SPEECH BY DR KOH POH KOON, SENIOR MINISTER OF STATE FOR HEALTH, AT THE MINISTRY OF HEALTH COMMITTEE OF SUPPLY DEBATE 2021, ON FRIDAY 5 MARCH 2021

Even as we continue the fight against COVID-19, MOH’s key priority continues to be a healthcare system that provides good quality, affordable, and sustainable healthcare for all Singaporeans. I will speak on how deepening our partnerships with the private sector, strengthening our healthcare financing system, driving greater value in healthcare delivery, and uplifting our healthcare workforce, can help us to achieve these aims.

Partnering private sector providers for a stronger healthcare system

2. Our strong partnerships with the private sector over the years has allowed us to mount a robust and coordinated national response to the COVID-19 pandemic.

3. For example, we had partnered private hospitals to provide subsidised care to patients, such as

a. Raffles Hospital for non-life-threatening emergency cases, an example referenced by Ms Mariam Jaafar; as well as
b. Parkway, Mount Alvernia, and Farrer Park Hospitals for other conditions, including dengue.
c. At the peak of COVID-19, up to 400 beds were provided across 7 private hospitals to manage recovering COVID-19 patients.
d. Private providers also supported our Community Care Facilities, clinics in worker dormitories, roving medical or swabbing teams, and more.

4. Our partnerships with private general practitioners (GPs) have also matured over the years.

a. Community Health Assist Scheme (CHAS) subsidies have expanded since 2012. Today over 2 million Singaporeans can access subsidised primary care at CHAS GP clinics. In FY19 alone, we disbursed more than $180 million in CHAS subsidies.

b. GP clinics in Primary Care Networks (PCNs) anchored care in the community, deriving economies of scales for ancillary services, and serving 130,000 patients with chronic conditions last year.

c. Over 970 private GP clinics serve as Public Health Preparedness Clinics (PHPCs), screening all patients with acute respiratory infections and conducted more than 250,000 swabs for early detection and containment of community COVID cases.

5. In the long-term care sector,

a. Private nursing homes receive funding to provide subsidised services.

b. Both private and not-for-profit organisations also operate many government-built nursing homes and eldercare centres, under a Build-Own-Lease arrangement.

c. In the pandemic, they actively stepped up safe management measures and supported COVID-19 testing and vaccinations to keep our seniors safe.

6. To mount a strong pandemic response, MOH also tapped on expertise and resources from:

a. Private laboratories for PCR testing capacity,
b. Vendors and distributors of medical supplies,
c. Cleaning companies that disinfected our medical facilities, and
d. Security companies, facility managers, and transport companies that supported our quarantine and other operations.

7. There are too many to list comprehensively but each one helped make our robust national response to COVID-19 possible.

8. On behalf of all Singaporeans, I thank our many private-sector partners for protecting Singaporeans from COVID-19.

9. I therefore agree with Ms Mariam Jaafar that the Government should continue to review and deepen our partnership with private healthcare providers.

10. First, we will uplift capabilities of our GPs through continuing professional education.

a. For example, the Agency for Care Effectiveness (ACE)’s Clinical Update Service (CUES) assists GPs in navigating areas of uncertainty and challenges specific to their area of practice through personalised, evidence-based discussions.

b. We will also train and equip GPs to care for persons with mental health needs. My colleague SMS Janil will share more on this.

11. Second, strengthening regulatory frameworks such as the Healthcare Services Act (HCSA), passed in January last year, will help us better regulate newer, non-premises-based, models of care such as telemedicine through a services-based licensing framework.

12. Fee benchmarks, an area which Dr Tan Yia Swam mentioned earlier, were introduced in 2018 gave patients seeking care at private sector providers more confidence that charges are fair and reasonable.

a. Early data showed that doctors have been taking reference from the benchmarks, with more than 80% of charges in 2019 within the upper limit of the benchmarks. This utilisation is about 4% higher than in 2018.

b. Therefore together with the Fee Benchmarks Advisory Committee, we introduced new benchmarks for anaesthetist and inpatient attendance charges in December 2020 and will continue to review and develop new areas of fee benchmarking.

Improve affordability and sustainability, and encourage right-siting of healthcare in appropriate care settings through healthcare financing policies

13. I will now move on to our healthcare financing system which is anchored on Government subsidies and the 3Ms: MediShield Life, MediSave and MediFund.

14. Today, the Government provides significant subsidies, covering up to 80% of treatment costs.

15. In FY19, government spending on healthcare subsidies amounted to approximately $5.7 billion dollars, or about 60% of MOH’s total operating budget that year. This is projected to grow to 6.5 billion in FY20; an increase of 13.6%.

a. As a society, we widely accept the need to be progressive and to target subsidies at those with greater needs.
b. When formulating subsidy levels across the various healthcare settings, we should also encourage right-siting of care.

16. We will therefore introduce a set of changes to the subsidy frameworks for

a. Inpatient care at the acute hospitals,
b. Specialist outpatient clinics (SOCs), and
c. Community hospitals.
Let mel go through each in turn.

17. First, the acute hospitals. For inpatient admissions to acute hospitals, we currently use individual income as the basis for means-testing.

18. I have seen in my clinical practice and also meet people during my Meet-the-People sessions, how a sole breadwinner may earn a high individual income, but shoulders the full responsibility for his or her household’s needs alone. For such individuals, healthcare costs can become a significant strain, and I have great sympathy for them. Per Capita Household Income (PCHI), which is already widely used in our healthcare system, is therefore a better measure of means, as it also considers the amount of household support available, and the number of household members that this individual supports.

19. MOH will thus align means-testing for inpatient admissions to acute hospitals from individual income to PCHI.

20. Another observation over the years is that the physical differences between B2 and C wards are no longer so obvious, following infrastructural improvements to raise patient safety and infection control standards.

21. However, we still have a legacy system of using choice of ward as a proxy of financial means to differentiate subsidy levels. Currently, B2 wards are subsidised at 50% to 65% and C wards at 65% to 80%.

22. With better means-testing through PCHI, there is therefore less need to rely on ward choice. Therefore we will unify B2 and C subsidies into a common framework, maintaining the same minimum and maximum range at 50% to 80%.

a. This acute inpatient subsidy framework will also be applied to day surgeries which are currently subsidised at 65%. Effectively, this will increase subsidies for 70% of day surgery bills and encourage day surgeries instead of inpatient admission when appropriate.

23. Overall, with MediShield Life and MediSave, we expect that most patients will not see a change in out-of-pocket (OOP) payments, with about 30% seeing lower OOP and about 15% seeing higher OOP.

24. Second, the SOC setting. While we raised SOC subsidies for the lower income up to 70% in 2014, higher-income patients and median-income patients currently receive the same 50% subsidy support, despite both having quite different financial means.

25. To bring about greater progressivity and allow resources to be better directed, MOH will introduce two new subsidy tiers in the SOC setting for patients with higher PCHI:

a. 40% for PCHI more than $3,300,
b. 30% for PCHI more than $6,500.

26. For a family of 4, these PCHI levels correspond to household incomes of $13,200 and $26,000 respectively.

27. Nonetheless these higher-income households may continue to tap on MediSave up to the applicable withdrawal limits to help pay for their healthcare bills.

28. With the introduction of the CHAS Green tier in 2019, higher PCHI patients with chronic conditions also have access to subsidised chronic care at CHAS GP clinics as an alternative.

29. Complex chronic patients who are not suitable for management at primary care will also be able to better utilise their MediSave through higher limits that are going to be introduced. I will speak more about this later.

30. Sir, having been in clinical practice for more than 20 years, I have also seen subsidised patients in the surgical SOCs who have at times preferred an A or B1 ward for specific procedures.

a. Some preferred air-conditioning and others wanted more privacy in the private wards.
b. But the cost of a potentially long tail of SOC consultations upon discharge worries them.
c. For this reason, some patients have sometimes had to forgo their preference, and request for a subsidised ward instead. This particular group was what Dr Tan Yia Swam shared earlier.
 
31. With better targeted subsidies at SOCs, we will now allow private patients in the inpatient setting to opt for either subsidised or private SOC for their post-discharge follow up. If subsidised SOC is chosen, the patient will no longer be able to pick their specialist, as is the current practice.

32. Overall, the SOC subsidy changes will affect about 30% of subsidised SOC patients, who are from higher PCHI households.

a. Of these, 7 in 10 will see an increase of less than $100 in total co-payment for their cumulative annual bills.
b. This can be further offset by MediSave or MediShield Life, or for those who have private insurance coverage.
c. For elderly patients, any increase in co-payment will also be partially offset by Pioneer Generation and Merdeka Generation subsidies.

33. This brings me to community hospitals (CHs). Having worked in an acute surgical ward, I have occasionally encountered patients who have recovered sufficiently to be well enough to be discharged to a CH for sub-acute or rehabilitative care, but who were reluctant to do so due to the differences in the subsidy levels between the acute and community hospitals.

34. We will therefore enhance subsidies available in our CHs to support patients in utilising appropriate care, and facilitate the smooth flow of patients from acute hospitals to community hospitals. This allows acute hospital resources to be available for patients who require more intensive acute care.

35. We will raise the maximum subsidy of CHs to 80%, aligned with that of acute inpatient care, and further increase the minimum subsidy from 20% to 30%.

36. Together with increased MediShield Life claim limits for CH sub-acute care from 1 March 2021, this should make CHs even more affordable, especially when compared to a prolonged acute hospital stay.

37. Almost all, about 95%, of CH patients will see an increase in subsidies.

38. Mr Chairman, subsidies are the bedrock of our healthcare financing system. Healthcare costs will continue to rise in the years ahead, and government spending on healthcare subsidies will commensurately increase even after all these changes.

39. The changes outlined will make healthcare subsidies more progressive and will help facilitate care at appropriate settings. We expect to implement these changes over the course of 2022.

40. In addition to these changes, MOH will also review the financing landscape in the Long-Term Care (LTC) sector. Last year, we launched CareShield Life and MediSave Care, improving affordability. However, as we uplift standards and draw in more Singaporeans to work in the LTC sector, cost pressures may potentially impact affordability. So in anticipation of these challenges, we will once again review the financing situation for the LTC sector to see if further changes are needed.

41. Next, I will speak on the enhancements to MediShield Life and MediSave.

42. First, MediShield Life covers Singaporeans for large hospitalisation bills and selected costly outpatient treatments.

a. Following the recent MediShield Life 2020 review, various benefit changes have been made to ensure that the scheme continues to provide adequate and meaningful protection to Singaporeans. This includes raising the policy year claim limit from $100,000 to $150,000.

b. Premiums will also be adjusted to keep the scheme solvent and sustainable. 

c. The Government will provide up to $2.2 billion in premium subsidies and support over the next three years. Net premium increases for all Singapore Citizens will be kept to no more than about 10% in the first year. Premium payment will also be deferred till the end of 2021 for those who have insufficient MediSave balances and are unable to pay their premiums due to the economic impact from COVID-19.

43. As noted by Mr Gerald Giam, the benefit changes and premium adjustments will take effect on or after 1 March 2021.

44. On premium pricing, I wish to assure Mr Gerald Giam that the pricing assumptions are assessed by independent actuarial experts. We are studying how technically complex actuarial reports can be shared in a meaningful way, and will provide an update when ready.

45. Second, MediSave helps Singaporeans set aside some income towards their future healthcare needs, such as co-payments for large bills and for health insurance premiums.

a. I would like to assure Dr Lim Wee Kiak that the MediSave contribution rates and Basic Healthcare Sum are reviewed regularly, in conjunction with other key healthcare financing levers such as Government subsidies and MediShield Life.

46. Ms Hazel Poa and Mr Gerald Giam asked how MediSave coverage can be expanded in the outpatient setting. We certainly recognise that seniors tend to have higher healthcare expenses, especially if they have chronic conditions.

a. From the start of this year, we raised annual MediSave limits from $500 to $700 for patients with complex chronic conditions under the Chronic Disease Management Programme (CDMP). The list of CDMP conditions will be reviewed regularly.

b. To support elderly patients in seeking outpatient treatment, we also introduced Flexi-MediSave in 2015, and lowered the age eligibility from 65 to 60 in 2018, allowing more patients to benefit. From 1 June 2021, we will further raise the Flexi-MediSave annual limit from $200 to $300.

c. We will continue to review the MediSave withdrawal limits regularly, to ensure that they remain relevant and adequate for Singaporeans.

Bringing innovative and patient-centred models of care to our patients 

47. Beyond healthcare financing, as Dr Lim Wee Kiak has pointed out, we must also control upstream growth in medical costs to ensure affordability in the long run. 

48. First, we should tap on technology to deliver care more effectively while optimising our limited manpower resource. 

49. Since the Circuit Breaker period, polyclinics, SOCs, and community nursing teams have used teleconsultation to reach their patients at home, allowing continued consultation and advice for these patients during the Circuit Breaker period. I understand from feedback that patients are comfortable with teleconsultation. 

50. Further, when ready, the National Central Fill Pharmacy (NCFP) will consolidate medications across multiple providers in a central location, enabling delivery of medications directly to patients’ homes, secured post boxes or other convenient locations. This will improve the access to pharmacy services, including for seniors with mobility needs, as Dr Tan Wu Meng mentioned, and support new care models such as telemedicine.

51. We also agree with Dr Tan that patient navigators can improve patient convenience, and our public healthcare institutions have increased the number of staff trained in such roles by 3% annually between 2018 and 2020. Beyond this, we have also improved scheduling services and offer telehealth follow-ups for suitable patients, helping to reduce the need for multiple hospital visits.

52. Second, innovative care models have been introduced to improve right-siting of care in the community.

a. Examples include the Urgent Care Centre (UCC) pilot concept and the GPFirst Pilot Programme which support patients with non-emergency conditions, helping them avoid unnecessary ED visits.

53. MOH will review the performance of such technology-enabled services and innovative care models, and explore how we can scale up promising ones.

54. We also strive for greater value and better services in our healthcare system.

55. The Agency for Care Effectiveness (ACE) helps us to ensure that the prices we pay for subsidised treatments and vaccines are fair and commensurate with the healthcare outcomes they confer.

a. This is done through health technology assessments and value-based pricing (VBP) negotiations.
b. ACE will continue to ensure that subsidised medicines and medical technologies are both clinically and cost-effective.

56. We also established ALPS in 2018 to aggregate demand and achieve economies of scale in procurement and supply chain management.

a. In 2019, ALPS’s Central Warehouse Distribution (CWD) pilot for polyclinics saved an estimated $1.7 million through advanced warehouse and logistics technology.
b. ALPS will study how this CWD concept can be expanded to the whole of public healthcare, boosting efficiency, resilience, and value in our healthcare supply chain.

57. We also agree with Ms Ng Ling Ling that funding mechanisms can drive greater value through influencing providers’ behaviour. We have implemented some of the ideas she had shared.

a. One financing innovation which MOH has started to adopt is bundled payments, where funding is based on a patient’s entire care episode, even across multiple healthcare settings or attendances. This gives providers the opportunity to optimise care, reduce costs, and pass on savings to patients.

b. MOH has also implemented
i. a Pay For Performance (P4P) framework which financially incentivises clusters to perform well in key priority areas,
ii. and the Value-Driven Care (VDC) Programme which tracks clinical performance and cost of care for medical conditions.

58. We will expand these positive efforts and study other financing solutions and innovations that encourage healthcare providers to optimise care and improve outcomes.

Redesigning healthcare jobs and training pathways

59. Beyond technology and care models, healthcare is ultimately a high touch and people-centric sector. Healthcare professionals are key in improving patient care and outcomes.

60. COVID-19 has shown us the importance of maintaining a resilient core of healthcare workers. Following the launch of the SG Healthcare Corps (SHC) in April last year, over 5,000 workers and volunteers have been trained, and provided support in areas such as the care of elderly in nursing homes, swab operations, laboratory testing and vaccination operations.

61. Going forward, we plan to develop the Corps into a platform for citizen engagement and volunteerism in healthcare during peacetime, and to serve as a reserve pool in times of crisis.

62. COVID-19 has been a trying time for all our healthcare staff and volunteers. I know many staff in our public healthcare institutions suspended their annual leave to meet the surge in manpower demands during the height of the COVID-19 crisis.

63. Many have played a critical role in the battle against COVID-19 and I would like to express our heartfelt thanks to all of them for their dedication and contributions, and their families for supporting them through this very tough period.

64. We also recognise and appreciate the contributions of our outsourced workers in the healthcare sector. We agree with Dr Tan that their work is intrinsic to the hospital as many of them, such as cleaners and health attendants, work alongside our healthcare staff in the wards. The intent of outsourcing is to leverage economies of scale and enable our public healthcare institutions to focus on the core mission of the delivery of healthcare services. While our public healthcare institutions are not their direct employers, they have also extended support and tokens of appreciation to these outsourced workers. We will continue to work closely with the outsourced companies to improve the work conditions of their staff.

65. To strengthen our healthcare workforce, I agree with Ms Mariam Jaafar that we need to attract more talent to healthcare, and build a strong local core.
 
66. First, we have strengthened our pipeline of fresh graduates.

a. Since 2012, we have increased intakes and retained a strong local core of doctors, dentists, pharmacists and therapists.

b. We have also strengthened the attractiveness of nursing, increasing intakes by about 45%, from about 1,500 in 2014 to about 2,200 in 2020.

c. At steady state, we will be training about 3,300 students annually in our Institutes of Higher Learning to become healthcare professionals.

67. Second, we have built pathways for progression, and continue to expand mid-career conversion pipelines.

68. We introduced new pathways for Enrolled Nurses to move from Nitec to Diploma-level qualifications within a shorter time and progress as a Registered Nurse.

69. In line with the recommendations of the Future Nursing Career Review Committee, we enhanced nursing career tracks and job scopes. Nurses can now perform a wider breadth of care tasks and make clinical decisions. 

70. We are seeing increased interest in our Professional Conversion Programmes (PCPs). Between 2018 and 2020, an average of 160 mid-career locals enrolled each year, about double our average annual PCP intake in the preceding three years.

a. This year, Ngee Ann Polytechnic (NP) will join Nanyang Polytechnic (NYP) in offering the 2-year accelerated PCP for diploma-level registered nurses.

b. We will also explore more pathways for mid-career entrants to complete their training in a shorter time.
i) The Singapore Institute of Technology is introducing an accelerated PCP in Occupational Therapy for those who already have a degree in a science-related field. They can complete their training in slightly under 3 years instead of 4 years.

71. Third, we actively partner healthcare employers in re-designing jobs for staff working in healthcare support and operations support roles.

a. For example, the Care Support Associate (CSA) role in SGH, and AIC’s sectoral job redesign project relook processes and blend clinical support, administrative and operations responsibilities into new roles. These initiatives encourage cross-deployment and multi-skilling of our staff, create new career pathways, and provide interestingdevelopment opportunities for them.

72. Finally, we are cognisant that salaries play a key role in the attraction and retention of staff.

a. Our healthcare workforce is the lifeblood of our healthcare system, and the work that they do is critical in protecting the health and safety of our society. 

b. We must maintain the salary competitiveness of healthcare staff against the overall market to attract and retain quality talent.

73. For doctors and dentists, we recently updated the salaries for junior House Officers, Medical and Dental Officers, Consultant Family Physicians and newly-promoted Associate Consultants within our public healthcare institutions in 2019.
 
74. I am pleased to announce that nurses in the public healthcare sector can look forward to an increase of 5% to 14% in their monthly base salaries, phased over the next two years. Allied health professionals, pharmacists, and administrative and ancillary staff, including support care staff, in the public healthcare sector can also look forward to an increase of 3% to 7% in their monthly base salaries this year.

75. We will also increase funding support to publicly-funded community care organisations to ensure that salaries of their staff also remain competitive.

76. The changes to both sectors will be implemented from July this year.

77. MOH will regularly monitor the salary competitiveness of our public healthcare workforce. Aside from salaries, we will also work with healthcare providers and Union partners to make healthcare a progressive and fulfilling career. 

Conclusion

78. Sir, COVID-19 has posed a major challenge to our healthcare system, but we have learned valuable lessons and we will emerge stronger. With deeper partnerships with our private sector providers, innovative, value-based healthcare delivery, a strong healthcare financing framework, and a resilient healthcare workforce, we will be better placed to provide all Singaporeans with good quality, affordable, and accessible healthcare.