Helping Patients Understand Hospital Charges

11 Oct 2002

The Minister for Health recently said that he supported the calls for more transparency and better disclosure of hospital fees, and more comprehensive financial counselling in our hospitals.

The Ministry of Health will be working with CASE and the hospitals to make hospital fees more transparent, so that members of the public who need to seek medical treatment can make more informed choices on healthcare provider and ward class.

INFORMATION ON HOSPITAL CHARGES

Currently, the information on hospital charges provided on the websites of public and private hospitals does not help the public to understand or estimate the expected bill size for a specific medical condition. There are several key deficiencies:

a). Estimation of total bill per episode of hospitalisation. Most of the information on charges is presented in terms of line items eg bed charges, laboratory tests, surgical operations etc. Based on this information the public would not know how much the total cost is likely to be for a procedure such as gall bladder surgery.

b). Exclusion of certain fees from quoted fee packages. Although some private hospitals have now started offering fixed fee packages for certain specific medical conditions such as total hip replacement, significant charges such as doctor's fees, implants and expensive investigations like MRI Scans are excluded.

c). Inability to make meaningful comparisons across hospitals. As there is no standardised way for fees to be presented, it is difficult for the public to make comparisons across different hospitals.

d). Accuracy of estimates. Some of the fees quoted have very broad ranges as they include simple as well as complex conditions. Having a point estimate of the estimated bill size may also not be very useful if there is significant variation in bill sizes for that particular medical condition due to different complexity level.

Going forward, the Ministry of Health would like to work with CASE to make information on hospital charges in both private and public hospitals more meaningful, transparent and user friendly to the public. The information available must be able to achieve the following:

a). enable the public and patients to compare estimated total bill size per episode of hospitalisation by medical condition, hospital and ward class

b). standardise the items to be included in deriving the charges to ensure comparability

c). provide estimates of average as well as range of bill sizes to take into account patient type and complexity of medical condition

The above information should be customised and presented using non- medical jargon and made publicly available through easily accessible channels such as the CASE website. The information should be updated regularly, and verified to ensure that it is timely and reliable.

The Ministry acknowledges that this would require commitment of significant resources and is thus prepared to co-fund 60% of the cost of developing this framework.

ITEMISED CHARGING

Patients should know what they are paying for. The Ministry is thus pleased to note that both public and private hospitals have introduced itemised charging for their patient bills.

Public hospitals currently provide their patients with summary bills that show charges based on categories such as ward, laboratory investigations, X-ray investigations, implants, drugs and surgical operation, etc. The hospitals also provide more detailed bills to patients who request for such bills.

The degree of details to be shown in hospital bills should depend on the patient. For some patients, a detailed bill can be several pages long and the hospitals have generated bills that are more than an inch thick for patients who have severe illness and stay longer in hospital. As not all patients may want such a detailed bill, our public hospitals do not consider it cost efficient or practical to do this routinely.

The Ministry will seek the inputs of CASE as the voice of the consumer in helping the public hospitals to review how to better present their bills. We could also explore options such as providing summary bills but detailing only items that cost more than a certain predetermined amount.

One category of charges that has generated much attention is ?miscellaneous charges?. These are in general discretionary, non-treatment related and non-Medisave claimable items such as extra meal by relative/visitor, sleeper unit, trunk call, hospital publications etc. These form only a small component of hospital bills. For example, miscellaneous items form only 1% and 2% of the total bill size of TTSH and NUH respectively.

It is inevitable that some items would have to be classified under 'miscellaneous' especially if it is an ad-hoc low cost item (e.g. an extra meal for a visitor). The Ministry has asked the hospitals to review the way they classify their miscellaneous charges so as to make them clearer for patients.

FINANCIAL COUNSELLING

Under the Private Hospitals and Medical Clinics (PHMC) Regulations, all hospitals, public and private, are required to provide financial counselling (FC) to their patients prior to or upon admission. The counseling includes information on the anticipated total bill for patient?s hospitalisation, average bill size per day at the various hospitals, hospital deposit requirements and 3Ms.

As part of its ongoing process to improve the FC process, MOH had formed a Financial Counseling workgroup (FCW) in July 2001 to strengthen the FC framework in the public hospitals. The FCW is chaired by Mr Chua Song Khim, CEO (NUH), with representatives from the various restructured hospitals (RHs). MOH has since accepted the FCW's recommendations and implemented several enhancements to the FC process on 1 Oct 2001 in all RHs, to ensure more consistency in the counselling process and to provide better bill size estimates to patients.

Extending FC beyond the admission phase

MOH has broadened the scope of FC to encompass the entire hospitalisation episode, rather than as a discrete activity done prior to or upon admission. RHs should systematically follow up with or inform their patients, when there were subsequent changes to the estimated hospitalisation bill sizes (due to complications, longer length of stay, more drugs/treatment required etc). This is especially important for patients admitted through the Emergency Department. As the diagnosis and/or treatment that the patient may require at the point of admission may still be rather uncertain, it is difficult for a proper FC to be conducted. The RHs should, therefore, conduct a second FC for A&E patients, within 48 hours of admission. By then, the medical condition of the patient would be better defined and the FC given would be more precise and useful to the patient and his/her family. The RHs are in the process of implementing this.

Standard FC protocol

The FC procedures for the RHs have been standardised through a standard FC protocol using a common checklist (please see Annex A). The protocol sets out the FC operating procedures in detail and serves as a reference manual for all RH staff conducting FC.

Staff training

The FCW has prepared a training package that the RHs could use to train their staff. The training package comprises a FC form which details the information that a patient might want to know, a script to assist staff in the delivery of the FC information, and a revamped 3M booklet which consolidates all the three schemes of payment. The FC script has been translated into other languages (Chinese, Malay, Tamil) for the FC staff's use. RHs have also conducted a second round of training in Jan 2002 to that their staff are properly trained in FC.

Additional enhancements pending implementation

The FCW has also recommended several other enhancements that are pending implementation by the RHs.

Information on financial assistance

To ensure that RHs provide information on the availability of financial assistance schemes (eg Medifund), the FCW has recommended that it be included as part of the routine pre-admission counselling and additional FC processes. The FCW is currently working with MCDS to prepare a brochure consolidating all the various community financial assistance schemes which could be given to patients during FC. Also, the RHs have been told to pro-actively identify patients who may find difficulty defraying their medical expenses through their ward staff and clinicians.

Enhancements to the FC framework at the SOC

Apart from enhancing the FC framework at the inpatient/day surgery level, the FCW has also initiated improvements to the FC at the SOC level. The aim of FC at SOC is to inform SOC patients whose bill sizes could be potentially large, so that they could seek financial assistance or request for cheaper alternatives.

The FCW has therefore designed the FC framework at SOC such that FC would only kick in for high SOC bill sizes. The trigger points could be based on certain defined expensive drugs and procedures. The FCW is currently working out the implementation process for the enhanced SOC FC together with the RHs as this requires significant enhancements to the hospital IT systems.

Incorporation on MediShield information in the FC process

Based on feedback from the public, MOH has accepted the need to include MediShield claim information into the FC process. The FCW Secretariat has proceeded to work with CPF Board on the implementation of this initiative.

Improved precision of bill size estimates

The results of the proposed MOH-CASE initiative on greater hospital fee transparency would be incorporated into the FC process to improve the precision of bill size estimates.