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What this MRA increase means is that for example, if a CPF account holder has $150,500 in his Ordinary and Special accounts but zero in his medisave account, he can only withdraw $24,600 (20 per cent withdrawal rule from 1 January, 2011 on current Minimum Sum (MS) of $123,000), at age 55, regardless of any MS property pledge. At the current rate of annual increase in the MS and MRA totalling $11,000 a year (MS $6,000 plus MRA $5,000), when the MS withdrawal rule is phased out to zero in 2013, those who have less than $183,500 (current $150,500 plus $11,000 times 3 years), may not be able to withdraw anything at all at 55.

The Medifund annual report says that over $64 million in Medifund was given out last year, and a surplus of $10 million will be converted to protected reserves when there is a change over of government – that is, before the next general election. It will then become part of the capital fund, which cannot be used by the Government. Only the president can authorise its use.

According to the recently released Singapore Census 2010, Singaporeans are getting older. Citizens aged between 45 and 54, now form the largest age group, compared to 2000 when it was those between 35 and 44. Healthcare affordability When I read this, the first thing that came to my mind was – no wonder Singaporeans have listed the affordability of healthcare as one of their greatest concerns, in practically every survey done in recent years. In this regard, a good starting point in my view, is to examine how much Class C hospitalisation bill size has increased, as it is the cheapest option for Singaporeans.

 

Leong Sze Hian recently wrote a letter to the Straits Times forum asking about the large jump in the size of class “C” hospital bills [Link]. In my blog, I’ve highlight numerous cases of families (that are not rich) shouldering enormous healthcare burden due to either cracks or inadequecies in the system. In the past 4 years, class “C” bills have nearly doubled and this escalating cost hit the sick and their family really hard. The latest case being that of Olympic hero Tan Howe Liang’s wife who had breast cancer [see article below]- fortunately an anonymous donor came the family’s rescue. The MOH’s reply to Leong Sze Hian generated by its PR (Corporate Communications) dept dismisses his concerns without addressing the real issue.

Singapore has a world-class healthcare system that is being reviewed as a model by the Obama administration’s healthcare team as it explores ways to reform the US healthcare system. In 2000, Singapore’s healthcare system was ranked by the World Health Organization (WHO) as the best in Asia - ahead of Hong Kong and Japan. In 2003, the Political and Economic Risk Consultancy (PERC) ranked Singapore healthcare as third best in the world. Currently, Singapore hosts 12 hospitals and medical facilities that are accredited by the Joint Commission International (JCI), thus accounting for one-third of all JCI-accredited medical institutions in Asia. In general, any type of medical treatment that you may require is available in Singapore at a reasonable cost and very good quality of service.

The objective of this article is to briefly introduce a newcomer to healthcare system in Singapore.

Healthcare infrastruture in Singapore consists of both public and private healthcare facilities with both offering high quality of medical care but generally different level of service and comfort. Health plans, insurance, and benefits vary largely and depend typically on your immigration status and the employer. Singapore citizens and permanent residents are entitled to subsidized government healthcare services through compulsory national savings scheme whereas foreigners holding various work passes get the health coverage either through their employer or purchase it privately on their own. It is not mandatory for employers in Singapore to provide health insurance benefits. As a general rule of thumb, the larger the company, the higher the probability that the company offers some type of health insurance benefits to its staff.

Healthcare Facilities

Government healthcare facilities

Government healthcare facilities are primarily designed to provide subsidised healthcare services to Singaporeans. These facilities consist of a number of government hospitals for inpatient services and numerous polyclinics offering outpatient services. Although wholly owned by the government, the public sector hospitals are operated as private limited companies in order to compete with the private sector on service and quality. They are a far cry from what is generally known as a “government hospital” in other countries. Government healthcare facilities not only provide very good healthcare services to masses but also handle the most complicated cases referred from other hospitals and neighboring countries. A list of major public hospitals and centres is available at the end of this article.

Government health system also sets the benchmark for the private sector on professional medical standards and fees. Specifically, the government influence most long-term trends such as the supply of hospital beds, the introduction of high-tech/high-cost medicine, and the rate of cost increases in the public sector which sets the bench mark in terms of pricing for the private sector. Charges in public health services are subsidised by the government while in the private hospitals and outpatient clinics, patients pay the amount charged by the hospitals and doctors on a fee-for-service basis.

Private healthcare Facilities

Private healthcare facilities in Singapore are as good as any in the world with excellent level of medical care and service levels. For non-Singaporeans, the difference in cost between government and private healthcare facilities is negligible as they directly compete with each other. Since private healthcare facilities in general offer better service level and minimum waiting times, most of the expatriates living in Singapore (as well as medical tourists from abroad) prefer to visit a private healthcare facility.

Private healthcare facilities consist of numerous private clinics offering outpatient services as well as private hospitals. Majority of the private hospitals are JCI-accredited. A list of major private hospitals and clinics is available at the end of this article.

Healthcare Coverage

Government health insurance

Singapore citizens and permanent residents are entitled to subsidized healthcare services provided through government healthcare facilities. Depending on various factors, the amount of subsidy can roughly  range from 50% to 80%. Further help in co-paying the balance of the medical bill is enabled through a compulsory savings scheme called Central Providence Fund (CPF). Depending on factors such as age and income, a percentage of the monthly salary of an employee is contributed to the CPF. Note that the CPF is not nationally redistributive in that whatever amount you contribute will be for your own or dependents’ use only, it will not be used to subsidize the benefits for another employee who may have earned less than you. Part of the CPF contributions goes towards medical insurance schemes namely Medisave, Medishield, ElderShield and Medifund that collectively can handle major part of the co-pay amounts.

To illustrate an example, Mr. X who is a Singapore citizen earns S$4,167 a month. He is then hospitalised where he chooses to stay in a Class C ward. Below is a breakdown of what he can expect to pay and what he can expect to be subsidised under two different scenarios:

Medisave Bill Subsidy (source: Ministry of Health)

To know more about subsidized healthcare system for Singaporeans, refer to Ministry of Health website.

Private health insurance

If you are a foreigner working in Singapore, you are exempted from CPF contributions but this also means that you do not have access to the government’s subsidized health insurance scheme as above. The good news is that day-to-day healthcare services are quite affordable in Singapore even if you don’t have any health insurance. However you must think about your health insurance options to handle any critical illnesses for you and your family.

If your Singapore employer is a medium to large size company, it’s likely that the company will provide a health insurance policy that covers you and your family. You should check health insurance benefits with your potential employer if you are in the process of relocating to Singapore. If you have your own business or are considering providing health benefits to your employees, you should seriously consider taking up a private health insurance policy to cover for at least critical illnesses. There is a variety of choices and healthy competition among internationally recognized health insurance companies who can offer you a policy that suits your needs. Depending on your age, lifestyle habits, and the type of policy, the monthly cost of a critical illness private health insurance may range from S$75 to S$400 per insured. Below is a list of some of the established private insurers in Singapore:

• Allianz
• Aviva
• Great Eastern
• Prudential

Finding the right medical insurance policy can be a very time-consuming task and prone to error as the insurance companies usually have many exclusions and exceptions in their coverage policies. It’s very important to read the fine print to be sure you know what you are getting in the policy. A good alternative is to engage an independent insurance broker who has in-depth knowledge of policies from various insurance companies and can recommend you a policy that’s best suited to your particular requirements.

Major Hospitals

Government Hospitals

Public healthcare facilities are divided into 2 clusters which are the National Health Care Group (NHG) and Singapore Health Services (SingHealth). These clusters were made to foster vertical integration of services, enhance synergy and economies of scale in-line with the government’s aim to spur innovation and improve the quality of healthcare while keeping medical costs affordable. NHG and SingHealth run these hospitals and specialty centres as private companies but remain wholly-owned by the government.

Below is the breakdown of public hospitals and centres under the NHG and Singhealth:

National Health Group	SingHealth
Alexandra Hospital	Changi General Hospital
National University Hospital	KK Women’s and Children’s Hospital
Tan Tock Seng Hospital	Singapore General Hospital
Institute of Mental Health/Woodbridge Hospital	Polyclinics SingHealth
National Skin Centre	National Cancer Centre Singapore
NHG Polyclinics	National Dental Centre
The Cancer Institute	National Heart Centre
The Eye Institute	National Neuroscience Institute
The Heart Institute	Singapore National Eye Centre

Private Hospitals

Below is a list of major private hospitals and medical centres in Singapore:

Major Private Hospitals	Major Private Medical Centres
Mount Elizabeth Hospital	Camden Medical Centre
Gleneagles Hospital and Medical Centre	Thomson Medical Centre
Mount Alvernia Hospital and Medical Centre	Novena Medical Centre
Raffles Hospital	Johns Hopkins Singapore International Medical Centre

You may also visit the MOH’s hospital directory for a comprehensive list.

Healthcare cost examples

Charges listed here are for general information purposes only and perhaps more relevant to non-insured individuals. For government subsidized as well as privately insured patients, clearly the majority of the medical services bill will be absorbed by the third party.

Primary healthcare costs

Day-to-day healthcare services are relativey affordable in Singapore. A routine check-up with a General Practicioner plus (generic) medicine will likely cost you around S$20-S$30 while blood-work and x-ray will cost you around S$50-S$80. Roughly 20% of primary health care is provided through the government polyclinics, while the remaining 80% is provided through some 2,000 private medical clinics. Specialist consultation in a private clinic might cost you between S$75 -S$125.

Hospitalization costs

Hospitalization charges vary depending on the type of ward choosen. Wards in Singapore vary from open wards with no air-con in place to a private medical suite that resembles a royal suite at a 5-star hotel. Accordingly the daily charges for a ward can vary from S$30 to S$3000. Charges between government and private hospitals for non-subsidized patients are very similar. For more details on charges by various Singapore hospitals, refer to MOH web page.

Major surgery costs

Singapore provides a unique value-proposition for major surgeries to patients arounds the world. The city-state is able to provide world-class healthcare service at a relatively affordable cost. The table below provide a rough comparision chart for illustration purposes:

Medical Procedure	USA	Singapore	Thailand
Heart Bypass	$140,000	$25,000	$15,000
Hip Replacement	$45,000	$13,000	$13,000
Knee Replacement	$40,000	$15,000	$12,000

As is evident from the above table, the cost for most procedures in Singapore is very affordable compared to the US.

Mr David Chua, who has high blood pressure and a family history of colon and stomach cancers, hopes for a top-up of his Medisave account. -- ST PHOTO: DESMOND LIM

TAXI driver David Chua, 57, is hoping that the Government will top up Medisave accounts when the Budget is announced next week.

He suffers from high blood pressure. Because he has a family history of colon and stomach cancers, he has to go for scopes every two years to get a health update. Even at subsidised rates, he has to fork out about $700 each time.

While he does contribute to his Medisave account every year - compulsory in order to renew his taxi-driving licence - the amount in it is dwindling.

Medisave can be used to pay hospital bills and up to $300 a year can be spent on some outpatient treatments.

In last year's Budget, Singaporeans received a top-up in their Medisave, the health savings portion of their Central Provident Fund accounts. The $200 to $500 top-ups went only to people earning $100,000 or less a year.

But Mr Chua worries that even if he gets a Medisave top-up, he still cannot run away from higher medical costs.

Since the last General Election in 2006, the cost of hospital care has shot up significantly, almost doubling in some cases, even for subsidised patients who have as much as 80 per cent of their hospital bills paid for by the Government.

Professor Euston Quah, who heads the Economics Division at Nanyang Technological University, said that as the economy was strong last year and is projected to do well this year, he hopes to see significant help for the lower- and middle-income groups.

'Health-care needs certainly should continue to dominate, given that the cost of treatment for all kinds of health ailments has continued to rise,' he said.

This is inevitable amid expectations from the public for the latest implants, new breakthrough drugs and a higher doctor-and-nurse to patient ratio.

In tandem, government expenditure on health care has risen over the years. In the 2009 financial year, it was more than $3 billion, up from $2.4 billion the previous year.

Health Minister Khaw Boon Wan has assured the public that hospitalisation remains affordable for the vast majority who have both MediShield insurance and Medisave to draw upon.

MediShield, the national insurance scheme, now covers 94 per cent of all working adults.

Dr Lam Pin Min, chairman of the Government Parliamentary Committee for Health, wants to see more people go for basic health screening.

'Keeping Singaporeans healthy will reap long-term benefits in terms of health-care expenditure and economic contribution,' he said.

Prof Quah expects greater attention to be paid to public health.

'I hope that some incentives could be designed to encourage people to adopt good practices in illness prevention,' he said.

He suggested 'some government subsidies may be given, such as more subsidised health checks and for purchases of established supplementary health goods'.

He sees the ministry spending more on health campaigns to raise awareness and disseminate information and education.

Dr Lam, an MP for Ang Mo Kio GRC, also wants more resources pumped into step-down care such as nursing homes and home care.

'Caregivers need be taken care of, both financially and emotionally, as looking after a dependant, especially an elderly sick relative, can be financially and emotionally draining,' he said.

He expects the Government to pump money into building more nursing homes, community hospitals and other step-down facilities to cater to the coming 'silver tsunami' as the population ages.

'More resources must be put in to develop this sector,' he said.

This will be a major focus for the ministry over the next five years, Mr Khaw said recently.

He wants to improve the level of care given at nursing homes so that more people can be rehabilitated and return home.

This means upgrading the skills of workers at such facilities or getting specialists to help patients, which might mean more funds for training.

As the population ages, this will become an even more pressing issue as the number of patients needing rehabilitation balloons.

Dr Lam also wants the Government to fork out more to keep top doctors in the public sector.

This needs to be done 'before the situation deteriorates', he said, referring to the exodus of specialists from public hospitals to the private sector.

He said: 'The public sector provides the bulk of health-care services to Singaporeans, especially those with low and middle incomes, and good quality health-care professionals need to be retained to ensure a high standard of care.'

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This is the breakdown of the costs of the care cycle for my father-in-law’s medical condition of low blood content, which required a recent diagnostic and treatment intervention to find out the cause.

Day Surgery Facility Charge $ 53.27
Consumables $ 218.74
Laboratory Investigations $ 269.00
Non Standard Medications $ 12.04
Standand Medications $ 28.32
Renal Dialsys (Peritoneal) $ 30.00
Minor Surgical Procedure $ 66.00
(Ligation of 3 internal piles)
Surgical Procedure $ 1,425.18
Gastroscopy Consumables Package $ 80.80

Total Charges $ 2,183.35

One will think that this is a reasonable amount for the intervention that he went through, and I agree. But the care cycle does not end there.

My father-in-law subsequently suffered a complication from new oral medications that he was discharged with after the intervention. This required a medical professional ( in this case me ) to step in to mitigate the problems. The prices here are an estimate as I obviously did not charge my father-in-law.

2 Home Visits ( one at 5am ) $ 400
Intravenous Dextrose drip for 24 hours $ 50
(provided caregiver changes dextrose bottles on their own every 6 hours)
Total charges $ 450

So the total cost is $ 2,183.35 + $ 450 = $ 2,633.35

The care cycle would end here if he was not admitted into the hospital through the emergency department. But for most families, the care cycle would have continued because they would not have a medical professional in the family to take charge of the situation arising from the side effects of those oral medications.

This method will be a good way to compare the value of any intervention by any healthcare provider to any patient. Only by comparing the total charges over the whole care cycle of a medical condition and its interventions can we truely choose the best for ourselves and our families.

09 December 10 The Strait Times
by Salma Khalik, Health Correspondent

Public hospitals lose more specialists

SINGAPORE is facing possibly its largest-ever exodus of specialist doctors from the public to the private sector, as the robust economy gives them the courage to leave secure jobs.

In the first half of this year, 68 specialists left the public sector, compared with 63 the whole of last year.

Among them were five cancer specialists, seven general surgeons, seven orthopaedic surgeons and seven diagnostic radiologists.

If this trend continues for the rest of the year, it will be the biggest outflow of specialists the public sector has ever seen. The previous high was a loss of 87 specialists in 2007. The Health Ministry could not provide more up-to-date figures for this year.

Industry observers say doctors are feeling confident enough to leave their safe jobs for private practice because of the booming economy.

A highly successful specialist in private practice can make up to 10 times what he was drawing in the public sector. These top doctors earn more than $1 million a year, with some reputed to rake in more than $5 million.

In the public sector, consultants earn between $12,000 and $60,000 a month, based on their seniority and specialty.

Even less successful private sector doctors would make about the same pay they were getting in the public sector, but with a much lighter patient load.

Not all who go private set up their own practice. Some find it easier to join an existing group practice, where their pay may not be as high but is regular.

Among them are about 20 specialists in seven specialities who have joined the Healthway Medical Group this year.

One is colorectal surgeon Adrian Leong, who is in his early 50s. He left the National University Hospital (NUH) in July to take on the role of group medical director.

He said the group pays more than the public sector, but 'not multiples' of what they were receiving.

Some specialists who have left said that pay is not the whole story.

Cardiothoracic surgeon T. Agasthian, 49, said there were many factors behind his decision to leave the National Cancer Centre in October to open his own practice. They included the desire to continue working beyond the retirement age.

'You can't start a practice at 62. It takes time to set up a private practice,' he said.

He added that while some very senior people are still around in public hospitals, not everyone is given the option to stay.

Dr Agasthian said he would have stayed on if he had been given a teaching post, since teaching the next generation is one of his passions. He added: 'To stay on in the public sector, we need to feel useful.'

Professor Leong, who holds an adjunct teaching role at the university, was also planning for his future when he left.

He said: 'You usually take about five to 10 years to make a significant impact in a particular arena. The time was about right to start on something new before I got too old.'

But he added that some of the new specialists at the group moved to private practice 'to get a better quality of life'. They now work part-time and choose their own working hours.

The Health Ministry has always maintained that it is the role of public hospitals to train doctors for the country. At the end of last year, Singapore had 3,180 specialists, of whom 1,927 worked in the public sector and 1,253 in the private sector.

There were then 42 oncologists in the public sector and 25 in private practice. With at least five moving out of public practice this year, the equation changes significantly.

Cancer is the top killer in Singapore, with more than 9,000 people diagnosed each year. The majority seek treatment at public hospitals.

Cancer patient Ananda Pereira has had two of his specialists leave for private practice this year, and is unhappy with the changes. Said the retiree: 'Patients often put their trust in their doctors. And when the doctor changes, it can affect their confidence in the treatment.'

Prof Leong said: 'I do feel sorry about some patients who wanted to continue to see me, including a very nice old lady who was crying in my NUH clinic when she was told.'

But hospitals said they have no problems coping with the losses.

The National Cancer Centre said its number of doctors is increasing and 'there is also no significant change in the waiting time for patients to see doctors'.

Tan Tock Seng Hospital, which lost nine specialists in the first six months, said the 'vacancies were quickly filled'.

salma@sph.com.sg

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ScienceDaily (May 11, 2010) — A new analysis finds that the costs of treating cancer have nearly doubled over the past two decades and that the shares of these costs that are paid for by private health insurance and Medicaid have increased. The study also reveals that cancer costs have shifted away from inpatient treatments to outpatient care.

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Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the information could be used to prioritize future resources for treating and preventing cancer.

Little information is available on how overall cancer costs have changed over time and who now bears the burden of financing the bulk of cancer-related expenses. To study recent trends in the medical costs of cancer and how these costs are paid for, Florence Tangka, Ph.D., a health economist at the Centers for Disease Control and Prevention (CDC) led a team of scientists from CDC, Emory University, and RTI International in analyzing data from the 2001 through 2005 Medical Expenditures Panel Survey and its predecessor, the National Medical Care Expenditure Survey, a one-time survey conducted in 1987. Both surveys are nationally representative of individuals across the United States and capture self-reported data on medical conditions and related expenditures.

The investigators found that in 1987 the total medical cost of cancer (in 2007 dollars) was $24.7 billion. Private insurance financed the largest share of the total (42 percent), followed by Medicare (33 percent). Out-of-pocket payments accounted for 17 percent of the costs, other public sources paid for 7 percent, and Medicaid paid for 1 percent. Between 1987 and the 2001-2005 period, the total medical cost of cancer increased to $48.1 billion due to new cases diagnosed among the aging population as well as an increase in the prevalence of cancer. In 2001-2005, private insurance paid for 50 percent of the costs, and Medicare paid for 34 percent. Out-of-pocket payments accounted for 8 percent of the costs, other public sources paid for 5 percent, and Medicaid paid for 3 percent.

The analysis also revealed that the share of total cancer costs incurred after inpatient hospital admissions fell from 64.4 percent in 1987 to 27.5 percent in 2001-2005. The decrease in cancer-related inpatient costs was accompanied by an increase in cancer-attributable outpatient expenditures.

"The information provided in this study enhances our understanding of the burden of cancer on specific payers and how this burden may change as a result of health reform measures or other changes to health care financing and delivery," said Dr. Tangka. The authors noted that additional research will be needed to determine the impact of these changes on costs and quality of cancer care in the United States.

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by American Cancer Society, via EurekAlert!, a service of AAAS.

Journal Reference:

1. Florence K. Tangka, Justin G. Trogdon, Lisa C. Richardson, David Howard, Susan A. Sabatino, and Eric A. Finkelstein. Cancer treatment cost in the United States: has the burden shifted over time? CANCER, 2010; DOI: 10.1002/cncr.25150

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.