to pay their own premiums has to come in.
Thirdly, limit the individual’s risk of medical bankruptcy by imposing a cap on what patients have to pay as their share of the total bill. How this quantum is worked out needs to be transparent, though.
The cap will need to be means-tested in keeping with the government’s philosophy of targeting subsidies, but patients need to know before the fact how the cap is determined and what they are expected to pay.
A point to note: Setting caps on what patients pay does not remove the financial risks in and of themselves. It just means someone else — in this case, the government — has to bear the risk. This will have downstream consequences: The government assuming the risks really means taxpayers carry the can.
Social activists advocating for “peace of mind” for all are really asking for the government to do more AND for taxpayers to fund these measures. Is this a price Singaporeans are prepared to pay for a better Singapore? I certainly hope so.
Minister Gan also highlighted the risks of over-servicing and over-consumption. These are genuine concerns. It would be naive to depend on the “nobility” of individual healthcare professionals who are paid at least in part on a “fee-for-service” model, and equally naive to expect patients to deliberately constrain themselves for the good of society.
What can be done then? Some suggestions build on self-regulation as a professional community, a privilege society extends to doctors.
The Singapore Medical Council is the watchdog for professional misconduct and egregious ethical breaches but what about overall clinical standards of practice? Singapore has a College of Family Physicians for general practitioners and family physicians, and an Academy of Medicine for specialists. These professional bodies can step up to the plate.
Developing clinical practice guidelines and coupling rigorous auditing processes to them to identify errant over-servicing doctors would be a good start.
The government’s electronic medical records system has been in the works for almost a decade now and when fully mature, can enable audits and recognition of negative outliers.
Public hospitals already have departmental structures where doctors in the same speciality peer-review each other’s cases, appropriateness of treatment and outcomes.
These could be built upon by government mandate enabling the college and academy to take these governance practices nationally.
Robust audits will be necessary to assure the government that risks of abuse of insurance schemes can be mitigated, and these can be built up progressively.
The challenges are formidable but the reward, a truly national MediShield makes it worthwhile.
On a trip to Taiwan last year, a young Taiwanese remarked to me: “The NHI (Taiwan’s National Health Insurance) makes me proud to be Taiwanese!” Years from now, what will Singaporeans say? ― Today
* Jeremy Lim has held senior executive positions in both the public and private healthcare sectors. He is writing a book on the Singapore health system.