Hospital charges, transfers based on patients' condition

MOH's reply

The Straits Times, 18 July 2018

Hospital charges, transfers based on patients' condition

We refer to Ms Salma Khalik's commentary (Be transparent on public hospital ward charges; July 10) and subsequent letters on hospital charges.

Ms Khalik asked why the patient had been transferred from Changi General Hospital (CGH) to KK Women's and Children's Hospital (KKH). A patient may be transferred when there is a clinical need for it, and this is done in consultation with the patient.

In this instance, the patient was assessed by CGH's clinical team to require gynaecological treatment.

As CGH does not offer obstetrics and gynaecology services, CGH consulted KKH, a tertiary obstetrics and gynaecology hospital, and both clinical teams assessed that the patient would be clinically better managed at KKH. The patient was consulted and agreed to the transfer.

Due to developments in the patient's condition during her 23-day stay in KKH, she was assessed to need further medical interventions requiring specialists in other areas. These specialists were brought in to provide care for the patient while she was at KKH. This need was not anticipated when the transfer to KKH first took place.

KKH had itemised the costs associated with the patient's care for transparency, including the costs incurred by the long length of stay at the hospital and the treatment she received in the different specialist areas. As she is a foreigner, she was not eligible for government subsidies and other forms of financial support.

The Ministry of Health monitors the overall bill sizes of public healthcare institutions (PHIs) to ensure they are affordable for Singaporeans. Due to the array of services offered, there are some variations in charges across these institutions. Nonetheless, these charges must be reasonable and proportional to the care rendered.

We understand that different approaches to charging across PHIs can be confusing for patients.

KKH has been in the process of aligning fees and charges with those of other PHIs, and has already included the charges for sponging and assisted bath into their ward charges. The alignment of other charges is ongoing and will be progressively implemented.

The Government provides subsidies to ensure healthcare costs remain affordable for Singaporeans.

Patients who cannot afford their bills after subsidies, MediShield Life and Medisave, can apply for Medifund.

No Singaporean will be denied appropriate medical treatment because of their inability to pay.

Lim Siok Peng (Ms)
Director, Corporate Communications
Ministry of Health

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Commentary

The Straits Times, 10 July 2018

Be transparent on public hospital ward charges

Ms Santhi Menon's experience with KK Women's and Children's Hospital (KKH), which was highlighted recently, raises three issues that need to be addressed.

The Australian citizen had taken ill suddenly while visiting relatives here. She was taken by ambulance to Changi General Hospital (CGH), where she was diagnosed with a reproductive system problem and transferred to KKH. In turn, KKH had to call in specialists from other hospitals, since it does not have the range of medical expertise that a general hospital does, and the patient was charged extra for this.

Ms Menon was also charged for a number of services that other public hospitals do not bill separately, as they consider these covered by ward charges, which are comparable to, though generally cheaper than KKH's.

The issues this incident raises are:

• Why was the patient sent from CGH to KKH?

• Why was she charged extra for doctors called in from other hospitals?

• Why do charging policies vary so starkly among public hospitals.

As with any emergency case, the ambulance had taken Ms Menon to the nearest public general hospital since such hospitals are all deemed capable of treating any medical condition. But in this case, the hospital did not feel equipped to deal with her problem and transferred her to another hospital.

It was a pity CGH did not transfer Ms Menon to Singapore General Hospital (SGH), which boasts a broad range of expertise, including obstetrics and gynaecology.

CGH, KKH and SGH are all part of the SingHealth cluster, so that should make a transfer easy, although there is nothing to say that patients cannot be transferred to hospitals in other clusters.

But moving a patient to a hospital that specialises only in children's and women's problems, in an emergency situation, means that should the initial assessment be wrong, the right doctors will not be available to treat the patient.

As this case showed, doctors from other specialities had to be called in - although as it eventually turned out, there really was no need to call in two of the three doctors.

But KKH cannot be faulted for calling them in, as it does not have respiratory or heart specialists in its ranks and played it safe by calling in external experts.

What was surprising was that the patient had to pay for these doctors separately.

Public hospitals have ward charges for beds, meals and basic nursing services, and daily treatment fees for the doctors who see patients in the ward. These are fixed fees, based on the class of ward, no matter how many specialists see the patient, or now senior the doctors are. Separate fees are paid should a patient require surgery, for example. So shouldn't KKH be able to call on doctors from within SingHealth, with patients being charged the same rate they would pay for any KKH specialist?

Hospitals like SGH and the National University Hospital (NUH) have specialists in all areas, but other small hospitals may need to tap specialists from other hospitals. But patients should not need to pay more just because they were sent to a hospital that is not so comprehensive, and need specialists from other hospitals to attend to them. Otherwise, every emergency patient would want to be sent straight to SGH or NUH.

The third issue is the most puzzling. Yes, all public hospitals are "restructured" hospitals with their own boards of directors. But shouldn't there be some standard charging policies across all public hospitals? A check by The Straits Times found that none of the public general hospitals charges extra for services such as sponge baths, or changing urine bags.

KKH does.

But none of this is reflected in its Web page. In fact, none of the public hospitals spell out what is covered by their ward charges and daily treatment fees, and what is charged separately. Maybe this should be stated transparently so that patients are aware of what is covered by the basics, and what they need to pay extra for.

Ward charges are not cheap.

As a foreigner, Ms Menon paid $436.70 a day for a bed in a five-bedded B2+ ward. If she had been a Singaporean receiving the maximum subsidy, the cost to her would have been $179, with the Government paying the rest.

The sum she was charged is pretty hefty, if it is just for a bed, meals and the patient's gown, with all other services incurring extra charges.

Perhaps the Ministry of Health (MOH) should step in to list certain basic services that should be included in ward charges and daily treatment fees. After all, it is the one that picks up most of the tab, since most patients in B2 and C wards do enjoy subsidies.

By all means allow hospitals to charge different rates for these services. This would be akin to the "Standard Integrated Shield Plan" that covers B1 wards in public hospitals, which the MOH got insurers to offer as part of MediShield Life add-on coverage.

The MOH decides on what needs to be covered and lets insurers charge what they want in order to provide it. This helps people choose which insurance company to go with. Similarly, MOH should list the things that all public hospitals should include under ward charges and daily treatment fee - and let them set the fee. This way, patients can opt for a cheaper hospital if cost is an issue.

In cases of emergency, patients cannot choose the hospital they are taken to. But emergency patients who need to be transferred subsequently should be sent to a public general hospital, rather than to a specialist hospital offering limited services.

Just because everyone here now has insurance coverage does not mean we shouldn't be prudent with our medical expenditure. We all have a duty to try to keep healthcare costs down, as only that can keep a lid on insurance premiums.