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.

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