November Ruminations

Before we know it, the nation is ambling towards the end of 2021. If you ask this hobbit, 2021 was even stranger than 2020. There wasn’t the shock and awe that inevitably accompanied the advent of a new pandemic. The fear is still there, but fear, like a fixed cost, sort of diminishes with time and vaccinations, replaced by an all suffocating sense of morosity, vexation and weariness.

Anyway, speaking of vexation, recently, there was a report about how a doctor was vexed when a 99-year old Covid positive patient died at home and the family experienced problems with procuring undertaking services immediately after the death. (The Straits Times, 1 Nov 21). A director from the MOH in charge of Aged Care Services replied that it need not have been so, “our (MOH?) processes allowed him to be conveyed to the mortuary but the undertakers were reluctant to do so”. He further said that “Many of our undertakers have undergone infection control training by the National Centre for Infectious Diseases, many may still be concerned about managing those who die of Covid-19”. (6 Nov, ST Forum)

In a rare case of factual rebuttal, the Secretary of Association of Funeral Directors Singapore wrote in the same ST Forum the next day, “Funeral directors, as of now, are permitted to handle bodies of Covid-19 patients only at hospital mortuaries. Even the casketing of the body has to be done on the mortuary services. The regulations do not allow funeral directors to do this anywhere else”. He added, “In Mr Teo’s (i.e. the deceased) case, the funeral director who was asked to assist but did not was complying with regulations set out by MOH. The funeral director would run afoul of the law if he had proceeded to move Mr Teo away from the residence”. He then stated the obvious, “If we are to allow persons with Covid-19 to undergo home recovery, we need to accept that some people will die at home”.

Ouch.

To-date, this hobbit is not aware that MOH has published any reply to this letter from the Association of Funerals Directors Singapore yet.

If only the dead could talk, maybe we should ask them about how they feel about this whole affair.

Going past the irony and pathos of the whole situation, this hobbit notes than 171 circulars have been issued so far. Actually, probably more than 171 circulars have been issued because nowadays MOH may issue “secondary” releases of circular on the same subject matter with an alphabetical suffix. E.g. In addition to Circular 170, there could be 170A and 170B and so on.

In 2020, 244 circulars were issued. In other words, probably 400 circulars have been issued since the pandemic began and Singapore saw its first case of Covid-19 infection on Jan 2020 till now. Of course, not all circulars are Covid-related, but the majority of them certainly are.

I guess with time, even the people who drafted these circulars and the issuers of these circulars may have forgotten about the content of earlier circulars. After all, events of a year ago seem a lifetime away. Alert readers of this blog may recall that it was on 28 Dec 2020 (i.e. Phase 3), that folks were allowed to dine in up to a group size of 8.  11 months later, eating in a group size of 8 seems like something so remote that it almost sounds bizarre.

The other possibility is that the whole thing has gotten so complex that different stakeholders may not be aware of what other stakeholders are doing. For example, the disease control folks have a set of concerns that could be quite different from the aged care people.

So this hobbit is not surprised one bit when the Director of Aged Care Services doesn’t seem to be aware of the MOH-issued prohibition on funeral directors to handle the bodies of Covid-19 patients outside of hospital mortuaries.

We now move on to the other big happening of November 2021, which is the announcement on 9 Nov 21 by MOH of the setting up of the Clinical Claims Resolution Process (CCRP) platform to resolve disputes among Integrated Shield Plan (IP) policyholders, IP providers and doctors. Tandem with this announcement is the commitment declared by IP providers to increase the size of their preferred provider (i.e. doctors) panels.

The CCRP is essentially a mediation platform. When disputes are filed and the stakeholders agree to go through CCRP for mediation, a CCRP Panel consisting of two medical director representatives from IP insurers and three relevant specialists chosen by the Academy of Medicine Singapore (AMS) and a non-voting representative from Consumers Association of Singapore (CASE) is formed to assess the case.

The hobbit thinks this is a significant development in both the patient’s and doctor’s favour as they seek a more level playing ground against the mighty IP providers. For one, hitherto to this, clinical issues really have nowhere to be addressed expeditiously unless one has the resources and tenacity to mount a law suit. The overarching insurance regulator, MAS, appears to be only interested in the financial viability of IP providers. MAS is either not equipped or has not shown any desire to be equipped with the knowledge and skills to deal with the clinical aspects of IPs. MOH, on the other hand, is also not the appointed administrator of legislation that directly oversees insurance company regulation. So clinical matters, such as whether a procedure should be reimbursed or not on clinical grounds, is really in no man’s land until now.

The other big development in the IP milieu is that IP providers have committed themselves to increasing the size of their doctor panels. At the beginning of this year, all IP providers, other than Raffles Health Insurance have panel size in the region of 300 to 400. By the end of 2021, these same IP providers are committed to having panel sizes of between 450 to 600. This is a step in the right direction. But there is still much room for improvement.

According to The Straits Times report “Give patients in Singapore better choice by having insurers share a common pool of panel specialists”, there are 1,235 specialists in the private sector who are eligible for empanelling. Since practically no one buys IP from more than one IP insurer, it means any policyholder only has less than half of eligible specialists available to him at any time should he need care to be covered by his IP.

Nonetheless, both the CCRP and the increase in doctor panel size are positive developments. It is therefore important to ask how have these positive developments come about and why.

Even before Covid-19 hit our shores, many private sector doctors have expressed disappointment with how some IP providers were conducting their IP business in terms of pre-authorisation processes, reimbursement rates and doctor empanelling. As far as this hobbit knows, all this came to naught as the doctors’ grievances fell on deaf years and were met with stonewalling.

Things only started to move after the 61st Council of SMA decided enough was enough and crossed the Rubicon on 25th March 2021 by issuing a Position Statement on “Troubled Integrated Shield Plans”.

This Position Statement

  • Described the historical context and development of IPs from the 90s till present, and explained how many of the problems faced by IPs were really of their own doing, when they, on their own volition, introduced IPs that were badly designed, e.g. as-charged plans, first dollar riders that did away with deductibles and co-payment etc.
  • Highlighted how IP providers misinterpreted and misapplied some of the recommendations of the Health Insurance Task Force (HITF) with highly exclusive panels (21% of eligible specialists), opacity in the selection criteria for panel doctors, and only respecting the lower-end of the MOH Fee Benchmarks
  • Questioned the sustainability of the entire IP sector; IP insurers were being indirectly and heavily subsidised by the government through this unique phenomenon of “voluntary downgraders”
  • Drew attention to the cost control efforts (or the lack thereof) of IP providers – the Statement referred to a Report published by the Singapore Actuarial Society (SAS) that shown IP providers’ management costs and commission costs grew much faster between 2016 and 2019 than gross premiums and gross claims. The SAS Report revealed that only 75% of premiums collected went to payment of claims.

There was intense public and media attention on the IP sector in the wake of the publishing of the SMA Position Statement. Just three weeks after the publishing of the SMA Position Statement, on 14 April 21, MOH announced the formation of the Multilateral Health Insurance Committee (MHIC) which comprised representatives from major stakeholders in the IP sector. According to The Straits Times, the changes that came about: CCRP and increase in doctor panel size were attributable to the recommendations made “by the MHIC which was set up by the Government in April to reshape the private health insurance market”. (“More specialists on IP insurance panels: What this means for you”; 9 Nov 21)

One can reasonably speculate that without the SMA Position Statement, the MHIC would not have been formed so quickly or even formed at all. And without the MHIC, there would have been no recommendations to set up the CCRP or to increase doctor panel size.

So let’s give the 61st Council of SMA a clap – without them and their Position Statement in March 2021, we may still be stuck in the trenches and facing stonewall after stonewall every time we tried to get a better deal for patients and doctors.

Clarification: First Note Republished

This evening (4 Oct 21) I was forwarded an opinion piece written by The Straits Times Senior Health Correspondent Ms Salma Khalik, “Covid 19: When there’s confusion. it’s tough to pull together against a common enemy”. It was posted on the ST website at about 2240hrs.

The article stated that “The Singapore Medical Association runs an opinion blog called hobbitsma, penned by an anonymous author”.

I guess the “anonymous author” means me.

The article by Ms Khalik makes many noteworthy points which I encourage you to read. However, I just want to make one important clarification. This blog is run by me. The Singapore Medical Association does NOT run this blog. It may choose to republish some of the posts from time to time with my permission, that’s about it.

The confusion may have arisen because of how my life began. I began as an occasional columnist in the SMA News some 20+ years ago. Then I left the SMA News in 2011 but SMA set up a Facebook account for me and long-term readers will remember that before I used WordPress, my posts were long Facebook posts. However in late 2015 , the Facebook account was discontinued and so even the last vestige of link with SMA has been cut and I now blog on the WordPress platform.

For the last 10 years I have been on my own. A “ronin” hobbit of sorts, not in service of any daimyo and answerable to any editor or editorial board. Completely independent.

This fact can be seen in the “First Post” on Facebook, which I reproduce here in full (first published on July 2011): https://wordpress.com/post/hobbitsma.blog/133

Dear Friends and Colleagues

Yes, the SMA Hobbit is back. But on a different forum from the SMA News.

Even an old coot like this hobbit has to keep up with the times and social media simply cannot be ignored.

The social media offers several advantages from an established hardcopy print medium like the SMA News. For one, there is no printing press deadline to meet. The SMA news goes to print every month and this hobbit has strived hard to meet these deadlines and come up with articles with some regularity in the past. There is no such requirement with the social media such as a blog or a post on Facebook. I can post every few days or every few months.

Secondly, hobbit columns in the past in the SMA News have to conform to rough expectations of print space, i.e. about two pages or about 1300 words. With the social media, there is no such expectation. A post can be just several words or a few hundred words or even more than the usual 1300 words.

Thirdly, there is no editing or censorship by the SMA News Editorial Board. What I post on Facebook is entirely my personal business. There are pluses and minuses to this new arrangement. The main plus is that I am not subject to the Editorial Board’s decisions on what to print and what not to print. The minus is that I am entirely on my own here. Don’t get me wrong, I respect the role and responsibility of the SMA News Editorial Board. They are volunteers and they have a job to do. Having said that, that doesn’t mean I necessarily agree with their decisions even though I must respect them when I contribute to SMA News. So when the differences came to a head over a certain article, I exercised my right to retire from the SMA News as a columnist. To be absolutely clear, there were many important reasons that led me to my retirement from the News about half a year back, including the demands of work, family, but the decision of the SMA News Editorial Board not to print a certain article was also a big contributory factor.

Enough of the past, back to the present. Since this is my first long post here, I need to stress that whatever is posted here does NOT represent in any way the official position of the SMA on any issue. The folks in SMA have kindly set up this Facebook account for me to continue my nonsensical and personal ramblings in Cyberspace. I appreciate this opportunity and new forum and I hope you will continue to support me here virtually as you have had in the past in print.

As you are well aware, the Hobbit lives in a mythical parallel universe called Middle Earth. Unless otherwise and specifically stated, events and personalities referred to in this Facebook account are completely fictitious and belong to the realm of utter fantasy. If you do suspect that I am referring to anyone or any event that you think may have occurred on planet Earth (i.e. 3rd Rock from the Sun, and NOT middle-earth), then let me again reassure you your suspicions are totally unfounded and without any basis.

For the avoidance of doubt and to be absolutely clear – all future writings and opinions expressed here on this Facebook account are un-researched, untrue and cannot be substantiated. So read at your own risk, folks.

The Meandering Undead

What Now:- The Undead Phase?

We are now in uncharted territory. We have gone where no human, hobbit, Klingon has gone before.

This hobbit is not even sure what phase we are in anymore. There were terms like Dorscon Orange, circuit breaker, phase 2 and 3, heightened alert, preparatory phase, transition phase etc that were invented by wordsmiths. Apparently, we may be now in the “stabilisation” phase.

I would like to think we may be in the necromantic “undead” phase. We will trudge on. Till when? To where? Nobody really knows.

I remember I had this discussion with a war historian many years back about why Germany lost World War 2. Man for man, equipment-wise, the German army was equal if not better than any other army at the beginning of the war. By 1941, Germany had conquered almost all of Western Europe. Those that were unconquered were allies of Germany or neutral. After the conquest of Western Europe, the Germans were mainly fighting the British (and later the Americans as well) in North Africa.

But they were defeated because they then chose to fight on two fronts in 1941 to 1942 when Hitler chose to invade Russia in the middle of 1941. Having failed to take Moscow in the winter of 1941, they decided to go for the oilfields in Caucasus in South Russia, which wasn’t a bad idea. The original plan was to just destroy the industrial capacity of Stalingrad and to capture the oilfields. But then Adolf Hitler decided that he wanted to occupy Stalingrad as well, which really was sort of a “vanity project”, as the city is named after his arch-nemesis Stalin.

As history showed, the main bulk of the German forces in the Battle of Stalingrad, the 6th Army, was wiped out in an encirclement by the Russian Army in the winter of 1942.

The German Army never quite recovered from the disaster in Stalingrad and so lost the war in the Eastern front. In the end, they also lost the war in North Africa because too much resources had been devoted and lost in Russia and the African front was hopelessly under-resourced. This led to the allies invading Sicily in 1943 and Normandy in 1944 while the Russians continued to push westwards and recovering all its lost territory. The war in Europe ended in May 1945 when Germany was defeated by the allies sweeping eastwards and the Russians marching westwards into Berlin.

Fighting on two fronts

When it comes to resources, it is really quite a finite zero-sum game, at least in the short run. Testing of asymptomatic cases, even when self-conducted, is not resource-free on the healthcare system. Testing involves the redeployment of resources and which could have been utilised elsewhere.  

This hobbit is not so sure what we are trying to achieve here. We seem to be going to something akin to a heightened alert phase when the number of cases rise. Then when cases drop, we relax a bit. Which in turn will probably lead to a rise in cases again as social interaction increases, and then we reflexively clamp down again.

Two questions need to be asked:

  • Are we in an interminable loop of relaxing/50% to work/5 to dine and restricting/WFH/HBL/2 to dine? Even though 82% have been fully vaccinated and another 3% more due to be fully vaccinated?
  • What exactly is this country pursuing as an overarching strategy? Are we pursuing a zero-case strategy like China, Taiwan, New Zealand etc? Or are we going for endemicity, i.e. living with the virus exit strategy?

The answer proffered is that we need to stabilise the situation in the hospitals. For one thing, the situation for those in ICU and those that need oxygen seems rather stable. But there are actually more than 1000 patients admitted for Covid-19. Are our admission criteria too lax? By now we should have enough data to know what are the patient profile characteristics that will give a good prognosis and those that we know will not do well later on. This data should be carefully analysed and translated into better clinical practice so that we do not admit excessively and take up too many beds. At present, out of all patients diagnosed, 1.8% require oxygen, 0.2% are in ICU and the rest are either asymptomatic or mildly ill. Given our extensive experience in the last 20 months treating Covid-19 patients, can we extract more efficiency out of the system in terms of hospitalisations of asymptomatic and mildly ill patients?

On one hand, we say we are resolute on opening up and living with the virus. On the other hand, when we test almost everyone under the sun, we seem to be also going for a zero-case disease elimination strategy. As one public health expert put it, it is like asking each and every person caught in a downpour, “Are you wet?”

Another expert put it more starkly, “the pain of transition is made worse by being stuck in applying disease elimination measures to deal with an endemic disease. Much of what is being done in the name of disease prevention is counter-productive”.

Social media groups involving doctors are rife with comments questioning our strategy of testing asymptomatic folks. And many of these folks are respected experts in the medical community – public health physicians, infectious disease specialists etc.  

We may have some of the best healthcare workers (HCWs) in the world. But we are really tired of fighting on two fronts, supporting policies that apparently are aimed at moving towards endemicity and another set of practices that are aimed at disease elimination. Such a schizophrenic approach quickly tires out people both physically and mentally.

The Costs of Abundant Caution

It is easy to say we must do things “out of an abundance of caution”, which is probably one of the most overused phrases in recent times. But this hobbit feels these folks do not adequately address two important facets of a so-called cautious approach (even though 82% of population have been fully vaccinated):

  • The economic cost and livelihoods lost, migrant workers’ well-being, children’s need for social interaction, mental health etc.
  • While we say we want to protect healthcare and HCWs, some of these policies ignore the fact that many policies make provision of healthcare so much harder: the 2x weekly swabs, stay home orders for HCWs who are well and vaccinated, confusion among the public so that their only recourse are GPs (who are equally confused) and the already excessively crowded A&Es.

Home Recovery: Policy is Implementation

The next issue that has caught the attention of the medical profession is that of our Home Recovery strategy, which has been declared as the “default care management model” for Covid-19 patients. In itself, this strategy is absolutely correct and in-line with our stated strategy of living with the virus. But the implementation was (out of an abundance of euphemism) in a word – suboptimal. Which is rather interesting, because our transiting into endemicity was not a sudden thing. It has been discussed publicly for months. Other countries have also done it; there are both positive and negative examples of this that we can learn from. Yes when the rubber eventually did meet the road, we were found wanting.

The famous World War 2 American general, George S Patton said “Good tactics can save even the worst strategy. Bad tactics will destroy the best strategy”.

Surely, if this was intended to be a “default” model, then small-scale trials could have been run earlier to spot potential problems in communication and implementation? For example, when a new and important software system is introduced in a big company, there is always User-Acceptance Testing (UAT) performed before the system is rolled out, so that teething problems can be identified and ironed-out. Was there any trial or UAT done before our Home Recovery care management model was implemented? A past Head of Civil Service once said “Policy is implementation”. Unfortunately, some folks obviously didn’t read his memo.

New NS Vocation: Patient Buddy

That leads us to the issue of operations planning and implementation. We are now 20 months into having Covid-19 infections on our shores. If there is one thing that appears to be obviously lacking, it is our capability to plan and implement operations on a large scale quickly and well. And each time, the SAF is called in to save our butts. This is troubling to this hobbit. In many other countries, the armed forces are called in to help out in sudden emergencies and disasters, such as earthquakes and typhoons. In Singapore, they are now called in to answer phone calls and be patient buddies after the country has battled the same Covid-19 virus for 20 months. Chew on that.

An insider commented to this hobbit, “It really goes back to the reward system. If the system rewards those that can best write beautiful policy papers, then the system will produce the best policy paper writers and presenters. If the system rewards those that can do the “sai-kang” (literal Hokkien translation – faecal work; i.e. grunt work) best, then the system will produce the best operators”.

As Mr Brown, the “blogfather” recently inferred in a post (“Kim Huat and the somewhat endemic phase”)  – stop dishing out all these complicated flowcharts that most people have difficulty understanding. In fact, this hobbit has some advice for these flowchart exponents – send your beautiful flowcharts to the most junior person in your department, such as the administrative assistant or receptionist. If they understand it, then it is a good flowchart. If these junior or lesser educated folks don’t understand it, it’s a lousy flowchart. Go back and redesign the workflow and flowchart until it is understood by junior staff before it can be allowed to be circulated. Because if they don’t understand it, chances are not many people out there will.

The Magic Number of 143

Going on to the subject of boosters. On 14 Sep 21, GPs were informed by AIC that boosters can be given for those 60 and above if they had received their two doses at least 6 months (or 180 days) ago. On 17 Sep 21, this was revised to 5 months (or 150 days). That’s fine. Then on 24 Sep 21, another (third) email was sent by AIC (on behalf of MOH) to yet again change the criteria to 143 days and if the person had received an SMS from MOH to take their booster shot.

Do the folks who craft and send out such emails in rapid succession think GPs have nothing to do but read their emails and circulars? Why 143 days? Why not 144 or 142? And why must it be accompanied by the SMS invitation? A nice number like 150 days or 5 months is very good. Thank you. Please don’t load us with more bureaucratic instructions that consumes more memory space. I have a small brain with limited memory space. This hobbit would like to suggest that bureaucrats should be given a KPI that states “Have you made HCWs’ life easier with less bureaucracy?” in their annual performance assessments. I think many will fail this KPI miserably.

So very, very sick of it

A GP working in the Queenstown area said it well in his FB post dated 20 Sep 21,

Every day MOH sends us a bunch of new directives; there’s so much that my free 5gb mailbox is actually almost full! One day they say one thing, one day we read it in the papers before we get informed.

It’s now 5pm and I wanted to go home at 2 and have a nap, instead I’m clearing all the *@# from just now. And I might as well just stay here since we start again at 6 anyway. I am sooooo sick of having to rush to see and jump queue for pts with a cold, and doing all the paperwork involved in swabbing them. I am so sick of having to trace results every night and calling the pts to tell them that it’s negative. Am so sick of having to learn one new thing after another, and reading about new policies which are not clearly thought out, in the newspaper… quarantine yourself, and then after 3 days gradual return to activities. What the heck is a “gradual return”?

So very, very sick of it”.

It is apparent that to this GP, all the many and periodic expressions of appreciation and gratitude by politicians mean little to frontline HCWs like him when the bureaucrats just insensitively shovel out loads of instructions that make no sense or make life unnecessarily complicated. Pleasantries unsupported by action can only do so much.

What We Need Now

What we need now is hope, not the dreary prospect of interminably oscillating between opening up and shutting down activities, when we already have one of the highest vaccination rates in the world.

What we also need now is unity of purpose to rally the people and the HCWs. This in turn requires clarity of thought.

Hope, clarity of thought and unity of purpose. To achieve these three, we have to first settle on a communications message that is consistent, cogent and concise. This message must then be delivered with great conviction. We then have to develop and implement operations that cohere with this message.

If not, we will just be meandering around like undead zombies in search of both disease elimination and endemicity and finding neither.

September Ramblings

2021 seems to be flying past even faster than 2020. Before we know it, we are now down to the last one-third of the year. Gone even faster is the immunity protection afforded by vaccination with Covid-19 vaccines. The government has officially announced that those aged 60 or above, living in aged-care institutions or above and those that are moderately or severely immunocompromised should go for their booster shots.

This hobbit is wondering why healthcare workers (HCWs) are omitted in this first batch of booster-eligible people. After all, HCWs are working in high-risk environments and pose a significant risk to the people they care for should breakthrough infections occur. Also, HCWs are the earliest folks to be vaccinated. Many HCWs were vaccinated even before senior citizens at the beginning of this year. This hobbit hopes HCWs will get their booster shots soon.

We now move on to something that is rather confusing to this hobbit. This hobbit must state that the confusion may probably have arisen because this Hobbit is completely untrained and insufficiently informed in matters concerning the law.

An anaesthetist/pain specialist was recently acquitted of molest by the State Courts of Singapore when the prosecution, i.e. Attorney-General Chambers (AGC) withdrew the charges. However the AGC apparently subsequently disagreed with some things that the doctor’s lawyer did or said and then released two press statements in as many days. In both statements, the way in which the molest was alleged to have taken place were described in quite graphic detail, including how the molester touched the victim’s hips, cupped her breasts and how high the arms of the victim were raised. Both statements strongly suggested that the AGC believed the victim/complainant did not lie.

And yet, the charges were withdrawn, because apparently there were inconsistencies in the evidence garnered from various sources and that from the AGC’s perspective, the high threshold necessary to secure a conviction could not be reached.

Let us first view this from the victim’s perspective. If the molestation did take place, then, we could well have an honest, molest victim out there whose case has been dropped by the AGC due to technical points of the law that few lay people would really understand. This would be a double blow, tragedy upon tragedy for the victim. One cannot imagine the mental devastation that this person has to go through, first to be molested, and then to have the case withdrawn by the public prosecutor because of legal technicalities. There is no closure, and there will probably be life-long and deep emotional scars in this victim’s psyche. It would not be surprising if she would need long-term professional psychological support. My heart goes out to her if she was indeed molested and yet her case was dropped, especially when (according to AGC) there is no evidence to show she lied.

On the other hand, if the accused was innocent and accordingly acquitted, this hobbit can imagine that the first thing the accused wants is to get on with his life, especially when he and his family had in the preceding four years suffered so much indignity and emotional upheaval. Yet, he now sees press statements describing his alleged molestation in detail being made because of some dispute between the AGC and his lawyer. At the emotional level, there is probably no closure for him as well, even though he has been acquitted.

They say the truth shall set you free but frankly, to this legally-ignorant and legally-untrained hobbit, both of the above scenarios come off as rather confusing if not unsatisfying. 

Let’s finally move on to some good news.

The latest SMC Annual Report was released to the profession on 30 Aug 2021. It is a fine document with purported efficacy against insomnia and/or constipation. Anecdotal experience also suggests that reading the case reports of SMC Disciplinary Tribunal outcomes can suffuse the reader with a surreal sense of misplaced schadenfreude.

Fear not, this Hobbit will summarise the Report so that you can have more time during the Pandemic to purse your Covid-related hobbies, such as and baking sourdough and pottery (i.e. baking mud).

First the good news. The number of complaints lodged with the SMC has plunged. While many may ascribe this to Covid-19, the fact is the numbers have been steadily falling since 2016. The last year merely accelerated this trend. The numbers don’t lie:

YearNumber
2016242
2017206
2018200
2019173
2020118

This decline in absolute numbers, more than half, is made all the more remarkable when you consider that the number of doctors has increased significantly over the same period (from 13478 to 15430, an increase of 1952 doctors or 14.5%). The complaints rate has declined from 18.0 per 1000 doctors in 2016 to 7.6 per 1000 in 2020.

Somehow, this hobbit doesn’t think the mainstream media will report this very encouraging trend.

From 2018 to 2020, the five commonest categories of complaints were (in order of descending number of complaints)

  • Rudeness/Attitude/ Communication Issues
  • Unnecessary/Inappropriate Treatment
  • Professional Negligence/Incompetence
  • Misdiagnosis
  • Consent-Related Issues

2020 also marks the year that the number of doctors exceeded 15,000 for the first time in Singapore. About one-third of these work in the private sector and about 39% are specialists.

Over the last five years, it is noteworthy that the number of new provisional registrations (i.e. housemen) have risen from the low 500s to almost 600 a year. About 150 are foreign graduates while the remainder come from the three local medical schools.

For the specialists, it is interesting to note that the five fastest-growing specialties from 2016 to 2020 in terms of percentage growth were:

SpecialtyPercentage Increase
Emergency Medicine43.6
Geriatric Medicine41.9
Orthopaedics37.6
Rehab Medicine30.0
Urology29.9

The five fastest growing specialties in terms of absolute numbers for the same period are:

SpecialtyIncrease In Number
Orthopaedics82
Paediatrics76
Anaesthesia73
Diagnostic Radiology71
Emergency Medicine/General SurgeryBoth specialties 68

Looking at these numbers, one must really ask – is the growth in both percentage and absolute number of doctors and specialists sustainable? While we are in the middle of the Pandemic, we certainly want as many doctors as can get our hands on. But when life settles down in a post-Covid world, can we keep up with this growth rate?

In 2020, the number of doctors who did not renew their practising certificates was 81. The nett increase in doctors was 554 for 2020, 542 for 2019 and 390 in 2018. It remains to be seen if the recent cutback in the number of medical schools recognised by SMC will have an appreciable effect on the number of foreign trained doctors returning or coming back to work in Singapore in the coming years. But if the current trends continue, we are talking about a nett increase of a thousand doctors every two to three years.

Legally Amoral

Why do some people turn to a life of crime? Or at the very least, why do some people live their lives skirting and flirting with the edges of the law?

There could be many reasons, but they probably fall broadly into these three mutually non-exclusive categories

  1. Times are very bad and the person turns to crime to survive. That’s why crime rates go up when unemployment rates go up.
  2. The person has a pathologically criminal mind and he loves breaking the law, much like what you see in the villains that Batman battles – the folks found in Arkham Asylum like The Joker, Penguin, Two-face etc
  3. The person desires to have extraordinary or supernormal profits or pay-cheques that normal business and employment activities cannot match. These people are usually motivated by greed, and their greed overcomes their fear of the law or whatever social stigmata that comes with the running of such (legal) “shady” activities

Obviously, many of these infamous KTV outlets are operated by people belonging to the above third category. These outlets are usually called KTV clubs, bars or lounges. There are also many “family” KTV outlets which are indeed bright and wholesome (which this Hobbit sympathises with – they should indeed be statutorily classified differently from KTV clubs). But those pre-Covid KTV clubs that come with hostesses are obviously not without social stigma, yet they exist because there is demand for them and there are people willing to run these businesses because the profits and margins are very attractive.

Taking this into consideration, this hobbit cannot help but wonder – what makes some people think that by just giving them Food and Beverage (F&B) licenses, these KTV club and lounge operators will suddenly be willing to pivot to a life in the slow lane of humdrum F&B normalcy? Especially when many of these outlets don’t even have commercial kitchens. And why would anyone go to these kitchen-less F&B outlets for the food? Couldn’t they get food delivery to deliver the food to their homes instead?

In addition, it was reported in The Straits Times on 22 July 2021 that “Only 18 ex-nightlife outlets (were) given support packages to switch to F&B” by Enterprise Singapore (ESG). It was reported that 400+ such nightlife establishments pivoted to the F&B industry and yet only 18 received these support packages. This would imply at least two things – the grant was exceedingly hard to get, or that the vast majority of the 400+ outlets did not apply for the package. If the latter is true, the next question that needs to be asked is why would people not want the grant? Take the example of couples who buy a property near their parents and qualify for a government housing grant. This hobbit has never heard of anyone who would not take this grant. People who have nothing to hide will take grants if they can qualify for them. On the other hand……

To this hobbit, this episode of the KTV cluster really shows a lack of understanding of the imperfect human condition and what drives people to do what they do. And yes, it would have been quite hilarious, if not for the serious public health consequences that had arisen from it.

It’s gotten so bizarre that on 25 July 2021 (“Group wants tougher penalties for errant nightline operators”), The Straits Times (ST) reported that “the Singapore Nightlife Business Association (SNBA) also recommended that the 400 nightlife establishments that switched to the food and beverage sector last October come under police supervision”.

This is the first time in a long time in super-safe Singapore that anyone or any organisation has volunteered to come under police supervision. The only folks we run towards here, regardless of race, language or religion, are the parking ticket aunties and uncles who are about to issue a parking ticket to your vehicle. We usually run away from police supervision, not towards it.

OK, so much for the light-hearted stuff. We move on to something more serious and saddening.

On 17 July 21, a letter to the Forum of The Straits Times by a Ms Denise Ho said that her hospitalisation insurance claim for stage 2 breast cancer treatment and claim for critical illness payout were rejected on the grounds that she had failed to report she had vertigo and asthma. These diagnoses were purportedly made after she made visits to a GP for dizziness and cough.

On 26 Jul 21, the Life Insurance Association (LIA) responded by giving by what can be described as a legally correct and general answer. The reply did not comment specifically on the case at hand, but gave the general principle that “in order to reject a claim or invalidate a policy, life insurance companies are responsible for proving that the non-disclosure of the health condition to a question asked in the application form is material to the underwriting outcome…”

LIA also said a person could seek redress with the Financial Industry Disputes Resolution Centre (FIDREC), and finally an aggrieved person can also explore legal action.

On 29 Jul 21, a letter from Mr Chia Boon Teck to the same ST Forum revealed important information. Apparently FIDREC does not allow for involvement by lawyers and “has a claims cap of only $100,000”. So for higher claims, the policyholder has to get legal help, which Mr Chia rightly pointed out, “victims in such scenarios would hardly have any money for their medical treatment, let alone for legal expenses”. Ouch.

Now the LIA reply took pains to say it “is not in a position to comment on any assessments by any specific insurer”, this hobbit is not bound by such self-imposed and convenient rhetorical handcuffs and mufflers of the LIA.

Interestingly, up till now, the relevant regulatory authorities have also kept silent on this matter.

Let’s now really examine the case at hand – breast cancer with a possible history of vertigo and asthma.

Anyone who is medically trained will wonder what has vertigo and asthma got to do with breast cancer. But according to the reply by LIA, the key words are “underwriting outcome”, which means anything that would have altered the insurance policy’s terms, such as loading of insurance premiums or limitation of coverage may allow the insurance company to “reject a claim or invalidate a policy”. This is evidenced by what LIA’s stated condition: – “the terms of the policy would have been different from the terms that were actually offered and issued”.

So while vertigo and asthma have got nothing to do with breast cancer, the fact that these conditions may lead to different terms of the policy from the terms that were actually offered and issued already entitles and justifies an insurance company’s action to deny a claim for breast cancer.

To this hobbit, this is the legally correct but amoral world that policyholders and healthcare providers have to contend with when we deal with insurance companies. It is effectively heaping misery upon misery on a sick person. It is bad enough to have cancer, but the policyholder has to now also contend with the shock and dismay of knowing the hospitalisation insurance policy is not providing coverage because of a technical breach of a contract and face the terrible consequences of this reality.

As a wise dwarven lord told me once, “Always look for the money trail”. On 2 Aug 21, Business Times (“Claims management measures help boost Integrated Shield 2020 results”) reported that Integrated Shield Plans (IP) insurers performed much better in 2020 than 2019. In fact, in 2019, only two (out of seven) IP insurers were profitable, in 2020, all but two insurers were profitable. In 2019, the seven IP insurers incurred an underwriting loss of $43.11M; in 2020, the same insurers made an underwriting profit of $103.75M, a swing of $146.86M!

The most impressive performance was put in by Great Eastern (GE), which went from losing 57.88M to making a profit of $23.29M, a swing of 81.27M. It also somehow managed to cut its management expenses from $33M to $22M from 2019 to 2020.

But let us briefly return to the KTV club sector again. Many KTV hostesses are poor young foreign women who may be brought here to be exploited as hostesses. That in itself is immoral. But many are also here of their own volition to earn a quick and big buck. In which case, other than the fact that there is a lot of negative stigmatisation, everyone gets what they want – the KTV hostess and operator gets paid by the client and in turn the client gets what he wants – varying degrees of physical (maybe carnal even) and emotional satisfaction.

Contrast this to the insurance industry. This industry is ostensibly here to serve their policyholders. But in so-called serving their policyholders, they have elaborate systems, contracts and processes designed to deny certain policyholders what they have actually paid for and now need. It appears they do so by relying on technicalities that few laymen would understand when they bought the policies. The interesting thing is, these insurance companies’ practices are probably deemed acceptable by the authorities, which is why no relevant regulatory authority has yet commented on the abovementioned series of letters in the ST Forum.

If you asked this hobbit, maybe the insurance industry should be the one that comes under police supervision instead of the nightlife sector.

Life can be legal, and also not fair. Get used to it

Happy 56th National Day

Personal Beliefs and Professional Positions

Hobbits are by nature fun-loving folks who firmly believe in the sacred value of liberty. The freedom to choose is a fundamental right hard-wired into every hobbit’s brain; unless that right is circumscribed or taken away by law. For example, you are not at liberty to choose whether to wear a mask or not once you step out of your home.

So this hobbit firmly believes that everyone has the right to choose for oneself to be vaccinated or not, and one’s children as well. We should also be allowed to choose what vaccines we want to be vaccinated with as long as the vaccines have been approved for use. Of course, with choice, comes responsibility. We have to face the consequences of our choices, be they good or bad.

Among doctors, there is a wide range of opinions and beliefs when it comes to Covid-19 vaccination. As individuals, they are entitled to their personal beliefs. And they are entitled to make choices and decisions arising from these beliefs. A doctor can choose to be vaccinated or not. We cannot take that right away from an individual, just because he happens to be a doctor.

But things may get a bit edgy when you propose a position to the public in your capacity as a doctor on something related to healthcare or a medical service or product. This hobbit believes you should be evaluated and judged in your professional capacity as a doctor.

In short, as an individual you can have almost complete liberty in choosing your personal beliefs, but not so when as a doctor, you choose your professional positions.

Take the recent two incidents involving a few doctors for example. Last month, 12 doctors penned an open letter on the risks of Covid-19 vaccination for children. They asked that traditional “killed” virus vaccines be used on children instead of the mRNA vaccines. 11 of the 12 doctors subsequently retracted the letter, including the author of the letter. The letter was addressed to “all parents deciding to vaccinate or not to vaccinate their child”. Many experts have since spoken out debunking the contents of this infamous letter.

In their retraction, these 11 doctors said “We like to withdraw all our humble ponderings, as some of our thoughts may be misunderstood by some laypersons. We will henceforth ponder in a more professional and private forum”.

This hobbit shares the same concern as the eleven doctors who retracted when it comes to “laypersons” – they need to be protected. Within the medical profession and the boundaries of civility, fellow doctors can discuss and argue different positions and viewpoints about certain contentious topics in medicine. In our careers as doctors, we have all seen robust discussions between learned colleagues on many subjects at different fora, ranging from the simple grand ward or morbidity and mortality rounds to international scientific and medical meetings.

Some positions forwarded by some doctors at times can be based on the most flimsy and unmeritorious of assumptions, but these arguments and propositions will be quickly disposed of by the majority of their peers armed with better knowledge and experience.

Unfortunately, this luxury of discernment frequently does not happen when the public is involved, simply because the public lacks the requisite knowledge to discern on highly technical matters.

It is for this reason that medical advertisement is tightly regulated in Singapore. Other than Over-The-Counter (OTC) Drugs, one is NOT allowed to advertise medicines to the public. You will not see advertisements like what you see in USA for example, where one will see many prescription drug advertisements targeted at the public.

However, in Singapore, advertisements involving prescription drugs can be found in materials that are mainly meant for doctors, dentists, pharmacists and nurses. For example, advertisement and marketing materials for prescription drugs can be found in the SMA News or SMJ.

The underlying logic here is that these professionals (and the students being trained for these professions as well) have the capacity to discern the issues therein. Hence the advertising restrictions targeted at these groups can be more relaxed. The piece of legislation called Medicines (Advertisement and Sale) Act reflects this thinking.

Well, it appears that three of the 11 doctors are now having another go at trying to dissuade people from getting vaccinated at mRNA vaccines even when they had said they wanted to “ponder in a more professional and private forum”. There is now another open letter by five doctors (of which three are from the original group of 11 doctors who retracted earlier on) asking the vaccination to be delayed for adolescents, especially males. Again, the experts have come out to debunk their argument which is based again on the most rickety of scientific foundations. Seriously folks, even though one death is too many, you cannot formulate a public health vaccination policy based on one death in which causality to mRNA vaccines is not even established.

The unwanted effects of these two episodes by a few doctors are:
• many members of the public are getting confused
• the vaccination programme is undermined
• experts have to make the effort to repeatedly debunk unmeritorious arguments forwarded by just a few doctors. A waste of their time and purportedly causing insomnia to one of the experts.

It is true that we have imperfect and incomplete information about Covid-19 and the vaccines. But the hard truth is that we still need to make decisions now based on imperfect and incomplete information where the benefits outweigh the risks to a community. And we certainly cannot make or defer making decisions based on theoretical possibilities that are NOT backed up by current data or extensive experience.

If you think about it, these doctors, in the process of publicly lobbying certain positions, are also trying, indirectly or directly, to persuade and advise the public to also believe what they believe – that mRNA vaccines should not be used.

This kind of persuasion can be likened to offering a form of health education or medical advice. Of course health education is part of the service a doctor is expected to give in a professional capacity. But this education must be of a certain quality befitting a doctor, since the public places a certain premium on information offered by doctors.

The Medical Registration Act, Section 53 (1)e states that if a doctor is found by a Disciplinary Tribunal “to have failed to provide professional services of the quality which is reasonable to expect of him” then he can possibly be punished.

To this hobbit these “professional services” would include unsolicited health education and medical advice where there is no pre-existing patient-doctor relationship. Doctors indirectly influencing the public to take or not take vaccines through the public lobbying of authorities to take a certain public health policy direction would also constitute health education and giving of medical advice.

This brings us back to be the principle that both the individual patient and the public need to be protected. We all make mistakes as doctors telling patients wrong things once in a while. But when there are repeated attempts by the same people to forward a position that is neither backed up by current scientific evidence nor an opinion from a respectable body of peers then something needs to be done.

To sum up, everyone is entitled to their opinion as individuals. Every doctor is also entitled to his profession opinion in the course of an academic or professional discussion with his peers; just be prepared to defend the opinion and failing which, understand well in advance that that position may be demolished within the medical community.

But every doctor is NOT entitled to push his professional opinion or position to the patient or the public when the position is not supported by science or a respectable body of peers. That would be unprofessional if not irresponsible.

After all, being licensed to practise medicine doesn’t mean you are licensed to practise quackery as well.

What this hobbit would really want to see is that these doctors (who are trying so hard and repeatedly trying to dissuade people from taking the mRNA vaccines in some way or the other) to meet in a professional forum with a few members of the MOH Expert Committee on Covid-19 Vaccination. The two sides can argue their case in a Zoom meeting and thousands of doctors can login to this meeting to decide for themselves which side has the stronger case. Perhaps the SMA or Academy of Medicine can organise such a forum. Stop this “open letter” business that can potentially muddle the minds of the public; meet up and argue your case out professionally doctor to doctor, based on scientific research and evidence, and let your peers judge you. If you really know your stuff, you should be able to convince a big segment of a learned audience who can then take up your case and promote your cause.

10 more issues for MHIC to ponder about…

It was heartening to see that the MOH is getting down to some serious business with Integrated Shield Plans (IPs). It was announced and reported[1] [2]that the Multilateral Health Insurance Committee (MHIC) will embark on four specific four workstreams:

  • Claims complaints process so that claims that IP insurers unfairly treating policyholders and doctors can be addressed
  • Look into the composition of insurance panels and the pre-authorisation process
  • Improve transparency across the board, including better itemised billings and publishing data on claims and premiums
  • Examining the issues from a patient and consumer-centric viewpoint and see how improvements can be made from this perspective.

However, this hobbit hopes that the MHIC will resist the temptation to just address superficial issues and move on. This is especially so when we still have a pandemic to fight and people in the healthcare sector are just exhausted both physically and emotionally after more than a year of living dangerously.

It would be naïve to think that if we can just increase the size of the panels and get the insurers to reimburse more and then everyone will live happily after. In the real world, even if you kiss the frog and it turns into a handsome prince, the prince will stall fart and burp loudly from time to time.

It is therefore encouraging to hear that MOH is considering the issue of IP portability. This is a key strategic consideration in the process to make the IP sector more free-market through competition between IP insurers. Currently, because a IP policyholder often cannot change IP insurers because of non-coverage of pre-existing diseases, the competition landscape for the 70% of the population who have bought IPs is rendered sclerotic.

In addition to the issue of IP portability, there are other hard questions that this hobbit hopes the MHIC can answer:

1 What is the desired market penetration for IPs?

Today, almost 70% of Singapore residents have IPs. Is this desirable when only 35% of Singapore beds are private, A and B1 beds? This question needs to be answered clearly and quickly. Even as we speak the market size for IPs is increasing rapidly. The Business Times reported “As at end-March 2021, 20,000 more Singaporeans and permanent residents (PRs) were covered by Integrated Shield plans (IPs) and riders which provide coverage on top of MediShield Life”.[3]

2 Should there be so many IP insurers?

As the SMA Position Paper on Troubled IPs stated – there is loss of economies of scale and duplication of costs when there are too many IP insurers. The Straits Times (ST) Forum writer Wong Sheng Min further suggested on 13 May 21 that “transferring the IP portfolio to a single, not-for-profit entity”. This hobbit thinks not-for-profit maybe a bit drastic.

Since IPs are products that bought on an annual basis MAS and MOH can come together and handle a tender exercise. Insurers can submit tenders to take over the IP portfolio. To avoid over-concentration of risk, perhaps two or three insurers with the most competitive tender submission can be awarded the right to sell IPs.

3 Should IPs be an insurance product bought on a yearly basis?

One of the key problems with the IP sector is a disjunction of expectations between the policyholder and the insurer. The IP contract is an annual one between the policyholder and the insurer. The insurer understands and behaves as such. However, this is often not the case with the policyholder. When a person buys an IP from an insurer, he doesn’t think of it as an annual contract. He is in it for the long haul and barring the unforeseen, he does not expect to ever change his IP insurer. So he gets very upset when he realises the terms of his IP may be varied from year to year or even in a matter of days, as some IP insurers tell their policyholders they can vary the terms and conditions of the IP policy by just giving the policyholder 30 days’ notice.

One of the key advantages of having a longer term IP or even “life” IP such as Medishield Life (MSL) is that of “front loading” of premiums. When a person is younger and earning a good pay, he can pay more premiums. These premiums can be used to fund claims later down the road when the policyholder is older and maybe retired.

Perhaps we can have this as well and IPs can be sold in blocks of 10 years or even 20 years with front loading of premiums. The insurers can therefore receive more premiums earlier in exchange for giving up the right to change terms and conditions at will.

4 Are IP contractual terms too loose?

The Aviva episode (whereby it was able to withdraw coverage for diagnostic scopes) highlights the issue that current IP contractual terms are probably worded too loosely so that policyholders can be adversely affected while insurers stay faithful to the wording of the contract.

LIA likes to make the case that the system is working because Aviva was made to revert to their original position of coverage of diagnostic scope.

Let this hobbit be blunt, I take little comfort that Aviva can be persuaded to do so. Will Aviva or other insurers behave responsibly in the future? There is no guarantee. I will sleep a lot better if contracts and laws are tightened instead. We should not mistake or conflate persuasion with the force of contracts and legislation.

5 What is the desired claims ratio or loss ratio?

Today, only 75% of premiums are used to pay healthcare providers. Even LIA in its position statement has said that this is a issue that should be explored further. Perhaps MHIC can come up with a desired claims or loss ratio?

6 What is the desired premium growth rate?

In the Singapore Actuarial Society paper, “Medishield Life 2020 Review, SAS Comments”, it was noted that premiums grew at a Compound Annual Growth Rate (CAGR) of 10% between 2016 to 2019. Claims grew at 11% while management costs grew at 16% and distribution costs (i.e. commissions) grew at 15% for the same period.

In the long run, costs cannot grow faster than premium growth. MHIC should come up with a sustainable premium growth rate and all major cost components must not exceed this premium growth cap.

7 How do we address the two “pre-existings” in the IP industry?

There are actually two “pre-existings” in the IP industry. There is the concept of pre-existing diseases which we are all familiar with. IP insurers attach great weight to pre-existing diseases and usually do not cover pre-existing diseases of policyholders when a new policy is bought.

On the other hand, IP insurers do not care much for the other “pre-existing” – pre-existing patient-doctor relationships which have enormous value in healthcare to patients, doctors and healthcare policymakers. In the implementation of preferred provider panels – IP insurers often seek to yank (or maybe inadvertently yank) policyholders from their existing doctors and introduce new panel doctors to them.

This great distortion in how IP insurers view pre-existing diseases vis a vis that of pre-existing patient-doctor relationships needs to be addressed urgently and comprehensively by the MHIC.

8 What is the role of claim-based insurance in IPs?

Two letters to the Straits Times Forum  on 12 May 2021 highlighted the shortcomings of claim-base insurance. One was from no less the Chairman of the now-disbanded Health Insurance Task Force (HITF), Ms Mimi S. Ho.

Claim-based IPs are being introduced by several insurers now. Please note that all IP insurers are members of the Life Insurance Association (LIA), which in turn was a member of the HITF. The LIA endorsed and supported the Recommendations of the HITF when they were published. Claims-based insurance is simply a pricing mechanism or penalty that loads up your future premiums once you make a claim at a private hospital (even when you bought a private hospital IP). It is similar to what is practised in the motor insurance industry whereby once you make a claim, you lose a substantial portion of your no-claim bonus when you renew your policy.

In the current claim-based IP context, there is no penalty or loading up of premiums if you choose to go to a restructured hospital (RH).

There are two main problems with claim-based IPs. The first, as highlighted by Ms Ho, is worth quoting here,

“The task force rejected claim-based pricing as it was agreed that it is not right to incentivise policyholders to avoid seeking medical attention for fear of a premium increase.

Untreated medical conditions may lead to more serious, and more costly, health issues later on.

Policyholders should make health-related decisions based on medical needs, not a fear of premium hikes.

Claim-based pricing is a pricing mechanism. It is not a product feature. Mr Tan (Mr Tan Ooi Boon, ST Invest Editor) seems to think policyholders can shop for claim-based pricing like shopping for motor insurance.

Unfortunately, older policyholders or people with pre-existing conditions cannot easily switch health insurance companies.

The root cause of rising health insurance premiums can be attributed to advancement in medical care, increased use of diagnostic testing and higher demand for medical procedures resulting from greater consumer health awareness.

Claim-based pricing is an expedient solution because it aims only to alter consumer behaviour – when in fact consumers may not have the necessary knowledge to exercise judgment – without addressing the root cause of rising medical cost.

It is also not viable in the long run, because it undermines the fundamental principle of insurance – that of pooling similar risks of a group of similar individuals”.

She concluded by recommending that both Monetary Authority of Singapore (MAS) and MOH should ban claim-based IPs.

The second problem was highlighted by the author of the other letter, Lim Kah Wee “Claim-based insurance may lead to strained public healthcare sector”.

Claim-based IP will push policyholders to seek care back at the RHs simply because they are incentivised to do so – future premiums do not go up to a different and more expensive tier when you seek care at a RH. Premiums do go up when a policyholder seeks care at a private hospital.

Does MOH and the RHs really want more private patient business for the RHs? That is a question best answered by MOH and the RHs. But judging from my experience, appointment and waiting times are really going through the roof even for private patients at the RHs. This is more so during this pandemic when efficiency is very suboptimal because of infection and disease control measures that have been implemented to battle the scourge of Covid-19.

Also, from an IP sustainability point of view, should IPs be subsidised by government through these “voluntary downgraders” (which this hobbit has mentioned in earlier posts)? Claim-based IPs sanctions, if not rewards “voluntary downgrading”.

9 What is the role of Third Party Administrators (TPAs)?

Several IP insurers have made use of TPAs to manage their claims process. There is nothing wrong with that in-principle. But once again, TPAs are not regulated or licensed entities in Singapore, unlike insurers or doctors and ultimately the licensed entities must be held accountable for what the TPAs do. Also, how are the TPAs’ costs accounted for in IPs? Are TPA costs part of management costs (they should be) or part of the claims ratio (Which means healthcare providers are being paid even less than what the claims ratio suggests)? What is MAS’s stand on the reflection of TPA costs in the data submitted to them by IP insurers?

Which brings us to the last point…..

10 What is the role of Monetary Authority of Singapore (MAS) in IPs?

Contrary to what my crazy wizard friend, Gandaft the Demented, told me, MAS does NOT stand for “Mostly Absent and Silent” when it comes to the IP industry.

MAS is very important to the IP industry. It is the licensing authority for insurers and therefore holds very important and powerful cards in the game of IP sustainability. The role of MAS is as important as MOH, which licenses doctors and hospitals. Yet, strangely, while MAS was a member of the HITF, it is NOT a member of the MHIC. It is absent in the MHIC. This is regrettable.

There is a feeling that regulation of IPs is done in silos. The medical part of it is done by MOH while the financial aspects of it is carried out by MAS. MAS appears to look at the IP business just like any other insurance business. It should not, because no other insurance business sector involves 70% of Singapore residents and very sizeable CPF monies used to indirectly fund IP payouts through Medishield Life. Therefore, IPs deserve special attention from MAS. But the fact that it is not even a member of the MHIC when it was a member of the HITF, is baffling if not disconcerting.

This hobbit feels that the two aspects of healthcare provision and financial viability are actually greatly-intertwined and must be viewed together holistically. One cannot talk about financial sustainability without understanding what is happening at the medical or healthcare service provision level and one cannot just talk about ensuring good coverage and provision of healthcare services by IPs without also looking into the financial aspects of IP in detail.

If we are truly serious about examining the whole IP milieu comprehensively and improving the IP industry, then MAS must not take a backseat (or have no seat at all) in the MHIC but instead play a leading role in it.

As the word “multilateral’ in MHIC suggests, surely there must be some room in the MHIC for MAS to play a (big) role?


[1] Claims complaints process to be studied by panel for Integrated Shield sector, Business Times, 10 May 21

[2] MOH to study if feasible to make IP insurance fully portable, The Straits Times, 11 May 21

[3] New sales in Singapore life insurance sector up 29% to S$1.25b in Q1, Business Times, 11 May 21

A Serial Nobody

On 19 May 21, World Family Doctor Day was celebrated around the world. Just three days later, ‘social influencer’ Calvin Cheng puts out a Facebook post in response to a statement released by 12 doctors.

The Facebook post stated, “What are GPs?

They are general practitioners who got a degree in medicine, who then either chose not to specialise in a certain field, or were not good enough to be chosen to be specialists. So they became GENERALISTS.

They look after small every day illnesses, and once an illness or disease is too complex for the, they refer them to the real experts, a specialist”.

First, let’s get back to the original statement put up by the 12 doctors. The statement questioned the safety of mRNA vaccines, in particular, for children; and advocated the use of “killed” vaccines instead. The statement was frankly, not based on current evidence and without much merit. In any case, the proper and usual word in this context for “killed” is “inactivated” or “deactivated”.

Next, there are specialists in the list of 12 doctors, including specialist physicians and surgeons, and also GPs.

So plainly, Calvin Cheng got the facts wrong.

By Calvin Cheng’s measure, GPs are GPs either by choice (“chose not to specialise”) or they were not good enough to be chosen to be specialists. They are also not “real experts” and only look after “small, every day illnesses”. In other words, to him, GPs are inferior doctors by choice or by lack of ability.

Well, that would mean the following people are inferior doctors:

  • Our Manpower Minister, Tan See Leng, was a GP for many years. And a very well trained one, with a M.Med (family medicine) and FCFP, the highest academic qualification given by the College of Family Physicians Singapore (CFPS). He went on to run IHH, one of the largest listed companies in Malaysia and Singapore with a market capitalisation well in excess of S$10B.
  • The founder, and Chairman of Raffles Medical, Dr Loo Choon Yong, is a GP. He is a veritable billionaire, owning about half of Raffles Medical. The market capitalisation of Raffles Medical is currently about $2B.

On the other hand, the company Calvin Cheng co-chairs, Retech Technology Co Ltd (listed on ASX, the Australian Stock Exchange) has a market capitalisation of about A$65 to A$70M. The company was listed a few years ago at 50 cents. It is now languishing below 30 cents.

So who is Calvin Cheng?

Here’s what can be found about him from publicly available sources:

  • He is 46
  • He was educated at Oxford University
  • He started his working life by running model agency franchises, and later founded an agency called Looque Models Singapore
  • He was also President of Association of Modelling Industry Professionals Singapore (AMIP)
  • He was a Nominated MP from 2009 to 2011
  • He was appointed a member of the Ministry of Communications and Information’s (MCI) Media Literacy Council (MLC) in 2012. He held this appointment for four years (two 2-year terms). The MLC is supposed to “promote civility and responsibility on the Internet”.

In 2011, the Competition Commission of Singapore (CCS) fined 11 modelling agencies for price-fixing; according to the Wikipedia webpage for Calvin Cheng (https://en.wikipedia.org/wiki/Calvin_Cheng#cite_note-14): –

“On 23 November 2011, several model agencies, including Looque Models, were fined for price fixing. Cheng profited from the higher agency commissions, claiming in defense that the goal was to raise wages for models. The CCS ruled that Association of Modelling Industry Professionals Singapore (AMIP) engaged in anticompetitive price-fixing, resulting in customers paying more and having a considerable and adverse impact on the market. The Competition Commission of Singapore (CCS) noted in its decision that as president of AMIP, Cheng played a central role by instructing AMIP members how to mask the collusion to evade detection and complaints. Cheng appealed, claiming that statements in the decision were damaging to his character; the appeal was dismissed because he had not been personally fined”.

For a more detailed account of this distasteful affair, one can go to:https://redwiretimes.com/former-nmp-calvin-cheng-accused-role-price-fixing-scandal/

And despite this incident in 2011, he was appointed to be a member of a prestigious government committee, the MLC, in 2012. This shows Singapore is indeed a land of second chances. But he didn’t take the appointment well. This can be seen by the fact that he later made some very controversial comments about terrorists’ children while he was a MLC member. https://www.todayonline.com/singapore/calvin-chengs-killing-children-remarks-insensitive-and-inappropriate-mlc-chairman

So as you can see, we really don’t have to take this chap seriously. Even though he was a NMP and a MLC member. This hobbit would like to suggest that deep down he knows that after being a NMP, he has become a serial nobody. So he tries to get attention by passing provocative comments in order to generate attention and responses from the community he attacks. In other words, he is a troll. He is a discredit to the parliamentary institution of NMP. As for his Oxford pedigree, well, Oxford also has a tradition of producing comedians, like Rowan Atkinson and Hugh Grant. Calvin Cheng is still a comedian, albeit a bad one.

Anyway, today, an unusual letter to The Straits Times Forum has been printed. It has no less than five signatories, although only two were featured: MOH and CFPS. The other three signatories mentioned were SMA, Academy of Medicine Singapore and Chapter of Family Physicians. The letter was meant “to address the misinformation in recent social media posts containing inaccurate statements about general practitioners”.

The letter went on to describe how GPs are trained and Family Medicine is recognised as a proper clinical discipline, and how GPs play essential roles in healthcare.

More damningly, the letter ended with this paragraph, “When writing about issues in the public sphere, we expect effort be made to check the facts. In a civil discourse, this is the responsible thing to do”.

Most readers will suspect strongly who this letter is referring to: – the person who was propagating misinformation in an irresponsible way as part of an uncivil discourse. Interestingly, the letter did not mention a person’s name. This hobbit thinks there is a reason for this: the letter is referring to a serial nobody whose name is not even worth mentioning.

Ring Of Inevitability

While it is not enshrined in the Constitution, I consider it my fundamental right as a citizen to be able to sit down in a coffeeshop or hawker centre every morning and have my kopi-O. So when this is taken away from me, I take it that we are in lockdown mode.

Of course this lockdown is not as tough as last year’s CB and Tightened CB. It’s a lot looser this time around. I can still go to my barber, see my dentist and see a show at the cinema. It’s a very ‘loose’ (as opposed to tight or tigher) CB, if it is a CB at all. Unlike what some people say, you can still have a little fun with a very loose CB.

But somehow the wordsmiths have failed us this round by not coming up with something catchy to describe what we are in (like CB and tightened CB). Instead, they have come up with a term like “ Phase 2 – heightened alert”. (Face-palm++).

I take umbrage at the use of the word “heightened”. The use of this word is very insensitive to us short people. As a halfling, I feel I am targeted if not discriminated against whenever I see the word “height” or “heightened” being used. Why can’t people use other terms like “broadened alert” or “widened alert” or just  “light lockdown”? Which is why this hobbit really hopes this country will have a short(er) prime minister soon, who can stand tall, I mean stand-up, for us short fellows.

To avoid the use of this very vexing word “heightened”, I will call the current phase as “loose- lockdown phase” or “LL phase”. “LL” sort of describes rather well how I feel now.

Many friends have asked this hobbit how should we respond to this new LL phase. Well, it’s obvious – just follow law. Stay at home if you can. Cook at home, eat home, work from home etc. Don’t go anywhere unless necessary and if you do, wear your mask and bring your TraceTogether along.

But beyond legal compliance, others have asked – how should we respond intellectually and emotionally?

Some chaps ask rather difficult questions like –

  • Could this LL have been avoided?
  • Could we have closed our borders earlier to countries that were having an exploding number Covid-19 cases?
  • Could we not have this LL phase now?
  • Could we have diversified our foreign labour sources and not take just from one region in the world, just like how we now have four taps to meet our water requirements? Isn’t there just too much risk concentration?
  • Should we have segregated high risk and low risk travellers in Changi Airport like what a Straits Times Forum writer said a month ago prophetically (https://www.straitstimes.com/opinion/forum/letter-of-the-week-stricter-covid-19-measures-needed-for-inbound-passengers-at-airport. (hobbit’s postscript: obviously the writers of the official reply dated 21 April didn’t think so –https://www.straitstimes.com/opinion/forum/airport-takes-multi-layered-risk-based-approach-to-curbing-infection)
  • Should we have better anticipated double mutation strains like B.1.617 are far more infectious than the old Covid-19 strains, considering what was happening in their place of origin?
  • Do we really need to do Routine-Rostered Testing (RRT) for all healthcare workers (HCWs)? Do we not trust our PPE, infection control measures and vaccination to protect our HCWs?

In short, these nasty questions centre around two themes – what lessons can we learn from this setback and are we managing this current wave correctly?

One angsty dwarven banker even asked – between keeping foreign labour coming in to support the construction, process and marine sectors (and helping with economic growth), and now the LL phase – which has a larger effect on the economy and emotional, mental and social well-being of the citizens? What is the trade-off we are talking about? The dwarf remarked – these policy wonks love talking about trade-offs all the time, but somehow nobody is talking about trade-off between keeping the process, marine and construction sectors going and what we are suffering now for four weeks.

I will be honest, having grown up in a fun-loving, carefree, beer guzzling shire in Middle-earth, all these questions are terribly complicated and distressful to me.

But a wise elven wizard helped this hobbit see the light when he commented on this statement:

“These cases all originated from imports because all borders are porous. All it takes is one case to cause an outbreak, and no country can seal itself off totally. At the minimum, citizens and residents must be allowed to return home”. (MOH Facebook Page, 15 May 2021)

He said, “this means it was all inevitable. Just like the Mother of All Clusters (MOAC) in the dorms last year. That was nothing we could have done. MOAC would have happened anyway. Similarly here. It was pre-ordained that we need to have those foreign workers coming in to support the process, construction and marine sectors. Thus we need to take the risk of these imported cases coming in, even though we know that it takes only one case to cause an outbreak”.

He added, “It was also predestined that the super-infectious B.1.617 strains would have led to the Changi Airport and TTSH clusters and probably now the tuition centre/schools clusters as well”.

He concluded, “Everything was preordained and predestined and hence inevitable. We made the right calls, no error of judgment was made. This is the way”. (In an elven accent – not Mandalorian)

Yes, it was all inevitable. And once we accept this explanation, a lot of other questions are also answered or become moot as well. It’s like you are playing an online role-playing quest game, and your avatar discovers this powerful magic item (more like you paid bucket-loads of money for it) that gives your avatar enormous benefits. Example – you discover the Amulet of KNN – which renders your character immune to psychic attacks, -8 to mace attacks, +5 to dexterity score and +50 hit-points.

The elven wizard then introduced me to this magic item called the Ring of Inevitability. He fished it out of the pocket of his Cloak of Non-culpbability; the Ring burnished under the midday light and I was immediately desirous to obtain it.

He whispered to me that once the wearer has the great magic item called the Ring Of Inevitability, he will be immune to questions such as “if only we had….?”, “Could we have…?”, “Could we not have….?” etc., etc. from all those around him, including himself. Such tiresome questions become inconsequential once we wear the Ring of Inevitability.

And he was right. Once I bought the Ring of Inevitability from him and wore it, I was happier and more peaceable immediately. I no longer asked myself all these vexatious questions and could accept the current LL phase with the kind of equanimity that Sir William Osler described. I also dismissed such questions from those around me as irrelevant and even irreverent to me, the mighty Ring-wearer. I felt l have become invisible to obnoxious questions as they passed right through me. I no longer took umbrage to these questions anymore as I became as invisible to these questions as the Nazgul Ringwraiths of the Second Age in Middle-earth.

I didn’t even feel LL at all about this LL phase anymore. Gosh, I hadn’t felt so good since I was given fentanyl by my anaesthetist for a procedure years ago…..

Before he left, the elven wizard grinned and said, “You should consider taking the Cloak of Non-culpability as well. The Cloak makes all accusations against the wearer hollow and ineffectual. It goes extremely well with the Ring of Inevitability”.

Note: for the avoidance of doubt – this post is a satire.

The Hobbit’s Guide To The Highlights Of LIA’s Position Paper and Industry Responses On IPs

After SMA’s Position Statement on Troubled IPs (29 March), the Life Insurance Association (LIA) responded with 2 and a half documents:

  • Industry Response dated 29 March 21
  • (Updated) Response dated 31 March 21 (This hobbit gives discount, count this as half document)
  • Position Statement (1 April 21)

Talk about overkill.

If you have trouble following their chain of thought and writing, this Hobbit will now give you an easy to understand informal guide to the highlights of these documents. Unless stated, the quotes refer to the Position Statement dated 1 April 21. Quotations are given in italics.

Highlight #1: What Has LIA Got To Do With Cost Containment?

Page 1, Last Paragraph lists the various cost containment measures: panels, copays and pre-authorisation, fee benchmarks to nudge positive changes in healthcare providers’ behaviour.

Page 2, Paras 5 to 7 states:

“The question really is, what balance should be struck between various cost containment measures?

The honest answer is that LIA Singapore and individual insurers do have a definitive answer as to what the right balance of measures is”

It will need to be an iterative process, because there will be trade-offs between the interests of policyholders, patients, and healthcare providers that all parties need to accept. Insurers are in the middle trying to seek the best balance to this equation in a sustainable manner”.

Please note that all the containment measures mentioned involve policyholders, patients and healthcare providers. They do NOT involve insurers. Insurers are just “trying to seek the best balance”.

Hello, dude, how about containment measures involving direct action by insurers, such as cost cutting insurers’ commissions and management costs?

In a newspaper article, the LIA spokesman further added, “Insurers agree that we should control our own costs but we don’t really think there’s a lot of fat in our expenses to be cut,”. [1]

Ownself say ownself got little fat, with no substantiation. This is really quite laughable and not worth the paper it is printed on. It’s like an alcoholic saying “I don’t booze too much”.

If every stakeholder also just say categorically, “we don’t really think there’s a lot of fat in our expenses to be cut” then everyone can just suck thumb, drink coffee and nothing will get solved. 

So these guys are still in denial that they are part of the problem. Sorry, but the Singapore Actuarial Society (SAS) has numbers to prove otherwise. Bloggers such as life finance also think insurers are a big root cause of the problem of IP sustainability.

Highlight #2: Possible Anticompetitive Behaviour By A Trade Association

Industry Response (29 March 21) (Page 2, Para 2)

The upper bound of the MOH Fee Benchmark range for a procedure can be up to five times of the lower bound4 . As such, proceeding per SMA’s suggestion without calibration may lead to substantial cost increases and further premium increases for policyholders.

Industry Response (31 March 21) (Updated) (Page 2, Para 2)

The average ratio of upper bound to lower bound for surgeon fee benchmarks is 1.84 . As such, proceeding per SMA’s suggestion without calibration may lead to cost increases and further premium increases for policyholders.

Position Statement (1 April) (Page 3, Last Para)

“Given that the upper bound is, on average, 1.8 times of the lower bound, setting panel fees at the upper bound of the MOH Fee Benchmarks will likely lead to escalation in claims costs and, as a consequence, premiums.”

These are very serious statements to make in the face of countervailing evidence; in particular, with respect to that of the high probability, if not inevitability of premium rises.

The SMA has, in its Position Statement on 28 March, called for all IP insurers to respect the full range of the MOH Fee Benchmarks instead of clustering their reimbursement fee scales around the lower end of these Benchmarks. The SMA further stated that one IP insurer (NTUC Income?) was in fact able to reimburse the full range of the Benchmarks, i.e. as long as panel doctors charge within the range of the Fee Benchmarks they will be paid as such.

It is therefore surprising to see the above quotes from LIA stating that premium rises are very likely?

How did LIA which can be considered a trade association of sorts, come to this conclusion when already a major IP insurer (NTUC Income) can reimburse up to the upper bound of MOH Fee Benchmarks without increasing premiums and in fact apparently generated a profit in 2019?

This statement by LIA therefore essentially tries to exclude or at least diminish the possibility that an IP insurer can respect the full range of benchmarks without raising premiums when an alternative reality already exists.

Therefore, this statement can be construed to either be encouraging IP insurers to set their fee scales to cluster at the lower end of MOH fee benchmarks and not to reimburse using the full range of MOH fee benchmarks or persuading IP insurers to raise their premiums should they respect the entire range of fee benchmarks, even when they may not have to do so in order to achieve profitability. The latter is clearly against consumer and even public interest, especially when about 70% of Singapore residents have bought IPs.

Declaring that increasing premiums as the preferred or most probable solution when other options and alternatives already exist can be considered to be an indirect form of price-fixing by a trade association such as LIA.

Relevant regulatory authorities may want to look in this possibly anti-competitive behaviour by a trade association.

Highlight #3: The Truth is OUT, Panels Are Really About Fee Control, not Quality Control

Page 2 Para 10 states “the underlying concept of a panel is to use the insurer’s bargaining power to negotiate preferential rates from healthcare providers in exchange for higher volumes. This is the way panels work in the employee benefits space in Singapore, and in multiple markets overseas. It is no different from the use of group procurement in industries outside healthcare. So long as a reasonable fee is left on the table for the doctor, and savings are passed on to policyholders in the form of lower premiums, this is a reasonable approach to take. Insurers are playing the role we should in stretching the healthcare dollar for policyholders.”

Bluntly put, as the above quote shows, panels are about fee control. But with IP insurers’ fee scales already clustered around the lower end of the Fee Benchmarks, how much lower do these IP insurers (sans one) want to go? Obviously they intend to bargain Panel Doctors to the bone and go below the benchmarks. If not why have panels when prices are already at the lower end of Fee Benchmarks?

So for those specialists who think short term and want volume now, be warned that you may be squeezed and squeezed on price later on. This reminds this hobbit a little of what Churchill said about appeasers and crocodiles.

The LIA has repeatedly claimed that larger panels will increase prices. Page 2 Para 4 states “Removing panels as a control measure means that insurers would have to seek other ways to compensate. These would likely take the form of increased premiums, increased co-pays, and/or stricter application of pre-authorisation.”

This statement has perplexed many doctors. If the insurers already control the fee scales, why would larger panels necessitate increases in premiums and co-pays?? In such an environment, overcharging is almost impossible and fee scales already cluster at the lower end of the Benchmarks. That leaves overservicing as a possible problem which can be easily solved by audits, hopefully independent audits.

So the real issue here is again, that with larger panels, insurers cannot bargain with doctors to offer their services at ever lower and lower prices. Larger panels do not by themselves contribute to higher premiums, especially if the services offered are clinically indicated and when insurers already control reimbursement rates.

In fact, as one smart observer mischievously commented, “if larger panels entail higher costs and premiums, then no panels will have no costs and lower premiums”.

A more subtle reading of this LIA claim is that perhaps insurers want to shift work back to the Restructured Hospitals (RHs). When panels are large, a policyholder can easily find a specialist. When panels are small, the policyholder may just give up and go back to RHs. There is nothing wrong with this, if MOH wants more work for the RHs.

This is already happening. As of 1 April 21, a major IP insurer revamped its offering to that of claims-made premiums. There are several premium levels a policyholder can pay. If he claims less he pays less. Nothing wrong with that. But it also states that if you seek care at private hospitals and the claims exceed $1000, your premiums (or premium level) go up. But if you go to a RH, your premiums go down one level (unless you are already at the lowest level then your premiums can’t go down anymore), irrespective of how much the claims are.

Again, nothing wrong with that as an incentive to control claims cost by insurers, because this hobbit is neither for or against RHs or private specialists. But good luck to our already very crowded RHs with long waiting times. One must also question if this is in-line with the government’s policy intent of having private hospital IPs in the first place.

Highlight #4: The Smoke Grenade of Enforcement

Page 3 Para 1 states “the fee benchmarks do not include an enforcement mechanism”. LIA goes on to say in the next para, “This issue of enforcement can be addressed through the appointment of panels, within which doctors sign on to enforceable contracts, and are therefore legally bound to charge within the agreed fee range”.

This really takes the cake, folks. Doctors and facilities get paid by an IP insurer AFTER a service has been rendered and resources consumed. What is there to enforce?

All the IP insurer has to do is state up front their fee scales and state they will NOT reimburse above this scale. This is not a situation whereby the doctor already took the IP money and the IP insurer is trying to claw back the money and therefore need some enforcement mechanism.

The IP insurer just pays up to its fee scale and the doctor cannot do anything much. What are the chances the doctor will sue and get more money than what is stated upfront on the fee scale, and more importantly, what are the doctor’s chances of winning such a law suit?

In fact, doctors and facility providers are the parties that really need an “enforcement mechanism” to ensure insurers pay up and pay up promptly, not the other way around!

Highlight #5 : Five Is NOT Equal to ALL Seven

LIA gives us some interesting data in Annex A, which hopefully the regulators can verify, because doctors and policyholders can’t. More Interestingly, it only has five out of seven IP insurers’ data, which means it is an incomplete picture, unlike SAS’s data which is based on all seven insurers.

It shows, as LIA has claimed, that insurers do pay above Fee Benchmarks some times. But obviously panel doctors are paid less than non-panel ones generally.

But the fact remains we do not know who these two omitted insurers are. Until data from these two insurers are out, it is not possible to draw conclusions at the national level, which is the most important thing for a meaningful discussion to take place. After all, these two omitted insurers may be large players with very sizeable market shares and therefore data presented in Annex A may be therefore significantly skewed.

 Highlight #6: Medishield Life’s Claim Rates May Be Excessive

Page 4, Para 6 states

“That IP claim rate trends are similar to Medishield Life’s claim rates trends are not surprising and implies nothing about whether or not the claim rate inflation is excessive”

SMA benchmarked the IP claims rate to that of Medishield Life’s (MSL) because that is the best SMA has at hand. By making this statement, LIA is suggesting that MSL Claim Rate may be excessive, even though MSL has features such as copayment and deductibles in place to address overconsumption.

Since this involves MSL, the government should come out and explain its position and understanding of the situation  – whether the MSL Claims Rate is excessive or not. It can either agree with LIA or refute it. Either way, this should be done and the public will be better informed for it.

Highlight #7: The Second Smoke Grenade of Longer Analysis Periods

Page 4, 3rd Last Para:

“Based on aggregate amounts, cost per claim has not risen in recent years . However, IPs have been around for many years now, and 2016-2019 is a relatively short part of this history. We should therefore take a longer-term view to understand the fuller picture”.

LIA went on to then analyse data from 2010 to 2019 (instead of Singapore Actuarial Society’s 2016 to 2019) and concluded “cost per claim rose very sharply from 2010 to 2014” to justify why recent rises for claims were more moderated (~ 10%). The longer dataset was used to justify that increases in management costs and commissions were actually more moderated over time (Page 6, Figure 2).

When it comes to prices and costs, recentness is everything. Can you imagine trying to recruit a person for an executive opening and saying he is offered the post for a salary of $2500 because that was the salary given for that job in 2010? The candidate will laugh at you.

Or the government saying property inflation isn’t so bad because over the last 10 years, the rise was moderate? Potential property buyers take reference from recent price increases, not what happened in 2010.

In fact, why stop at 2010? Maybe if we extrapolate back to 1965, the Compound Annual Growth Rate (CAGR) for management costs will drop to 1%. Who knows? And if you go back to when Sir Stamford Raffles landed in Singapore, the CAGR will drop to 0.3%.

As the saying goes, no need to talk about the time when policeman wore shorts. For issues such as costs and prices, it is here and now. Or the recent past few years at best. The older the data, the less relevant it is to addressing today’s problem on costs and prices.

Highlight #8: If 10% is bad, 15%/16% is worse!

Page 5, Para 2:

“The key question, which remains unanswered, is whether a 10% CAGR in claim rate is appropriate and manageable. The implications of continued claim rate inflation of this magnitude are potentially serious”.

The hobbit agrees that 10% CAGR may be actually bad.

As a first step to achieving sustainability, all cost components must have a CAGR that is less than the premium CAGR. Claims rate CAGR is now 11%, just 1% more that premium CAGR. We can talk about lowering the premium CAGR to less than 10% when cost components are approximate at the premium CAGR.

This is why a 15% to 16% CAGR for commissions and management costs is even more unconscionable and needs to be tackled aggressively and immediately.

So I don’t know what LIA is trying to say. Especially the LIA spokesman with his/her “there’s not a lot of fat” statement. There is a lot of fat in a 5 to 6 percentage point gap between commissions/management costs and premium CAGR!

Highlight #9: Rolling 3 Year CAGR from 2013 to 2019

LIA uses the tool of 3-year Rolling CAGR to bolster its argument that the phenomenon of “Growth in management expenses and distribution costs have generally lagged that of claims” (page 6, para 3), and this trend reversed in 2017.

It further stated in the next para. One possible explanation is that insurers started implementing the HITF recommendations, and incurred management expenses for doing so. At the same time, the implementation of these recommendations may have had the effect of moderating claims growth. If this is true, then on an overall basis, the HITF recommendations have had the beneficial effect of moderating overall cost growth”.

Except that this is not necessarily true. A 3-year Rolling CAGR includes data from the previous two years. For example, 2015 data actually includes data from 2013, 2014 and 2015, hence the term 3-year Rolling CAGR. It is important to look at absolute numbers but it is also important to look at the trend. As the saying goes “The Trend Is Your Friend”

The HITF Report was published in October 2016, which means that its recommendations will only have had any efficacious effect with effect from 2017 at the earliest, if not 2018.

Taking a closer look at Figure 3 on Page 7 will reveal that 3-year Rolling CAGR for Gross Claims have been falling quickly since 2015, and 2015 Includes data from 2013 and 2014. Whereas Commissions have been rising since 2017 (which includes data from 2015, and Management costs also rose sharply since 2018, which includes data from 2016.

In other words, the recent trends of declining 3-year CAGR for claims and the unfavourable trends for rising 3-year CAGR trends for commissions and 2016 for management costs started before HITF recommendations were implemented.

Chew on that, folks

Highlight #10: Will New IP Entrants Ever Reach Economies of Scale?

Page 6, Last Para:

“Another factor to consider is that 2016 and 2018 saw new entrants into the IP market. As new entrants have relatively small portfolios, they will tend to have higher management expenses as a fraction of premiums. In addition, distribution costs are higher for policyholders in the first year of a policy, as considerable work is involved in the inception of IP policies.”

The IP market is at a high of 70% market penetration already. Will more Singapore Residents buy IP such that the market penetration goes up much further? This hobbit thinks not.

In other words, new entrants will continue to have “relatively small portfolios” unless it can gain market share from other established players. This is unlikely unless these established players do not defend their turf and roll over and let the new players take their cheese.

The distribution costs (i.e. commissions) may come down as policies age, but certainly management costs will not come down much in this scenario.

This hobbit is glad that LIA has stated that they will share their findings on this matter “publicly”. Let’s wait and see then.

Highlight #11:  The Policyholder Should NOT Be Paying For Lack Of Economies Of Scale And Other Inefficiencies

Page 7, Para 2:

“it may not be appropriate to directly transplant Obamacare regulatory requirement of an 80-85% loss ratio to the Singapore context”.

LIA goes on to give several reasons why this is so, such as lack of economies of scale among local insurers when compared to USA ones and that health insurance premiums are much higher in USA.

It is true USA insurers are larger and have economies of scale. But unlike Singapore, there is practically no “voluntary downgrading” effect in USA. As stated in Parliament and SMA Position Statement, voluntary downgrading inadvertently consumes public healthcare resources and subsidises the IP insurers. This actually means that IP insurers already have more fat built into the system than American insurers.

American healthcare is one of the most litigious in the world and legal costs are factored into the premiums. On the other hand, we are nowhere as litigious as America and again IP insurers benefit from this.

In addition, Singapore is well known for our efficiency and cost-effectiveness. So why should we settle for a system that is even less efficient than the notoriously inefficient American healthcare system (i.e. less than 80 to 85% gross claims or medical claims ratio)?

This should again draw the spotlight again on the fact that perhaps there are too many IP insurers in a slow-growth market. Policyholders are in fact paying higher prices in a market that is not truly free, i.e. policyholders with pre-existing diseases who are stuck with the same insurers, and paying for insurers’ inefficiencies arising from their lack of scale.

Highlight #12: Who Is The REAL Misleading Party?

The LIA Industry Statement has a whole section devoted to this on page 2:

Misleading analysis should be avoided

“It is important that organisations put out objective analyses which avoid biased conclusions. In this regard, we find SMA’s analysis of insurers’ costs and claims costs to be misleading. Claim increases are the main driver of premium increases. LIA Singapore will fully address this in due course, along with more detailed comments on the rest of SMA’s position statement”.

If one reads the LIA’s Position Statement, LIA makes no serious attempt to prove that SMA has misled anyone in the SMA Position Statement. LIA has not managed to debunk the SAS data in any way. The SAS table remains correct down to the last digit and LIA did not contest the table’s figures when it could have. SMA’s numerical inferences (in the last two rows of the table, absolute & increase and CAGR) therefore remain consequently 100% correct.

What LIA has done is to offer an alternative perspective using a longer timeline (from 2010 instead of 2016) and to use 3-year Rolling CAGR. This hobbit has already addressed these two points earlier on. When we look at prices and costs, the importance of recentness is paramount. Please don’t tell me my kopi-O in SGH Houseman Canteen cost only 50 cents 20 years ago. That’s irrelevant to the pain or prices people are facing today.

In a valiant attempt to levy a false accusation against SMA, the LIA claimed that SMA’s position was that management costs and commissions were the main reasons why premiums were increasing. The SMA made no such claim. What the SMA said was “We (i.e. SMA) suggest that the IP industry should take a hard look at how it justifies its management and commission costs as the first step in ensuring the IP industry is sustainable” (SMA Position Statement, Para 26).

This was repeated again in Para. 27: “Instead of repeatedly lamenting that healthcare providers and policyholders are to blame for the losses incurred by some IP insurers through overconsumption, overservicing and overcharging, IP insurers should take the necessary steps to explore cutting their own management and commission costs to enhance the sustainability of the IP sector”

The biggest component of premiums is claims, but the biggest contributor to the lack of sustainability are the fastest growing components – management costs and commissions.

By conflating cost composition and unsustainability, it is LIA that is misleading.

In summary, SMA and LIA can argue whether using data from 2016 or 2010 is better, but there is nothing misleading about SMA’s analysis. The internal validity and external validity of SAS’s numbers and SMA’s elaboration on them remain intact and congruent.

Conclusion

This hobbit will end with this parable:

There was once a manager who wanted to buy lunch once a month for his team: a monthly team-building lunch for his five-member team.

He gives $100 to the office pantry aunty to do so. The aunty buys $75 worth of food and drinks for the team. She spends the rest on transport, such as taking the bus or even a taxi or car-hire services, which is of course necessary. The manager is kind and tells her to spend some of the remaining $25 on herself for a meal, which she duly does, such as buying a cup of tea and a bowl of noodles for lunch at the coffeeshop. Then, this aunty goes from eating noodles to economy rice (2 meats + 2 vegetables) and consumes more of the remaining $25. The manager doesn’t think much of this and thinks it fine too.

After a few more months, the manager finds out the pantry aunty is now treating herself to more and more things, such as a beer and even gourmet burgers and is taking premium car-hire services.

Finally, after a few more months, the pantry aunty now tells the manager that $100 is no longer enough, and she wants $110. But the amount actually spent to buy food and drinks for the five-member team remains at $75. Alternatively, the pantry aunty says she can live with $100 but then tells the manager that only $65 will be spent on food and drinks for the five-member team, down from $75.

What shall the manager and department do with this pantry aunty?


[1] Having more doctors on IP panels may lead to higher premiums: Life Insurance Association, The Straits Times, 2 April 21