Criteria for Inclusion of Medical Specialists into Insurer's Panel for Integrated Shield Plans

NOTICE PAPER NO. 325, 392, 398, 400, 418, 420 
NOTICE OF QUESTION FOR ORAL ANSWER
FOR THE SITTING OF PARLIAMENT ON 10 MAY 2021

Name and Constituency of Member of Parliament
Dr Lim Wee Kiak
MP for Sembawang GRC

Question No. 828

To ask the Minister for Health (a) whether the Ministry will look into the process of empanelling specialist doctors to the approved list of insurance companies; (b) what is the Ministry's stand on the violation of medical ethics in the scheme where insurance companies basically reward patients for choosing their panel of doctors; and (c) whether these insurers will be allowed to challenge the opinions of specialists after they had rendered treatment to their patients.

Name and Constituency of Member of Parliament
Ms Ng Ling Ling
MP for Ang Mo Kio GRC

Question No. 979

To ask the Minister for Health with regard to the Multilateral Healthcare Insurance Committee (a) whether it will be made transparent to the public, the criteria for inclusion of specialists into an insurer's panel for its Integrated Shield Plans; (b) whether there will be a more controlled rate of premium increase for such plans to safeguard the public's ability to sustain such plans as they age; and (c) what is the expected timeline for the Committee to complete its review and recommendations.

Name and Constituency of Member of Parliament
Mr Yip Hon Weng
MP for Yio Chu Kang

Question No. 997

To ask the Minister for Health (a) whether empanelling of specialist doctors for Integrated Shield Plans will result in anti-competition; and (b) whether the Ministry has considered the possible impact on patients having to switch doctors mid-treatment due to this practice of empanelling doctors.

Name and Constituency of Member of Parliament
Dr Tan Wu Meng 
MP for Jurong GRC

Question No. 1000

To ask the Minister for Health (a) over the last five years (a) how many Singaporeans relinquished an existing Integrated Shield Plan; and (b) what is their median age; and (c) of the above, how many did not later purchase a new Integrated Shield Plan and how many were subsequently admitted to public hospitals.

Question No. 1001

To ask the Minister for Health what measures are there to protect Integrated Shield Plan policyholders in the event of an Integrated Shield Plan insurer exiting the market.

Question No. 1002

To ask the Minister for Health whether the Ministry has studied the regulation of private health insurance in overseas jurisdictions and the possible learning points for Singapore, in particular the feasibility and implications of requiring Integrated Shield Plan (IP) insurers to accept policyholders intending or forced to switch from another IP provider, such that existing covered conditions are not permanently excluded from future coverage.

Name and Constituency of Member of Parliament
Mr Pritam Singh
MP for Aljunied GRC

Question No. 1100

To ask the Minister for Health (a) whether the Ministry actively tracks and compares the itemised bills of Integrated Shield Plan (IP) patients who use public and private healthcare institutions respectively; (b) what strategies has the Ministry embarked on over the last 10 years to address the problem of overtreatment by some doctors; and (c) what role does the Ministry envisage patients playing to address the problem of overtreatment

Name and Constituency of Member of Parliament
Mr Gerald Giam Yean Song
MP for Aljunied GRC

Question No. 1134

To ask the Minister for Health what proportion of Singapore residents are current policyholders of an Integrated Shield Plan (IP) for (i) standard IP for public hospital Class B1 coverage (ii) Class B1 coverage (iii) Class A coverage and (iv) private hospital coverage.

Answer

All Singaporeans and Permanent Residents are covered under our national MediShield Life (MSHL) health insurance scheme. MSHL is universal, covers pre-existing conditions, and provides basic protection against large healthcare bills. MSHL can be used in both public and private healthcare institutions, and coverage is sized to be sufficient for subsidised care.  The Government provides means-tested subsidies for MSHL premiums and MediSave can be used to pay for premiums to keep them affordable. 

Individuals may choose to purchase an Integrated Shield Plan (IP) which provides additional benefits beyond MSHL to provide more coverage for private healthcare services. MediSave can be used to pay for IP premiums, subject to withdrawal limits, to help defray the cost of private insurance. Currently, less than 1% of Singapore residents have a Standard IP, 10% have a class B1 IP, 20% have a class A IP and 40% have a private hospital IP. 

In addition, some individuals may also purchase riders on top of their IP plans, if they prefer additional coverage and can afford their premiums. Riders commonly cover the deductible and co-payments portion of the bill. Riders are fully private insurance products that must be paid by cash and MediSave withdrawals are not allowed for rider premiums. Less than half of Singapore residents have riders. 

In essence, MediShield Life is universal, is sized to cover the bulk of the large hospital bills for subsidised care. IP plans ride on top of this to provide for hospital bills, and riders go further on top of IP plans to cover for the deductibles and the co-payments, so you can see it as a three-tier thing.

MOH does track and monitor the bills from both public and private healthcare institutions. Private healthcare costs have been rising rapidly in Singapore. Between 2007 to 2019, private hospital bills among IP cases grew at 4%, twice as fast as unsubsidised bills in PHIs. In both private and public hospitals, investigations, surgeon fees, treatment services, and operating theatre facility fees were key drivers of cost growth for private patients. 

In 2016, the Health Insurance Task Force (HITF) comprising members from the Singapore Medical Association (SMA), Life Insurance Association (LIA), Consumers Association of Singapore (CASE), MOH and MAS had recommended various measures, such as panelling and fee benchmarks, to help contain claims and healthcare cost escalation. MOH has been working to implement the HITF recommendations. Fee benchmarks have been rolled out since 2018, along with appropriate care guides.

One of the recommendations from the HITF was to introduce a minimum co-payment requirement, as IP riders that fully covered deductibles and co-payment had contributed to rising private healthcare cost. The co-payment ensures ‘skin in the game’ to encourage patients and their doctors to make careful and deliberate decisions on the choice of treatment and care. MOH therefore introduced a minimum 5% co-payment for all new private riders in 2018. The IP insurers have also extended this requirement or alternative claims-based pricing from Apr 2021 to their existing policyholders with riders. While this is not a requirement imposed by MOH, the Ministry supports the move as it will help to encourage appropriate care.  To provide some assurance to policyholders who were concerned with potentially large co-payments, MOH allowed insurers to apply a $3,000 co-payment cap for treatment from panel doctors with negotiated fee arrangements with insurers. This would mean that bills above $60,000 are capped at $3,000 co-payment. To put things in perspective, less than 3% of inpatient bills in private hospitals today exceed this $60,000. So the vast majority of inpatients bills do not actually hit the $3,000 cap.  

This co-payment cap could not be applied to all claims, as it would negate the effect of co-payment once the $3,000 cap was reached.  For example, if the co-payment applies to all claims, policyholders may choose a treatment which costs $100,000 instead of another equally effective treatment at $70,000. This is because the policyholder would pay the same amount of $3,000 for either option. The additional costs would be borne by the insurer and this eventually translates to higher premiums for other policyholders. Therefore, the cap was applied to panelled doctors, where there are established fee arrangements to ensure that appropriate and cost-effective treatment is provided. 

Some have raised concerns with regard to the use of panels. Questions have been raised on whether limited panel sizes are in the best interest of the patients, and whether such practices are anti-competitive or if there are medical ethical concerns around such practices. 

The use of panels was recommended by the HITF. Internationally, panels have been used by some countries to keep healthcare costs more predictable, to reduce variation in practices and charging. These practices do not contravene the Competition Act as any decision to empanel doctors is made by individual insurers independently with doctors, on mutually agreed and acceptable terms. Such practices do not restrict insurers from competing with one another on their prices, insurance products, or choice of doctors. Nevertheless, MOH has encouraged insurers to make their panel selection criteria more transparent, a move which is also supported by LIA in its “Panel Good Practice Guide” to all Insurers.  

On the issue of medical ethics, the Singapore Medical Council’s Ethical Code and Ethical Guidelines stipulates that doctors should have the best interests of their patient at heart when treating them. This includes prescribing appropriate and cost-effective care that best meets the needs of their patients. Access to medical care and clinical judgement should therefore not be influenced by empanelment nor any other financial constraints or pressures inherent in any health system. Should doctors find that the conditions of being on a panel would impose constraints on their ability to care for patients, they may decide for medical ethical reasons to not participate in such panels. 

We want to emphasise that patients can make claims for all treatments covered under their IP, regardless of whether the specialist is on a panel or not. Nonetheless, some doctors have expressed concerns that IP panels do not have an adequate number of specialists, restricting referrals to the appropriate specialist for continuity of care. Patients have also raised concerns that the doctor they are comfortable or familiar with is not on the panel of their IP insurer and they may not enjoy the additional panel benefits such as the $3,000 co-payment cap. To address this, MOH has encouraged all insurers to grow the size of their panels, and some have already increased the number of specialists on their panels by more than 40% since August 2019. Today, more than 70% of private specialists are on at least one IP panel.  

Some have asked insurance panels to be expanded to include all doctors, as long as they do not have a poor track record with the Singapore Medical Council (SMC). However, some doctors may choose not to be empanelled as they may already have a sufficient pool of patients. This is especially the case for areas where there are very few specialists locally. Hence, MOH encourages IP insurers to enhance their pre-authorisation processes, to give approval for hospitalisation or treatments and their associated costs beforehand. With pre-authorisation, insurers are able to assess treatments for medical necessity and fee appropriateness, including for doctors who are not on their panel, and patients can also have greater peace of mind knowing that at least a significant portion of their bill will be covered by their IP. With pre-authorisation, the risk of runaway bill sizes would be minimized. Hence, some insurers have extended the co-payment cap to pre-authorised claims for treatment by non-panel doctors to provide policyholders with greater assurance, and we certainly encourage more to do so.

While policyholder benefits may differ depending on whether they see a panel doctor or a non-panel doctor who is pre-authorised, these benefits should not differ to the extent of prohibiting patients from seeing non-panel doctors, or influence patient choices in an undesirable way.

MOH recognises that some policyholders may wish to switch insurers, whether for more competitive premiums or for better benefits such as access to more panel doctors, but are unable to do so because of pre-existing conditions.  IPs are commercial products, and their features and pricing are ultimately determined by private insurers. MOH will study whether IP insurance can be made fully portable, including looking at examples abroad. However, insurers may potentially need to increase the premiums significantly for all policyholders to price in the increased risk they assume for portable IP that covers pre-existing conditions. This is why MSHL is designed as a scheme to cover all Singaporeans for life with no exclusions and covers all pre-existing conditions to give reassurance to all Singaporeans should they chose to relinquish their private IP plans, for whatever reasons.  

Over the last 5 years, about 5% of IP policyholders relinquished their IP per year on average. This could be because they may have opted for different coverage, after considering the cost of the premiums, their financial resources and their different healthcare needs. Their average age was 34. Data on the number of policyholders who did not subsequently purchase a new IP or were later admitted to public hospitals is not available. 

Consumers should understand their IP terms and conditions when choosing their IPs. Insurers offer policyholders enhanced policy benefits such as the co-payment cap, lower deductibles, or a longer period of pre- and post-hospitalisation coverage for panel treatments. All this must be made known to the policyholder prior to policy purchase and at least 30 days before any changes in policyholders’ benefits. Policyholders must be properly advised at the point of purchase or renewal about their coverage, so they can make informed choices about their IP, and choice of doctors and care setting. 

Some have asked if insurers can simply use MOH’s Fee Benchmarks to determine all insurance payouts. As fee benchmarks are designed to be reasonable ranges of fees for large majority of cases, insurers can generally take reference from the benchmarks for most payouts. Doctors do charge below and above the benchmarks, depending on the nature and medical complexity of the cases. However, insurers also need to take into account the medical complexity and specific clinical circumstances, and deviate from the benchmarks for justifiable and exceptional cases. According to LIA, between 5% to 15% of IP claims for surgeon fees were approved above the upper bound of the fee benchmarks, depending on the insurer. 

Claims scrutiny by insurers may have been perceived as challenging a doctor’s professional judgement. Insurers scrutinise claims to ascertain whether treatments were medically necessary and charged appropriately. This protects the interests of policyholders who may otherwise see their insurance premiums rise should claims be paid out indiscriminately. MOH recognises that this is an important process for the integrity of the healthcare system, and it is a common practice internationally. It is nonetheless important that the process be handled professionally and efficiently by each insurer. Insurers should not make the process onerous and ask for unnecessary information unrelated to the claims, imposing a heavy administrative burden on the doctors. The questions and information sought for common conditions can be standardised and streamlined so it will not be perceived as questioning the decisions and judgement of the doctors. If a particular claim is justified, insurers should pay according to the policy benefits. We will be looking more into this issue.

Dr Tan Wu Meng has raised concerns with the risk of IP insurers exiting the market. To ensure that insurers remain financially sound and are able to meet their obligations to policyholders, MAS exercises regulatory oversight over the insurers’ financial standing, risk management and governance. This is accomplished through measures such as establishing regulatory capital requirements and setting corporate governance and risk management requirements and guidance, which are in turn reinforced by regular onsite inspections and close engagement with the boards and senior management of insurers. MAS also takes action against insurers whose practices are found to be wanting or where there are breaches of MAS’ regulations.
 
An insurer may decide to exit the IP market because of commercial reasons, or due to insolvency. In the event that an insurer exits the IP market, the insurer or the liquidator will seek to arrange for the IP policies to be transferred to another insurer for continuity of coverage. MAS will ensure that the existing insurer and the insurer taking over the IP policies properly account for policyholder’s interests.

The various initiatives covered above will take time to bear fruit. However, we are confident that these measures will help to keep healthcare costs more sustainable. Looking ahead, the refinement of various IP features will continue to be a multilateral effort between MOH, hospitals, doctors, and insurers. To support these efforts, MOH appointed a 12-member Multilateral Healthcare Insurance Committee (MHIC) in April this year to provide a platform for healthcare providers, payers, consumer representatives and the Government to work on these issues related to health insurance. The MHIC comprises representatives from the Academy of Medicine, Singapore (AMS), the Consumer Association of Singapore (CASE), the Fee Benchmark Advisory Committee (FBAC), the Life Insurance Association (LIA), the Singapore Medical Association (SMA), private hospital representatives, and with the Monetary Authority of Singapore (MAS) as an observer.

For a start, the Committee will prioritise four specific workstreams: (i) panels and pre-authorisation, including streamlining processes; (ii) issues pertaining to improving transparency across the board, including providing more detailed and itemised information about healthcare bills and publishing data on claims and premiums, so that insurers, providers and policyholders can make better informed decisions; (iii) establishing a claims complaints process supported by AMS and LIA so that stakeholders have an avenue for recourse should they feel unfairly treated, such as where insurers or patients may wish to raise concerns about over-servicing or over-charging, or if doctors have concerns about certain insurer practices; and (iv) examining the issues from a patient and consumer-centric viewpoint to ensure that the patient and public interests are best safeguarded. On this particular last issue, CASE will be leading a sub-committee to the MHIC to deal with the matter comprehensively. 

As these issues are complex, some time will be required for the Committee to develop and agree on practical solutions. Processes within the institutions, hospitals, and clinics may also have to be adjusted to make it more seamless and streamlined The Committee has already began its work with the first meeting held on 27 April. MHIC will share its recommendations progressively as they are ready and is working towards a first round of recommendations in the next few months. 

The issues surrounding IPs are multi-faceted and require thorough discussions as well as careful balancing of various considerations, to find solutions that best benefit policyholders and patients. With continued healthy dialogue through the MHIC, MOH will work together with all stakeholders towards developing sustainable solutions for policyholders, payers, and providers alike.