29th May 2021
1. It is a pleasure speaking to you at our annual Work Plan Seminar. There are two priorities – in the short term, win the COVID-19 battle. In the long term, ensure healthcare is affordable to families and also our country; and continue to deliver better healthcare. Let’s first talk about the long term issues.
A SUSTAINABLE HEALTHCARE SYSTEM
2. Our current national healthcare expenditure has almost doubled from $10 billion in 2010 to $21 billion in 2018, and is expected to increase further in the next decade. This exponential rise is worrying.
3. In terms of public expenditure, by 2030, around 3% of GDP, will go to healthcare.
Love, Rationality and Time
4. Why is healthcare expenditure rising so rapidly? We can decipher the reasons if we look at our own experiences.
5. When we are young, our healthcare bills are lower. We only need to visit our regular GP usually for health screening, with most having no chronic illness. As we become old, we have more illnesses.
6. When illnesses strike, we may consult different doctors and specialists, even put ourselves through different treatments. Some are expensive, especially the newer options. We may still try them out, even if effectiveness is not so proven. Because our family members love us, and will want to do their best for us.
7. Fortunately, we are covered by MediShield Life. On top of that, many of us also bought Integrated Shield plans. With an as-charged Integrated Plan plus a rider, we may pay very little or no out-of-pocket expenses for private care.
8. But the problem is that while such a worry-free plan may work for us now, it creates problems for future generations.
9. It’s the classic buffet syndrome. Insurance companies over time will find it too expensive to sustain, and premiums will go up. When healthcare expenditure goes up, so too subsidies, and that adds pressure to Government’s fiscal position.
10. When we aggregate this experience across all households and individuals, it fuels a rise in our national healthcare bill that we will find increasingly hard to afford.
11. That is my simplified way of explaining escalating healthcare cost all over the world. It is driven by powerful forces – love, rationality and the march of time.
12. Our love for family members means we often spare no expenses on healthcare. With full insurance coverage, it becomes rational for us to spend without worry because someone else is paying. And with time, we inevitably get older and have more illnesses, and this is compounded by unhealthy lifestyles which often start from young and have irreversible consequences.
Beyond Quality to Value
13. Taming healthcare costs is therefore not about denying quality healthcare. It is about dealing with these powerful forces, so that we spend wisely, effectively, reduce wastage, and keep it affordable for families and our country. Our society is ageing, but we cannot let rising healthcare costs cripple our future.
14. The approach is captured in one of MOH’s vision of the Three Beyonds – from quality to value. There are concrete things that we must do.
15. One, containing the cost of drugs and treatments. We have to evaluate which are the most cost-effective. From there, maintain a list, align it to our subsidy framework and even insurance claim limits, and negotiate with suppliers to ensure that the prices charged are commensurate with the outcomes they deliver.
16. This is a tried and tested approach adopted by many countries. We have many treatments and drugs covered under the Standard Drug List, but we can expand to cover more under this framework.
17. Two, we need to rein in cost inflation fuelled by insurance. Healthcare insurance serves an important purpose, which is why MediShield Life is designed to cover all Singapore residents.
18. The key is to ensure that we do not inadvertently erode the spirit of co-payment. Once there is some skin in the game, consumers will exercise prudence in healthcare spending and doctors will exercise more discretion in recommending the appropriate treatments.
19. Three, we need to deliver better healthcare. Better does not necessarily means more expensive. Instead, it can be more efficient, patient-centric, and affordable. This is the next topic I want to talk about.
DELIVERING BETTER HEALTHCARE
20. A lot has been accomplished over the past years, and more are being done.
21. For example, major efforts are underway to develop our healthcare infrastructure – expanding the number of polyclinics, building new nursing homes, community and acute hospitals in Woodlands and Bedok. They form a comprehensive continuum of healthcare services.
22. IT systems are being revamped; private GPs are being brought into networks; community healthcare outposts and urgent care centres have been set up.
23. Intervention has gone upstream as population health is deservedly receiving strong attention. Whether it is war on sugar, battle with salt, alliance with exercise – the Health Promotion Board and our clusters must integrate their efforts and do what it takes to reshape lifestyles. After all, we are Ministry of Health, not Healthcare.
24. Let me share what I think we should not do, and what we should do.
25. What we should not do is to further review the structure of our clusters. Our hospital structure has moved from two clusters, to six, and then to three. There are pros and cons to being big or small. Big clusters have scale and comprehensive capabilities. Small hospitals can be agile and innovative.
26. We should continue with the structure that we have. Within each cluster, we will have to find ways to make space for skunkworks, and make unorthodox ideas become mainstream. Bring out the best of both worlds.
27. What we should do is to press on with the other two Beyonds – from hospital to community, from healthcare to health – towards a more patient-centric, efficient, and effective healthcare delivery system.
28. Let’s find the three or four most strategic and transformative priority moves, use the next few years to pilot and scale them across the healthcare delivery system.
29. These priority moves must achieve the following. It must mean a more holistic and seamless way of taking care of our patients, leveraging the GPs and polyclinics, acute care hospitals, community hospitals, to intermediate and long-term care options, pharmacists, and community nursing care.
30. The centre of gravity must shift away from the acute care hospital, towards the community, with focus on appropriate care in the right setting. Patients will benefit from less hassle, greater accessibility to care, and at lower cost. Long-term chronic care is one area that will benefit from more healthcare delivered in community settings.
31. That way, our already heavily loaded hospitals can then focus on patients who need specialist care or emergency cases. At the same time, numerous primary healthcare providers in the community can take on larger roles.
32. For patients in rehabilitation, they should ‘step-up’, not step-down, to community hospitals and long-term care facilities. The multidisciplinary team, often consisting of geriatricians, allied health professionals and medical social workers, at community hospitals can provide the right care at the right site for medically stable patients requiring rehabilitation.
33. Polyclinics have already become community institutions, providing continuing and holistic care to patients. We will benefit from private GPs becoming an integral part of the continuum for healthcare.
34. A GP’s care for his patient goes beyond the four walls of his private clinic. He can be the village doctor that understands the patient and his family, helps them manage chronic diseases; the confidant that stubborn family members listen to, and often the link to the wider healthcare network.
35. Pharmacists can also be more empowered to play important complementary roles, such as providing trusted information on drugs, prescribing certain drugs, and educating patients on proper use of medication to reduce re-admission to hospitals.
36. The frontline empowerment extends to our nurses too. Equipped with enhanced clinical skills and evidence-based practice, they are increasingly doing frontline work in the community. Advanced Practice Nurses trained in the diagnosis and management of common medical conditions can order tests and prescribe medicines, helping patients save time and cost.
37. Our entire resourcing system must uphold and engender these imperatives. The objectives, outcomes and incentive signals must percolate from MOH HQ to the cluster CEO to every frontline healthcare worker.
38. I am heartened by your passion to serve patients and the clear sense of purpose and change we need to bring. I look forward to working with you to tackle the big challenges before us.