Means testing - Why simpler guidelines works better for deserving cases - Today

10 Mar 2008, Today

Question

Means testing: the human touch matters

Friday March 7, 2008

IT once generated boisterous public debate, including during the 2006 General Election.

But of late, the subject of hospital means testing seems to have evoked a more muted response and has centred more on the hows and whats of Health Minister Khaw Boon Wan's proposals than about why it should be implemented.

And since the scheme is simple, as Mr Khaw had rightly decreed it should be, one might assume this is a sign of Singaporeans' acceptance, not incomprehension, of the scheme's rationale and methodology.

Surely, people agree on the fundamental principle of the rich paying more and the poor paying less. Confirmed criteria of the means testing scheme for Class B2 and C wards, to kick in from next year, were announced this week.

But while the details seem magnanimous enough, Mr Khaw could not set a timeframe as to how long the current parameters would stand. There are considerations, such as future changes in health ministers and the state of the economy, he told Parliament.

One thing Singaporeans will likely expect, is for the Government to stand by Mr Khaw's description of its approach to means testing as "erring on the side of generosity".

The current parameters mean that those earning more than $3,200 a month will get smaller subsidies, on a graduated scale. And there will be those who believe they have been assessed unfairly by such parameters — such as sole breadwinners with multiple dependents, upper middle-income group earners with massive mortgages, or casual workers who may earn a lot in one month and nothing the next.

Such patients have been assured that they can be more thoroughly assessed on a case-by-case basis. Time will tell how many of such appeals will be received. It is how hospitals cope with the situation, and the MOH monitors developments as the scheme progresses, that is important.

Will the initial spirit of compassion by the current healthcare administration be diluted, or lost, over time in the humdrum of having to daily administer means testing to a multitude of ward admissions cases?

Then there is the issue of healthcare costs, which are going up around the world, and rising expectations of patients who will desire better medical care in even the lowest ward classes.

If charges go up as a result, could people eventually end up having to pay more than they can afford? And would the means testing criteria then be adjusted to be as generous then as it is now?

Consider the lesson of MediShield. In 2004, this individual catastrophic medical insurance scheme — designed to help Singaporeans pay part of large hospitalisation bills — was pronounced by the Health Minister himself to have lost its effectiveness.

Why? Because its parameters had not been tweaked since its introduction in 1990, and because it was in direct competition with private Shield plans then. The scheme had been left to flounder for more than a decade, before revisions were made.

The MOH needs to ensure that the means testing scheme for in-patient hospital stays does not fall into the same trap.

As administrators try to come to terms with medical inflation and the attendant problems of an ageing populace, it is important — in an area as sensitive as public healthcare funding — to also not forget the complex social needs involved.

It is not enough to just do what is necessary according to qualitative indicators, but also to maintain consistency and compassion with a human touch.

After all, the reason for means testing is so that authorities can go ahead with upgrading services in Class B2 and C wards over the long term, without having to worry this will lead to an uncontrolled deluge of higher-income patients filling up the beds and competing with the lower-income for subsidies.

But in implementing the solution, it would not do to introduce a new set of problems for the future.

Reply

Reply from MOH 

We certainly agreed that in "Means testing: the human touch matters" (TDY, 7 March) as opined by Ms Tan Hui Leng. 

As assured by the Health Minister, means-testing will not affect a large majority of patients.  For patients earning significantly more than average Singaporeans, they will co-pay more but the reduced subsidy will still result in largely affordable bills given their healthy Medisave balances.   We do know that there may be some with special circumstances who may need additional assistance.  For instance, they may have many dependents or are looking after family members who may have complicated congenital illnesses, rendering them uninsurable.  Given the wide range of possibilities, rigid guidelines will not be practical and will likely miss out other unanticipated circumstances which deserve help. This is where we need the human touch.

Hence, we have a simple guideline that "all those with genuine financial difficulty paying essential treatment should be assisted". This works much better and offers our hospitals wider leeway.  This is not a theoretical formulation.  For example, the Hospital Medifund Committees have been performing such tasks for years.  They are assisted by our Medical Social Workers and the approach has served their objective well. We are therefore confident that this can be done.

Meanwhile, middle and upper-income Singaporeans should remember to subscribe to MediShield and top that up with a private MediShield Rider, if they have not already done so.  Premiums are affordable and with such insurance protection, they will not need to worry about means-testing at all.