SPEECH BY MR EDWIN TONG, SENIOR MINISTER OF STATE FOR HEALTH, AT THE MINISTRY OF HEALTH COMMITTEE OF SUPPLY DEBATE 2019, ON WEDNESDAY 6 MARCH 2019

SUPPORTING SINGAPOREANS TOWARDS A SUSTAINABLE AND INCLUSIVE HEALTHCARE FUTURE

               Minister for Health has emphasised in his speech earlier our collective responsibility in ensuring better health for all Singaporeans. With a united front, I believe we can do much more moving forward to ensure that healthcare remains sustainable, accessible and also affordable for all Singaporeans.

2.             Let me now elaborate on how the Ministry of Health (MOH) can help to strengthen our support for individuals, providers and the community in enabling us to achieve this together.

We Will Support Singaporeans in Making Healthcare Affordable

3.            Ms Tin Pei Ling asked how can we keep our healthcare affordable and sustainable. Mr Pritam Singh also wanted to understand how can we pay for our hospitalisation bills that fall below the MediShield Life deductible.

Overall Financing Framework – “S+3Ms”

4.            As a starting premise, our healthcare financing system is designed to ensure that no Singaporean is denied access to appropriate healthcare because they cannot pay. We provide support through multiple and often overlapping layers, each one playing an important but different role.

5.            First, the government provides means-tested subsidies of up to 80% for Singaporeans across all public healthcare settings.

6.            In addition, all Singaporeans are covered by MediShield Life, for life. MediShield Life focuses on large bills and selected costly outpatient treatments to keep the premiums affordable.

7.            Next, we then have MediSave to help Singaporeans set aside part of their income to pay for future healthcare needs. Singaporeans can also tap on MediSave to pay for MediShield Life deductible and co-insurance.

8.            Finally, MediFund provides a safety net for Singaporeans who face financial difficulties with their remaining healthcare bills.

9.            Overall, our system has worked well. In 2017, the majority of Singaporeans already pay little or no cash after subsidies, MediShield Life and MediSave for their subsidised hospitalisation bills. Seven in 10 subsidised hospitalisations by Singaporeans did not require any cash payment, and eight in 10 paid less than $100 in cash after subsidies, MediShield Life and MediSave.

10.         Nonetheless, we must continue to constantly innovate, raise productivity, manage costs, and also be responsive to changes, in order to ensure the long-term sustainability of our healthcare financing model.

11.          Ms Tin also asked a broad question on how ready an average Singaporean might be, in terms of coping with his or her healthcare cost, especially in old age.

12.         Projections on expenses give us some guidance, but we have to remember that healthcare cost can vary, and vary quite easilywith a myriad of factors such as personal health management, disease progression trends, medical technological advances and effectiveness of our care model transformation. These are in turn shaped by actions of individuals, providers and payers. We therefore take a calibrated approach, to regularly review and take stock, see where we are, and ensure that our financing schemes continue to be relevant and adequate. We will continue to do so, to keep care affordable and accessible at each setting.

Subsidy: Enhanced Community Health Assist Scheme (CHAS)

13.         At the primary care setting, we have targeted subsidies at Singaporeans who need them more. CHAS enables Singaporeans from lower- to middle-income households to receive subsidies at participating general practitioners (GPs). In 2018, about 630,000 patients have benefitted from reduced out-of-pocket medical expenses due to CHAS and are therefore better able to cope with their bills, especially for chronic conditions such as diabetes.

14.         With an ageing population, we expect that more Singaporeans will require assistance to help manage their chronic conditions.

15.         Primary care, being the foundational bedrock of our healthcare system, plays a critical role in shifting healthcare beyond hospitals and into the community. We want Singaporeans to be able to obtain chronic care in the community, and to work with GPs in enabling that. We have therefore reviewed our financing structure, to better achieve this, with the whole primary care sector and our partner GPs.

16.         As mentioned by Prime Minister at the National Day Rally last year, we will extend CHAS to cover all Singaporeans with chronic conditions. This is a major philosophical shift, as Singapore has never had universal subsidies for GP care, but we believe this will help Singaporeans as they grow old, and also allow for a greater anchoring of chronic care in the community, and as Dr Lily Neo put it, to facilitate the seeking of early treatment as far as possible.

17.         This new tier – CHAS Green – will soon be available to all Singaporeans who previously did not qualify for CHAS Blue or CHAS Orange. This would consist of households with per capita household income (PCHI) greater than $1,800. It will provide up to $160 of annual subsidies for chronic conditions. In addition to keeping primary care affordable, CHAS will be another step towards transforming our primary care system to serve Singaporeans.

18.         To better support existing CHAS cardholders as well in managing their chronic conditions, we will also be increasing the annual subsidies for complex chronic conditions for CHAS Blue & Orange cardholders. They will see an increase of up to $20 in their annual subsidies. This means that existing CHAS cardholders can now enjoy up to $500 in annual chronic subsidies.

19.         We will also be introducing additional subsidies for CHAS Orange cardholders. They will be able to receive up to $10 in subsidy per visit for common illnesses, such as cough and cold, at CHAS GP clinics.

20.         Collectively, we expect to pay out more than $200 million a year on CHAS subsidies.

21.         These changes will take place from 1 November 2019 onwards. We will provide more details closer to that date.

22.         To encourage more Singaporeans to tap on the scheme, my Ministry is also looking into ways to simplify the application process for CHAS. We are developing an online application, which we expect to be ready by September 2019. It will be more convenient for Singaporeans thereafter to apply and we hope that more Singaporeans can benefit from CHAS.

23.         At the same time, as CHAS helps more Singaporeans manage their chronic conditions at CHAS GPs near their home, we will put in the measures to monitor that CHAS clinics are in fact delivering good outcomes.

24.         MOH is also reviewing clinical guidelines for care provided at CHAS dental clinics, to ensure that the care delivered is appropriate, relevant and meets the needs of the patients.

25.         Finally, as I have mentioned in this House last month, Dr Chia Shi-Lu will be pleased to know that we will continue to review the PCHI criteria for CHAS and other healthcare subsidy schemes, so that the appropriate target group of Singaporeans can continue to benefit from these subsidies. 

MediSave: MediSave Withdrawal Limit

26.          Aside from government subsidies, we also review our MediSave limits regularly to keep subsidised healthcare affordable for all Singaporeans.

27.         Mr Muhamad Faisal Abdul Manap asked what are the considerations in determining the MediSave withdrawal limits.

28.         MediSave withdrawal limits are set to be sufficient for the vast majority of expenses in each healthcare setting, after government subsidies and MediShield Life payouts, where applicable, are taken into account. For example, for inpatient stays which MediSave is primarily designed for, we set different withdrawal limits to take into account the varying charges and also the different complexity  of surgical procedures. MOH also considers the use of MediSave beyond withdrawal limits on a case-by-case basis, taking into account factors such as the need for more complex treatments, sometimes unforeseen circumstances or complications, and also financial difficulties which may make it hard for the family to pay the outstanding bill. Ultimately, we need to strike a right balance between present use of MediSave and its role as savings to cater for healthcare needs in old age.

29.         Dr Lily Neo asked about the affordability of long-term care, and more specifically, Mr Daniel Goh proposed increasing the MediSave withdrawal limits for such care. 

30.         Let me first set the context. Today, around two-thirds of households qualify for means-tested subsidies of up to 80% for intermediate and long-term care services. We will be introducing CareShield Life, which provides a payout of at least $600 per month for persons who are severely disabled. In addition, we also enabled a cash withdrawal of up to $200 a month from MediSave to complement these schemes. Severely disabled individuals with $20,000 balance in their MediSave, can expect to withdraw MediSave up to about 70 months (after setting aside a minimum of $5,000), taking into account other MediSave uses such as paying for medical expenses, and that is not too different from the median 59 months which is proposed by Mr Daniel Goh. The amount of MediSave withdrawal has been carefully considered to strike the right balance between the long-term care and other medical needs of an individual, such as insurance premiums and also hospitalisation expenses. Those who require further assistance beyond what I mentioned, can seek help from MediFund, ComCare, and the upcoming ElderFund.

31.         The long-term care needs of Singaporeans are therefore not solely reliant on a single point or a single measure like the MediSave withdrawals. They are supported in fact by a robust long-term care financing framework that mirrors the current financing framework for acute care, which has worked well for us.

MediShield Life: Pregnancy and Delivery-related Complications

32.         Let me now turn to MediShield Life, another key pillar of our healthcare financing system. To alleviate concerns over healthcare expenses related to marriage and parenthood aspirations, we mentioned last year that MOH would review how to extend MediShield Life to cover serious pregnancy and delivery-related complications.  These complications could give rise to large bills and become a worry for expectant parents.  Mr Christopher de Souza, who raised the point last year, asked for an update on this review.

33.         I am happy to say that we have completed the review after consultations with senior clinicians, and have decided to extend the coverage of MediShield Life. From 1 April this year, MediShield Life will cover inpatient treatments for serious pregnancy and delivery-related complications such as eclampsia, cervical incompetency and postpartum haemorrhage, under the existing inpatient claim limits. There are a few more of such complications which will also be covered, and a full list will be found on the MOH website. This enhancement can potentially benefit up to 4,000 patients each year.

MediShield Life: Coverage for Emergency Departments to Community Hospitals Transfer

34.         Besides providing greater assurance against large hospitalisation bills, we also regularly review how MediShield Life can stay relevant as the model of care evolves.  Let me share two examples.

35.         First, on direct admissions into community hospitals which Mr Murali Pillai asked about and raised a suggestion made earlier in this House to allow patients who were directly admitted into community hospitals to tap onto MediShield Life and MediSave, similar to those who were transferred from the acute hospitals for continuation of care. I am happy to say that since 15 July 2018, MediShield Life coverage has been extended to patients directly admitted from the emergency departments of public hospitals into community hospitals.

36.         Patients identified for such direct admissions have to be reviewed to be in a stable condition with a clear diagnosis, and require a period of medical, nursing or rehabilitation care. Reason for that is because you are stepping down to a community hospital. This is to ensure that patients are appropriately right-sited and care is safe for patients. 

37.         All patients in community hospitals can already tap on their MediSave, regardless of where they were admitted from. We will continue to review MediShield Life coverage for other direct admissions into community hospitals, based on assessment that such admission is appropriate and safe for patients.

MediShield Life: Autologous Bone Marrow Transplant

38.         Second, on bone marrow transplants, patients undergoing an autologous bone marrow transplant for multiple myeloma used to be admitted for the entire transplant treatment. Presently, however, part of the transplant treatment, including conditioning, stem cell infusion and post-transplant monitoring can now be done in an outpatient setting for suitable patients. This potentially shortens the inpatient stays by up to three weeks.

39.          To better support these patients in continuing their bone marrow transplant treatments in the outpatient setting, MediShield Life will be extended to cover these costs up to a claim limit of $6,000 per treatment at approved hospitals.  This will apply to treatments performed on or after 1 April 2019. This enhancement can potentially benefit over 20 patients a year. Treatment received in the inpatient setting will continue to be claimable under the existing inpatient claim limits.

MediShield Life, CareShield Life: Scheme Transparency and Adequacy Ratio

40.         In addition to MediShield Life, we will soon introduce our second national insurance scheme, CareShield Life, next year. Mr Pritam Singh asked for more transparency on the adequacy ratios and the assumptions behind premium pricing for these schemes.

41.         As a start, it must be remembered that MediShield Life and CareShield Life are not-for-profit, long-term schemes. Collected premiums and investment returns are used solely for the administration of the scheme and for the benefit of policyholders. There is no other use of these funds. Premiums are priced by external professional actuaries based on established actuarial principles, taking into account scheme benefits, claims experience, and future changes in demographics, utilisation rates and of course, the costs of medical treatment, among other factors.

42.          For MediShield Life, the actual claims experience has been close to the projections used in the pricing of premiums. In 2017, for example, our actual claims amounted to 99% of expected claims.

43.         But we have to bear in mind that these are current-year claims. MediShield Life however, is designed as a long-term scheme, and part of the premiums collected are set aside as reserves to support long-term commitments and to buffer against adverse scenarios such as a worse than expected claims experience. To help with the affordability of premiums in advanced years, policyholders also pay ahead during their working ages, so that their premiums rise by less in their older ages, when, at that stage, they become less economically active. 

44.         Quite apart from that, we also regularly monitor the Capital Adequacy Ratio and Incurred Loss Ratio of the Fund to ensure that the Fund remains healthy.

45.         The Capital Adequacy Ratio reflects the scheme’s ability to meet its liabilities under adverse scenarios. MediShield Life’s Capital Adequacy Ratio for 2017 falls within the range of the private healthcare insurers’ (205% - 282%). As part of our ongoing review of the MediShield Life claim limits, we will also be reviewing the scheme’s Capital Adequacy Ratio, in tandem with its impact on premiums.

46.         The Incurred Loss Ratio of the MediShield Life Fund over the last five years was approximately 97% – sufficient to ensure the sustainability of the scheme, but not excessive. This ratio compares the total premiums collected to the total monies required to ensure that the Fund is able to meet both current-year claims and also its liabilities into the future. Total monies required for the Fund includes immediate claims paid out each year and the change in required reserves needed for future payouts.

47.         A less appropriate approach sometimes cited to assess the adequacy of the Fund’s premium collection is to compare the total premiums collected to total claims paid in the same year. This approach is not a holistic representation as it omits a large part of what MediShield Life premiums are meant to support, namely future long-term claims and premium affordability in advanced ages.

48.         For MediShield Life, the benefits are outlined in the information booklet issued to all members. Further information about the Fund size, the reserves and Incurred Loss Ratio is published on the MOH website, and the MediShield Life financial accounts are audited by an external auditor and then submitted to Parliament every year.

49.         In addition, the independent MediShield Life Council also reviews premium collection and claims experience, amongst others, and thereafter provides recommendations to the government to ensure that MediShield Life provides effective protection in an affordable and sustainable manner.

50.         The CareShield Life scheme design was also discussed in this House in 2018. CareShield Life supports the long-term care needs of Singaporeans in old age. Premiums are paid during the working ages, for lifetime coverage should the policyholder become disabled.

51.         Similar to MediShield Life, an independent CareShield Life Council will be set up to advise the government on the sustainability of the CareShield Life scheme.

We Will Support Singaporeans in Making Healthcare Accessible and Closer to Home

Caregiver Support Action Plan

52.         I turn now to address questions and cuts on caregiver support. Even as we address Singaporeans’ concerns over healthcare expenses, we also recognise the need to consider accessibility to healthcare, which is critical for the timely management of a condition. This is especially so for elderly who needs long-term care, and we must also care for the caregiver. With this in mind, MOH had announced a Caregiver Support Action Plan earlier last month to strengthen support for senior caregiving.

53.         Ms Tin Pei Ling and Mr Charles Chong have asked what we intend to do to continue to support caregivers. We intend to do more in at least three areas – financial support, flexible work arrangements and options for respite care for caregivers.

54.         Firstly, in terms of financial support, we have put in place several financial support measures to help defray the costs of caregiving, such as means-tested subsidies for aged care services, the Seniors’ Mobility and Enabling Fund which subsidises the costs of assistive devices and home healthcare items, and the Caregivers Training Grant which subsidises training.

55.         In addition to this, we will be introducing a new Home Caregiving Grant (HCG) by end 2019, as further financial support to care recipients living in the community with permanent disability and require some assistance in at least three Activities of Daily Living. The HCG replaces the existing Foreign Domestic Worker (FDW) Grant with an enhanced quantum of $200 per month. While the FDW Grant helps to offset the costs of hiring an FDW, the HCG provides greater flexibility to help offset more caregiving expenses, such as the costs of home and community-based services, and transportation to medical appointments. Some might prefer to hire an FDW to help; others might not. It does not matter. The HCG can be used in either scenario.

56.         Secondly, the Ministry of Manpower has shared their plans to increase the budget for the Work-Life Grant to allow more companies to benefit from the grant and implement flexible work arrangements for their employees. This will help working caregivers to manage their work and caregiving commitments, and is a key step to building a sustainable approach that balances the needs of both employers and employees.

57.         Third, we will be expanding the existing respite care services. We currently have respite services at our centres and nursing homes to allow caregivers to take a break from their caregiving duties. Centre-based respite services cater to the needs of caregivers who need a few hours off, while nursing home respite services allow overnight stays from several days to a few weeks. To date, over 2,400 clients have benefitted from these respite services.

58.         We will be piloting a new night respite service with selected nursing home providers in the second half of 2019, to support caregivers of seniors with dementia who experience behavioural and sleep difficulties at night. We will continue to explore new models of care to meet the needs of caregivers.

59.         The Caregiver Support Action Plan complements the already existing suite of services and schemes currently available to seniors and their caregivers. MOH will be implementing the Action Plan over the next two years to better support caregivers, and will provide more details on other specific measures in the coming months.

We Will Support Providers to Provide Better Care and Value to Patients

60.         Further to strengthening the financial and caregiving support, we also believe that having a reliable healthcare network is fundamental to every successful healthcare system. And this could be achieved through proper regulations.

61.         Associate Professor Fatimah Lateef has asked for an update on our regulatory approach and progress with regulatory sandbox.

62.         As a regulator, our priority is with ensuring patient safety and proper continuity of care, as new and innovative care models evolve to meet the healthcare needs of Singaporeans.

63.         To do so effectively and safely, there is a need to review and replace the current Private Hospitals and Medical Clinics Act (PHMCA). The proposed Healthcare Services Act (HCSA), which will come before Parliament shortly, aims to enhance regulatory clarity as to the types of healthcare services regulated, strengthen the governance of the licensees providing the healthcare services, provide the necessary safeguards to patient safety and welfare, and ensure continuity of care and accountability.

MOH Regulatory Sandbox

64.         To complement the change in our approach to regulation, we have also launched a regulatory sandbox in April last year to support the safe growth of new modalities of care and innovations within current care services – the Licensing Experimentation and Adaptation Programme or LEAP.

65.         Doctor-led Telemedicine and house-calls were the first services to come under LEAP, and within the last year we have 11 providers on LEAP. As providers and models mature, we are also encouraging a shift in the services provided, from managing simple acute conditions such as cough and cold to more complex chronic diseases such as diabetes, supporting MOH’s “Beyond Hospital to Community” strategy.

We Will Continue to Emphasise Innovation and Productivity

66.         Associate Professor Fatimah Lateef will be pleased to note, and I think Mr Leon Pereira also raised a point about encouraging innovation in the intermediate and long-term care sector, that we are constantly looking at how technology can help us to create a sustainable healthcare future. We are also supporting our healthcare institutions to find solutions to increase productivity through the Healthcare Productivity Fund. We are seeing some early results – on the average, our productivity efforts have saved about 300,000 man-hours across public healthcare and community care institutions per year.

67.         However, even with innovations in modalities of care and changes in the way patients can access healthcare services with technology, we are mindful that there are certain aspects of care that we should not or perhaps ought not to replace – e.g. the human touch. One of our key strategies in supporting productivity is to continually explore how innovations can free up manpower from routine work so that they can go back to the business of caring for patients directly.

Conclusion

68.         To conclude, the government will continue to support productivity and innovation for greater healthcare sustainability, affordability and accessibility. We hope that new policies such as the enhanced CHAS scheme will encourage all Singaporeans to seek help early and in the community. We will also be helping caregivers to continue to care for their loved ones in the community. Let us all work together and move away from healthcare to health. Help us, help you – with each and every one of us taking good care of our own health, we can all be hopefully happy and active in our golden years.

Thank you.