WHAT IS “THE NORM” AND WHOSE NORM ARE WE TALKING ABOUT?

It’s been some three months since this hobbit went into retirement mode.

Recently, a local politician was interviewed on mainstream media which gave much food for thought to the small brain of this hobbit. Hence this, the first of the occasional posts since my retirement announcement in January this year.

The interviewer asked him, “Is it because doctors also anyhow charge? Should something be done about the way doctors’ bill patients?”

He answered “I think they should. I won’t say a lot of doctors are doing this, maybe a small percentage, could be making use of the situation to perhaps prescribe certain tests and certain procedures that are not the norm. so that I hope that with the new changes, this will cause such behaviour to be lessened”.

The fundamental question here is what is the norm? And who decides what the norm is?

To doctors, the basic tenet is encapsulated in this line that is found in the SMC’s Physician Pledge – “make the health of my patient my first consideration”. This is the “duty of care” that we owe our patients, and which our patients expect of us. This is repeated in the SMC Ethical Code:- “Uphold patients’ welfare and best interests as your highest consideration, Section 3(a)(ii).

This duty of care is so important that in our Ethical Guidelines, it is found in Part A (Good Clinical Care) under Section A1: Duty of Care. (i.e. it is the first section of the first part of the Ethical Guidelines)

I hope no one should have any doubt about the primacy of the duty of care that we owe our patients in all that we do as doctors. In fact, this hobbit has been told by two senior lawyers that the duty of care doctors owes their patients can be considered to be a fiduciary one.


What is a fiduciary relationship? According to ChatGPT, it is –

“A  fiduciary relationship is a legal or ethical bond of trust between two parties where one person (the fiduciary) is required to act in the best interests of another (the principal or beneficiary). It is one of the highest standards of care recognized by law, requiring the fiduciary to prioritize the other party’s needs above their own.”

Scholarly papers have been written on this subject1. The local (SMC) ethical framework can be largely traced back to the 4-principle framework of Beauchamp and Childress: Non-Maleficence, Beneficence, Autonomy and Social Justice. And here is what they wrote in their seminal work “Principles of Biomedical Ethics” about fiduciary relationship, ‘The patient-physician relationship is a fiduciary relationship—that is, founded on trust or confidence; and the physician is therefore necessarily a trustee for the patient’s medical welfare”

I guess if there was something akin to the Ten Commandments of Medical Ethics, Duty of Care would be a strong candidate to be the First Commandment.

Other fiduciary relationships include lawyer-client, company director and shareholders, guardian and ward etc

Arising from this duty of care, we derive norms for how doctors must conduct themselves when dealing with patients. And when these norms are seriously deviated form, doctors can be punished by a Disciplinary Tribunal. This is provided for under Section 59D(1) of the Medical Registration Act. Under subsection (c) and (d), it is stated:

c) to have been guilty of professional misconduct

d) to have failed to provide professional services of the quality that is reasonable to expect of him

The test for professional misconduct is often also called the Low Cze Hong test2 and there are two limbs to this test (Chat GPT)

1. The First Limb: Intentional Departure 

This applies to an intentional and deliberate deviation from accepted professional standards, often involving breaches of the SMC Ethical Code and Ethical Guidelines (ECEG). 

2. The Second Limb: Serious Negligence 

This applies to serious negligence representing an abuse of the privileges of medical registration. It typically involves indifference to patient welfare or duty, and usually does not include isolated, non-intentional technical mistakes. 

As you can see, words like “deviation from accepted professional standards” and “indifference to patient welfare and duty” all point to the importance of upholding this duty of care and the consequent normative behaviour and practices that this duty obliges every doctor to subscribe to.

In summary, as doctors, we have to live within the professional norms of the profession, of which the duty of care we owe to patients, i.e. putting their interests before ourselves, is the cornerstone. Serious deviation from the duty of care and these consequent norms may expose ourselves to disciplinary action, which may include fines, suspensions and striking-off.

Next, we move on to the insurance industry. You may think the insurance companies and their agents work on the same norms as doctors. For a start, and let’s get this over with, the company directors of an insurer owe a fiduciary duty to the company’s shareholders, but they don’t owe a fiduciary duty to its policyholders.

What rules the financial sector is the test of suitability while what rules the healthcare and doctor’s lives is the fiduciary duty that we owe our patients. So, there are two standards: the fiduciary standard and the suitability standard.

The test of suitability that is commonly used in the financial (and hence insurance) sectors require a financial or insurance company to understand their clients by asking questions to see if the client (and his circumstances) is suitable for the product the company is trying to sell.

Take the example of Insurer A that has 3 insurance products and they are all deemed suitable for Client B. The insurance agent doesn’t have to recommend the policy that he thinks is best for Client B. He can choose one of the 3 suitable plans that makes the most money for himself and the insurance company he works for to sell to Client B, provided that there is a “reasonable basis” for the agent to do so. And that is perfectly fine in the insurance industry since it is the suitability standard that applies here. The suitability standard is the insurance industry’s norm.

Of course, there have been cases where financial advisors have been punished by the regulator for selling a product that is entirely unsuitable for the client. For example, a retiree that needs a steady low-risk low-return investment is instead sold a high-risk, high-return investment product.

Now contrast this with the medical profession and the fiduciary standard that is applicable.

From the patient perspective, the doctor must always act in the best interest of the patient, even when it is NOT in the doctor’s interest. A good example is a medical oncologist who fails to offer a surgical option to his patient when evidence shows surgery shows better (or even just comparable) outcomes and only offers chemotherapy. The medical oncologist would be considered to have failed in the discharge of his (fiduciary) duty of care to the patient. If the patient complains, the doctor will, in all likelihood, be punished by the Disciplinary Tribunal. This fiduciary standard is the norm of the medical profession.

Another example would be how a ruptured cerebral aneurysm is treated. Nowadays, one can treat a ruptured aneurysm mainly by two ways: open surgery and endovascular procedure if a patient is brought by (usually) a SCDF ambulance quickly enough to a restructured hospital

An endovascular procedure is the treatment of choice, since endovascular procedures show significantly better results than open surgery. It is the standard of care now if it is available. And applying the current standard of care is certainly a good way of discharging a doctor’s duty of care to his patient. Admittedly, not all hospitals offer this service, but if the patient is brought to a hospital that offers endovascular procedure quickly enough, it is a no-brainer. I am told reliably that in hospitals that offer this service, 80% to 90% of ruptured cerebral aneurysms are treated by endovascular procedures and only the remaining 10% to 20% are treated with open surgery. This is a testament to the quick response time of our SCDF ambulances and our restructured hospitals as well as the excellence of our interventional radiologists and their supporting staff.

However, there are Critical Illness Plans that dictate that reimbursement takes place only when open surgery is performed and endovascular procedures are not reimbursable. Therefore, what is sold as a Critical Illness Plan covering ruptured cerebral aneurysms effectively only covers 10% to 20% of such cases.

This obviously makes no sense at two levels. At the first level, to the doctors and other healthcare workers, why would the company not cover a superior treatment modality that is in-line with current standards of care?

At the second level, why would anybody pay money for such a plan which in reality covers only 10% to 20% of cases of what is obviously a life-threatening emergency?

But all this makes sense at the third level, to the insurance company and the insurance agent that sold this policy. It makes money for both the company and the agent and at the same time it is a “suitable product” for the client (I suppose from a certain reasonable perspective, a 10% to 20% chance of getting a successful payout is “suitable”).

In any case, this hobbit thinks Critical Illness Plan is a bloody misnomer. Let me suggest a more appropriate name: –  Critical Illness But Ancient Intervention Plan (CIBAI Plan).

It is also why an insurance case manager can ask why a doctor did not try conservative treatment for an anal abscess first before performing surgery. I suppose trying conservative treatment instead of draining the abscess is “suitable”, for at least a few days to a week, never mind the pain of having the abscess and the increased risk of getting septicaemia.

Which is why doctors and insurers can never live together happily ever after. They two work on different premises and norms that are often in conflict with one another. Currently when there is a conflict, it is often the suitability standard that prevails over the fiduciary standard. Insurance norms eat the medical profession’s norms for lunch and insurance-based medicine trumps evidence-based medicine almost all the time in Singapore when there is an insurance claim. Should a doctor demand that the fiduciary standard prevails, he may run the risk of being delisted from an insurer’s panel with no reasons given.

In an ideal world, the relevant regulator(s) should step in and legislate that the fiduciary standard is applicable even for insurers and insurance agents for health insurance products. This will ensure that public and the patient’s interest is well-served. Doing so will also address the persistent friction and unhealthy tension that exists in this sector, where the standards of the medical profession and the insurance industry intersect.

I wish the politician who gave that interview stated that, in reality and on the ground, the applicable norm today is the insurance norm that is based on the suitability standard. Let’s call a spade a spade.

And to that unenlightened interviewer who asked if the problem was due to doctors who “anyhow charge” – I hope she knows that there are MOH fee benchmarks that insurance panel doctors have to follow. What is more, most IP insurers only reimburse at the lower end of the benchmarks. So how to “anyhow charge”? Can this interviewer don’t anyhow ask such questions which shows her shallowness? Even if there were such doctors who “anyhow charge”, they are very few in number, which in turn, means they do not move the needle at the national level in terms of controlling healthcare costs in the private sector.

1 Ludewigs S, et al. J Med Ethics 2025;51:59–66. doi:10.1136/jme-2022-108539;

Ethics of the fiduciary relationship between patient and physician: the case of informed consent

2 Tan Siang Yong, Medical Legal Dimension of Professionalism, SMA News, Pages 26-27, June 2015.

Valinor* Beckons

And just like that, we are into 2026. Another year of joy, achievements, sadness, failures, and abuse by IP insurers.

This hobbit really feels that age is catching up with it, despite all the health-giving properties of beer and clean air in the shire.

You know you are old when you remember the days when your home telephone number had only 5-digits. Then it went to six, then to seven (1985) and then to eight digits (2002). Finally, now, I do not have a home telephone….

You know you are old when you remember when your postal code went from 2 digits to 4 digits (1979) to the current 6 digits (1995).

On the medical side, I remember the days of the long and very high-ceiling “Nightingale” wards in old colonial buildings where patient privacy meant the nurses and doctors had to pull a movable screen to shield the patient from other folks when you examined or performed a procedure on the patient. There were no curtains.

Things got a bit better when the new hospitals were built. By this I mean the “new” SGH that was built in the 70s which we are still using. This hobbit still reminisces the gentle breeze that percolated SGH’s first floor, because in those days, the first floors of Blocks 4 to 7 were largely empty. They were void decks. But most importantly, the happy memories of Houseman Canteen, which was the nexus of true knowledge and fount of medical news until it was replaced by this ghastly architecture called the Academia. Compared to the Academia, Mount Doom in Mordor looks more alluring.

Things have gotten better since the bad old days in certain ways. Houseman calls were unpaid calls and MO calls allowance was $40 until the 5th call, when the call allowance was raised to $100. I remember the undying gratitude I felt when my registrar handed me fifty bucks and asked me to buy supper for the on-call team. I half-suspected that one of the metrics HOs and MOs were assessed by was the quality of supper you could come back with. These were the days before there was food delivery. You, the HO or MO, was the food purchaser and deliverer.

The HO was also the IV medication deliverer, along with being the hypocount performer (which took 120 seconds). The good news is that consent-taking was a lot easier and that the entire process often took place faster than the hypocount. Being informed was not one of our priorities. (And I mean the HO or MO being informed, not the patient or his NOK). Did I really know the benefits, alternatives and risks of a TURP when I took consent?

I did my first locum in a clinic in Jurong at night at $40 an hour. Which is a princely sum if you remember I was also paid $40 for an MO call. There was no EMR. Actually, there was no computer in the consultation room. Everything happened on patient record cards.

Which was also the way things were done in the polyclinics. Polyclinics or its predecessor the OPD (Outpatient Patient Department) clinics were interesting places. I once worked in an OPD which had a NCC (National Cadet Corps) Camp next to it with chickens running around in the fenced compound.

Another polyclinic had 2 levels. Patient records were transferred between the two floors by putting the files in a basket that was attached to a pulley hung from the ceiling of the building atrium. The pulley system transported stuff rather efficiently between the two floors.

Yet another polyclinic had the best patient care assistants (otherwise known as “amahs”) I had ever experienced. They were dressed in pristine white “samfoos” (bajoo tops and slacks) and were very experienced in queue management. By this I mean when the patient was a little more loquacious than desired, the amah would cut him or her off and intoned in Hokkien or Cantonese, “Doctor is too busy, don’t talk so much!”. In addition, she will helpfully put on the BP set cuff and semi-inflate it for me, so that I only had to pump the cuff two or three times more before the BP was taken. How is that for service? And oh, did I forget to mention? The OPD, including the consultation rooms, did not have any air-conditioning, and that BP sets and thermometers contained real Mercury so that if you broke them, cleaning up had to be done very carefully.

Well, I could go on and on like an old hobbit who has gone through one too many quests, rambling off yarns of yore to younger folks in the shire.

But as is the way of most things good or bad, this must come to an end.

I would like to use this post to announce that as of 2026, this column will be slowing down quite a bit. For many years, since it was a column in the SMA News, and then going on its own as independent Facebook posts and then now as a blog, this hobbit has largely tried to adhere to a format of a monthly column. Sometimes when there are issues to comment on in a more timely fashion, the posts may be more frequent. But the frequency of posting monthly has been the norm since this column started; and if you haven’t noticed or realised, this hobbit has been here since the last century/millennium.

It’s been that long and save for a few columns written by other guest hobbits, everything has been spun out of one single small halfling brain. It has been an equally exhilarating and exhausting journey all these years. And it is time to take a slower pace. From 2026 onwards, this column will be an occasional column instead of a monthly one. If you hear from me, well and good, but if you do not, it is not to be unexpected.

Eventually, maybe sooner rather than later, this column will cease, unless a successor is found soon.

I wish to also take this occasion to thank the readers of this column. It is you that have kept me going.

Over the years, I have tried perhaps to achieve too many things all at once. Admittedly, it is difficult to be funny and informative, relevant and irreverent, sarcastic and sincere all at the same time; all too often failing in my efforts.

Many issues continue to bedevil the profession today. These include low morale, mental well-being of doctors, the scourge of IP insurers, the weight of excessive regulation in some areas and the dark void when there is little or no regulation in other areas, forging satisfying career paths and training opportunities for younger doctors, as well as just simply keeping up with the rising costs of living and meeting the (realistic) material expectations of doctors.

This list goes on. This hobbit has concluded that even though the fight must go on, others have to take over. Because Valinor beckons and the ship is already waiting to take me there.

Thank you once again. I hope all of you had as much of a good time reading this column as I had writing it.

*Valinor – also known as the Undying Lands or Blessed Realms located in the West, across the seas and far away from Middle-earth, where immortal elves longed to go to. Some non-mortals were given this privilege of going to Valinor too in the Lord of the Rings trilogy, At the end of the trilogy, Frogo Baggins was given this privilege to sail with the elves to Valinor.

The All-Compelling Insurance Based Medicine (IBM)

The first reading of the Health Information Bill (HIB) has just been completed earlier last week in Parliament. The bulk of the Bill deals with how the National Electronic Health Record (NEHR) will be introduced nationwide. Currently submission of data to NEHR is only limited to the public sector. After this Bill is passed and the Health Information Act comes into force, all licensed healthcare establishments and pharmacies will be required to submit data to NEHR.

The Bill comes with many provisions that protect the public so that there is no unauthorised access, collection and disclosure of health information that is stored in the NEHR. The Bill, together with the attached annexes and explanatory statement, runs for 186 pages1. It is a massive document. For some strange reason, what all doctors had known for years as the “NEHR” is now known as the “National Electronic Records System”, the word “health” has been omitted. No matter.

It is very noteworthy that in Pages 16 and 17 of the Bill under Section 6 of “Part 2, National Electronic Records System”, it is stated the following:

“excluded purpose”, in relation to the access or collection of accessible health information about an individual (P), means any of the following purposes:

(f) deciding whether to insure P or any other individual, or to continue or renew the insurance (whether on the same or different terms) of P or any other individual;

(g) making a claim on the insurance of P or any other individual, or processing a claim made on the insurance of P or any other individual;“

In other words, information stored in the NEHR is NOT to be used for insurance purposes. The NEHR information also cannot be used for assessing if a person is suitable for any kind of employment or as a platform worker.

The following guidelines2, while still a draft was released sometime in December 23 and could be found in the MOH website under the “healthinfo.gov.sg” section. We reproduce the relevant section here.

DRAFT GUIDELINES ON APPROPRIATE USE AND ACCESS TO NATIONAL ELECTRONIC HEALTH RECORD (NEHR)

Page 9: 3.1.2.2 Authorised and Unauthorised Access to NEHR:

“Healthcare professionals should ensure that they regulations/circulars/directives issued by MOH regarding purposes for accessing NEHR.

Institutions should establish policies and procedures and provide appropriate training to ensure that NEHR is only accessed for authorised purposes. Unless specified by legislation or prior approval from MOH has been obtained, healthcare professionals should not access NEHR for non-patient care related purposes. This includes accessing NEHR to obtain information for employment, insurance, education, training, audit or research purposes, even when the patient has provided consent.

In the event that such information was previously transcribed from NEHR into the patient’s clinical notes, it would be treated as part and parcel of the medical record belonging to the healthcare institution. In this regard, the healthcare professional could use this information in the clinical notes for non-patient care related purposes, including the ones listed above”.

So far so good.

However, it recently has come to this hobbit’s attention that panel doctors of a certain Integrated Plan (IP) insurer were made to sign a new contract with this insurer because apparently, they have gotten rid of the third party administrator (TPA) that was previously managing these panel doctors and hence, a new contract is needed.

One of the clauses in this contract read,

“Inspection And Right To Audit”

The Treatment Provider shall keep complete and accurate records of all of his/her work and expenses in providing the treatment and medical services to the Policyholders during the entire term of the Agreement. In order to verify its compliance with this Clause 7 and the terms of this Agreement, the Treatment Provider shall, upon reasonable notice, allow GEL, its management, its agent(s), its internal and/or external auditors (“Authorised Personnel”), the opportunity of inspecting, examining and auditing the Treatment Provider’s operations and the medical records (including but not limited to patient case sheet, treatment plan and/or dispensing record) which are relevant to the treatment and medical services provided to the Policyholders. The Treatment Provider shall cooperate fully with the Authorised Personnel to ensure a prompt and accurate audit.

Apparently, this IP insurer may not be the only party that has such clauses. Other insurers and TPAs may likewise incorporate similar clauses into their contracts.

Whether you are a doctor or a policyholder, you should be very concerned that such clauses exist. This hobbit would like to point out three possible ramifications of such “inspection and right to audit” clauses in the context of the HIB and draft NEHR Guidelines.

Firstly, this clause does not state whether access to the patient case sheets, treatment plan and dispensing records by the insurer is limited to those incidents or aspects that are covered and reimbursable by the insurer. Ideally, the insurer has no business poking its nose into stuff that its policies do not cover.

But in truth and as we all know, medical records of the policyholder are NOT divided into IP-covered portions and non IP-covered portions. They are all more or less combined or integrated to facilitate better care, usually arranged in chronological order.

Let us take the hypothetical example of a policyholder who was admitted for a laparoscopic cholecystectomy for gallstones and an inflamed gall bladder. After the operation, a claim dispute arose and the insurer wants to now audit the “medical records”.

Since it is an abdominal surgery, the surgeon had previously accessed the NEHR to look for records of previous procedures performed on the abdominal and pelvic regions. In the process, he noted that the patient has had one missed abortion, 2 IVF cycles done, an appendicectomy and a Caesarean Section. In addition, the patient had a previous episode of post-natal depression as well as tummy-tuck (liposuction) surgery. All these findings from the NEHR were duly noted in his case sheets, both in his clinic records as well as in the hospital records when the patient was admitted to the private hospital for the surgery.

The next question we need to ask is, does the patient or policyholder want the insurer to know she has had the missed abortion, IVF procedures, Caesarean Section, post-natal depression and breast augmentation done? To the surgeon, all previous abdominal procedures are relevant, because he needs to know what to expect when he enters the abdominal cavity, e.g. peritoneal adhesions etc. But does the insurer need to know all this? Does the policyholder want the insurer to know all this?

What is more, under the draft NEHR Guidelines, such information transcribed from the NEHR is now considered “as part and parcel of the medical record belonging to the healthcare institution. In this regard, the healthcare professional could use this information in the clinical notes for “non-patient care related purposes, including the ones listed above”.

In other words, it could perhaps be used for insurance-related decisions, which the HIB has expressly stated the information in the NEHR should not be used for.

While the HIB and draft NEHR Guidelines are well-intended, the co-existence of such “inspection and right to audit” clauses may well mean that NEHR information can be used to achieve the “excluded purpose” of deciding whether a person should be insured or not, or to have a claim reimbursed or not” as long as they had been previously transcribed into the medical records. This is a loophole that a smart insurance executive can easily exploit by citing the “Inspection and right to audit” clause.

It would also not be inconceivable that the insurer has signed similar contracts or clauses with private hospitals that enable it to inspect and audit the hospital’s medical records. The incentive for the hospital to accept such a clause could be that the hospital can be a preferred hospital provider with the insurer. After all, for the insurer to know and satisfy itself that the care given was appropriate and reimbursable or not, it would have to have access to both the doctor’s and the hospital’s records. Inspecting only the doctor’s records in the clinics would not be sufficient in many instances if the intent of inspection and audit is to satisfied.

The second point to be made is that of informed consent. Of course the default position insurers will adopt is that if the patient or policyholder gives consent, then why can’t an insurer inspect and audit the medical records?

We do not know the details of consent that was given and if the policyholder knows the scope of consent he has given. It is reasonable for a policyholder to think that he has given consent for the insurer to know enough to decide on what and how much should be reimbursed.

For example, the diagnosis, procedures, investigations, medications, treatments and charges for these items should of course be given to the insurer. But does the insurer need to know that certain family members of the policyholder visited the policyholder in the ward and subsequently they had an argument (as recorded in the nursing notes) in which hospital security had to be called in to escort the family members away? Or out of anxiety and frustration, a patient cried a few times, and nurses and doctors had to console the patient? Did the policyholder really consent to giving the insurer unfettered access to his full medical records? We need to ask ourselves honestly, how many of us really know the scope and details of what we consented to when we bought any insurance policy?

Thirdly, in Singapore, the patient himself does NOT have full access to his own medical records. Unlike in certain other countries, the patient in Singapore cannot ask for a copy of his hospital or medical records to be made available to the patient. He can ask for a medical report in which key points are summarised. So if the patient himself does not have full access to the medical records, why should the insurer have such access? In this era of smartphones, it is all too easy for every page of the medical records to be photographed as well. Can a patient consent to giving access to an insurer the medical records (and possibly copies of the medical records be made as well) that even the patient himself does not have?

As doctors, we are trained and used to relying on Evidence-based Medicine (EBM) and our Ethical Code and Ethical Guidelines (ECEG) to illuminate us on the path of good medical practice. But increasingly for private sector doctors, EBM and ECEG have to contend with a third and possibly far more compelling force that now dominates the landscape – Insurance-based Medicine (IBM). Unlike EBM and ECEG, IBM answers to no one but the insurance companies.

1 https://sso.agc.gov.sg/Bills-Supp/20-2025/Published/20251105?DocDate=20251105

2 Chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.healthinfo.gov.sg/files/Draft_NEHR_Guidelines_for_Public_Consultation.pdf

LPPL Insurance Situations

Recently, our Health Minister launched four short social media clips to educate the public about health insurance, in particular riders for IP policies. The take-home message is that riders are expensive and get more expensive as the policyholder gets older. It may be better, especially for an older policyholder, not to buy riders or to buy cheaper riders. Of course, cheaper riders mean less coverage and more deductibles and co-payment. All very sensible. I urge you to watch the clips.

At about the same time, Singapore’s “Blogfather”, aka “MrBrown” aka “Kim Huat” also posted two clips to explain what some colloquial short forms mean. In the second of 2 posts so far, he explained what “LPPL” stands for1.

According to him, LPPL stands for “Laugh Please, Please Laugh”. It can also stand for Log-Periodic Power Law in the field of economics and finance.

To this hobbit, it can also mean a certain location in the human body, namely “Longitudinal Perineum Permanent Location”.

For example, the government introduced the Cancer Drug List (CDL) in 2022. This was introduced ostensibly to empower the government to negotiate for better prices from drug companies and to discourage the use of certain cancer drugs for non-mainstream indications so as to curb rising costs of cancer treatment.

However, many IP insurers then quickly introduced riders to cover for the use of non-CDL drugs. Of course, such riders2, while generating more work and income for some medical oncologists in the private sector, has the downstream effect of encouraging what the introduction of the CDL was meant precisely to discourage  – more use of such drugs which will lead to an unnecessary and avoidable rise in prices and overall healthcare consumption and expenditure

The quick introduction of non-CDL riders by IP insurers effectively negates the policy intent of CDL. And we are back to square one and the government is caught in an LPPL situation. The only consolation is that such riders must be paid with cash.

Why does this happen and why do we allow it? This hobbit doesn’t have the answer. Or even if he thought he knew, he won’t say it here, that’s for sure.

The first thing to know is that we often (if not always) buy insurance because we want peace of mind. Peace of mind is a wonderful thing. But really, if you think about it, the flip side of peace of mind is fear. Fear and peace of mind are but two sides of the same coin. We buy riders for peace of mind, and we buy riders out of fear. The fear that in case we need these non-CDL drugs, we have no access to them and even if we had access, we can’t pay for them. So we buy these riders.

The IP insurers are making lots of money selling these LPPL non-CDL riders in return for giving us peace of mind, or feeding on our fear (depending on one’s perspective).

And as any psychologist will tell you, fear is a great driving force for animals with some intelligence (and that includes humans). The response to fear is a primal one, hard-wired into the human condition through hundreds of thousands of years of evolution, or adaptation, call it what you may.

While this hobbit really likes the Health Minister’s video clips on riders and that he is a great communicator, this hobbit is not sure the clips can countervail the power of fear and the natural response to fear. Especially when this fear and the response to it is also being actively cultivated and reinforced by many insurance companies and insurance agents who get to make a buck or two out of selling such LPPL riders.

Let us move on to another insurance-related matter that has garnered many eyeballs recently. While this matter is about a motor insurance claim, it is nonetheless medically-related.

It was reported that the Courts awarded $417,000 in damages in a traffic accident case. Unfortunately, this decision was arrived at some 5 years after the accident occurred, and only after the traffic accident victim had passed away. The son of the victim, who is his main caregiver for the many years the victim was incapacitated until his death, was the plaintiff.

The sheer callous temerity of the insurance company was most telling. In the opening paragraph of the Judgment3 given by the District Judge, it was stated, “This is a judgment that documents NTUC Income’s wholly unreasonably behaviour”. This hobbit has read quite a few Judgments before, but none has come close to such a resolutely damning statement right at the start of a Judgment document.

In summary, the case involved a person who was seriously injured by a traffic accident. This victim then made a claim against the driver that caused the accident.

It was noted by the Judge that NTUC Income effectively took over the defence of the case because it would have to foot the bill should the courts decide in the plaintiff’s favour.

NTUC Income efforts to deny the claim was akin to “the sort of casually impersonal  stonewalling that some would associate with the worst administrative processes” (Judgment, para 3).

Some particularly galling examples of this impersonal stonewalling –

  • Claims for pain and suffering and amenities was denied because the victim was comatose and could not have appreciated any pain and suffering at all, even though the victim was intermittently conscious until his death (Paras 14 and 17, Judgment)
  • Claims for loss of income was denied, even though the victim was working at the time of the accident (Para. 34)
  • Claims for ambulance-related expenses was denied (Para. 36 of Judgment)
  • Claims for milk powder for the patient was denied because it was too expensive as the patient could have used a cheaper brand such as “Ensure”. (Para. 61 of Judgment). This hobbit is not so sure if “Ensure” appreciates such publicity from NTUC Income.

And if you think this unreasonable behaviour was arrived at because NTUC Income received poor legal advice, the judge made it clear that the lawyers were merely conveying their clients’ instructions. The judge added that the lawyers’ “advocacy was candid, well-organised and fully in line with their duties to the court”.

Against the backdrop of the furore that ensued, the CEO of NTUC Insurance (NTUC Income was rebranded as NTUC Insurance recently) issued an internal memo addressed to “colleagues”. This hobbit obtained a screenshot of this memo, in which he explained the company’s position and then signed off with “Cheers”.

This hobbit must say he has no clue what is there to be cheerful about.

I think the incident shows publicly that the local insurance sector is truly now in a new era of American-style climate of “delay, deny, defend”, which many doctors are already familiar with while caring for IP policyholders in the private sector. So far, the private patients in A1 and B1 class have largely been spared of such agony because IP insurers generally do not question or apply friction to claims for care delivered in restructured hospitals. But who knows what will happen in the future? This may occur sooner than we think.

This case also illustrates the inadequacy of scope in what is offered by the financial and insurance industry to adjudicate claims before it reaches the courts in the form of civil suits. Today, if someone is aggrieved by an insurer, he can take up his case with the Financial Industry Disputes Resolution Centre (FIDReC) which is a platform to adjudicate disputes involving financial institutions (which includes insurers).

However, this is a platform that is only open to the insured (i.e. policyholders who make claims) and their beneficiaries as well as to those parties who have a “customer relationship” with the insurers

It also only covers disputes of up to $150,000.

In this case, neither the victim nor the plaintiff (the victim’s son) is the insured. They don’t have a customer relationship with NTUC Income either. Strictly speaking the plaintiff is not even a beneficiary of the policy as well. What is more, the amounts accumulated over a four-year period far exceed $150,000. So he can’t use FIDReC and so, he has no choice but to sue. But not many people have the financial resources to mount a civil suit. And of course, there is a lot to lose if he does not win the suit. The plaintiff’s legal costs may be easily six-figures if the suit is protracted, and in a worst-case scenario, costs may be awarded against him, i.e. he has to pay for the other party’s costs too.

The plaintiff in this case has obviously weighed his chances, examined his financial resources and then decided to pursue the civil suit route.

As for healthcare-related or IP-related matters, the situation is even worse off in at least three ways.

  • FIDReC is not open to service providers that provide a service or goods to the insured. So, hospitals and doctors who experience unreasonable delays and denials of claims cannot use FIDReC.
  • FIDReC also only handles complaints when a claim has been made, and not before. So FIDReC does not handle issues such as pre-authorisation or how doctor panels are constructed, because no claim has been made.
  • FIRDeC also only handles disputes that are clinical in nature on a voluntary basis. When such a dispute occurs, IP insurers can choose NOT to participate, even if the policyholder has lodged a complaint with FIDReC.

To use a partially real-life example. A patient has an anal fistula abscess. The panel doctor seeks pre-authorisation but is denied. Inexplicably, the case manager suggests that he tries to manage the anal fistula abscess “conservatively” (doctors and nurses reading this, please don’t laugh). This advice to treat an abscess conservatively is not made-up. It actually happened.

If you think the insurer’s case manager should and could be held accountable for making medically unsound and unsafe suggestions and recommendations, you are wrong. Insurers and their employees are not regulated at all for making recommendations and decisions that impact on the clinical aspects of healthcare delivery to their policyholders. For all you know, the case manager has a degree in art history and has recommended the use of Chlorox bleach to treat strangulated piles, and he can get away with such an unsafe recommendation with no consequences to himself or the insurer that he works for. Actually, I exaggerate. I know a few art history graduates who know more about healthcare and medicine than many IP insurers’ case managers. Let’s not unjustly belittle art history grads. They are good people doing good work, which is more than what I can say for many case managers.

OK, this is where the real part ends. We go on to the hypothetical part.

Suppose the surgeon and patient agrees to surgically drain the abscess anyway (because as any 2nd year medical student will tell you, abscesses must be drained – just in case any case manager is reading this and is confused). However, for reasons beyond anyone’s control, the 70 year-old patient with well-controlled diabetes gets pneumonia post-op and gets hospitalised for longer than expected, and the hospitalisation includes 2 days in the ICU.

The claim for the hospital stay is denied because the doctor and patient did not first try “conservative” treatment. The patient/policyholder then files a complaint before FIDReC. The insurer declines to take part in the FIDReC process citing that this is a clinical matter.

What is the patient, surgeon or hospital now to do? The total bill could be say, about $30,000. The aggrieved parties may think that well, the legal fees for bringing this to court alone could well be close to or exceeding $30,000. The surgeon may be fearful that should he pursue the civil suit route, the insurer may well remove him from the insurance panel after this. After all, no reasons need to be given for selecting or removing a doctor from the panel.

And so, all the other stakeholders are again stuck in a LPPL situation, with the insurer being the only party to benefit from such LPPL situations.

Whether we want to admit it or not, “Delay, Deny, Defend” works most of the time. Such is life. LPPL.

1 https://www.youtube.com/shorts/RCSvZUgOCgM

2 https://www.singsaver.com.sg/blog/best-ip-riders-and-supplementary-coverage-for-cancer-protection

3 https://www.elitigation.sg/gd/s/2025_SGDC_150

It Is What It Is

Recently, a House Officer was suspended for the maximum period of three years by a Disciplinary Tribunal (DT). The House Officer had falsified two Medical Certificates (MC) so that she could take the days off.

Many doctors expressed concern at the severity of the sentencing.

Not many doctors may know about this, but there is a SMC document called the Sentencing Guidelines, which is available on the SMC website. It was issued in 2020 after the work by a SMC Sentencing Committee was completed. This Committee was chaired by a Court of Appeal Judge. Other members included another High Court Judge and a Judicial Commissioner, along with many senior doctors and several MOH officials.

The medical profession is given the privilege of self-regulation in Singapore through the SMC and Disciplinary Commission (which commissions DTs and is now independent of the SMC), but this is not an absolute privilege. Ultimately, the decisions of DTs can be subjected to appeal to the Court of 3 Judges (C3J), and this includes decisions related to sentencing.

So while the DT can decide on the severity of sentencing, ultimately its decisions must be able to stand a good chance of being upheld by the C3J should an appeal occur. An appeal can come from either the SMC’s lawyers or the Respondent (i.e. the doctor being charged).

Within the Sentencing Guidelines, there is a subsection called “Dishonesty” (Page 18) under the Section “Removal of Doctor’s Name from Register (s53 (2)(a) of MRA)”. This provision under the MRA or Medical Registration Act is what we doctors commonly call the “Struck Off” clause.

To cut a long story short, the Sentencing Guidelines state that the default sentencing for acts of dishonesty is striking off. There are some conditions and circumstances where the DT may impose a lighter sentence but I won’t go into the details here. In any case, the DT is in this case did NOT impose a striking off sentence but instead suspended the house officer for 36 months. The house officer’s lawyers had asked for 20 months’ suspension but they also did not appeal against the 36-month sentence. 36 months is the maximum period a doctor can be suspended under the MRA.

The DT in its Grounds of Decision, referred to 3 previous SMC cases and 4 Law Society cases and the Harm-Culpability Matrix for guidance to arrive at the final sentence of a 36-month suspension. Personally speaking, I thought the 36-month sentence was a tad harsh. I cannot see how the public’s trust and confidence in the medical profession can be “severely” harmed by a house officer falsifying MC on two occasions, even though the house officer’s culpability was high if not total. I think the public can discern the impact between dishonesty by a house officer and an experienced doctor and the consequent loss of public confidence. But that’s just me. We halflings always err on the merciful side. Maybe that’s our weakness.

But it is what it is.

However, this hobbit was kind of taken by surprise by this article that appeared shortly before the SMC announced the suspension of the house officer earlier this month, “Lawyer who sent misleading letters to 22 doctors fails in bid to quash $18,000 penalty” (The Straits Times, 13 August 25”

https://www.straitstimes.com/singapore/courts-crime/lawyer-who-sent-misleading-letters-to-22-doctors-fails-in-bid-to-quash-18000-penalty

This case involved the sending out of misleading letters to 22 doctors that practised in TTSH, KKH and SGH. The letters stated that as required by the High Court, these 22 doctors had to give a statement to the law firm which the lawyer practised in, which was untrue and misleading. There was no such High Court requirement. According to the Straits Time report, the letter further stated “The doctors were told not to discuss their testimony with anyone, including their legal advisers and insurers. The letters also warned of “severe penal consequences” if the doctors did not comply”.

To give you an idea of how serious this is, the CMBs of all three aforesaid hospitals filed a complaint against this lawyer with the Law Society. The exact wording of one of the two charges against the lawyer is as reproduced below

https://www.elitigation.sg/gd/s/2025_SGHC_159

“First Alternative to Second Charge” (Section 5)

You, AAAAAAA (NRIC No. XXXXXXX), an advocate and solicitor of the Supreme Court of Singapore, are charged that you, took unfair advantage of various potential witnesses in High Court Suit No. HC/S 702/2020 and/or acted deceitfully towards them or otherwise contrary to a legal practitioner’s position as a member of a honourable profession, by issuing and sending letters dated 12 May 2022, 13 May 2022, 25 May 2022 and 22 June 2022 to these potential witnesses, which said letters created a misleading impression of and/or misrepresented the legal requirements in connection with the requirements for giving evidence in High Court Suit No. HC/S 702/2020 and the consequences of non-compliance with those alleged requirements, and such conduct amounts to a breach of Rule 8(3)(a) and/or Rule 8(3)(b) of the Legal Profession (Professional Conduct) Rules 2015, and you are thereby guilty of improper conduct or practice as an advocate and solicitor of the Supreme Court of Singapore under Section 83(2)(b) of the Legal Profession Act 1966.

To summarise, there were actually two charges. The first charge involved breaching Rule 7(3) while the second charge involved Rule 8(3)(a) and 8(3)(b). The one reproduced above is only the second charge. The defendant lawyer was found guilty of both charges and fined $18,000. The lawyer then appealed against the sentence. The case was heard before a High Court Judge who upheld the decision of the DT.

To bring more clarity to laymen such as doctors, halflings and other folks reading this, this hobbit reproduces the text of the relevant Rules of the Legal Profession (Professional Conduct) Rules 2015 for the second charge here:

Legal Profession (Professional Conduct) Rule 8(3)(a) and (b) states:

(3) A legal practitioner

  • must not take unfair advantage of any person; and
  • must not act towards any person in a way which is fraudulent, deceitful or otherwise contrary to the legal practitioner’s position as a member of an honourable profession

The question that befuddles this hobbit (who admittedly is untrained and not at all clever at these legal stuff) is how did this lawyer of apparently more than 30 years’ experience only get a $18000 fine for doing something that is “fraudulent, deceitful or otherwise contrary to the legal practitioner’s position as a member of an honorable profession” AND also to have taken “unfair advantage of any person”? Is issuing misleading letters that are deemed “fraudulent and deceitful…” also not an act or acts of dishonesty? It would take a long stretch of anyone’s imagination that a person trained in law and court processes was not aware that these letters were misleading.

On the other hand, the house officer was found guilty of bringing disrepute to the medical profession (under Section 59D(1)(b) of the MRA) because she was dishonest and consequently suspended for 36 months.

How do we make sense of the sentencing for these two cases; one involving a lawyer of many years’ experience and a house officer with only a few months’ record of being a provisionally-registered doctor?

Perhaps we should not. Doctors are not lawyers and vice-versa. It is what it is.

SG60: What if……

As we celebrate our nation’s 60th birthday, perhaps it is time also to think what may happen in the next 60 years for doctors living on this island. Certainly, the medical profession has come a long way since 1965. The profession’s trajectory has been largely a positive one, both for itself, the country and the community it serves.

We have become bigger and more complex. Each year, thousands of applicants vie for the 500 or so places in our medical schools. Another 200 come from foreign universities. Taking into account retirements and deaths, our ranks have increased by about 600 to 700 a year in recent years. We have grown to 35 specialties and 10 subspecialties.

But do these numbers mean that everything is hunky dory down the road for the next 60 years or even just the next 10 to 20 years?

Let’s ask a few questions (which will NOT be answered in this column):

  1. What if doctors are no longer trusted by the public and held in high esteem by society?
  2. What if our medical schools no longer attract the brightest to apply?
  3. What will happen if only the rich can afford to send their children to our local medical schools?
  4. What if there are significant numbers of doctors who cannot get a well-paying job after they finish their housemanship or their 5-year government bond and most of our young doctors no longer think Singapore is a good place to work and make a living and go elsewhere to practice medicine and raise their families?
  5. What if defensive medicine takes root and becomes pervasive in Singapore?
  6. What if two-thirds of our doctors quit public service and go into private practice? (Presently, the converse is true: roughly two-thirds of the medical profession work in the public sector)
  7. What if the medical profession loses our professional independence and practice in a way that is dictated by other parties with different priorities, such as insurance companies and third-party administrators?
  8. What if we are no longer seen to be a country that can offer the most advanced medical services in the region and regional competitors have surpassed us in capability and skills and Singaporeans have to go to a neighbouring country to get access to advanced treatment modalities and highly skilled doctors?
  9. What if large numbers of doctors no longer believe it pays to be ethical because making a living as an ethical doctor is just too difficult and unrewarding?
  10. What if the majority of doctors can no longer afford private housing or own a car at even say, 40 to 45 years-old?

These are uncomfortable questions to which we instinctively know the answers to, but which are difficult to say aloud, especially to non-doctors. What is more, many of these 10 questions are actually interlinked or correlated.

While we have every reason to be thankful these 10 questions are really hypothetical in nature now, we also always need to be alert and to guard against the possibility that the answers to these questions becomes reality in Singapore.

Happy SG60!

Grape Cistern Insurance Company: Operation Great Pincer

(For the avoidance of doubt, it is hereby stated that this post is a satire)

Board Memo

To the Chairman and Members of the Board of Directors

Operation Great Pincer (OGP)

I wish to update you that we have begun a major strategic initiative against a hospital service provider – Most Excellent Hospital or MEH in short. This hospital has been a great source of frustration and annoyance to our Company.

This initiative is called Operation Great Pincer (OGP) and its aim is to bring this hospital service provider to its knees and to yield to our Company.

Background

We have to first understand that a hospital needs three other parties to survive: patients, attending doctors and payors. In times past, the payor is often the patient. But nowadays, with bills getting larger, bills are often settled by insurance products which the patients or their employees buy from companies such as us.

Usually, the patient doesn’t really choose the hospital but instead chooses the doctor he wants to consult with, and the doctor happens to work in this hospital or chooses to admit the patient to a hospital where he has admission or attending rights. The doctor is NOT an employee of the hospital but an “attending physician’. In other words, the patient has a choice, and the doctor also has a choice.

Finally, when services have been rendered, the bill will be settled by the payor, I.e., insurance company that sold the insurance policy to the patient/policyholder some time ago.

Once you understand this, you can now proceed to develop a pincer strategy that squeezes the life out of MEH by getting the two other parties to be aligned with the Company: the doctors and the policyholders.

The Pincer Attack

Similar to what we know of a crab claw or crab pincer, a pincer attack must have two limbs or two prongs. Here, as you may have already guessed, one limb or prong is the doctor and the other prong is the policyholder.

A pincer attack or pincer offensive is nothing new. It has been used since the beginning of human warfare and if well executed, is highly effective and deadly. The difficulty lies in getting the two limbs to pivot and close around your prey or enemy until it is encircled and crushed.

A most famous example is the Stalingrad Campaign in World War Two when the Soviet Army managed to mount a counteroffensive by using the pincer attack to squeeze and finally encircle the German 6th Army in Stalingrad in the winter of 1942. By the time the Campaign ended, it was estimated that the Axis forces (led by Germany) lost between 600,000 to 1.1M men (killed, injured, missing or captured). It never recovered from this and it has been said that this was the pivotal moment when Nazi Germany began its inexorable march to ruin and ultimate defeat.

OGP: Our Two-pronged Pincer Attack

Let us now return to OGP and the MEH.

The Build-up

We will first manipulate one of the two prongs to be on our side. And of course, we will choose the weaker prong – the doctors who admit patients to MEH. To this end, I have in my armamentarium the weapon of preferred physician panels. I have already weaponized this by telling these empanelled doctors that they are strongly encouraged to admit to other hospitals and not MEH. To sweeten the deal, I put in place small incentives such as free parking and fruits baskets for my policyholders. Finally I carry the big stick called “depanelment”, which means removal of the doctor from the preferred physician panel. Actually, there is no such word called “depanelment” in the English language. It was probably invented by some insurance executive of antiquity who did not achieve a good grade in English when he was in school; but you get the idea. In any case, I have started the fear rolling like a ball last year by depanelling many doctors.

Launching Operation Great Pincer With The First Prong

In order to maintain the element of fear and uncertainty among panel doctors and to ensure they remain subservient to the Company like groveling dogs, the criteria of depanelment will remain quite opaque and the depanelment process is subject to our whim and fancy. To this end, I have formed a nice sounding department called Provider Management Department and I have instructed it to issue a statement explaining a few of the many reasons for which a doctor can be depanelled. These reasons are ultimately meaningless because it is followed by the one and only factor that really matters, something akin to a Ring to control all other rings (sounds familiar?). This all-powerful clause states “ the Company may or will exercise its sole discretion to make any decision regarding depanelment reasons”. In other words, all the reasonable sounding factors the Provider Management folks have mentioned earlier on in the aforesaid statement are just smoke and mirrors. What really matters is that the doctor’s continued existence on our panel is decided by the Company only. With this, I expect the panel doctor, to toe the line and NOT admit to MEH. But if the doctor still does admit to MEH, then it is time to say “Adios” to him on the panel. It’s not personal, it’s just business.

The Second Prong

Getting doctors to cooperate is the easy part, because doctors are weak. Getting the other party, the policyholders, to work as the second limb of the pincer is more difficult. This is because unlike the doctors who don’t pay our Company, we need policyholders because their insurance premiums keep this Company going. Pincer attacks must be executed quickly and in a coordinated way if you are to trap the enemy and prevent it from escaping. So just one day after our minions have issued the above statement to our panel doctors, the Company will issue another statement saying that we no longer issue pre-authorisation certificates (PACs) to MEH. And without PACs, the issuance of Letters of Guarantee (LOG) will either be very delayed or even not happen at all.

This again has the effect of sowing fear and uncertainty in the second target group, the policyholders, just as we had sowed fear and uncertainty in the first target group, the empanelled doctors.

Without pre-authorisation, policyholders will in all likelihood not get their LOG in time or at all. This leads to two possible consequences for the policyholder:

  1. The policyholder has to stump up cash for his hospital deposit, and also make progress payments along the way during his admission as his deposit is used up to pay mounting bills; and
  2. After the hospitalisation or treatment episode, there is an increased risk that the insurer will not pay his claims since there wasn’t any PAC or LOG issued beforehand.

The first consequence is a matter of cashflow for the insured since his policy is now run on a reimbursement basis. I submit that the hospital can help to alleviate the cashflow burden of the policyholder by waiving the requirement for a deposit or progress payments.

The second consequence is more serious as it is a matter of risk. Without a PAC and LOG, there is an increased uncertainty that the insurer can and will deny the claim. This is something that the hospital cannot address on its own.

To make it sound even more nebulous and scary, our minions will issue statements that obviously run contrary to experience and common sense, like “there is no change to your coverage or benefits when you submit claims or receive treatment with this initiative”. Obviously, cashflow of the policyholder is affected when one has to stump up cash for a deposit when one did not have to do so previously with a PAC. Also, the probability of having a claim denied is obviously higher without a PAC and LOG than when a policyholder has these documents. It has to be so, because if not, then why did we even come up with stuff like PAC and LOG in the first place?

Consequently, all these superficially balmy statements do little to assuage the fear and uncertainty that the policyholder feels when they are told PACs will no longer be issued for certain hospital(s). The trick is that we choose our words carefully, because cashflow and probability of claim denial is not a contractual term or feature of “coverage” or “benefit”. Therefore, while coverage and benefits remain constant in a legal sense, fear and uncertainty in the policyholder increases when a PAC and LOG is not issued.

Encirclement

With this, our second prong, the policyholders, will likewise fall in line with us. Like our panel doctors, they too will also not choose MEH.

With both prongs in place and aligned with us, the Operation Great Pincer (OGP) attack is well underway, and the enemy is choked off from the business that we have previously brought to them. We have entered the final and decisive phase of a pincer attack – encirclement and probable decimation.

The art of the pincer attack is not really the actual decimation of the hospital. But rather, the threat of decimation is sometimes more frightening that the actual act itself. One insurance company cannot decimate a hospital. But many can. As such, the real and great fear of the hospital is that our competitors may do likewise to them.

And so, in time and out of fear, the hospital will yield to us and give us the prices and discounts that we want. We will no longer be price-takers from MEH but instead we will be price-setters. We will then replicate the same strategy with other private hospital operators and be able to cut our payouts to these hospitals drastically, just as we have done so with the doctors using preferred physician panels and fee schedules.

Significant Threats to OGP

At this juncture, it is my responsibility to also point out and evaluate the downside risks of Operation Great Pincer. There are at least two significant threats to OGP that we have to be cognisant of: (1) our competitors and (2) our regulators

Our competitors may steal a little of our market share as new customers who want to buy a health insurance may not choose us, since OGP does limit their choice of hospitals and our repeated depanelment exercises have left our preferred physician panels smaller than before.

But this is a considered downside that we are prepared to stomach. This is because

  1. We are already an insurance company with sufficient heft, with a large pool of policyholders
  2. The market penetration of this sector is already high with a large majority of the potential policyholder pool having already bought health insurance either from us or from our competitors. Future growth is therefore limited
  3. Most of our policyholders will stay with us anyway, since some brilliant minds have already decided that there won’t be full portability in our line of business.
  4. Which means the only real options many of our policyholders have are either to stay with us or stop buying any kind of private health insurance altogether. Those that leave us may not be such a bad thing because they are likely to be older policyholders who are more likely to make claims. This is business we can afford to lose.
  5. Having a slight smaller market share but significantly higher profit margins and actual profits can be a desirable thing.

We have little to fear from our regulators as well. Our primary and first regulator empowered by the relevant legislation, the National Agency for Snooze (NAS) continues to be in a somnolent state. Our other regulator is awake but in truth has few legislation tools under its belt to be of concern to us. We will continue to help them in all earnestness to understand us better. Our strategy is to foment better understanding with our second regulator while avoiding regulation from the first.

Conclusion

Our overarching strategy to increase shareholder value continues to be based on the time-honoured precepts of our industry, which is to Delay, Deny, and Defend. With fear and uncertainty as our allies, we will continue to employ tactics of delay and denial (or threats thereof) against healthcare providers and policyholders, while keeping our regulators far, far away. As long as NAS continues to slumber, there is no need to even defend. Indeed, when one is under-regulated, there is little to defend against.

I remain optimistic about our industry and our company’s future

Finally, if any of you (or your family and close friends who are our policyholders) require medical care from any private specialists and any private hospital, please reach out to me. I will process your requests with the utmost confidentiality and rest assured that your treatment options and insurance coverage are not restricted in any way to any preferred physician panels or preferred hospitals list that the Company may have issued to our policyholders.

Yours sincerely,

Hobbitsma
CEO
Grape Cistern Insurance Company

About That $52,000 Rental Bid

About that $52,000 monthly rent…

The hottest topic on both the mainstream media and internet lately has been that HDB shop-lot in Tampines that attracted a successful bid of $52,188 rental a month.

Minister for Health Mr Ong Ye Kung expressed dismay at this outcome and said ultimately it would lead to “higher cost of healthcare one way or another”. More importantly, he noted that “higher rental bids do not necessarily translate to the best healthcare that the community needs”. (4 June, Facebook post).

He went to restate what has been previously reported in the news: MOH is working with HDB to launch a new tender system such that quality of care accounted for 70% of the tender evaluation, and rental price accounting for the remaining 30% with Bartley Beacon, another HDB estate.

Obviously, the recent trend of rapidly and sky-high rental bids has not gone unnoticed by MOH. In February 2024, a 2nd-floor clinic space, also located in Tampines (633 Tampines North Drive 2), attracted a successful bid of $39,938 rental a month. And if you think this is an outlier, the answer is negative. The next two highest bids were $39,888 and $36,138 respectively.

In January this year, a clinic space at Tengah went for a rental bid of $40,088. As you can see, the trend is ominous. So, getting to $52K today is something that is while “obscene”, (To quote Dr Hishamuddin Badaruddin, the doctor who originally made public this figure on his social media account) but hardly unforeseen.

Another interesting factoid is that these new HDB shop-lot are about 550 square feet in size, which is about 100 square feet smaller than shop-lots launched say, 20 years ago. Older HDB estates commonly have shop-lot sizes between 650 to 700 square feet. This loss of 100 square feet is about the size of a small consultation or procedure room. In other words, whereas in the past you can squeeze in two consultation rooms and a procedure room in to the HDB shop-lot, you probably can’t do that with 550 square feet. So, the assertation that the high rental is workable because you can have two doctors working in two consultation rooms simultaneously is a stretched one; what if suddenly an asthma patient needs a nebulizer? Are you going to neb him in the waiting area with the other patients? Or neb him in your consultation room and you suspend patient consultation in the meantime?

But the larger issue besides such operational ones is what is the role of the market and market forces in healthcare? In one corner, you have the “purists” who maintain that market forces will allocate resources most efficiently through the forces of demand and supply. So, $52000 rental is not a problem. The market will work itself out and everyone will live happily after. In the other corner, there are those who think the healthcare sector needs to be managed, and sky-high rentals do not lead to good outcomes for the public that requires such services.

But what does the Government say? Or at least, what did the Government used to say?

In 1993, the Government published a White Paper titled, “Affordable Health Care”. The White Paper was the work of a Ministerial Committee on Health Policies. The Committee was originally chaired by then Deputy Prime Minister Lee Hsien Loong followed by Minister Mr Dhanabalan, and its members were several Cabinet Ministers and Ministers of State.

Notably, right from the outset of the White Paper, this was stated, “Any healthcare policy has to trade off among four competing goals

  • Equitable access
  • Freedom of choice for patients
  • Affordability; and
  • Freedom to organise production and to price

No known health care system achieves all four goals simultaneously. A system can achieve three of them with some compromise. Which three to aim for depends on the prevailing social, financial and political conditions. Given Singapore’s environment, we have to compromise the last goal: freedom to organise production and price”.

(page 13, Affordable Health Care)

The Paper came up with a “Proposed Health Care System” that entails a “hybrid approach to controlling health care costs: neither to create a totally regulated national health service, nor to give providers full freedom to organise and to price health services in a completely free market”.

(page 14, Affordable Health Care)

Moreover, it was also stated in  Chapter 2 of the same Paper “Health Care Philosophy” that “health care is an instance of market failure” (page 18).

Let’s now look at what happened when we let unbridled market forces determine our fate.

In 2008, the government tendered out a piece of 99-year leasehold land for the building of a private hospital. Since then, no land has been released for this purpose in Singapore. The tender was awarded on 18 February 2008. It involved a site area of 12,226 square metres yielding a Gross Floor Area (GFA) of 72,350 square metres or 778,775 square feet. The successful bid was $1,246,200,389. For those of us not accustomed to counting so many digits, that’s ~$1.25B or $1,600 per square feet of floor space. This was and I believe still the most expensive piece of hospital land ever sold. The hospital today standing on that piece of land is Mount Elizabeth Novena Hospital (MENH). If my memory serves me correctly, the 2nd highest bid was about half of this figure.

This is the free market at work. And by winning this bid, Parkway Hospitals (then) managed to maintain its dominant position in Singapore’s private hospital segment. But in the process, as most of us doctors will know, it also probably contributed to more healthcare inflation once the high land cost of this project was factored in. The total project cost was probably somewhere between $1.5B to $2B, once you include construction, equipment and commissioning costs. And this was more than 10 years ago.

This high land price has far-reaching consequences for us even now, some 17 years later after that momentous tender exercise. It probably also set a new benchmark for private hospital land in Singapore. In government land tenders, the Chief Valuer sets a secret reserve price for the piece of land being tendered. If all tenders come in below the reserve price, then the tender is not awarded. This non-award of tenders because all tenders came in below the reserve price has happened before.

One wonders, what will be the reserve price for private hospital land now, if a new tender is called? Can a new hospital operator come in to this market segment since the reserve price is certainly influenced to some extent by precedents?

Thankfully, this situation of a very high bid affecting subsequent tenders does not apply to this $52,000 bid. HDB has clarified that “The rental for this Tampines clinic does not set any price requirements for future tenders by HDB, and it also will not affect the rentals that HDB is charging other existing clinics,”.

Unfortunately, no government official has said the something to the same effect for private hospital land.

It is worth repeating here what those wise people wrote in 1993 in the Affordable Health Care White Paper,  “health care is an instance of market failure”.

An Insurer Can Do Many Things

I read with interest this rather long opinion piece by an ex-ST journalist in The Straits Times “Some practical ways to rein in rising healthcare costs, premiums” (Claire Huang, 21 May 25, The Straits Times)

In particular, one section highlighting Integrated Plan (IP) insurer Great Eastern Life deserves scrutiny.

Let’s reproduce the section here,

“What an insurer can do”

“IP insurers are constantly looking for ways to sieve out doctors and hospitals that like to maximise profits.

In this area, Great Eastern Life might have found an achievable and pragmatic way out.

In October 2024, the insurer launched its own medical care concierge, where its in-house officers help match patients to doctors, based on their IPs.

These 10 officers, who are experienced in handling patients or are medically trained, are employed by the insurer and receive a fixed salary.

They first determine what benefits apply based on the policy the patient has, then they recommend specialists who are on Great Eastern’s panel.

Patients can also choose to seek treatment from specialists who might not be on Great Eastern’s panel.

In such an instance, the co-payment amount will logically be higher and some benefits may be moderated if the specialist is not on the panel.

The cost estimates and differences will be made known to the patient.

Those who opt for panel doctors will receive pre-authorised certificates and their claims will be guaranteed by the insurer.

Already, the scheme has worked for Great Eastern, whose concierge team has processed more than 1,100 policyholders so far.

Besides preferred doctors, insurers also have their preferred hospitals.

The preferred hospitals approach functions on the basis of the insurers’ bargaining power, which has grown as medical tourism here dries up.

Some insurers secure bill discounts for patients by agreeing to send these patients to preferred hospitals.”

Let this hobbit now comment and offer another perspective on this subject in addition to this piece of awkward journalism.

In particular this statement, “IP insurers are constantly looking for ways to sieve out doctors and hospitals that like to maximise profits”.

This is true to a certain extent. But then, to be fair to both doctors and hospitals, aren’t the insurers, as companies responsible for maximising shareholder value, almost always trying to maximise profits too? Why only focus only on doctors and hospitals? Should IP insurers also be sieved out when they maximise profits?

Anyway, in this hobbit’s opinion, let us look at some past behaviour and practices as well as the track record of GE to see if it is as good as it is made out to be by this article.

In the 2022 IP Providers’ Ranking Survey conducted by SMA which was published in the SMA News June 2023 Issue, GE did not do so well: (https://www.sma.org.sg/news/1953/June/SMA-Integrated-Shield-Plan-Providers-Ranking-Survey-2022).

In fact, of the 4 largest IP insurers, (Income, AIA, Prudential and GE), it regularly came in last on many fronts. The Survey involved respondents who were doctors. Out of a scale of 1 to 5 (5 being the best), it achieved an overall score of 2.5, which was only higher than the two smallest IP insurers: Singlife and Raffles (which has an employee-physician model). Overall, it was placed 5th out of 7 IP insurers.

In terms of doctor-panel management, GE did pretty well in the 2022 Survey, in terms of inclusiveness and transparency of criteria for doctor selection, scoring 2nd out 7.

But for 5 out of the remaining 6 questions asked, it ranked a poor and consistent 5th place out of 7 insurers, above Singlife and Raffles but consistently below Income, AIA or Prudential. These 5 questions are: ease and timeliness of pre-authorisation, timely payment to doctors and appropriateness of fee scales and putting up obstacles to dissuade policyholders to see non-panel doctors.

Of course, one may say well, this is all about doctors’ perspective which may be biased. Well, let’s look at MOH data then.

Lest we think that panel management is something that GE is good at, and maybe that is the case in 2022, latest and official MOH data suggests otherwise: (https://www.moh.gov.sg/managing-expenses/schemes-and-subsidies/integrated-shield-plans/about-integrated-shield-plans/)

Let’s look at what happened in 2024 for the Big 4 IP insurers according to MOH data

PanelNo. of Private Specialists (Total)No. of Private Specialists Who LeftNo. of Private Specialists who Joined
AIA5942512
GE77912674
Income8073793
Prudential81416154

The data provided by MOH claim with this footnote/disclaimer:

“The higher private specialist attrition in 2024 was due to Great Eastern Singapore’s planned panel review. Great Eastern Singapore continues to maintain a large pool of private specialists on its panel”.

I would hazard a guess that this footnote was inserted at the insistence of GE but to be fair, one does not really know who wanted it to be there. But the MOH numbers speak for themselves.

Adding on new specialists is always a good thing for policyholders because it gives them more choice. But removing specialists may not be a good thing. It leads to loss of choice and more importantly, continuity of care probably suffers. 126 out of 779 is a turnover rate of 16%. The footnote only states that it was due to a “planned panel review”. The statement doesn’t state how often such planned panel reviews occur. Could it be yearly, or more frequently or less frequently? Anyway, if you remove 16% of specialists each year, you can effectively turn over the entire panel in 6.25 years, and that is assuming you top up each year with the same number of new specialists that you remove, which is not even the case here. The panel size actually shrank in 2024, because GE only added 74 private specialists while it removed 126. The panel size of GE for 2022, 2023 and 2024 were 764, 831 and 779 private specialists respectively.

As a policyholder, one should assess an IP insurer’s panel management not just on the absolute number of specialists and whether the panel size is increasing, but also the amount of turnover (number of specialists leaving and joining). The worst scenario is when panel size decreases and at the same time the panel experiences high turnover. You have less choice and continuity of care suffers as your preferred doctor is removed from the panel.

One can easily access MOH data from the link given above and see for yourself and come to your own conclusions as to which IP insurer is better managing their panels for the benefit of policyholders and not just for other reasons, e.g. profit maximisation.

Next, we come to look at some examples of how GE (or rather their appointed third party administrator, Adept Health) communicates with some of their panel specialists. Several specialists have surfaced essential copies of the same letter to this hobbit sent out in Aug 24. An excerpt from this letter reads

“XXH Privileges, Great Eastern (GE) is pleased to announce that XX Hospital (XXH) has been designated as the priority and preferred hospital for Great Eastern Life customers. This selection is based on XXH’s commitment to delivering exceptional care, which aligns with the goal of providing the best possible healthcare experience for the customers”

If the panel doctor does not play ball and admit GE policyholders to XXH, then they may receive another letter several months later. Excerpts from this letter (which this hobbit received with the doctor’s name redacted, so the doctor’s identity is unknown even to this hobbit):

“We have recently noticed that the clinic has not been prioritizing admissions to GE preferred hospitals, such as the XXH. This may result in non-compliance with our guidelines.

As a result, Dr. YYY name is currently removed from the Health Connect website.

If you are accredited, we kindly request that you prioritize admitting patients to GE preferred hospitals during this 3-month observation period.

Should you have any questions or require clarification, please do not hesitate to contact us.

Dr YYY, apparently appealed, because a month later, the TPA replied with an email. Again, excerpts from this email,

“Thank you for allowing us the time to review this matter.
 
Based on our PAC issuance data of Year 2024, we do observe there are patient admission from Dr YYY mostly at ZZ Hospital (You can refer to the PAC data captured at DA Adept records for your reference). As we are also informed by GE side of data (for non PAC cases) it was observed with similar trend as well.
 
We are open to understand more from Dr YYY if there are any challenges or concerns in supporting this initiative.
 
Please note that despite the temporary removal of Dr. YYY’s name from the website, Dr YYY still remains as a panel specialist under GE Shield. This change will not impact Dr. YYY’s PAC requests”.

Finally, Dr YYY was terminated from the panel recently by email:

“We regret to inform you that we’re serving this termination notice on our Health Connect Provider Agreement”. No specific reasons were given for the termination, but one can reasonably come to your own conclusions from the sequence of events and previous communication the reasons for the termination.

A few points are worth discussing here. As an insurer, it is free to source for the best deal from private hospitals, generally speaking. But as a doctor, I can tell you, there are hospitals and then there are hospitals. This is the same for restructured hospitals. There are things that SGH can do, that well, Sengkang General cannot support well as a hospital. There are complicated stuff that NUH can do, that NTFGH cannot. MOH acknowledges this as much – different restructured hospitals have different levels of capability.

And so it is too with the private sector. There are complicated procedures that XXH cannot support, that another private hospital can. Of course these better equipped and staffed hospitals are often more expensive. To simply say that one must admit their patients to a certain hospital just because an insurer has a special arrangement with that hospital ignores the complicated nature of medical practice and hospital capabilities, and may even promote unsafe clinical practice just to satisfy an IP insurer’s commercial interests.

Please also note in the above correspondence that the TPA did not once claim Dr YYY was expensive and did not follow GE’s fees schedules. The professional fees charged by Dr YYY was never highlighted as an issue.

More importantly is the whole idea of transparency. Has GE informed its policyholders in the first instance that panel doctors who don’t use their preferred XXH hospital will be penalised? And perhaps even eventually removed from the panel? One must tell the good news with the bad news. One should not only tell policyholders that they will get free parking and a free fruit basket etc if they go to XXH. They should also tell them that there is a risk of their preferred panel doctors being removed from the panel if they do not agree to being admitted to XXH, leading to a loss in the continuity of care.

In fact, the IP insurer should tell potential customers of their IP plans upfront that their choice of care is largely limited to certain preferred hospitals, or rather private specialists admitting to these preselected hospitals before IP policies are sold or purchased. Then folks shopping for an IP policy can then make an informed choice of which IP insurer to use or buy their IP policies from. What GE is doing is essentially selling a “bundled” IP product, with preferred specialists and preferred private hospital(s) bundled together. Nothing wrong with that, but they need to tell everyone upfront, including existing policyholders and potential customers who are seriously considering buying their IP policies. They can then compare the price of a bundled product with the price of another IP product that gives them more choice of not just doctors, but hospitals as well.

Back to the subtitle in the opinion piece in The Straits Times, “What an insurer can do”. There are many things that an insurer can do. Perhaps too many. This is because the clinical aspects of the IP sector are largely unregulated while the assigned regulator, the Monetary Authority of Singapore (MAS) is interested mainly in ensuring that an insurer is financially viable and does not go bust. Indeed, the insurer can do many things legally. But should they?

Now, based on the above information, would a hypothetical construct called “the reasonable lay-person” still buy an IP policy from GE? Perhaps he will, perhaps he won’t. This hobbit doesn’t know. Perhaps Ms Claire Huang may know and you can ask her.

How You Pay Affects How Much You Pay (and How Much Taxes We Pay)

Last month, DPM Gan Kim Yong and Health Minister Ong Ye Kung gave an interview to The Straits Times’ Ms Salma Khalik (Healthcare financing in Singapore: 10 Questions for DPM Gan and Health Minister Ong, 10 April 25). These are two persons who collectively have run MOH for 14 years and they really know what they are talking about.

But for the avoidance of doubt, the serious smart money is on the interviewer, Ms Salma Khalik, who has been covering health for ST since BC times (Before Clustering) and possibly even before there was Internet and the smartphone. This hobbit thinks only Senior Consultants can safely claim they were already born when she started covering health matters for ST.

A few things struck me in that interview, which includes lightning, since it was so near to the General Elections 2025 when the interview was given. The first notable point is that by 2030, the MOH Budget likely to approach the eye-popping figure of $30B. To revisit the first of Minister Ong’s two truisms of healthcare which he mentioned last year in Parliament (6 March 24) – the people always pay. This $30B will be paid by the taxpayers, since MOH Budget is mainly funded by government revenue.

Another important point made in the interview and also previously on other occasions is that one in two persons with Integrated Shield Plans (IPs) and riders opt for subsidised care.

These two points are worth mulling over especially in the context of Minister’s Ong’s second truism – How you pay affects how much you pay.

Personally and selfishly speaking, I do hope that people with IPs and riders do not opt for subsidised care. The logic is simple: – subsidies are always paid by every taxpayer, and that includes me. But if folks use more insurance to pay for their healthcare expenses, then the taxpayer pays less. It’s almost literally a zero-sum game because insurance is funded by policyholders and returns from investments by insurance companies using the premiums collected.

However, whenever folks do NOT utilise their IP entitlement and go to the subsidised classes, taxpayers end up paying most of the bill. Even for B1 class, taxpayers pay because B1 class is subsidised a bit. Only A class is unsubsidised.

The next question to ask is then why are so many people with IPs and riders opting for subsidised care? There are many reasons but one of the most often quoted reason is that they worry about difficult access to subsidised care after a hospitalisation or procedure. Current IP plans all cover the patient at the outpatient level only for a very limited period after a hospitalisation or a procedure. After the coverage expires, the patient has to pay the expenses himself. And once a patient opts for private hospital care or A or B1 care in the restructured hospitals, he will continue outpatient follow-up care with either private specialists or the private (unsubsidised) clinics in the restructured hospitals. Many such conditions are chronic ones and they require a long, if not life-long, outpatient follow-up and many people need subsidies due to the high cost of such long-term follow-up.

The end result is that many people then opt for subsidised care despite having bought IPs and riders so that they can avail themselves to these subsidies during follow-up.

To better understand this flight to subsidy safety among IP policyholders with riders, we can conceptually divide policyholders into three groups:

• Group 1: Folks who will always use private sector services for inpatient and outpatient care
• Group 2: Folks who will select between private sector and subsidised services depending on insurance coverage and subsidy policy
• Group 3: Folks who will always use subsidised care (basically, they didn’t really know what they were buying when they bought an IP)

For the avoidance of doubt, “private sector services” refer to services that are completely unsubsidised – private sector hospitals and clinics and also A class inpatient and private (unsubsidised) specialist clinics in restructured hospitals (RH) since the latter do not consume government subsidies.

The 2nd group is what concerns us today. As aforesaid, because of the bundling of subsidised inpatient care with subsidised outpatient care, many policyholders forgo the use of private inpatient services so that they can enjoy subsidised care during follow-up. And as our population ages, the follow-up of chronic conditions discovered during before or during an inpatient episode can be for a long time, if not life-long.

This results in unnecessary consumption of the MOH Budget (i.e. taxpayers money).

This policy has been in place for a long time because policy wonks are worried that folks will game the system. I.e. these folks want the best of both worlds: by consuming inpatient services paid for insurance and then using subsidised services when insurance coverage ceases. But in reality, as we shall see, this worry has been downgraded somewhat in recent years.

If one thinks about this again, by continuing with this policy or practice, many people end up using subsidised, inpatient services unnecessarily which generally speaking, are a lot more expensive to the taxpayer than outpatient services. Again, we have to remember it is better if policyholders finance their healthcare needs with insurance monies than with tax revenue.

However, if we truly allow patients to cherry-pick (by using insurance-funded inpatient services and taxpayer-funded subsidised services), then a problem will arise with the first and second groups. The attraction of subsidies is so great that some folks in these groups will migrate towards outpatient subsidised services.

There is already some pre-existing friction put in place to discourage this because one cannot choose the specialits of his choice in subsidised services, whether inpatient or outpatient. Also, appointment times for private SOCs are significantly shorter than subsidised SOCs. But this hobbit readily admits this friction or obstacle is not really big enough to prevent overconsumption of subsidised services. Further trade-offs may be therefore necessary.

Moreover, access to subsidised specialist outpatient clinics (SOCs) and services have been made much easier in recent years with the CHAS, Pioneer and Merdeka Generation benefits. It used to be that only polyclinics and A&E referrals will give a patient access to the subsidised SOCs. But now any Healthier SG family physician can make referrals to the subsidised SOCs and their patients will enjoy subsidy levels according to their CHAS, Pioneer, Merdeka Generation card status. This is what I mean when I say the worry of overconsumption of subsidised services have been downgraded somewhat in recent years.

This hobbit doesn’t have the data, but it would be good if someone with the data does a simulation on how much of the MOH budget is used to finance subsidised inpatient cases that come from IP policyholders who voluntarily downgrade at the inpatient level. These are the potential savings from that could have been realised if inpatient subsidies were not doled out to this group.

This hobbit would like to suggest that to reduce the number of IP policyholders voluntarily downgrading to subsidised services without using their IP benefits, it is worthwhile to just allow IP policyholders to choose a private service for an inpatient stay and then let them have the option of choosing subsidised SOC services when they go for follow-up. If the policy wonks are worried that this would lead to everyone choosing subsidised SOCs, then we can perhaps strike a compromise – we would limit this option to conditions that had been newly diagnosed (i.e. just before or during the inpatient stay) for the purposes of this inpatient or procedural episode.

For example, if a patient goes for a Total Knee Reconstruction (TKR) at a private hospital or as a Class A patient in a RH, but is diagnosed to have diabetes just before admission as he is being assessed by the anaesthetist, then he should be given the option after the operation to be followed up at the subsidised SOC at a RH. The subsidised SOC can then decide to follow-up this patient or discharge him to the polyclinic when his diabetes stabilises.

Today, certain RHs already allow for downgrading to subsidised SOCs after B1 or A class inpatient episode. But to further discourage unnecessary downgrading, we should maybe allow private hospital inpatients (not just RH’s inpatients) to use subsidised SOCs as well after IP coverage expires.

If the patient or IP policyholder is given this optionality of delinking outpatient subsidy from the inpatient episode, we can perhaps get more IP policyholders to use their IP benefits at the inpatient level and rely less on funding via subsidy, i.e. how much the government or taxpayer pays.