Integrated Shield Plans: The Veneer Of Choice

Empanelling: Trust Me, You Will Take The Blue Pill

Over the last few days, a series of letters to The Straits Times Forum has appeared that commented on some of the choice-limiting practices of Integrated Shield Plan (IP) insurers. (Mr Tan Siak Khian, 19 and 24 Feb 2021; Dr Tony Ho, 22 Feb 2021)

It deals with the “restrictions” placed on IP policyholders’ choice of doctors when they use their IPs. To be fair, there are no “hard” restrictions – every IP insurer will tell you (and the regulators) that policyholders can still see the private specialist they want, subject to certain processes and approvals being obtained. There are no hard restrictions or outright bans on seeing an “un-panelled” private specialist for a certain condition or procedure that is covered by the IP.

In short, the system is designed to impose “friction” on the policyholder, such that the policyholder is “disincentivised” from seeing a non-panel doctor. The policyholder has to jump through a number of hoops before he has access to the doctor he wants. These hoops include coming up with a cash deposit himself that the IP insurer will probably (not 100% guarantee) reimburse later, the non-panel doctor has to seek pre-approval by filling up a long form trying to justify the procedure and include more than enough information necessary for a pre-approval to be processed.

Added to all this friction is the ultimate deterrent – the need for cold, hard cash. The Straits Times Invest Editor, Tan Ooi Boon highlighted this “When cash is needed for those big hospital bills” on 28 Feb 2021. The column highlights the burden that IP insurers pile on policyholders when they see non-panelled doctors by issuing Letters of Guarantee (LOGs) that may not cover big hospital bills and the policyholder has to fork out the remainder while the claim is processed (with no guarantee the claim will be fully paid).

The whole process is designed to sow fear and uncertainty in the policyholder and to inconvenience him to the point that he chooses a panel doctor. In other words, although there are no hard restrictions as to what doctor you can see, the system is designed so that you, the policyholder, is likely to cave-in to the IP insurer’s preferences and use a panel doctor. Please note, it is not a demand, as in a hard requirement, but a preference of the IP insurer. But for this to happen, the policyholder must cave-in, and believe you me, the insurers are very good at making you cave-in. It’s like the movie Matrix, no one forces you to take the blue pill, but by jolly, they make it so tough for you to take the red pill that you cave-in and take the blue pill. But they will tell you it’s your choice that you did not take the red pill. No one really forced you. This hobbit calls this the veneer of choice or pseudo-choice.

Half the IP insurers claim to have lost money on IPs in 2019. Some have lost for several years. In the business world, if you lose money in a certain business segment for a few years you will think about exiting this segment. But no one has done so. No one has even threatened to do so. That means either they are very charitable or something else is afoot.

Nothing Personal, It’s Just Business

In Malaysia, it is very difficult to buy personal hospital insurance unless you also buy a life insurance product. The two are usually ‘bundled’. This is because life insurance products are almost always profitable while personal hospital or healthcare insurance may not be. But personal hospital or healthcare insurance is a ‘loss leader’; i.e. the insurance company accepts that it will likely make losses in this segment but he will make money in the life insurance bit.

Here, there is no bundling, but it may be that insurance companies want to enter the IP segment so that they offer a complete suite of products and services so that they can sell more insurance policies in the profitable segments. This hobbit really doesn’t know, to be honest.

A blogger has examined the IP industry and have commented that neither ‘kiasu’ patients and greedy doctors are to blame of IP insurers losing money. The blogger has written twice on this topic. Go to It’s all there. It’s a treasure trove of information and analysis about IPs.

Basically the blogger concluded that IP insurers are in the red mainly because of:

  • Lack of economies of scale
  • High management costs
  • High distribution costs (what insurance agents and financial advisors earn from selling IPs)
  • An ageing population. (The ‘first’ generation of IP policyholders are now nearing 60)

The blogger further stated there is no clear evidence that doctors’ fees is the main cause of the IP as losses the claims ratio is manageable. In fact between 2016 to 2019 the average pay-out per claim fell by 1% per year!

A note to add here is that management costs is a highly variable thing. It can be high because of inefficient management, or inappropriate cost apportionment or that people are simply paid too well to run the IP business. Claims ratio is an objective measure. Claims ratio is a measure of how much is paid out as claims as a ratio of premiums collected. Distribution costs is what is actually paid to the insurance agents and hence is also a more objective measure.

But the fact that no IP insurer has exited the IP segment because of repeated losses implies that IP business can well be a loss leader. Or that the losses are simply due to apportionment of costs which could be accounted for somewhere else. Food for thought.

Further food for thought is what if an IP insurer actually exits the scene? Let’s say company IP X exits the business. What will happen? For a start, all of the folks who bought IPs from IP X now have no IP cover after their current contracts expire. IP policies are bought and renewed on an annual basis. These folks would have no cover in months. Can they buy from another IP insurer? The answer is yes. But it is a BIG conditional yes. The new IP insurer is under no compunction to cover for any pre-existing disease that the policyholder had developed during the time he was covered by IP X. Healthy policyholders may not be affected adversely as they can get an IP from another insurer easily, but those with pre-existing diseases may experience the following

  • Loading of premiums for pre-existing diseases
  • Denial of coverage for pre-existing diseases
  • Unable to buy an IP altogether  

This hobbit hopes the regulators have drawer plans in place for this scenario so that IP policyholders are not left high and dry.

LIA’s Letter to ST Forum

On 27 February 2021, The Life Insurance Association (LIA) of Singapore’s Executive Director replied in The ST Forum to the three letters. This hobbit has reproduced the entire letter here from the 3rd paragraph onwards (in bold and italics). The first two paragraphs are really administrative in nature. Like how a histopathologist examines a space occupying lesion excised for suspected cancer, slide by slide, this hobbit examines this letter paragraph by paragraph and also asks some inconvenient questions.

3          Integrated Shield Plan (IP) insurers have an interest in ensuring that their panels are comprehensive, as this increases panel usage and helps IP insurers better manage costs. In line with this, insurers are continuing to expand their panels.

Comment: Not really true. Data shows that each IP insurer have only about 20% of private specialists on their panels. Even if an insurer double the panel size it would be only 40%. Insurers do not make money by having comprehensive panels. Some insurance companies promise panel doctors large volumes of work in return for low doctor fees. Small panels shift the balance of bargaining power from the panel doctor to the insurer and the insurer can extract lower and lower fees by promising more and more work to a small group of doctors.  Can LIA recommend a target for its members – like what percentage of private specialists should be on an IP panel?

4          Life Insurance Association (LIA) Singapore has also provided guidelines on the implementation of preferred healthcare panels, which includes the need to ensure that the network is sufficient to offer a wide range of medical services to policyholders.

Comment: The original document that recommended panels was in the Health Insurance Task Force (HITF) Report. It stated “To enhance and ensure transparency of the arrangement (e.g. disclosures on the healthcare provider selection process)”.  I.e. IP insurers should state the criteria used to select doctors to be on a panel.

To date, not one insurer has disclosed what is the selection criteria for healthcare providers (i.e. why a doctor is selected to be on a panel while another is not). Can LIA make its members (i.e. IP insurers) come clean on what is the selection criteria and remove this opacity? Not just general statements about criteria etc but actual quantitative or qualitative measures that make up these (now secret) criteria.

5          Mr Tan asked what happens if a doctor is removed from the panel. IP insurers generally decide to remove doctors from a panel only as a last resort or in extreme circumstances. Should removal of a doctor be necessary, an adequately long notice period will be given to allow patients to transition to another doctor, should they wish to do so.

6          Doctors may also choose to leave panels for various reasons, and this is not within the control of IP insurers. Should there be transfers of care, doctors are professionally obliged to provide sufficient documentary medical information to enable continued quality care.

Comments: It is true that that IP insurers seldom remove a doctor from the panel. But the whole point is not whether a doctor is removed, but rather if the panel was adequately constituted in the first place! If you start off with 20% of private sector doctors then it is manifestly inadequate even if you do not remove any doctors from any panel.

The Executive Director then tries to give the impression that a significant root cause of the problem is that  doctors choose to leave panels voluntarily. Doctors leave for one reason and one reason alone – the IP insurer is paying badly. If you reimburse at below or at only the lower end of the fee benchmarks, then some doctors may and will leave. Why would a doctor otherwise leave when being a panel doctor usually means more work and more earnings?

This hobbit has not heard of anyone wanting to leave NTUC Income’s panel. This is because NTUC Income pays the doctor as long as he charges within the entire range of MOH’s fee benchmarks. Doctors will leave panels because they perceive the insurer is not giving them a fair deal.

7          Mr Tan also asked whether there are checks in place to ensure insurers do not make unfair changes to terms of contract.

8          IP insurers do not make changes to their insurance contracts lightly, particularly when it comes to changes that affect in-force customers, and such changes go through extensive internal review.

9          In addition, all contractual changes to IPs must be approved by the Ministry of Health.

Comments: This is technically true and the policyholder is apparently protected. But again in real life it is not so. If the contract is well constructed then the policyholder is protected. But if the contract is lax and amorphous then good luck. Which is exactly what happened when Aviva unilaterally stopped coverage of diagnostic scopes in its IP Plans. The contract was so loosely worded that it could do so (i.e. not reimburse for diagnostic scopes) without changing contract terms. This incident showed that Aviva (and by extension, any other IP insurer) could withdraw coverage for something as fundamental as diagnostic scopes without changing its contractual obligations. Chew on that, folks.

10        Finally, the Monetary Authority of Singapore requires representatives to disclose at point of sale that IP and rider contract terms allow insurers to change the terms and conditions. IP insurers must notify policyholders before doing so.

Comments: I hope MAS is enforcing this through routine checks. For a start it could send in some “mystery shoppers” to purportedly buy IPs and see if the agents are doing so. Also please note that LIA has said that contractual terms cannot be changed without MOH’s approval but insurers can change terms and conditions. This hobbit doesn’t really know what this means in real life. Maybe someone can educate the public on this oddity.

11        LIA Singapore and IP insurers are committed to playing our part in ensuring the continued accessibility of healthcare in Singapore.

12        We urge all parties involved to play their part, too.

Comments: On the bright side, this hobbit suspects that 2020 was a good year for IP insurers. This is because in Covid-stricken 2020, people generally loathed going to hospitals. Healthcare-seeking behaviour changed drastically as people feared getting infected with Covid-19 at healthcare facilities. Many electives were postponed and people only sought urgent or emergency care and absolutely essential care in 2020. In all likelihood claims ratios will drop even further while IP insurers continued to collect premiums.

Can LIA “play their part” by cutting 2021 premiums?   Please don’t  pocket all and return some of the 2020 profits to the policyholders? Please…..?


In summary, doctors in the private sector have long known how the IP insurers behave to stack odds in their favour. There is little trust between them and the IP insurers. In fact, this hobbit would say there is no love lost between the two.

Of course, in defence, IP insurers will highlight how some specialists have “over-charged” in the past but this issue is now already dealt with by the MOH Fee Benchmarks. In any case, “overcharging” became commoner after the SMA Guideline of Fees (GOF) were removed reluctantly by SMA because the government had outlawed such guidelines. The SMA had warned everyone about the negative consequences of withdrawing the GOF to no avail. You can’t just lay 100% of the blame on doctors. The regulators allowed such an (GOF-less and benchmark-less) environment to exist which led to rapidly increasing doctors’ fees between 2007 and 2016.

Private sector doctors saw how some insurers seemingly took and twisted the recommendations of the HITF Report to their maximal benefit. Having small panels and reimbursing below MOH Fee Benchmarks are two such examples.

Some have said this is akin to religious extremists twisting and contorting mainstream orthodox religious teachings to their own benefit, but this hobbit readily admits this is too serious a charge to levy on IP insurers. IP insurers are not extremist. They are probably just profit-maximising, business people.

But now the public have also gotten wind of these practices and now realise they too could well be receiving the short end of the stick.

IP insurers should know that losing the trust of doctors is one thing, but losing the trust and confidence of consumers is another thing altogether. Trust is hard-earned but easily lost in the twinkle of an eye.

I hope regulators empathise with the patient, because obviously we should not trust IP insurers to, going by past behaviour. In the current climate, the only real choice the patient has is to decide whether he should buy an IP or not and which IP to buy. After that he only has the veneer of choice or “pseudo-choice”, or no choice at all:

  • He falls sick and it is not a choice to fall sick (assuming he led a reasonably healthy lifestyle)
  • He can technically choose a specialist, but in reality he has to choose from a very limited panel of specialists (pseudo-choice) even if the specialist he prefers charges responsibly (according to MOH Fee Benchmarks)
  • He grows old and develops pre-existing conditions (not a choice) and he cannot switch IP insurers unless he incurs significant additional costs or suffers penalties (pseudo-choice)

Finally, some say light is the best disinfectant and indeed the IPs offered by insurers can benefit from much more light indeed. Independent bloggers such as those in and journalists such as Mr Tan Ooi Boon play an important role in educating the public about the whole IP milieu which is hitherto shrouded in jargon and complexity. People always talk about reducing the information asymmetry between doctors and patients. It is also time now to reduce the information asymmetry between IP insurers and patients as well.

Let there be light.

The Basket Case of Doctorxdentist (DXD)

The dust looks to have settled for now with the DoctorxDentist (DXD) saga.  On 27 Nov 20, Senior Minister of State Dr Koh Poh Koon posted this on his Facebook account:

“Many of my medical colleagues have been troubled by the methods adopted by DoctorXDentist (DxD) to promote doctors who paid for their services. It is also unclear whether some of the patient “reviews” on the DxD website are genuine and consistent with the relevant rules and regulations. Following discussions with the Ministry of Health, Singapore, Singapore Medical Association and Singapore Medical Council, DxD will now remove all doctors and dentists from their website listing unless the doctor or dentist has opted in.

MOH and SMC are continuing to monitor the situation and will make further investigations into the DxD website where appropriate. We will not hesitate to take further action if necessary. We must safeguard the integrity of the profession and protect the interests of patients”.

I hope this will draw to a close to this rather tiresome if not vexing Search Engine Optimisation (SEO) company’s past distasteful practices which they claimed to have discontinued on 22 Nov (as reported on their website). DXD has said it will now adopt an opt-in model where it will only publish names of those doctors and dentists that opt-in to collaborate with them. It stated, “All medical professionals who do not wish to be on the Find A Doctor directory will have their entire profile removed”. On 26 Nov, DXD also said it will remove all patient feedback and ratings.

Now if only DXD adopted this reasonable position from the beginning, then all this gnashing of teeth and clenching of fists would not have been necessary.

Nonetheless, even as DXD has now apparently adopted a new and reasonable position to continue their business, it is instructive to recap what it did in the last few weeks and months to incur so much indignation from the authorities and the medical community.

Let’s now have a short curious case-study of the DXD…..

An overbearing attitude that dismisses a doctor’s rights to non-association with DXD.

It claimed (as stated in the previous post) that its mission overrides a doctor’s rights to non-association. Clearly a preposterous position for a privately-owned company to adopt, given the fact it is not a regulatory authority backed by the force of specific legislation.

Instant “ownself give ownself” mandate to be the patient’s champion

As stated also in the previous post, the co-founder of DXD, a certain Tristan Hahner replied to a doctor with these words earlier in the year, ““We are required to list all doctors practicing in Singapore. In other words, our directory has to be complete in order not to mislead patients. We are allowed to display factual information available in the public directory of the Singapore Medical Council without your explicit consent”.

We now know with some certainty after clarifications from MOH, SMC and SMA that no-one required them to list all the doctors. DXD probably “ownself require ownself” and tried to give the impression that they had a “mandate from heaven”, so to speak. Until SMA called their bluff. The misleading party here is indeed DXD, by claiming that they are required to do something when they cannot give any evidence of who this requiring entity is.

Their repeated use of the word “our patients” in their communications is also very disconcerting. It implies that they actually have patients when they don’t. The fact is, when someone or some facility claims to have patients, it means that these persons or entities owe a professional duty of care to these “patients”. But this understanding must be bilateral. This hobbit thinks DXD doesn’t know what they are talking about and it’s all fluff and bluff. After all, does the “patient” even think or agree that DXD owes him a duty of care? Even for a doctor – he can’t just pick someone from the street and declare unilaterally this someone to be his patient and he owes this patient a duty of care unless this someone agrees that “Yes, Dr X is my doctor” and therefore Dr X owes this patient a duty of care.

Misrepresentation of MOH’s position

If there is one raw nerve that civil servants have – it is to be misquoted or misrepresented. DXD’s early statements claim that they have arrived at their position of compulsory inclusion of all doctors and dentists on their DXD directory after consultation with MOH’s compliance officers. With MOH’s clarification to the contrary (MOH website 20 Nov 20), this is obviously untrue.

Refusal to issue an erratum, let alone apologise

To-date, despite MOH’s request for DXD to publish the erratum on 17 Nov, DXD has yet to do so. This gave MOH and SMC no choice but to publish the erratum on their own websites on 20 Nov 20 respectively. Frankly, if I were the Health Minister, I would have thrown the POFMA (POFMA – Protection of Online Falsehoods and Manipulation Act) at DXD in the face of such defiance.


DXD can flip their position faster than a prata.

Incident 1:

On 7 Nov, DXD said in Update 4 that it will be “removing all doctors who have requested to be delisted”. But on 14 Nov, it said it will “republish” these delisted names

Then, to add insult to injury, in a Business Times article (20 Nov 20), their General Manager Ms Tyr A Ding was reported to have said, “But after a closed door meeting with representatives from SMA, SMC and MOH, Ms Ding on Sunday told BT that the company has made a determined decision not to delist any private doctors” from its platform”. She was quoted as having said, “This decision is ours alone, and was made on a sound legal basis”.

22 Nov 20, DXD announces it will remove all names that request so. What happened to “determined decision not to delist…” and “This decision is ours alone, and was made on a sound legal basis”? Tsk tsk. Malu Sial.

Incident 2:

On 10 Nov 20, DXD announced that they will be publishing the full minutes of a meeting that was to be held on 13 Nov with MOH and SMA. On 13 Nov, they stated that they have requested for a “closed doors, non-prejudice meeting and will not be publishing meeting minutes”.

Unauthorised Use of SMC Website and Data

SMA announced on their website on 13 Nov 20 that SMC had informed SMA that DXD had not sought permission from SMC for use of SMC data on doctors and SMC had also not given DXD any permission to do so.

Questionable Use of Patient Feedback and Ratings + Lack of Understanding of Regulatory Requirements

On 25 Nov, SMC announced in an advisory that “Medical practitioners should refrain from participating in online SEO platforms that make use of patient feedback and ratings, as these feedback and ratings can be considered to be patient testimonials which are forbidden in G2(7) of the SMC ECEG and G2.3 of the HME”. An advisory with similar content was issued by the Singapore Dental Council. This really reflects on DXD’s failure to understand what are the prevailing professionalism and ethical standards that is imposed by the regulatory body, i.e. SMC on doctors. This is especially galling when you consider the opening paragraph of their post on 22 Nov 20:

“DoctorxDentist loves what we do, which is to partner with medical practitioners to create expert health content and bring free access to health knowledge. It is a mission that our team continues to believe in wholeheartedly”.

The first thing about partnering doctors is not to get doctors intro trouble. Duh?

When you look back at all this, it is easy for anyone to realise why DXD is such a basket case of a company. This hobbit wonders – can DXD ever achieve credibility as a serious player in healthcare with a track record such as this?

Sequence of Events

3 Nov 20

SMA sends an email to all members offering as a free service to its members, to publish a list of members who do not wish to be associated with the DoctorXDentist (DxD) website, so that the public may be informed that the DxD website does not have the support of these SMA members.

4 Nov 20 (DXD Blog)

DXD publishes statement that they “made the decision to include all doctors after our consultation with MOH Compliance Officers back in 2018…. This decision is supported by our lawyers”

7 Nov 20 (DXD Blog)

DXD publishes on its blog under “Update 4”, “we consulted a team of lawyers who abide by Private Hospital and Medical Clinic (PHMC) Guidelines and local regulatory compliance laws. They advised us to automatically list all doctors on our platform using the SMC Directory to retain an unbiased and comprehensive listing for our readers”

DXD mentioned “we would also like to respect the wishes of various bodies pending further discussions. As such, we will be removing all doctors who have requested to be delisted while we arrive at an amicable resolution for both sides”.

10 Nov 20 (DXD Blog)

“DoctorsxDentist will be meeting with SMA and MOH Regulatory officers on the 13th of November 2020 (2-3pm). We will be updating this blog after the meeting with full meeting minutes as well as resolution details.”

13 Nov 20 (DXD Blog)

“DoctorxDentist has requested for a closed doors non-prejudice meeting and will not be publishing meeting minutes”.

13 Nov 20 (SMA update to members)

The SMC has since clarified in a reply to SMA dated 12 Nov 2020 that “SMC has not given permission to DoctorXDentist to use, reproduce or appropriate the comments found on the online Medical Register on the SMC website, and neither has the SMC received any request from DoctorxDentist for permission to extract the data for use on their website. The SMC will be writing to DoctorsxDentist to seek their explanation on the above. In particular, the SMC will be requesting that DoctorxDentist refrains from using information obtained from the SMC’s website”.

14 Nov 20 (Straits Times, Docs up in arms over website listing their profiles, Joyce Teo)

“After a virtual meeting yesterday with representatives from SMA, SMC and the Ministry of Health, DxD said it will republish profiles”

19 Nov 20 (DXD Blog)

DXD publishes Update 7 at 2pm which was removed at 3:20pm. (100 minutes of existence)

20 Nov (Business Times, DoctorxDentist’s headache grows as MOH, medical bodies lean on platform, Olivia Poh and Claudia Chong)

“In a recent clarification on MOH’s website, it came to light that MOH had neither endorsed nor approved the online platform, despite statements on DoctorxDentist’s website that might have given the impression that MOH had”.

“But after a closed door meeting with representatives from SMA, SMC and MOH, Ms Ding on Sunday told BT that the company has made a determined decision not to delist any private doctors” from its platform””

“This decision is ours alone, and was made on a sound legal basis. As a company, we are unable to compromise the quality of our patients’ healthcare journey just because we are told to drop it. This would be in direct contradiction to our belief that healthcare access should be transparent and made available to all”.

22 Nov (DXD Blog)

Announces that it will work on a opt-in model (no erratum)

25 Nov (SMC website)

SMC issues advisory to all doctors not to take part in SEO platforms that have patient feedback and ratings as patient testimonials are forbidden by SMC ECEG and HME. It further stated that “ In particular, medical practitioners should not be paying for such services by purchasing packages from these platforms for the purpose of obtaining patient testimonials, as payment for such packages or services could be considered to be express agreement on the part of medical practitioners to allow patient testimonials to be part of their publicity and medical advertisement activities”.

26 Nov (Various Newspapers)

DXD announces it will remove reviews, feedback and ratings of doctors from its website

The Curious Case of DoctorXDentist (DXD)

Over the last week, an interesting chain of events has unfolded with regard to this company called DoctorXDentist (DXD). This is not a new company. It has been around since at least 2018, if not earlier. But it is a unique company. It is a company that purports to be trying to do many things. But as any experienced businessman will tell you, go look at the money trail.

Essentially, it is a company that deals with Search Engine Optimisation (SEO). For doing this, according to The Business Times Report dated 7 Nov 20, (quoting a Tech in Asia report), DXD earns US$150,000 revenue in recurring revenue a month.

This revenue is presumably achieved through selling of “DXD Clinic Solution” packages. Several doctors this hobbit knows have received communication from a person named “Casey” who purports to represent DXD in the selling of such packages.

Examples of these packages:

  • Pro 6 package for 6 months costs $9000
  • Premium 6 package for 6 months costs $22,000
  • Premium 10 package for 10 months costs S38,000

So far so good. This hobbit has nothing against doctors and clinics who want to advertise, as long as they do so ethically and don’t run afoul of the law. And people need to get paid. What the package contains and how much a package costs is a commercial decision between the advertiser and DXD. But as anyone can see, DXD is not exactly an entity that runs on love and fresh air.

SMC Directory

The first issue we need to deal with a company like DXD is how is its database constructed and how reliable and up to date it is. DXD claims to be using information lifted from the SMC website – “All Doctor Profiles have been updated from the SMC Directory”. However, the SMC website states:

6. Except as otherwise provided, the Contents of this Web Site shall not be reproduced, republished, uploaded, posted, transmitted or otherwise distributed in any way, without the prior written permission of the Singapore Medical Council.

7. Modification of any of the Contents or use of the Contents for any other purpose will be a violation of the Singapore Medical Council’s copyright and other intellectual property rights. Graphics and images on this Web Site are protected by copyright and may not be reproduced or appropriated in any manner without written permission of the Singapore Medical Council.”

Has DXD gotten permission from SMC to use SMC’s website or directory?

A quick check of the DXD website will make one realise that some of the information is quite out of date and hence not factual. Just a quick check on three doctors using the DXD website by this hobbit today revealed the following:

  • A doctor who has changed his place of practice for many months still has the old place of practice listed there
  • A doctor who has retired and closed his practice is still listed as practising in his old practice address
  • Worse, a doctor who has an interim order served on him by SMC (widely reported in the press) apparently has a clean record with SMC

Non-Manageable Risk to Doctors

The second issue is the risk that directories such as the DXD one may pose to doctors. The issue or risk may be limited if the DXD is just a directory and nothing more. But it is not. It has ratings and comments from patients (Which may be construed to be patient testimonials of sorts), estimation of bill sizes, and appointment-making services.

The SMC Ethical Code and Ethical Guidelines (ECEG) is pretty clear about the issue of advertising of information. Patient testimonials are not allowed.

In Section G5(2) of the ECEG, it is stated, “Even if you have little control over the healthcare organisations, if you participate in events, publications or media content disseminated by the organisations, you must ensure that the information you provide abides by the standards required of medical advertising”.

The Publicity Regulations issued under the PHMC Act is even more specific. These Regulations apply to the licensees of healthcare institutions, including clinics.

Para 12.1 of the “Explanatory Guidance to the Private Hospitals and Medical Clinics (Advertisement) Regulations 2019” issued  by MOH; states: “It is the licensee’s responsibility to ensure that the style and content of the HCI’s advertisement, and the manner in which the HCI’s advertisement is published, complies with all relevant provisions of the Advertisement Regulations”.

The takeaway message can be summed up to be – doctors are responsible for the publicity that pertain to us or our clinics (when we are the licensees), even when such information is published by third-party sites and sources. There is simply no escape from this professional responsibility. This is how the regulatory framework is structured. We cannot say “don’t blame me, blame the third-party website”.

DXD: The Special One?

There are several other such SEO companies; e.g. docdoc, doctoranywhere, getdoc, singaporedoc etc, just to name a few. But what sets DXD apart is its insistence that its website must contain practically all registered medical practitioners in Singapore and that even if the doctor wanted to have his/her name removed from the DXD website, it will not do so. It was only on 7 Nov 20 that DXD finally agreed to remove names and information of doctors who have requested to be taken off the DXD website.

With responsibility comes control. What DXD is saying (until 7 Nov 20) is that you, the doctor, does not even have the right to decide whether your name appears on the DXD website, let alone control over other information that is related to you or your practice. In other words, while MOH and SMC says the doctor is responsible, DXD says the doctor has no control. Well, SMC and MOH are backed by the force of law. Laws are enacted by Parliament which in turn is elected by the people. What is DXD backed by?

A doctor who wrote to DXD in early 2020 received this reply from a certain Tristan Hahner, claiming to be co-founder of DXD; he wrote “We are required to list all doctors practicing in Singapore. In other words, our directory has to be complete in order not to mislead patients. We are allowed to display factual information available in the public directory of the Singapore Medical Council without your explicit consent”.


These audacious words of Mr Hahner just takes this hobbit’s breath away. First, he says “We are required…..” without stating who actually requires DXD to do so. Is it MOH? Or SMC? Or maybe a mythological creature (like this hobbit) called Smaug? Or the dwarves of Moria under the Misty Mountains?

Secondly, does DXD really have “patients”? As far as this hobbit concerned, only healthcare institutions such as hospitals, clinics and laboratories have patients; or licensed healthcare professionals like doctors, dentists, nurses, TCM practitioners, and allied health professionals such as physiotherapists, speech therapists etc, have “patients”. DXD is neither a facility nor a professional that treats patients. The fact that DXD claims its potential or actual customers (i.e. users of its portal) as “patients” may be misleading in itself. DXD may or may not end up misleading people, but let’s be honest about it, it doesn’t have any patients. If it had, MOH would have licensed DXD as an institution or as a healthcare professional. Doctors have patients, dentists have patients. This hobbit reiterates – legally and ethically speaking, DXD may have customers, but it has no patients. Get that straight.

The final sentence “We are allowed to display factual information available in the public directory of the Singapore Medical Council without your explicit consent” is the proverbial straw that breaks the camel’s back.

Their justification for not removing the names and particulars of doctors when requested to do so just smells (and it’s doesn’t even smell funny, it just smells). In a blog entry dated 4 Nov 20 addressed to doctors,, the General Manager of DXD, Tyr A Ding, claimed that “We (i.e. DXD) made the decision to include all Doctors after our consultation with MOH Compliance Officers back in 2018” and that “this decision is supported by our legal advisors”.

Now that SMA has counter-proposed to DXD with a meeting with MOH officers around (5 Nov, SMA Website), this hobbit really hopes DXD can produce documented evidence of what MOH “Compliance Officers” had advised them in 2018 as well as the legal opinions of its advisors, should this meeting take place.

The first-line justification for their actions, beyond legal and compliance considerations, can be seen by this sentence “this (practice of listing everybody and not removing anyone) offers an unbiased and comprehensive listing of all available options for our readers to make informed decisions for themselves without any commercial intent on our part”.

Another “wow”. No commercial intent? What about those packages that cost thousands of dollars from “Casey”? Is DXD a registered charity or Institute of Public Character? If you have to pay taxes when you make a profit or surplus, then I will take the “no commercial intent” phrase with a pinch of salt. After all, when the taxman believes you are non-commercial then I will likewise believe. Until then, this hobbit reserves judgment.

But what is more disturbing is that embedded in this sentence is the following idea or ideology:

DXD’s expressed aim (whatever that may be) overrides a doctors’ rights to have freedom of choice to associate or disassociate with an organisation such as DXD. It is interesting to note here that except in emergency or life-threatening situations, a doctor can unilaterally end a doctor-patient relationship (provided he offers and if necessary, makes continuity of care arrangements for the patient). But DXD has decided for doctors that doctors cannot end the DXD-doctor relationship or DXD-doctor association, implying that this DXD-based relationship or association with the doctor is even stronger than the patient-doctor relationship. You can even divorce your spouse, but you cannot get your name removed from DXD (until 7 Nov, that is).

Even in its blog entry on 7 Nov, when DXD announced its decision to remove the names of doctors who have requested so, it stated why it did what it did pre-7 Nov, which was – “In order to make expert health knowledge accessible to all, we need to have a balanced and fair view on how we manage doctors on our site”.

This hobbit asks DXD – who gave you the authority to “manage doctors on our (your) site”? Make no mistake, the word “doctors” here refers to all doctors on the DXD website, and not just doctors who have expressed their desire to work with DXD. Who made DXD the manager of Singapore doctors? Smaug again? The Eye of Sauron? Directors and shareholders of DXD? MOH? Parliament? Donald Trump? Did SMC outsource their work to DXD?

The SMC-DXD Bundle

It would appear to this hobbit that perhaps DXD has a mandate from heaven, to be so powerful as to force or want to foist an association onto practically all doctors in Singapore.

If you think about it, even the Triads and Secret Societies are more reasonable organisations. In the beginning, you have to sign up with them, which in itself is an act of free will. Nowadays Triad bosses don’t put a gun to your head to force you to join them. But once you are in, it’s true that it’s almost impossible to get out unless you go to jail for a long time.

But here, you are in the DXD website even though you didn’t sign up and then you also can’t get out. It sounds like the online version of Hotel California.

Effectively, DXD was saying (pre-7 Nov) that DXD is bundled with SMC. If you are on the SMC Register, you must be on the DXD website as well, just like you can’t delete Siri when you buy and use an iPhone. Awesome isn’t it?

These self-proclaimed rights to “manage doctors”, and to be the offeror of “an unbiased and comprehensive listing of all available options for our readers to make informed decisions for themselves” are so overpowering that they subjugate the basic right of doctors: the freedom to associate or not associate. The freedom to associate or not is really quite a basic right of an individual in a free and democratic society, as SMA had said to DXD on 7 Nov. There are extremely few institutions that can take away that right in Singapore and it is only done so in the rarest of situations, e.g. National Service – all able-bodied Singaporean males have to enlist for and serve National Service. He has no right to non-association with MINDEF, SPF or SCDF (wherever he is posted to for NS). Together, being Singaporean, Male and serving NS is a bundled deal.

Apparently, (until 7 Nov), DXD is another institution that can take away my freedom to associate or not in the form of the SMC-DXD bundled deal.

Finally, this hobbit has one suggestion for DXD. If DXD thinks that its position pre-7 Nov is so right, honourable and great, it should perhaps expand its offerings and activities as well as also apply the same principles and practices to the legal profession – list all the practising lawyers on its website, and refuse to take down the names and particulars of lawyers who request DXD to do so, giving lawyers and Law Society similar reasons that it had given to doctors and SMA. Just replace the word “patient” with “client”. It will be very interesting to see what happens then.

The IP Titanic

Question 1:

How does a health insurance company make money?


Its rather simple – the company collects more premiums than the pay-outs it makes to policyholders after accounting for business costs. If the pay-outs are more than the premiums collected, the company loses money. Plain and simple.

Question 2:

What is the usual narrative by the health insurance companies when they lose money?


They blame the doctors. Doctors overcharge and over-service. Sometimes they also blame the hospitals and facility operators, e.g. day surgeries for over-charging. They also may blame the patients.

Question 3:

What is the health insurance companies’ biggest bargaining chip against politicians and patients to get them to cooperate and support their practices?


The threat of higher insurance premiums.

Current Situation for Integrated Shield Plans (IPs)

The performance of IP insurers for 2019 has just been released. Two IP insurers are now making money: Prudential and Income. Prudential for the 2nd year running, making $51.99M, while Income made a modest $4.21M for 20191. The remaining 5 insurers made a combined loss of $99.31M.

For 2018, only one out of six IP insurers made money (results from the latest IP insurer, Raffles Health, was not available yet) . Prudential made $42.73M while the other five insurers lost a total of $80.49M. In 2017, All six IP insurers lost a total of $145.88M. For 2016, combined losses from the same six insurers was $98.59M

And so, we are told that unless doctors don’t charge less or do less, premiums have to go up. This is taken almost as received wisdom and cardinal truth. Doctors earn a fair bit and are often seen as fat cats. It’s easy to lay the blame on them. No one doubts this ‘blame the fat cat’ logic.

This hobbit does.

Under-utilisation and Structural Under-capacity

Let’s look at how health insurance really works. It works by pooling of risk. In any given year, the people that don’t fall sick don’t make claims. Their premiums are used to subsidise those people who do fall sick and make claims.

There is no carry over beyond the same year. It is a pay-as-you-go system, year by year accounting. This is opposed to Medishield Life (MSL) where because it is compulsory and life-long, there can be “front-loading” of premiums. In other words, MSL collects more premiums from us when we are young, so that they can collect relatively less when we are old, even though we consume more health services as we get older.

Front-loading of premiums is not possible in IPs, because they are voluntary and commercial, there is no guarantee that a person will sign up again the following year when the current contract expires with the same IP insurer. Even though in most cases, the policyholders almost invariably sign up again. That’s because as you get older, you can’t change insurer as you develop more medical problems because these problems will be excluded from coverage when you sign up with a new IP insurer. In other words, you are stuck.

So in the usual case, a commercial health insurance company has to balance the books and hopefully make a profit by collecting enough premiums from healthy people to subsidise those who make claims. Nothing with wrong that. This is how health insurance is supposed to work.

In almost all other developed countries, a health insurance policyholder will exercise the full benefits of his policy. But in Singapore with regard to IPs, they don’t. This is very peculiar to Singapore.

For the purposes of this discussion, private healthcare is considered to be private hospitals plus A class and B1 class beds in restructured hospitals (RHs). MSL and IPs are mainly concerned with bigger bills generated by private healthcare as well as expensive outpatient treatment such as chemotherapy and day surgeries. B1 beds actually receive some subsidy, at about 20% of costs. But again for the purposes of this blogpost, we will consider them as unsubsidised.

The Life Insurance Association (LIA) reported that two-thirds of Singaporeans have bought IPs. In an article in Business Times dated 1 Oct 2020 by Ms Genevieve Cua, it was stated “An estimated 70% of Singaporeans subscribe to an IP plan, to complement their MSL cover”.

According to MOH website2, in 2019, there are 11,321 acute hospital beds in Singapore. There are 1,629 beds in private hospitals and 288 beds in not-for-profit hospital (probably Mount Alvernia?), making a total of 1,917 beds.

It was also reported that 81% of RH beds are B2 and C class3. Therefore the remaining 19%  or 1,787 beds of the total number of 9,404 beds in RHs are B1 and A Class beds.

Total number of private healthcare beds (private hospital and A1 + B1) = 1,917+1,787=3,704 beds.

Therefore, private healthcare market share = 3704/11321 x100 = 32.7% or ~33%.

This is a very interesting statistic. It shows that despite 70% of Singapore residents buying IPs, the entire healthcare system is structured such that only ~33% of beds are private. There is obviously a structural mismatch between demand for IPs and supply of private healthcare beds.

The private healthcare market share for day surgeries and certain expensive outpatient treatment that are covered by IPs may differ from the figure of 33%, but probably not by very much.

In other words, in the case of Singapore, IP insurers have a second source of policyholders to balance the books in addition to healthy people – IP policyholders who choose subsidised healthcare in RHs, even though they are entitled to private healthcare. This is self-evident because there won’t be enough capacity in the private sector if all 70% of IP policyholders really exercised what they are entitled to. This “under-utilisation” of IP benefits is very interesting and needs to be studied further. Hopefully MOH or MAS has the data on how many IP policyholders do not utilise their IP benefits fully but instead opt for B2 and C class services in RHs and this data can be made public for all to study.

It could be that Singaporeans are by nature very conservative and prudent and hence will choose subsidised care even when they have IPs. Moreover, this 33% capacity figure is actually a conservative one because it ignores capacity taken by foreigners who came to Singapore for healthcare in pre-Covid-19 days. If you take into the capacity taken up by foreigners, the figure is probably below 30% and the structural mismatch is even more pronounced.

The nett effect is that when these IP policyholders choose subsidised care, the government is actually subsidising the IP system in the form of B2 and C subsidises given to these patients who otherwise could have chosen care that could have been paid by IP funds instead.

Young Policyholder Pool

The next thing we have to note is that currently, IP policyholders are generally a younger lot. The first provider was IncomeShield in the late 90s. This was followed by AIA and Great Eastern in 2002 (please see previous posting). It was only in 2005 that IP formally came into being. So The history of IP is about 20 years or so, give or take a few years.

In other words, we can generalise that the oldest IP policyholders are probably only in their early or mid-50s, while the bulk of IP policyholders are younger, probably in their 30s and 40s. People fall sick and make big claims usually when they older, in their 60s and 70s or even older. But in all likelihood, these older people are NOT IP policyholders now.

Of course, there will be a day of reckoning when the bulk of IP policyholders get older and sicker and make more claims from their IPs.

In summary, to stay profitable, IP insurers have two big advantages when compared to private health insurance companies in other developed countries, e.g USA:

  • Many Singaporeans under-utilise their IP entitlement and choose subsidised care.
  • Most IP policyholders are young and therefore relatively healthy.

Yet, at last count, five out of seven IP insurers are losing money.

Incredible, isn’t it?

Yes, some doctors may over-service. A few doctors may even overcharge (which is unlikely as long as they adhere to MOH Fee Benchmarks). But surely these factors are more than adequately compensated by the IP policyholder pool being younger and government subsidies to policyholders who under-utilise their IP benefits?

So why are IP insurers losing money?

What Can “Affordable” IPs Really Afford?

The answer goes back to the adage by Deming: – Every system is perfectly designed to get the results it gets.

To understand this, we have to get back to the basics – The Golden Triangle of Healthcare: Affordability, Accessibility and Quality.

The lesson here is that because of limited resources, no healthcare system can achieve all three. A system can at most achieve two and compromise on the third.

A health insurance agent or company is incentivised to sell more policies and collect more premiums. The easiest way to sell more policies is to price these policy premiums as cheaply as possible. Which is probably what has happened as all IP insurers compete for market share. But these premiums cannot really pay for what the IPs purports to cover, even with the two advantages described above. So to balance the books, you compromise on accessibility- Small panels of doctors, pre-authorisation forms etc. Quality, too, can be compromised, e.g. by telling gastroenterologists they have to provide sedation themselves and not use an anaesthetist. These are all measures that can be considered to bring friction and obstacles into the system by limiting accessibility and quality, so as to balance the books.

All these may work in the short term. But in the long term, all serious stakeholders must ask the tough questions that include:

  • Do we really believe 70% of Singapore residents can afford private (especially) inpatient care? If so, what do we build so many subsidised beds in RHs?
  • Why are we selling so many IP policies to so many people, many of whom will probably either won’t or can’t use their policy entitlement, but instead seek subsidised care in RHs?
  • Is the current IP market really a sustainable one when it has to depend on policyholders under-utilising their IP benefits (and consuming government subsidies in the process)?
  • What will happen if all 70% of Singapore residents exercise their full IP benefits?
  • Should we private healthcare acute hospital beds only amount to 33% of all beds, when 70% of Singapore residents have IPs?
  • What happens when the bulk of IP policyholders grow old and need more care? Will premiums shoot up then and many will have to give up their IPs just when they need IPs most?
  • How fast will IP premiums go up? Already the MSL proration percentage for private hospitals has been cut from 35% to 25% which means IP premiums has to go up very soon.
  • Going forward, what can “affordable” IPs really afford?

Yes, we can still continue with the tired narrative that doctors are mainly to be blamed for IP insurers losing money. But as this post has clearly shown, while doctors do make decisions that impact cost of healthcare, the long-term problems facing the IP industry in terms of sustainability are:

  • A structural mismatch between private healthcare bed capacity and number of IP policyholders
  • Misplaced incentives leading to unrealistically low premiums, i.e. IPs insurers are incentivised to sell as many IPs as possible to gain market share
  • A possibly misplaced belief by many IP policyholders that their “affordable” IPs will give easy and wide access to quality private healthcare when the reality is much less exuberant.
  • An IP industry that is indirectly dependent on government subsidies, i.e. IP policyholders under-utilising their IP benefits and getting subsidised care in the RHs.

Clearly, these icebergs are already visible now in the IP industry. In order to avoid ending up like the Titanic, we have to face the hard truths and make some painful adjustments now.

Unlike what Rose and Jack said in the movie, we have to let some things go. Because the disappointment and pain that will happen down the road will be much worse and widespread if we don’t make the right but difficult decisions today.


1Business Times: Most Integrated Shield insurers improve underwriting results in 2019, 5 Oct 2020.



The “Unbalanced” Hand of the Private Health Insurance Market

A recent letter from SMA to The Straits Times Forum brought to surface some of the unsavoury if not unjust and even unsafe practices of certain private insurance companies offering Integrated Shield Plans, usually called “IPs”.

Newly minted Chairman of the GPC (Government Parliamentary Committee) for Health, Dr Tan Wu Meng also quoted this letter in his recent Parliamentary Speech on 1 Sep 20 highlighting the problems facing people who have bought IP Plans.

He said,

“In a Straits Times Forum letter published on 29 Aug this year, the Singapore Medical Association shared that That some insurers are no longer allowing claims for diagnostic endoscopies even when medically necessary. This is a serious development. Implications for patient care. implications for patient safety. It is also a very visible sign that Individual patients, individual customers do not have bargaining power to stop insurance companies from such practices. When an insurance company moves the goal posts for an Integrated Shield Plan, it is not so easy for a patient to switch provider, because existing conditions become pre-existing conditions under the new policy”.

He further made the call for the authorities to step in, “The invisible hand of the market appears to have become unbalanced. And so I call upon MOH and MAS (i.e. Monetary Authority of Singapore) to look at this and to see if the visible hand of the regulators need to come in, to level the playing field and our people”.

Dr Tan is a medical oncologist, and he knows better than anyone else what are the consequences when a diagnosis of cancer is missed or delayed because people cannot get a diagnostic endoscope done because there is no cover under an IP. Some of the commonest cancers in Singapore need endoscopies for accurate diagnosis – colorectal, nasopharyngeal, stomach, bladder and so on.

As we all know, many Singaporeans buy such IPs. In the October 2016 Report of the Health Insurance Task Force (HITF), it was reported that about two-thirds of Singapore residents have an IP Plan, of which half (i.e. one-third of Singapore residents) have bought IP riders that pay for the co-payment and deductible requirements of IP plans. These IP riders are paid with cash while IP can be paid for by Medisave. This is a big-money business by any measure.


The precursor of IP was called PMIS or Private Medical Insurance Schemes. The first to offer PMIS was NTUC Income. By 2002, AIA and Great Eastern also offered PMIS. PMIS was a standalone product that was unlinked with Medisave or Medishield. They paid for expenses incurred when a patient consumes medical services in private hospitals or in unsubsidised wards (i.e. B1 and A Class) of Restructured Hospitals.

In 2005, Medishield was reformed and PMIS was renamed IP, IPs were linked to Medishield and Medisave in that they could be funded by Medisave monies. So far so good.

The problems really started when one IP provider started providing as-charged plans in 2005 and by 2006, all IP providers followed suit. In 2006, IP providers also provided the aforementioned IP riders, which paid for the deductible and co-payment parts of the bill. This is called “first-dollar” coverage in the insurance industry because the policy holder doesn’t even have to come up with one dollar before the policy kicks in to cover you. Someone dropped the ball on this in MAS and MOH obviously because the experience of this the world over is that first-dollar coverage will lead to more frequent claims. This is not rocket science.

Then in 2007, the SMA Guidelines for Fees (GOF) was outlawed by the then Competition Commission of Singapore (CCS). Which meant there was now no clear guidance really for private sector doctors on how to charge. And with as-charged plans being offered by all IP providers, this expectedly led to higher claims, as well as more frequent claims.

Looking back, this Hobbit thinks the main root cause was both under-regulation and over-regulation. The insurance industry was somehow under-regulated, leading to proliferation of undesirable IP products such as as-charged plans and first-dollar coverage riders. On the other hand, CCS over-regulated the SMA GOF to its eventual withdrawal by SMA. It is this Hobbit’s opinion that these two events led to both an increase in number of IP claims and IP bill sizes.

It wasn’t before long the IP providers realised the error of their ways and then as the Hokkien saying goes, these providers “Cry Father, Cry Mother” about rising healthcare costs associated with IPs, especially those that come with as-charged and first-dollar coverage plans. But who came out with these IP products in the first place? Not doctors. Not patients.

Certain IP providers (i.e. members of the Life Insurance Association or LIA)!

Their trade association, LIA then wanted to address this problem. The Health Insurance Task Force (HITF) was thus formed in early 2016, with representatives from LIA, CASE, SMA, MOH and MAS.

The Report of the HITF was published in Oct 2016. Some of the major recommendations included:

  1. Have a new set of Fee Benchmarks or Guidelines
  2. Introducing Panel of Preferred Providers
  3. Pre-approval of Medical Treatment

The government kept its side of the bargain and MOH came up with its Fee Benchmarks for the commonest procedures in Nov 2018, after extensive consultations with stakeholders including LIA, doctors, hospital administrators, CASE and even the unions. So after 11 long years, the role that SMA GOF served in controlling healthcare costs was resurrected as the MOH Fee Benchmarks in a wonderful act of policy necromancy.

The Current Situation

You would think that all IP providers, being members of the LIA, will support the fee benchmarks. After all, this is what we would expect out of good faith and especially the benchmarks were from the government, no less. But it turns out that several IP providers have since reimbursed doctors at rates that are at the lower end or even below the low end of the fee benchmarks. Those that now go below the fee benchmarks make a mockery of the process and maybe even a betrayal of the hard work that has gone into making the fee benchmarks a reality.

Next, we look at the issue of IP providers coming with panels of preferred providers. A few IP providers have done so. One or two have done so in the wrong spirit. In the original HITF report, it was written that these panels are to be appointed in the hope of “Enhancing Insurance Procedures and Products Features. To achieve so, IP providers are  “To enhance and ensure transparency of the arrangement (e.g. disclosures on the healthcare provider selection process)” (Page 16 of HITF Report)

The exact opposite has happened. No IP provider has come clean to state what are the exact criteria they are using to select and empanel doctors. Some panels are restrictively small. Some specialties, especially the smaller ones, have no representation on the panels at all.

Many IP providers say they have many doctors on their panels, but on closer scrutiny, many of these are actually specialists from restructured hospitals (RHs) and very few are actually from the private sector. It is obvious that many IP providers are trying to shift work from private hospitals to the RHs by having panels that are heavily weighted towards the RHs and sparsely populated by private sector specialists.

In the current climate, all healthcare providers are functioning at reduced efficiency when compared to pre-Covid. The appointment and waiting times at RHs are already more trying during this Covid-19 pandemic. Do the RHs need any more business? On top of that, some IPs guarantee that their policy holders can get a specialist appointment within 48 hours, which as we all know, is practically an impossibility in most RHs.

So let us now get back to the centre of healthcare, the patient. The IP patient to be exact. He or she has paid good money to get an IP. Half of these folks have even forked out cold, hard cash to get these IP riders.

What does he get in return? Well, it all depends. If you are an Incomeshield IP plan holder, (like this hobbit), you can sleep reasonably well. Because as long as the specialist adheres to charging to within the fee benchmarks, there is little fuss. But woe be unto you if you have signed up with the “wrong” IP provider. You may well discover that one or more of the following:

  1. The doctor you have seen in the past is not an empanelled doctor
  2. You have to jump through hoops to see him,
  3. Your non-panel doctor has to justify at length why some admission or procedure is needed and what are his estimated charges, and seek approval from the IP provider
  4. The approval may take days which leads to anxiety and delay, or the approval may never come and you are forced to see someone else if you want coverage or ease of coverage
  5. Now you have to pay cash up-front to see a non-panel doctor and wait for the IP provider to reimburse you later, and there is no assurance they will do so
  6. The panel does not even contain a private specialist in the hospital or speciality that you need or want
  7. Certain things you assumed were covered no longer are – like diagnostic endoscopies such as colonoscopy. Even though you have a family history of colorectal cancer and needs periodic screening
  8. You cannot change IP provider because no new IP provider will cover you for conditions related or can be associated to e.g.  a small benign polyp that had been taken out 5 years ago during a colonoscopy

even though you have been paying years of riders for first-dollar coverage and covering as-charged bills

It is the “unbalanced” hand of the market at work, unbalanced in favour of the IP provider.

What is really the point of having IPs?

But let us take a step back and ask what is the policy intent of having IPs offered by private insurance players in the first place?

This hobbit thinks IPs were allowed by the government so that more Singapore residents can receive private healthcare. Private healthcare means primarily private hospitals, but for completeness’ sake, will also include the unsubsidised care in RHs. But RHs’ private or unsubsidised patients were not and is not the main intent or focus of IPs. Why is this so?

Think about it, the government owns MOHH which in turns own the clusters and RHs. They have great influence over how cluster boards are run and how top hospital management are appointed.  In other words, there is great influence (if not a strong degree of control) over both costs and pricing.

There is really no need for the private insurance companies to participate in IPs if the intent was for IPs just to mainly cover consumption of B1 and A class services in RHs. The government can definitely do a better job and save patients money by cutting out the middleman (i.e. the private insurance companies).

So the apparent strategy by some IP providers to try and shift work to RHs is doomed to fail in the long run.

This hobbit thinks it is perhaps time to exclude private companies from offering IPs that cover RH services. After all the government has done a good job running Medishield Life which covers C and B2 classes (i.e. subsidised classes). It doesn’t take much more to extend Medishield Life to B1 and A services.

Then, we can leave private insurance companies to only offer private insurance plans that can be partially funded by Medisave monies for those Singapore residents who wish to be served in private hospitals only. And that we can stop these IP Plans from trying to shift work to RHs and derive big profits from doing so when this was probably never the policy intent of IPs.

Regulatory Lacunae

What about the un-covered diagnostic endoscopes that we talked about earlier on? Well, we hope the guy with the regulatory muscle, MAS, will do the right thing and sit on these IP providers who are obviously doing the wrong thing. Now that it is out in the open and even discussed in Parliament, this hobbit thinks something will happen. Some authority will tell the insurance company or companies that this is not right and these companies will comply and cover diagnostic scopes once again.

This is the nub of the problem because with such a regime, people are motivated to try their luck every now and then and come up with money-making ideas at the patient’s or doctor’s expense.

Part of the problem of regulating IPs is that it perhaps falls through the cracks. IP providers and insurance companies are licensed and regulated by MAS. But really, MAS has no expertise in healthcare. And perhaps they have bigger fish to fry than IPs. On the other hand, MOH has the healthcare expertise of course, but they have little or no regulatory muscle to compel insurance companies to do the right thing because MOH really does not administer any law that can punish insurance companies.

There is thus no real punishment for the party that comes up with these unethical and dangerous ideas that compromise patient rights, patient safety and clinical standards. Today it is diagnostic scopes, tomorrow it may be biopsies.

Today, if a doctor does something that compromises patient safety or autonomy like taking a patient consent that does not meet the basic standards of the SMC Ethical Code and Ethical Guidelines (ECEG), he may be sanctioned by SMC. But will MAS, the regulatory body of insurance companies sanction or punish an insurance company for forcing doctors to adopt clinical practices that compromise patient interests (like treating patient with hydrogen pump inhibitors before scoping)? They probably do not know what are correct clinical practices in the first place.

So clever insurance people will continue to exploit this lacunae in health insurance regulation and try to push their luck. I don’t blame them. The system is performing exactly the way it is designed to. There is no downside other than the IP provider being told to withdraw the undesirable practice.

The way forward is perhaps for every IP provider to have a registered medical practitioner as medical director before an insurance company can be accredited as an IP provider. This medical director is like the head of compliance in a bank; he has double reporting lines, one to the bank CEO and one to MAS, the regulator of banks. Should the CEO of the bank try something funny, it is his duty to advise the bank CEO. If the bank CEO doesn’t comply, then he can report the CEO’s plans or deeds to MAS. If he fails to report the CEO to MAS, the head of compliance can be sanctioned too. I am told by a banker this is how bank regulation works in Singapore and every head of compliance of a bank has to be approved by MAS before he can be offered the job by the bank.

This hobbit thinks it is high time that the health insurance industry is regulated in a similar way. The medical director can report to the insurance company CEO and  to someone in MAS, perhaps a Health Insurance Commissioner seconded to MAS from MOH. If the medical director fails in his duty to ensure that the insurance company does not put up practices and policies that compromise patient safety and interests, then the medical director himself can be reported to SMC for investigation and possible punishment.

Simply put, we have to put in place a regulatory regime that has a deterrent effect, one that stops people from pushing their luck to try something that is bad for patients and the healthcare system.

The Reopening

Give yourselves a clap. We have successfully emerged from a tight CB period. In case you have forgotten, it was the Prime Minister no less who announced the “tighter CB period” on 21 April 2020 which would last until 1 June 2020 (inclusive).

The website actually stated,

“PM Lee on 21 April 2020 announced tighter measures to the Circuit Breaker period, to further reduce the transmission of COVID-19. He also announced that the Circuit Breaker period will be extended by another 4 weeks until 1 June 2020 (inclusive)”.

This hobbit was thinking to himself on 21 Apr 20, “Wah. I thought the CB already very tight. Now even tighter and must be inclusive too”.

You really have to give it to those wordsmiths in the civil service and political leadership.

Anyway, we are now in Phase 1 of “The Reopening”. That’s when you realise nothing much more has reopened. Except the schools, car and air-con servicing, hairdressers and basic pet grooming. Interestingly, animal rehab and physio are allowed too.

That brings us to our pet peeve today (pun intended). What is allowed and what is not allowed in The Reopening: Phase 1. In medical school, when we construct a research study design and draw conclusions, we are told to make reality checks. These are called internal validity and external validity checks. Internal validity checks are checks that ensure the conclusions from the study drawn make sense within the aims and methodology of the study while external validity involves comparing study conclusions with what was already known in the external environment to also see if the conclusions make sense.

Policy-making is no different. There should be internal and external validity checks. Now let’s come to the subject of aesthetic medicine. These are largely banned. Aesthetic doctors are only allowed to treat organic diseases like acne and eczema. I suppose there is some internal validity when you compare aesthetic practices to what is allowed in the practice of Western Medicine. But when you think of what is allowed in other areas, then you will probably wonder where is the external validity?

Is aesthetic medicine less essential or more dangerous than basic pet grooming? Or complementary medicine such as TCM, Ayurvedic practice or chiropractic and osteopathy? Can we allow “basic” aesthetic medicine without allowing invasive or aerosol-generating aesthetic practices? So many questions arise when you look at the aesthetic medicine issue from an external validity angle.

To top it off, even HDB may be into the act of regulating aesthetic medicine. Apparently, a GP was told by a HDB officer that he had to close his HDB shop-lot clinic because it was named “XYZ Aesthetic Clinic” when all he was doing was just opening it to see common GP ailments and treat severe acne.

(For the avoidance of doubt, this hobbit has no pecuniary or physical interest in aesthetic medicine. He is an ugly, old coot who doesn’t practise the stuff and he hasn’t received any form of aesthetic treatment).

A whole-of-government to fighting the Covid-19 pandemic is largely a good thing. Because no single ministry has enough resources to do this alone. But from observation, this hobbit suspects that one of the problems of a whole-of-government approach could be what the age-old adage says, “When everyone is in charge, then no one is in charge”. The other problem with this approach is that when everyone in authority can make rules, then they indeed do, but no one is looking over their shoulder and having a helicopter view of what each and every department is doing. The result is that people on the ground are saddled, if not crushed by a mountain of regulations and requirements issued by a myriad of agencies.

An example is the construction industry. The BCA announced that construction workers in dorms can begin work again once they are tested. But I guess they didn’t check with MOH when they said this. Because none of the folks out there who provide testing, i.e. the polyclinics, PHPC clinics, hospitals, are allowed to offer Covid-19 testing to anyone unless there are clinical and/or epidemiological indications. I wish I could, but I cannot offer a swab to a billionaire even if he paid me $100,000 for a swab, unless he possessed some indication for swabbing. The same applies for construction workers. So many of us were swarmed with requests by construction industry bosses, supervisors last week in the first few days following end of CB for their workers in dormitories to be swabbed. All this angst, frustration and disappointment could have been simply avoided by coordination between MOH, BCA and MOM. They could have issued a joint statement in the last week of May that goes like “All construction workers would be allowed to start work again after CB if they are tested. However, please note that construction workers will be notified through their employers or dormitories by MOM/BCA/MOH as to where and when they should go for testing. In the meantime, please be patient”.

The same considerations apply to the Malaysian workers who are stranded here. The Malaysian government has said these returning Malaysians may avoid quarantine if they are tested negative for Covid-19 in Singapore. But again, there is no testing available here. Meanwhile some of them have had their pay cut or even retrenched. This has been reported in the mainstream media and this hobbit won’t elaborate here. But the point is, there have been many such requests and the PHPC GPs have to be the bearer of bad news to these stressed-out folks.

Instead, the various agencies had to run around and do service recovery. The 2nd Minister for National Development had to announce in Parliament on 5 June that BCA would be the one-stop agency for these workers and their employers to go to with their concerns and queries. He said “BCA will be the point-agency in Government or the one-stop shopfront for all matters regarding construction restart”. This could and should have been said before 1 June, before the end of CB, so as to avoid the chaos that ensued from 2 to 5 June. And of course front-line GPs and PHPC doctors had to manage the demand for testing when there was effectively zero supply at the frontline. As if though we don’t have enough problems of our own, huh?

Yet another example is the announcement of swab stations in the community, e.g. One Farrer Hotel about a week ago. Again, there was a small rush by some folks to be swabbed there when these places are meant only for people who need to be re-swabbed. Again, people at the frontline had to face irate members of the public.

The message is not getting through. In other words, the people must be told they will not be tested unless they meet specific MOH criteria, e.g. they are sick. Please do not just say we are ramping up testing capacity to many thousands a day. That is only one side of the story. There are ministerial speeches going on now every few days. Can one of the ministers say this out loud and clear that there is NO testing for the public unless they meet MOH criteria? Because there is great demand for testing from the public which healthcare providers cannot meet because of regulatory prohibition. We have to give the good news and the bad news to the public and manage expectations on this subject of testing. It will save the public and us healthcare workers a lot of grief. Thank you very much.

Even in MOH itself, it appears no one is taking a look at regulation from the end-user’s perspective. Today, if a 75-year-old patient comes into my PHPC clinic for flu, do you know how many forms I have to fill? I have to

  • Fill up the Flu Subsidy Scheme (FSS)  once a day for the clinic for all FSS patients, which in itself is a lot of work.
  • Fill up a swab form if I performed a swab or fill up the Swab Referral Form which is two pages-long per patient if I refer the patient elsewhere.
  • Fill up the Patient Risk Profile (PRP) form through the Patient Risk Profile Portal. Many of the fields in this PRP are already filled in the daily FSS submissions. It will save everyone a lot of work if MOH can merge the databases of FSS and PRP.

On top of filling up forms and making submissions up to my goggle-encased eyeballs, I have to remember a phalanx of policies like

  • What drugs are reimbursable under the FSS
  • Suspect Case definitions
  • Who to send for enhanced Swab and Send Home (SASH)
  • Advise irritated patients who are given 5-day MCs that the MC is essentially a 5-day Stay at Home Notice (SHN).
  • Social or physical distancing in my clinic

Another side but important point about enhanced SASH is that certain patients “should” go for swab if they qualify under certain conditions. But the key word is “should”. “Should” is not a “must” and many patients have refused to go for swabbing. What does a GP do? The PRP form does NOT have an option for this. No one seems to know the answer.

I suspect all these different requirements and regulations are issued independently by different departments within MOH and no one is putting themselves in the GP’s shoes and realising how collectively these demands will drive private sector doctors and their clinic support staff nuts.

I know if I take your money for FSS I must suck thumb and take all this. But can you just cut me a little slack?

There is a lot of fine-tuning of language in policies and circulars that frankly, the busy and tired doctor find difficulty in grasping. Put it simply, enhanced SASH should be mandatory and not a “should”. This pussyfooting is doing no one any good. Most doctors at first instance understood it to be mandatory anyway. It was only on second or third reading that they realised enhanced SASH was not a “must” but a “good to have”. There are no penalties for refusing enhanced SASH. Such nuancing creates difficulties on the ground. By now, doctors are so tired, we are long past the stage where we can perceive and appreciate linguistic finesse.

Another example is in the language used in some circulars. If we doctors were so good with language we would have become lawyers. In a MOH circular dated 19 May, it is stated in para. 3, “MOH proposed 2 phases for the resumption of more of the healthcare services”. In para 10 of the same circular, it stated “This circular is for your compliance”.

I don’t get it. If MOH “proposes” then maybe it is something that can be discussed? But if it is “for your compliance”, then there should be no discussion; we just get on with it. It’s like Mr Tan Ah Kow proposes to Ms Ong Ah Choo, but Ong Ah Choo must marry Tan Ah Kow.

This hobbit is stunned like vegetable.

Finally, as this pandemic wears on, the authorities must explain why certain policies are necessary and how they are effected in a fair and transparent way. For example, till today, people do not understand how the number of essential workers are arrived at in clinics. People also do not understand why aesthetic medicine is less essential than pet grooming, rehab and physio. People who do not understand why unlicensed and largely unregulated treatments like osteopathy and chiropractic have higher priority than certain treatments and interventions offered by doctors (and dentists too, I guess).

Sometimes things are so complicated that maybe even public institutions cannot keep up. According to a GP friend, he referred a 13-year old patient with ARI to be swabbed at the polyclinic. The parent reluctantly did bring the teenager there, only to be told they won’t perform a swab on the student. Another GP referred another teenager to polyclinic for a swab. She was accompanied by the grandparent. The polyclinic staff said the teenager must show her birth certificate as documentary proof. A student pass is not good enough. The clinic staff actually called up the polyclinic to double-check and confirmed that a birth certificate was necessary. Imagine what these GPs had to endure from the patients and their parent/grandparents consequently. With polyclinics like these, who needs pandemic-causing viruses?

In summary, this hobbit sees three areas that need to be dealt with:

Regulatory Fragmentation – e.g. the construction industry is pulled apart by different regulatory requirements by BCA, MOM and MOH; clinics regulated by MOH and MTI; polyclinics making up their own rules.

Regulatory Redundancy and Overlap – e.g. many forms and submissions for one single patient for one diagnosis, e.g. PRP form, FSS submission, SASH form

Regulatory Opacity – who decides and what is the criteria for decisions? Any external validity checks across ministries and agencies?

The sum of all these problem areas is

  • Confusion and bewilderment (directives and policies should be short, simple and clear. Avoid “coulds” and “shoulds” if possible; what do you do with a patient who declines enhanced SASH?)
  • Extra and unnecessary work is created (multiple form filling)
  • GPs and frontline healthcare workers are made to bear bad news (“I can’t test you”…..I have to give you 5-day MC…..)
  • The public and certain industry stakeholders aren’t happy
  • The doctors and their support staff aren’t happy

We all know we need to make sacrifices and endure pain in this pandemic. But let’s not make it more painful than what is absolutely necessary.

CCB – The Good, The Bad And The Mysterious

We have been in Circuit Breaker (CB) mode for about four weeks. The original CB period was supposed to end on 4 May. But this mode is going to continue for another 4 weeks, until 1 June. We are therefore now in CCB mode – Continued Circuit Breaker Mode. Hopefully it will not be extended or tightened again. Somehow only my gynae classmates find tightening of CB measures amusing.

There are encouraging signs on the data front. While Covid-19 rages on in the dormitories, such that 500 cases a day is now considered not bad news, numbers in the community have been coming down. These can be seen in the daily Situation Reports put out by MOH. This hobbit finds these Reports interesting and informative. There is a mountain of data in the Reports but let us just concentrate on two aspects – Unlinked Community Cases and Unlinked Work Permit (WP) Holders Not Residing in Dorms. These two sets of numbers are found in Table 1.1 of the daily Situation Reports.

We concentrate on unlinked cases because these are the cases that present the greatest threat to us. With all the dorms under lockdown, new cases found there do not present a significant threat to us in the community. That is not to say we should adopt an indifferent and callous attitude to these poor folks stuck in the dorms, but these do pose a different level of threat to the rest of us. The same goes for linked cases in the community, because containment measures such as contact tracing and quarantine would have kicked in quickly once they are linked, so as to lessen the threat of transmission.

That leaves us with the unlinked community cases and the unlinked work permit holders NOT residing in dorms. To this hobbit, it is the same whether a person has a work permit, an employment pass or even a pink IC – if they do not live in the dorms, they should be considered a community Covid-19 case. Because the virus doesn’t care if you hold a certain type of identity document or not.

In the MOH Press Release dated 1 May, it was said,

“The number of unlinked cases in the community has also decreased, from an average of 16 cases per day in the week before, to an average of 6 per day in the past week. We will continue to closely monitor these numbers, as well as the cases detected through our surveillance programme”.


“The number of new cases amongst Work Permit holders residing outside dormitories has decreased, from an average of 27 cases per day in the week before, to an average of 14 per day in the past week”.

This hobbit (like most hobbits) is a lazy fella. Instead of using a 7-day moving average like what MOH has implied above, we can derive a 14-day moving average simply by subtracting the top row from the bottom row of Table 1.1 in the two relevant columns to get the total number of cases in the 14 days up till the day of each situation report. Divide that number by 14 and you get the daily average over 14 days for each day. So here is what the figures look like: (this format of reporting by MOH first started on 17 April):


Date Total Cases over 14 days for Unlinked Community Cases Average Per Day for 14-day period Total Cases over 14 days for Unlinked WP holders NOT in dorms Average Per Day for 14-day period Total Unlinked Cases Average Per Day for 14-day period
17 Apr 291 20.8 97 6.9 388 27.8
18 Apr 285 20.4 95 6.8 380 27.1
19 Apr 281 20.1 96 6.9 377 26.9
20 Apr 276 19.7 103 7.4 379 27.1
21 Apr 284 20.3 116 8.3 400 28.6
22 Apr 266 19.0 121 8.6 387 27.6
23 Apr 264 18.9 121 8.6 385 27.5
24 Apr 258 18.4 115 8.2 373 26.6
25 Apr 248 17.7 108 7.7 356 25.4
26 Apr 242 17.3 116 8.3 358 25.6
27 Apr 219 15.6 122 8.7 341 24.4
28 Apr 200 14.3 112 8.0 312 22.3
29 Apr 180 12.9 103 7.4 283 20.2
30 Apr 168 12.0 97 6.9 265 18.9
1 May 157 11.2 83 5.9 240 17.1
2 May 138 9.9 79 5.6 217 15.5


  • The trends looks promising
  • Unlinked cases peaked on 21 April, which was exactly the day the Prime Minister addressed Singapore which was followed by policies that furthered tightened the CB with barbers and bubble tea establishments closing
  • While unlinked community cases have more than halved since 17 April, the unlinked cases involving WP holders NOT residing in dorms have proved to be a tougher nut to crack, the downward trend in this category is not as pronounced as the unlinked community cases. This is very worthy of our concern.

One caveat is that you have to use the individual daily reports and not rely on just the report of the current (latest) day because figures change for a certain day when cases become linked after several days of investigations.  For example for the Situation Report dated 18 April, the number of unlinked cases for WP holders NOT in dorms was 13 for 18 April. But this same statistic for 18 Apr dropped to 5 by the time the Situation Report for 23 April was published.

The average total unlinked cases for both categories is now 15.5 for a 14-day period. Hopefully, by the end of CCB, this will drop to <5. In places like Taiwan and HK, the total number of cases (whether linked or unlinked) is in the single-digits, so aiming for the same number for us just for unlinked cases alone is not a tall order. For example, since 15 April, HK has not had more than 5 cases a day, linked and unlinked. The same goes for Taiwan, which other than for 22 cases reported on 19 April due to cases found on a warship, they too haven’t had more than 5 cases a day either. In South Korea, new cases a day are now in the single digits, and the highest number they have had since 15 April was 22 cases. But Korea is a country with 51 million people, about nine times the size of Singapore.

There are policies, and then there are policies. As we are now into the 5th month of our struggle with Covid-19, let’s look at some of them. This hobbit thinks policies can be roughly grouped into the good, the bad, and the mysterious.


The Good

Recently, the SMC has just modified the requirements for CME in this current cycle in response to a request from the SMA. All Covid-19 related CME activities are now considered Core points for all doctors. Also, the cap for self-reading of journals (Category 3A) has been raised from 10 to 20 points. This is very good.

The locum rates for doctors who work at Community Isolation Facilities (CIF) is $130 per hour. This is a very fair deal. Good too.

In a Webinar, the DMS said MOH was committed to support all PHPC clinics with free PPEs beyond the initially stated 12 weeks. This is to be welcomed too.


The Bad

Let’s imagine this – you are one of the squad leaders on top of Helm’s Deep in Part 2, Twin Towers of The Lord of the Rings Trilogy. You are put in a charge of a squad of 10 elven archers and you and your squad face this sea of orcs, trolls and Uruk-hais marching towards you. You are scared shitless. But you swallow your fear in spades and await the onslaught from these beasts with your small squad of elves as well as the rest of the Elven and Human Army. Suddenly, this guy comes up behind you and says in an authoritative tone, “Dude, I am cutting your squad strength by half. You now only have 5 archers left. Good luck”.

“Whaaaaaat?!?!?” you scream out in anger, fear and frustration. Meanwhile, the orc and trolls army has multiplied further and are marching closer and closer to Helm’s Deep.

Sounds crazy? But this is exactly what is happening in the trenches today with our medical clinics.

To be fair, there are medical services that are obviously non-essential and should be closed, such as aesthetics and health screening. There are even some specialist services that are probably non-essential and should be limited as well, such as stable cataract surgery or joint replacements.

But GP services, especially Public Health Preparedness Clinics (PHPC)?

This hobbit has seen numerous GP and PHPC clinics’ requests for full manpower denied. This whole process of registering your essential staff is so illogically painful it is shameful. The IT system itself is a basket case – it hangs frequently. There is also no clarity and transparency in how decisions are arrived at. Some clinics were given a total of two workers while there is another that is given five. How are these numbers arrived at? What is the criteria? Yet another clinic was given 400+ workers (probably a mistake, but still…)

There is no consensus amongst doctors whether number of employees/workers includes or excludes doctors. Some doctors take it to only include non-doctor workers. Some doctors think it excludes cleaners who come by for an hour a day to do cleaning.

The number of staff allowed – are they for one shift, or for the whole clinic per day? Nobody really knows. What if you have different staff for different shifts? Can you have six workers in a clinic working three shifts? i.e. two workers per shift or must it be the same two workers in all 3 shifts?

This is one big royal mess. A GP running a PHPC Clinic is very clear in his mind – He says  “I have four clinic assistants. If they give me only two, then I will reduce my clinic opening hours by 50%”. I know a few senior GPs who told me they will close their clinics altogether because they can’t take this anymore. If all these GPs cut their opening hours by half, then the combined effect would be a significantly diminished PHPC capacity. Is this really the policy intent of enforcing worker limitations in GP and PHPC Clinics? To cut capacity in the PHPC system? Instead of mustering all the elves and humans to fight the orcs, you tell your frontline warriors to stay at home? How does this gel with the Health Ministers saying “healthcare workers are our most important resource?”. Clinic assistants are also healthcare workers, aren’t they? And yet we want them to stay home….

The usual answer one gets is “you can appeal”. But to appeal is unnecessary work at best and demeaning at worst. If I am truly frontline GP battling Covid-19, why should I have to appeal? Why don’t you reduce the opacity and tell me what is your criteria for deciding on how many workers a clinic may have?

One wonders, is there any other country in the world that wants to decrease service capacity in the primary care system during this Covid-19 pandemic? We may be the only one.

My clinic’s workload has come down by at least 50%. Most GP clinics I know have seen their workload cut by between 50% to 75%. So on one hand, it is true you may not need so many staff from this perspective. But due to current infection control measures, efficiency and productivity also drops significantly, so less patient volume may not correspond to a tandem reduction in manpower needs.

In any case, pre-Covid, GP clinics running out of 600 to 700 square feet shop-lots are already some of the most efficient healthcare providers on this island. How much more productivity do you want out of each of them? Do the authorities actually think GPs hire more workers than they need in peacetime? Especially when they are paying each and every of these clinic assistants out of their own clinic takings?

But moving beyond numbers, we need to have more empathy with what the GP is going through while fighting two fronts:

  • The GP is risking life and limb with his clinic team to continuing serving his patients amid the Covid-19 pandemic (Physical Threat and the Disease Front)
  • He is very stressed by the loss of patient load which translates to very diminished income. (Financial Damage and the Economic Front)

He doesn’t really need to have a third front, which is to contend with the authorities on justifying why a clinic assistant is needed on the Regulatory Front. As one PHPC family physician said, “You are supposed to help me make my life easier as a frontline healthcare provider, not add onto the stress and psychological trauma by cutting down my staffing and threatening to fine me or put me in jail, especially when I am supposed to be helping the country battle Covid-19”. He followed through with a string of expletives which this hobbit has censored. (Sorry, bro, cannot post lah).

Interestingly, this same doctor told me he has seen his clinic staffing cut to 2 but he knows a lawyer has been given a quota of 5 essential workers. He rationalises that maybe there are many people who want to have their wills written in a hurry.

So what is going on with the GP is that he has to fight the virus, stave off economic ruin and contend with the most unfriendly GoBusiness IT system and live in fear of the threat of being punished under the ID Act should he offer some service that is deemed non-essential.

But that is not all. We also now have additional interpretations of what is essential medical services and what is not.

For example, in a directive dated 30 April, it was said some of the non-essential services that were discovered in medical clinics included:

  • Consultation for skin and hair conditions which are stable and on long-term follow up;
  • Provision of botox, fillers and chemical peels for aesthetic purposes; and
  • Supply of facial cleanser, lotion and cream refills over the counter.

As previously said, banning of provision of aesthetic service is straightforward enough. But the other two points are not so simple. The main issue for GPs is that we really do not know who walks into my clinic beforehand every day and what are their reasons for seeing me. I do not have a triage to sieve cases out, and even if I had, it is gone now, thanks to GoBusiness who just halved my number of clinic assistants.

A patient who comes into my clinic say for diarrhoea may at the end of the consultation ask me for another tube of steroid cream for her stable eczema. Do I give it to her or not? And why would any patient pay for delivery charge for medicines when he walks into my clinic to refill his acne medicine after buying takeaway food from the hawker centre which is located 30 metres from my clinic? Do I deny the patient his bottle of cleanser for acne or the diarrhoea patient her tube of steroid cream?

Many non-essential services are offered opportunistically together with essential medical services given in the same sitting, and often so at the patient’s request.

Somehow I think all these directives are written by people who do not understand GP practice and have not practised as a GP in the heartlands. This hobbit suggests that these powerful directive folks read up on Stott Davis Model and Pendleton Model of Family Medicine consultation models in addition to their usual work of writing and issuing directives. Or as suggested by a general surgeon – perhaps talk to a real doctor.


The Mysterious

Immunisations. MOH considers adult immunisations as non-essential and that influenza and pneumococcal vaccinations can be given only if the patient is also “being seen for essential routine chronic care”.

WHO does not make a difference between adult or childhood immunisations. Here is what the WHO says in its website:

One of the “Guiding Principles” states…

“Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where feasible. Immunization delivery strategies may need to be adapted and should be conducted under safe conditions, without undue harm to health workers, caregivers and the community”.

One of the “Considerations” for routine immunisations:

“Where health system capacity is intact and essential health services are operational (e.g., adequate human resources, adequate vaccine supply), fixed site immunization services and Vaccination-Preventable Disease (VPD) surveillance should be executed while maintaining physical distancing measures and appropriate infection control precautions, equipped with the necessary supplies for those precautions”

I guess either our health system is not intact or our MOH is not taking guidance from WHO on this.

Another great mystery is of course our Dorscon system. In the beginning, I guess most of us didn’t really understand it. Then many started making jokes about it. Now, nobody even bothers to refer to it except in the most perfunctory way. When it gets to this level of irrelevance and irreverence, it is perhaps time to bury it.

Next we move on this ban on walking pets and exercising in the private estate grounds. The ban was first announced on 28 April by the Building and Construction Authority (BCA) before the decision to reverse it was made on 2 May and the reversal will be implemented with effect on 5 May. It took all of four days to reverse a decision and another 3 days to implement the reversal. Mysterious isn’t it?

To be absolutely clear, this hobbit thinks the original decision didn’t make much sense and caused a lot of grief. Some condo estates may be very big, and a resident needs to walk 100 to 200 metres to the main gate and enter public areas where the dog can walk. So what must the resident do to abide with this directive? A dog lover friend of mine contemplated carrying her dog for 200 metres to the main gate, or putting the dog in a baby stroller and pushing the dog in the stroller to the main gate. Luckily, she owns a poodle which is small. But what if you own a golden retriever or a Doberman? Lug the mutt like an army full-pack for 200 metres?

Next we move on the ban on home-based food businesses such as baking, which was announced on 26 April. You can order fast food delivery to your home but you cannot perform home-based food businesses and get the goods delivered elsewhere by similar professional delivery services. The decision to reverse this was made yesterday (6 days from announcement) and the implementation of this reversal decision will be made on 12 May (16 days from 26 April). Frankly, my public health and epidemiology knowledge is limited at best (I slept through most of COFM class, like many other people), but this hobbit thinks really the additional epidemiological risk posed by home-based food businesses baking is quite limited if you already allow deliveries of goods and cooked food from establishments, restaurants and hawker centres to homes. So why this sudden albeit transient attention on home-based food businesses? Another mystery.


The Biggest Mystery of All

And now we will move on to the really important news in our  nation’s mighty battle with the Covid-19 – The Virus Vanguard.

The Virus Vanguard must be the shortest-lived superhero grouping in the history of the galaxy. It survived for as long as SARS-CoV-2 did in my 70% alcohol sanitizer. Which is really a pity.

Anyway, this hobbit has to go. I have an important date with my fellow mythological character, Care-leh Dee, the Virus Vanguard trillionaire philanthropist superhero who can hopefully give me some financial assistance for my loss of income. And I will also ask her to use her empathy to remove all the negativity I have about GoBusiness and my inability to give a tube of steroid cream to my diarrhoea patient with stable eczema.

I also hope to get MAWA Man’s autograph through her. Wish me luck.


Gentle Reminder – Do remember to vote in next week’s SMC elections.





Part 2: MOAC – The Mother of All Clusters

We are now quarter-way through the circuit breaker (CB) mode, two weeks down and about another six more to go. The situation is not quite encouraging as yet. Of course, this is already by hobbit standards, and hobbits are by nature optimistic, as opposed to elves and dwarves.

For one, as of this afternoon, the number of Covid-19 cases in Singapore has exceeded 10,000.

Secondly, if you look at the doubling time of the epidemic in Singapore, it is now about 5 days. This is shorter that what was quoted previous by WHO when the disease first appeared – 7.4 days.

The other issue is that of unlinked cases. From the MOH website, you can see there are two types of unlinked cases:

  • unlinked community cases and
  • unlinked work permit cases NOT residing in dormitories.

From 8 April till 21 April, the total unlinked cases from these two categories reported each day has varied between 24 and 31. But on 21 April, the number went up to 44 (23+21). We hope this high number of 44 is a once-off aberration.

The largest sub-cluster of the MOAC, the S11 dormitory cluster now has 2143 cases as of 21 April. This dormitory has a capacity to house 13000 foreign workers. Assuming full occupancy, the prevalence of Covid-19 in this dormitory has reached a staggering 16.5%. And this number may get higher as we test more of the dormitory residents. To illustrate the mind-boggling effects of exponential growth, on 6 April (10 days after the S11 cluster was declared), it was reported in The Straits Times that the S11 cluster had 88 cases. 15 days later, it has grown to 2143 cases (21 April 20). The larger picture is also rather discouraging, as clusters are now found in 28 out of 43 dormitories.

There are actually three phases in the local outbreak with respect to the foreign worker dormitories, which this hobbit will call the MOAC War. The first phase was really the preparatory phase which took place in early January till early or mid-February, right up till the Seletar Aerospace Heights Cluster was declared in mid-February. The 2nd phase would stretch from the end of Phase 1 (when we realised that a foreign worker cluster was not a possibility but a reality) to March 25, when the first foreign worker clusters were declared: the Mustafa and Toh Guan Weslite clusters. Since March 25, we have been in Phase 3 for exactly 4 weeks, the phase that entails the entire healthcare system battling MOAC. After 4 weeks, there are now some 7500 foreign permit workers infected, with the 3 largest foreign worker clusters being S11 (2143 cases), Sungei Tengah Lodge (629) and Tuas View Dormitory (519) (MOH report dated 21 April). These numbers are deeply disconcerting if not frightening.

Another key factor is that the number of patients now being admitted into our restructured hospitals has reached about 3500. Notwithstanding that most of these patients are young patients, we only have about 9500 beds in the public acute hospital system, and 3500 is a very sizeable proportion of the total.

What is heartening to note is that the number Covid-19 patients requiring ICU beds have consistently remained in the 20 to 30 range. But I can imagine that the doctors and nurses are now locked in a daily titanic life-and-death struggle against the virus in the restructured hospitals. There are also hundreds if not thousands of doctors and nurses now manning isolation facilities in private hospitals, community isolation facilities and community hospitals. A friend of mine has described his experience fighting the virus akin to the elves at Helm’s Deep keeping waves and waves of orcs at bay. No matter what you do and how hard you try, the virus just keeps coming, relentless and unforgiving. And you fear that sooner or later, you will run out of energy and arrows and be overwhelmed.

All this is rather gloomy even for a hobbit like me that is usually given to a cheery disposition. Let’s move on to something hopefully more encouraging and reassuring.

It was reported in The Straits Times on 22 April that during the press conference given the day before, the Manpower Minister said her ministry had instructed the dorm operators as early as early January to put in place mitigation measures, including asking the operators to “raise the standards of hygiene and sharing information with workers how to protect themselves against the virus”. Later on, further measures were introduced, including safe distancing, and closing non-essential facilities such as TV rooms. These measures would probably correspond to Phases 1 and 2 of the MOAC War that have been described above.

The Minister then went on to say that more stringent measures, which were only recently introduced in the CB period, would “need to have been done in the context of a circuit breaker where most work has stopped” (quoted from The Straits Times dated 22 April 20, Page A6). These more stringent measures that have since been implemented in the CB period, include:

  • not allowing the workers to cook in communal kitchens located within the dorms,
  • not allowing them to go out on their rest days and interacting with their friends,
  • not even allowing them to go to work,
  • dispersing the workers to live elsewhere so as to make the dormitories less crowded (as they are doing now).

The circuit breaker was announced in the first week of April, which would have been in Phase 3 of the MOAC War.

It is interesting that the Minister has said that these measures could only be implemented during the circuit breaker period. Let us take a break to think about this in some detail. For a start, what is a circuit breaker, really? Although obvious, it must still be said that to break a circuit, the circuit must first exist before the breaker can be applied. The pre-existence of a circuit is therefore a precondition for the application of a breaker. In other words, there must be something to break in the first place. This is opposed to say, a lockdown. You can apply a lockdown or like the Malaysians, apply a Movement Control Order, even when there are no infections because the lockdown or MCO could be aimed at preventing any infection or transmission from taking place when they may be no infections at all in the first place. But, a circuit breaker can only be justified when there is something already going around (i.e. a circuit). As you can see from the numbers above, there was already some serious circuitous phenomenon or disease transmission in existence when the CB was applied 2 weeks ago.

I may be wrong, but what the Minister is saying is that really, a lot of mitigation measures had been done before the CB was announced. As such, we need to look at these two illuminating points:

  • Whatever more serious measures that could have been done, could only have been done in the CB period, when the disease was already transmitting so significantly that it required a CB to be applied. These serious measures therefore cannot be preventative or pre-emptive, (before a circuit has taken or is allowed to take place).
  • But in hindsight, we also know that the mitigation measures implemented in Phases 1 and 2 could not and did not prevent a big circuit forming which necessitated a CB.

Therefore, taking these two points together, this would also imply that MOAC was really inevitable.

Yes, in conclusion, it now appears that MOAC is an inevitability. And by logical extension, the war against MOAC is also an inevitable war.

This is a very crucial and enlightening point that bears repeating. This is because as we battle MOAC and CB is extended to eight weeks, it is also inevitable that there will be much suffering and economic loss, despite the Finance Minister announcing a slew of generous assistance measures. Many workers will suffer hefty pay cuts, and many may even lose their jobs. Some businesses will close as well. Many healthcare workers are working tirelessly, exposing themselves to the possibility of mortal harm. The whole country is probably suffering from high levels of emotional stress as well, from the social distancing, as well as coping with the repeated and increasingly severe limitations to personal freedoms that battling Covid-19 demands during this CB period.

But we all need to suffer and put up with this because now we know this has always been an inevitable war. Because it has been implied that MOAC was inevitable, it also means no one should or could be held responsible or accountable for it.

As such, I urge all of you, especially my fellow healthcare workers, to just accept this revelation of inevitability and press on with the fight.

MOAC – The Mother Of All Clusters

We were looking like the smartest kid in the class In February, except for isolated bouts of toilet paper hoarding and mask buying that potentially “sia-suayed” our country and parents. In March, we were still looking rather clever, like the blissful cool GEP kid in RI that still gets to be called gifted and yet not appearing to be a chao mugger.

Now in April, Singapore is looking like the below-average Integrated Programme kid, struggling to complete his hefty homework load and have a decent CCA record as well. He is still an IP student, but if he mucks up anymore, there is a good chance the IP school will ask him to take the O levels.

What happened?

In three words – foreign worker dormitories

This is going to be the Mother Of All Clusters (MOAC) in Singapore. As of today 11 April, the cluster comprises Mustafa, two construction sites and 6 dorms totalling 631 cases. There is another cluster of 5 cases at 31 Sungei Kadut which hasn’t been linked to the MOAC yet. About 20,000 foreign workers work in these affected dormitories. Nationally, it is estimated that there are 200,000 such workers living in foreign worker dormitories.

Just to give you a recap of how fast things have deteriorated, about 2 months ago when this hobbit wrote Part 2: The “Perfect” Communicable Disease Outbreak on Valentine’s Day, we had a grand total of 67 cases in Singapore. Now we have 2108. (Gentle reminder: no more 4D betting during CB period).

The first sub-clusters of the MOAC were declared on 25 March 20: Mustafa Centre and Toh Guan Weslite. The next cluster is the huge S11 sub-cluster which was declared on 28 March 20. Generally speaking, even with our excellent case detection and contact tracing capabilities, transmission probably took place about 10 days earlier. These cases picked up around 23 to 24 March (you need a day or two to wait for confirmatory testing results to be announced on 25 March) already included both the first and second generation of infected cases.

Therefore, the original transmission from the MOAC index case to the immediate subsequent cases probably took place around mid-March, between 10 to 15 March. We started gazetting dormitories as isolation areas (which in effect is a total lockdown of these gazetted areas) about a week ago on 5 April. The period from 15 March to 5 April is about 3 weeks. How will this turn out?

We can take some guidance from the biggest cluster of cases in neighbouring Malaysia: The Seri Petaling Tabligh Cluster. Unlike our MOAC, we do not have to guess when the original infections took place: the Tabligh event took place from 27 Feb to 1 March and was attended by some 16,000 people.

On 18 March, some two and a half weeks after the event, Malaysia went into their version of a limited lockdown – the MCO (Movement Control Order). The New Straits Times reported on 4 April (2+ weeks after MCO) that the cluster had 1545 cases. On 10 April, the cluster had grown to 1701. The growth is slowing after instituting MCO for 3 weeks.

So despite some serious intervention to have social distancing since 18 March, the cluster had grown to about 10% of the original size of the attendees. Of course, not all of the 1700 infected people had attended this event, it is just that their infections could be traced back to the people who had originally attended it

In the Malaysian Seri Petaling Tabligh cluster, most attendees had left and went back to their homes which were all over Malaysia. They had effectively dispersed, which would contribute to the spread to more cases. However, Singapore’s MOAC did not disperse, but really, the spread took place in the cramped conditions of the dormitories where many amenities are shared, which also lead to more efficient disease spread. The disease transmission dynamics could be worse in a foreign worker dormitory than in the community, where living conditions are less congested.

So it should not come as any surprise should the size of our MOAC well exceed 1000 eventually.

Nonetheless, we need to ask some hard questions.

The first foreign construction workers to be infected belong to what is known as the Seletar Aerospace Heights Construction Site cluster. This occurred around mid-February and involved 5 workers. This cluster has no proven link to the MOAC. But this would undoubted have alerted the authorities and the dormitory operators that there was a real possibility that transmission between foreign construction workers could occur.

In large organisations, the management is usually required (sometimes mandated by law even) to perform a risk analysis. They have to identify key risks and have plans to manage away the risks. Sometimes these risks cannot be managed away, but management must then draw up mitigation plans and then implement these plans to mitigate or lessen the risk.

This hobbit has no doubt that the relevant regulatory authorities and the dormitory operators are trained, hardworking and experienced; they would have identified that Covid-19 transmission among dormitory residents living in close proximity to one another is a clear and present possibility and would have instituted mitigation measures at least after mid-February when the Seletar Aerospace Heights cluster came to light.

These mitigation measures in dormitory may include simple things like

  • Temperature and symptom screening of residents
  • Segregation of residents such that different groups have different meal times, bath times, recreation times etc
  • Limitation of movement within and outside the dormitories, for example not letting residents of different floors or blocks mix and interact, or different times for different groups to go outside and buy things etc

Construction site management is also a crucial element. Different workers from different dormitories could have been asked to work in different areas of the site to discourage mixing and interaction etc.

This hobbit suspects most of the above were probably already implemented before mid-March by the dormitory operators and regulators. But yet we now have the MOAC. So it is quite baffling.

If you think about it, both the SAF and MOE have conditions that may facilitate the formation of large clusters – the army barracks in SAF and the schools and hostels in our universities. Yet, they have largely escaped unscathed for now. What is it they have done right and the dormitories haven’t? This hobbit doesn’t have the answers here.

Were the conditions in the dormitories so challenging that the mitigation plans eventually proved to be not as effective as hoped?

Perhaps MOH can conduct an in-depth epidemiological study into the MOAC, and study the transmission dynamics of Covid-19 in these dormitories and compare the results with community spread.

In the meantime, my heart goes out to the foreign construction workers, especially those in the affected dormitories in lockdown. (the rest of us are in CB mode, but these workers are literally under lockdown). We must give them adequate hope, support and care.  We cannot let 20,000 young men lose hope. Because if 20,000 young men lose hope, then the rest of us on this small island will also probably be not far from being in deep trouble as well.





Private Healthcare Insurance: Trust & Transparency

In life, there are errors of commission, and there are errors of omission. Dr Alan Ong’s opinion piece in The Straits Times on 7 March is of the latter. His column “The coming healthcare crisis: Unsustainable financing” talks about the dangers of having runaway healthcare inflation and offers several solutions.

He is the medical director of AIA Singapore, a major player in healthcare insurance locally. Therefore he must know what he is talking about. And what he commits or omits glaringly is most worthy of our attention.

What does he commit in the abovementioned article?

  • Singapore needs to have a financially sustainable healthcare system
  • Integrated Shield Plans (IPs) will become unaffordable if current healthcare inflation trends persist
  • We need to maximise the value or healthcare outcome out of every healthcare dollar spent

The healthcare insurers feel that to maximise the healthcare outcome of every healthcare value spent, the following needs to be achieved:

  • Appropriate healthcare behaviour
  • (better) Collaborations between healthcare providers and insurers
  • Greater transparency in outcomes

In providing recommendations and possible solutions to the above, Dr Alan Ong quotes extensively from the recommendations of the Health Insurance Task Force (HITF) Report. The HITF was a Taskforce that comprised representatives from Life Insurance Association (LIA) of Singapore, SMA, CASE, MOH and MAS (Monetary Authority of Singapore) and it was chaired by an independent chairperson. The Report of the HITF was published in October 2016.

He states that MOH’s move to stop the sale of full riders (as recommended in the HITF Report) and introduced co-pay riders for new IP plans will promote appropriate healthcare behaviour.

He further opines that the appointment of certain doctors to preferred provider panels will improve collaboration between insurers and healthcare providers. He gives an example of healthcare screening as an example of how having empanelled doctors will prevent consumption of unnecessary tests. He further states by steering higher volumes of work to empanelled providers is good for these select few who will benefit from more work and policy holders will also likewise benefit as insurers negotiate better treatment pricing for them from these empanelled providers.

Dr Ong then goes on to discuss pre-authorisation, which is also a recommendation of the HITF, and says that with the implementation of this through a standard industry-wide form, the insured will have better peace of mind that their claims will be covered.

On the issue of costs, Dr Ong states that “Singapore already has a fair degree of transparency”. What Singapore needs is more transparency on clinical outcomes and quality indicators so that patients can make better informed choices, providers can improve and insurers can know what they are paying for.

All this sounds fairly reasonable. Now let’s look do a deep dive into the facts.

The whole gist of Dr Ong’s article is that as long as there is no unnecessary consumption of healthcare, financing will be sustainable. Actually, that is one big assumption. Sometimes even when there is no unnecessary consumption, financing is still insufficient or unsustainable, because the premiums collected are just plainly not enough or when the middle-man takes too much. Middle-man being people like Managed Care, Third Party Administrators and even folks like actuary practitioners and insurers.

In any case, let’s give him the benefit of the doubt, since he is a public health specialist (i.e. with specialist knowledge of healthcare policy and financing, presumably). Unnecessary consumption can be therefore divided into two categories – overpricing and over-servicing. Often, it is a combination of both.

HITF’s #1 Recommendation

The HITF report made several recommendations. Two were stated in the article, preferred panels of providers (doctors) and pre-authorisation.

Very interestingly, he failed or omitted to mention the FIRST recommendation of the HITF, which is the recommendation to have Medical Fee Benchmarks or Guidelines. Arising from this recommendation, MOH formed the Fee Benchmarks Advisory Committee in January 2018. In Nov 2018, this Committee published fee benchmarks for 222 commonest procedures covering the vast majority of procedures performed in private hospitals in Singapore.

All IP providers in Singapore are members of the LIA, which in turn was represented on the HITF. The HITF had government and consumer representatives as well, in addition to SMA, which represented doctors. Arising from the HITF’s recommendations, the MOH (i.e. government) formed this Benchmarks Advisory Committee which promulgated the fee benchmarks in November 18. It must be stated that these benchmarks serve as guides, and there is no legal obligation of providers to adhere to them. But nonetheless, doctors, being generally obedient people, largely do charge according to these benchmarks nowadays, since they are issued by MOH.

Therefore, in theory and on moral grounds, all IP providers should respect and subscribe to the recommendations of the HITF (because there were members of LIA), as well as the benchmarks published by a Committee appointed by MOH (MOH being a fair, neutral arbiter). Adherence to these benchmarks will effectively stamp out overcharging and go a long way in making healthcare financing sustainable in the private sector.

An Error of Omission

But this is what actually happened. In a brief survey done in late 2019 for common procedures done by doctors, a year after the benchmarks were published, only ONE IP provider fully respected the fee benchmarks: NTUC Enhanced Incomeshield. Incomeshield will pay its empanelled doctors as long as they charge within the benchmarks. AIA and Prudential reimbursed doctors at the lower end of the fee benchmark bands. AIA basically took the lower limit of the band and added another 10%.

For example, the MOH fee benchmark for gastroscopy was $600 to $1000, AIA’s reimbursement rates was $660. For removal of single breast lump, the benchmark was $2500 to $3200, AIA’s reimbursement rate was $2750.

To be fair, that is still OK, because the AIA reimbursement rate falls within the range of the MOH fee benchmarks, albeit at the lower end. But another 3 IP provider’s reimbursement rates fall below even the lower limit of the MOH fee benchmarks!

Frankly, for the MOH fee benchmarks to work (to make healthcare financing sustainable), everyone needs to play their part and NOT UNDERMINE these benchmarks. This would mean doctors must not charge beyond the higher limit of the benchmarks, and payers, such as IP providers, must not reimburse below the lower limit. If IP providers do NOT RESPECT the benchmarks at the lower end, why should doctors charge within the higher limit?

This hobbit is quite sure an experienced industry player like Dr Alan Ong knows all this. But he has not mentioned any of these practices of other members of the healthcare insurance industry. In fact, he makes NO mention of the MOH Fee Benchmarks at all! It is as if though MOH Fee Benchmarks have no role in making healthcare financing sustainable and averting his “coming healthcare crisis”. Hello, these are MOH fee benchmarks, not the hobbit’s grandmother’s benchmarks, ok?

Incredible isn’t it? I call this an error of omission. And a glaring one. As to why this omission happened, you, the alert reader of this inconsequential column, had better ask Dr Ong yourself. Did The Straits Times run out of newsprint because all the paper has been redirected to make toilet paper? But we do have the online version now after all…..

We now go on to empanelling doctors, otherwise as “preferred providers”. He gives the example of how unnecessary screening can be curtailed with this. This hobbit is confused. Since when did IP Plans cover screening? Also, if you want to curtail unnecessary screening, just state clearly what an insurer would pay (and how much) and what it wouldn’t pay for. It’s that simple.

The second point on empanelling is even more disturbing. He wrote “Patients will benefit too, as panels allow insurers to negotiate better treatment pricing, leading to lower co-payments and premiums”. It means it empowers insurers to extract even lower prices from providers (including doctors) when half the IP providers are already reimbursing below the lower limit of the MOH Fee Benchmarks. AIA is now at “lower end+10%”. How much lower do you want doctors to go, Dr Ong?

In itself, pre-authorisation is not a bad thing. But the information sought for in this standardised pre-authorisation from the LIA members initially did not give the assurance that the information will not be used against policy holders when they renew their policies. It was only after repeated attempts by SMA to get this assurance for patients and SMA’s initial refusal to support the pre-authorisation form that LIA finally clarified and assured that information collected from the pre-authorisation form was to be used solely for pre-authorisation.

The Big Picture

Let’s now get back to the big picture.

Private insurance plays a small part in the health financing of Singapore. 40% of the financing comes from government. A lot of the remaining 60% comes from our savings in Medisave, State-run insurance Medishield-Life, employment benefits and out-of-pocket payments.

While private healthcare insurance plays an important part in the bigger scheme of things, fixing it alone won’t make healthcare financing sustainable. This is important to note, in case anyone gets delusions of importance or grandeur with regard to private healthcare insurance. We are actually not as dependent on private healthcare insurance as many other developed countries.

Secondly, there are four big stakeholders in the private healthcare insurance space:

  • Patients
  • Government
  • Providers (including doctors)
  • Private Healthcare Insurance Companies (especially IP providers)


The patient is at the centre of it all. Who does he trust most? In Singapore’s context, it is probably the government, often seen as a fair (albeit stern) arbiter of various stakeholders’ interests

Who does the patient trust more, after the government? I think if you were to poll many patients and ask them to choose between doctors and private insurance providers, most of them will choose doctors.

This hobbit’s hunch is that generally speaking, the public trust private insurance companies less than the government or the medical profession.

And of course, doctors trust the insurance industry even less.

Life is tough when you have a deficit of trust from both patients and doctors. I don’t know how much the government trusts the insurance companies, so I won’t comment on this aspect.

What can the insurance companies do to improve the situation? The answer is in what Dr Ong went to at length in the second part of his column: transparency


He mentioned about the need for cost transparency, transparency on quality and clinical outcomes. This hobbit would like to suggest a few more areas in which we can have much more transparency:

  • Can the insurance companies be transparent about the criteria by which doctors are empanelled? And why some doctors cannot be empanelled? No one now knows how insurance companies select doctors to be empanelled.
  • If we extract price savings from doctors, how much of these savings will be passed onto as savings on premiums of insurance policyholders by the insurance companies? How many cents for the dollar? Some listed companies have a dividend policy, promising X% of their profits will go to paying out dividends to shareholders. Can IP providers make such a commitment? If so, doctors may be encouraged to cut fees  to ease the policyholder’s burden.
  • Can we be transparent on what is reimbursable and what is not and publish these online, so that not just doctors, but policyholders can also see clearly for themselves?
  • Can we also be transparent on doctors’ reimbursement rates to policyholders? As a policyholder holder myself, I would like to select my IP provider based on several factors. One of which must be how the IP provider pays the doctors that take care of me. I might want to choose the IP provider that pays the doctor the most, or the least. That choice should be for me to make as a consumer or patient. But this information is now not available to the public.
  • How many doctors are empanelled in each IP provider? Will every IP provider publish this important metric? I think MOH also has a role in ensuring better transparency in this aspect. If the IP providers do not want to publish this individually, for a start, it can publish how many empanelled doctors there are in each of the IP providers. Split the data into two categories: private specialists and specialists in the restructured hospitals. It would empower the public to make an informed choice when they buy an IP Plan.

Trust and transparency. We all need them to make healthcare financing sustainable in the private sector. The private healthcare insurance sector included.