And just like that, not only are we in 2025, but the Year of the Snake has slithered into our lives as well. Life is stressful as it is and this hobbit has decided that we will start off the year with some light-hearted stuff – about multi-talented doctors who are famous for stuff other than the practice of medicine. Here is a sample of such famous (or depending on perspective, infamous) medically trained people
Sir Roger Bannister (1929 ~ 2018)
The first man to run the mile in less than 4 minutes on 4 May 1954. He was also a revered neurologist in his later years and was Master of Pembroke College, Oxford. He did much research on the autonomic nervous system. He also published a very well received neurology textbook, Brain and Bannister’s Clinical Neurology.
He said he would rather be remembered for his work as a neurologist than for his running. But alas, the reverse is true.
Michael Crichton (1942 ~ 2008)
He is best known for writing Jurassic Park. In real life, he graduated from Harvard Medical School with an MD, although he never practised medicine. He was also the creator of the long-running and popular TV series ER. His books have sold 200 million copies worldwide.
Sir Arthur Conan Doyle (1859 ~ 1930)
The author of Sherlock Holmes really needs no introduction. He was a graduate of the University of Edinburgh and had wanted to be an ophthalmologist. He started off as a ship doctor before setting up practices in Plymouth, Portsmouth and Southsea, all of which were not particularly successful. But he struck gold when he created the character Sherlock Holmes.
The rights to his first Sherlock Holmes novel (A Study in Scarlet) were sold in 1886 for only 25 pounds. But the character became so popular that it literally refused to die. Conan Doyle had Sherlock Holmes killed in the 1893 novel “The Final Problem” so that he could concentrate on writing other genres. But there was such a public outcry that he had to resurrect the character in the famous “The Hound of the Baskervilles” in 1901
Tun Mahathir Mohamed (1925 ~ )
And of course we have Dr Mahathir, the longest serving Malaysia Prime Minister (a total of 24 years over two spells) and the world’s oldest (at 93). An alumnus of our local King Edward VII College of Medicine (the precursor of NUS YYLSOM), he graduated in 1953 with a LMS (Licentiate in Medicine and Surgery, the precursor to our MBBS) qualification.
As a student in Singapore, he was once driven to the servant quarters of the KEVII Hall instead of the medical student hostel wing because the Chinese taxi driver could not believe that a Malay could be a medical student. And that probably explains why he liked to make things difficult for Singapore from time to time when he was in charge. In any case, in the 2022 Malaysia General Elections, he lost his seat and election deposit as well, which probably reflects how far he has fallen from his once lofty perch.
Ernesto “Che” Guevara (1928 ~ 1967)
A Marxist revolutionary of almost mythical proportions who played a pivotal role in the Cuban Revolution. He was once labelled as “Castro’s Brain” by Time magazine. He was born in Argentina to an upper-class family. As a medical student, he travelled widely across South America and witnessed the widespread poverty and suffering. He concluded that this was the result of capitalist exploitation by America.
He died at the age of 39 when he was captured and killed in Bolivia while trying to start a guerilla insurgency there to overthrow the local government.
Anton Chekhov (1860 ~ 1904)
The great Russian short story-writer and playwright whose body of works has had great influence on other writers and playwrights in the last century. It is said his plays have been made into so many movies that he is second only to Shakespeare. He wrote seven full-length plays, one novel and hundreds of short stories.
He famously said, “Medicine is my lawful wife and literature is my mistress”. He died at the age of 44 after a long fight with tuberculosis.
Albert Schweitzer (1875 ~ 1965)
Doctor, Theologian, Missionary and Nobel Laureate (Peace Prize). His life is the stuff of legends. He has been described as a polymath. He spent his youth studying theology and only entered the University of Strasbourg to study medicine at the age of 30, in 1905, after had been made the principal of the Theological College of Saint Thomas in 1903. He was also an authority in the repair and restoration of old pipe organs that were usually found in churches.
But he is perhaps best known for his missionary work in Gabon and his philosophy of the “Reverence of life” for which he was given the Nobel Peace Prize in 1952.
It is worth remembering what he said on this, “Standing, as all living beings are, before this dilemma of the will to live, a person is constantly forced to preserve his own life and life in general only at the cost of other life. If he has been touched by the ethic of reverence for life, he injures and destroys life only under a necessity he cannot avoid, and never from thoughtlessness”.
Sun Yat-Sen (1866 – 1925)
The man who overthrew the Qing Dynasty and more than two millennia of imperial dynastic rule in China can arguably be said to be the one doctor who has changed more lives than any other medically trained person. He is so revered that they even named the town or city he was born in after him: Zhongshan, which is adjacent to Macau. In China, cities are never named after a person, not even after founders of dynasties. He is venerated in both Mainland China and Taiwan.
He was one of the two students out of 12 to graduate from the Hong Kong College of Medicine for Chinese (What is now known as HK University) and was licensed to practise medicine in 1892. Before studying in Hong Kong, he actually spent a few years in Hawaii with his elder brother, where he picked up English from attending school there.
He fomented many unsuccessful uprisings before finally succeeding in 1911 with the Wuchang Uprising, using money raised from Penang Chinese. The two or three uprisings prior to the Wuchang uprising were financed by Singapore money, but they were unfortunately unsuccessful. So ever since then, Penang has had the bragging rights to claim that Qing Dynasty was finally overthrown by money from the Chinese community in Penang (and not Singapore, sigh).
Lo Ta-Yu (1954 ~ )
He is sometimes called the godfather of pop music in Taiwan. He hails from a family of doctors and became a doctor to comply with his family’s ambitions for him, graduating from the medical school in Taichung. He wrote the Chinese equivalent of “We Are The World” – “Tomorrow Will Be Better” which was performed by more than 60 artistes from HK, Malaysia, Taiwan and Singapore in 1985. His hits are too many to list here but it is fair to say that anyone who knows Mandarin and who are above 40 years old would have heard and hummed one of his songs sometime in their lives.
Michelle Bachelet (1951 ~ )
Descended from winemakers from Chassagne Montrachet, Burgundy, she ran Chile for 8 years over two spells (2006 to 2010 and 2014 to 2018). Her father was a Brigadier General in the Chilean Airforce and was purged and tortured for opposing a coup led by Augusto Pinochet and she had to flee Chile after his death and live in exile in Australia and East Germany for a few years. Her first spell as President was a very popular one with her achieving approval ratings of a record 84% when she left office (Chilean Presidents are not allowed to serve two consecutive terms). However, her second term was not as successful and she left office with approval ratings of only 39% in 2018. She obtained her medical qualification from the University of Chile in 1983.
Bashar al-Assad (1965 ~),
Bottom of the list is Dr Assad who ruled Syria for 24 years from 2000-2024, after his father died. He was a graduate of Damascus University and was training to be an ophthalmologist in London before being recalled by his father back to Syria after his elder brother died.
Between 2011 and 2024, it is estimated that some 500,000 to 600,000 people died in the Syrian Civil War before he was toppled from power by a revolution led by a coalition of Syrian rebels. He ran a totalitarian regime and was not averse to using chemical warfare on his opponents during the civil war. He has fled Syria last year and now lives in exile in Russia. Maybe he should have stuck to his ophthalmology training in London.
(With apologies to CS Lewis and “The Screwtape Letters”)
My dearest Wormwood,
I bring you great felicitations from the High Command of the Infernal Insurance Conclave. Your sterling efforts in beguiling the masses and policy wonks have caught the eyes of our Dark Lords there. In particular, the pronouncement that IP policies, (in no small part due to your powers of subterfuge and persuasion) will not be fully portable has gained us valuable breathing space and time.
High Command has given me the most pleasant task of informing you that you have been promoted within the Conclave Lower Ranks to Senior Beguiler Class 2. Our whole family is proud of you, and we are at this very present moment celebrating this news with a salubrious portion of a dead (and unsuccessful insurance claim) policyholder’s flesh and a generous pour of a physician’s blood, toil, tears and sweat. As you can see, even in hell, there can be moments of mirth. And greater mirth there will be, when you return from the frontlines battling those damned policyholders and physicians, while keeping the policy wonks on your side. The 3Ps: Policy Wonks, Policyholders and Physicians. Just keep the Policy Wonks on your side, and you will be fine against the piteous Policyholders and the pathetic Physicians.
By IPs remaining non-portable, we stay immune to the forces of competition and the free market once the unsuspecting customer has bought a policy and has developed pre-existing diseases. It is said that healthcare is an example of market failure. Post-sale IP without portability, and hence competition-proof, is proof of this adage. And yet they still fell right into it. Please forgive me if I sound uncharacteristically gleeful.
We must now press our advantage with our potent miasmatic concoction of deceit and duplicity. On one hand, we will continue our sorrowful and specious tale of not being successful or sustainable as a business, which will gain us much unmerited sympathy from all the silly people in high places.
On the other hand, and with some luck, we will continue to have a low claims ratio, while paying ourselves more and more in the form of management expenses and distribution costs (i.e. commissions). Our ostensibly pitiful tale will be bolstered by the fog of “change in reserves and other expenses”, which will vary a lot from year to year and which nobody can explain clearly why this is so.
Our self-gratifying efforts in terms of ever-increasing management expenses and distribution costs can only be thwarted internally – when those morons on the investment side fail miserably to deliver any returns on their investment activities, and even, Our Father Below forbid, make losses.
But this is only half of the equation. It is imperative that you continue to bring legions of souls to feed the all-consuming IP behemoth that in turns funds our lavish lives. We do this by exposing our multitudinous targets to the coalface of their insecurities and fears, knowing fully well that in the end, half of them who have bought IPs will never make a claim, even when they fall sick in the hospitals. They still opt for the subsidised care funded by public monies, which in turn are mined off the bent backs of our burnt-out taxpayers.
This beauteous state of affairs can only be sustained by ensuring that their fear of not having access to subsidised care after discharge from private care remains palpably intimidating if not paralyzing.
Nearly 70% of the population have bought IPs. Can we do better? 80%? 90%? Delirious joy awaits us if we can hit these higher numbers, which will lead to more and more remuneration and commissions for ourselves.
However, it is my duty to remind you, my dear nephew, that you must never confuse the Policyholder with the Patient. For indeed, while they are physically the same being, the two cannot be more different. The IP Policyholder is a prey that has been captured; a resource that can feed our ravenous appetites for material gratification as long as he pays his insurance premiums every year, while the Patient is someone who has fallen ill and will do exactly the opposite as the Policyholder. The Patient will consume the very same monies that we have so successfully leeched out of the Policyholder. We compete for policyholders. We do NOT compete for patients. Policyholders are good news until they become patients, because patients are bad news. We have great affection for the would-be or pre-policyholder, but we have no mercy for the patient. That is why the Dark Lords of the High Command of the Conclave always publicly say “Our first responsibility is to the Policyholder”. Nobody talks about Responsibility to the Patient.
We must stay the course of limiting access to those pesky physicians. Once again, I recall with great pride and fondness my classmate in the Abyss Academy, Slubgob’s role (now Lord Slubgob) in introducing the idea of preferred physician panels. What genius! This was a turning point in our battle with the Forces of Light. The only thing “preferred” about these panels is that we prefer them to be as small as possible. Indeed, the policy wonks did put pressure on us to increase the size of these panels slightly initially after they were introduced and we did so to superficially appease them. But as long as these panels remain, we have all the aces in the game of limiting access. We also continue to increase the friction in gaining access to these panels for physicians, and obscure our true intent by remaining completely opaque on the criteria that we use to bestow (with that obligatory whiff of sovereign disdain) on a physician a place on our panels. (If truth be known, sometimes we just flip a coin and let the Fates decide). Do remember, that you must make sure a physician knows it in his bones that he exists on our panels at our whim and fancy. If need be, sometimes he must be made to grovel to keep his status as a panel doctor. Like patients, show no mercy to them either. For panel physicians who show no less than perfect obeisance, drop them.
The true power of panels is that they scythe through that most hated and oft-quoted construct called the patient-doctor relationship. The Conclave doesn’t say so publicly, but it finds the concept of the patient-doctor relationship abhorrent and gnaws at the core of what the Conclave stands for, which is lucre.
With panels, we can dismantle old patient-doctor relationships and replace them with transactional claims and disbursements between policyholders and physicians that are completely controlled by us. With panels, we, the intercalators, have surreptitiously become more powerful than whatever detestable direct bond that physicians thought they had with their patients. With panels, we march on with our plans to obstruct and obfuscate.
Finally, we have to stay alert to the powers of the regulators. Fortuitously, they remain somnolent and oblivious to the cries for regulation with regard to the clinical aspects of IPs. We must keep up with our veneer of commitment to participating in whatever mediation or remedial processes the policy wonks have come up with, as long as our participation remains discretionary.
We must once again use our powers of deception and misdirection to keep the current state of non-regulation under the shroud of pseudo-adjudicatory forums. For once we are compelled to participate and follow decisions made by external parties on matters concerning what is appropriate clinical care that should and must be funded by us, we are then regulated, and in truth, quite done for. However, it would be remiss of me not to remind you that we must also keep up the illusion of sincerity and guise of congeniality by participating in some cases which we are most likely to win the debate, while refusing to take part in those many cases where the facts are patently against us.
Please give me an update next month on your continued training in the field of regulatory capture and your masters dissertation on this same subject. Until then, I remain,
Your affectionate uncle,
Screwtape
Hobbitsma’s note:
For the avoidance of doubt, this is satire. All characters mentioned in this post are fictional.
CS Lewis (1898 to 1963) was an Oxford professor in English Literature. He wrote many books, including The Chronicles of Narnia. The Screwtape Letters is a Christian Apologetics fictional novel written by him and dedicated to JRR Tolkien (his contemporary and good friend from Oxford, who wrote Lord of the Rings) and it is written in a satirical and epistolary style.
“First published in February 1942, the story takes the form of a series of letters from a senior devil, Screwtape to his nephew, Wormwood, a junior tempter. The uncle’s mentorship pertains to the nephew’s responsibility in securing the damnation of a British man known only as “the Patient”.
If the Income-Allianz deal was subjected to a vote by Singaporeans or Income policyholders, then the outcome would probably be that the deal should be called off. Despite all the clarifications and reassurances from the Board of Income Insurance and NTUC Enterprise, the man in the street never quite warmed up to this proposed acquisition.
As a policyholder myself of an integrated shield plan (IP) sold by Income, I am also happy that the deal has been blocked by the government. Income’s Outcome is good to me.
But the revelations made by the MCCY Minister Mr Edwin Tong on 14 Oct 2024 in Parliament is nothing short of a bombshell to this hobbit IP policyholder. The capital reduction or extraction that came with the acquisition by Allianz was never made public before that. It is not peanuts we are talking about here, but $1.85B!
What is more interesting is that Income Insurance first announced that they were in discussions with Allianz on 14 June 24 and exactly four months later, on 14 Oct 24, Income announces that they respected the decision of the Government to not approve the deal.
In these four months, between the initial announcement of 14 June and the announcement of 14 Oct, Income Insurance made four announcements on its website with regard to the proposed acquisition. None of them mentioned anything about capital extraction.
The Income Insurance board has 12 directors, of which 10 are independent. It is noteworthy that on the press release dated 27 July 24, it was stated that all 12 directors approved the proposed transaction.
Which really brings to mind what were these 12 experienced and intelligent individuals thinking of when they approved the deal?
In addition, there was also a Board “Steering Committee” set up to recommend to the full Board with respect to this proposed acquisition. It consists of a majority of independent directors and was chaired by an independent director. This Committee is supposed to ensure that “the interest of policyholders and shareholders were considered, in evaluating the transaction”. Did they have public interest and social mission in mind in addition to considering the interest of policyholders and shareholders when the evaluated the proposed acquisition?
What were the members of this Steering Committee thinking when they (presumably) recommended to the full Board to approve the transaction?
It is also reasonable to think that for the deal to have gone through the board approval of Income Insurance, the support of its largest shareholder, NTUC Enterprise would have been obtained before the deal was made public. NTUC Enterprise owns 72.8% of Income Insurance. The NTUC Enterprise Board and Executive Directors are all very experienced people, including a few very senior union leaders and ex-politicians. Indeed, NTUC Enterprise and its Chairman have defended the deal on at least two occasions (25 and 300 July) and these were made public through press releases by NTUC Enterprise.
Therefore, there were at least three levels of approval or concurrence that were probably obtained: Income Insurance (Board) Steering Committee, Income Insurance Board of Directors and NTUC Enterprise Board. Did these three bodies take into consideration the issues of
capital extraction
fulfilling its social mission
public interest?
If they did, then how did they and MCCY arrive at such divergent positions (Paras 41, 42 and 43(ii) of Minister Edwin Tong’s speech in Parliament on 14 Oct 24):
Here are the excerpts of the Minister’s speech as taken from the MCCY website:
“41 First, we find it difficult to reconcile the proposed substantial capital reduction, soon after the transaction is completed, with Income’s representations to MCCY during the corporatisation exercise that it was aiming to build up capital resources and enhance its financial strength.
i) As I had explained, as part of that exercise, Income had sought and obtained an exemption to allow it to carry over a surplus of S$2 billion to the new corporate entity.
ii) The proposed capital reduction runs counter to the premise on which the exemption was given
iii) If not for the Ministerial exemption in 2023, Income Co-op’s accumulated surplus of some S$2 billion would have gone to the CSLA after being wound up, to benefit the Co-op movement in Singapore as a whole.
iv) MCCY has not seen any arrangement within the present transaction to account for the estimated S$2 billion surplus that was carried over to the new corporate entity, due to the exemption. There is no clarity on how this sum will be directed towards advancing Income’s social mission.
42. Second, MCCY is not satisfied that Income will be able to continue fulfilling its social mission after the proposed transaction.
i) There are no clear binding provisions or structural protections in the deal to ensure that Income’s social mission will be discharged.
ii) It is also not clear what Income might do after the capital extraction, for example, to adjust or trim its insurance portfolio, and what impact this could have on policy holders.
iii) NE has stated that it intends to maintain Income’s social mission. MCCY accepts that NE is making this commitment in good faith. But MCCY is not confident that NE’s intentions, or the assurances Income gave earlier to MCCY, can be upheld”.
Para 43(ii) further states “As such, it is the Government’s view that it is not in the public interest for the transaction, in its current form, to proceed”
What this hobbit would give to be a fly on the wall when the Income Steering Committee and Board met to discuss, recommend and approve the proposed acquisition.
This blog discusses primarily about health matters so let us get back to health matters, in which Income plays an important role as a big provider of IP policies and the impact that it has on doctors who provide services to their policyholders.
Anecdotal evidence suggests that Income was a very decent IP provider in the past. They respected the MOH Fee Benchmarks in its entirety, unlike many other IP insurers: as long as you charged within the lower and upper limits, Income would reimburse.
But things have gotten worse recently. Some private specialists claimed that the change coincided with the appointment of a Third Party Administrator (TPA) to handle IP claims. Some say it all began when Income ceased to be a cooperative and got corporatized. We may never know if these claims and theories are true as it is very difficult to prove causation in such matters.
Also, the extended panel (EP) practices of Income is apparently quite different from how other IP insurers run their EPs. Some private sector specialists have opined that it is not popular with both policyholders and doctors. Apparently, in contrast to other IP insurers’ EP policies and practices, the Income EP features more friction and more disincentives.
Well, now that the deal in its present form is effectively deader than the dodo bird, this hobbit hopes that the Income Board and Management can refocus their energies on making their IP Plans better managed, giving their policyholders (e.g. me) a better deal and more choice of healthcare providers.
On the larger front, it was only as recently as September 2023 when the Monetary Authority of Singapore (MAS) classified Income as one of the four “domestic systemically important insurers” (effective 1 Jan 2024). In other words, Income is actually one of the Big Four in the local insurance scene, together with AIA, GE and Prudential. Income has the scale, and resources to innovate, stay profitable, look after its policyholders well and at the same time also fulfill its social mission and serve public interest. Let’s hope that happens now as we put this unpleasant episode behind.
The context of this race to the bottom analogy is that IP insurers “have been offering very attractive terms to encourage sign-ups and win market share. This includes IPs that promise no claim limits, and riders to protect policyholders from co-payment” which contributes to the buffet syndrome occurring downstream. The outcome for IP insurers is that “with escalating claims, insurance companies are hardly making profits on their health insurance portfolios”
The minister further opined that “we may be in a health insurance vicious cycle, of overly generous insurance policy design, buffet syndrome leading to more non-critical or even unnecessary tests and treatments being prescribed, which in turn leads to bigger bills and higher premiums for all. We are chasing our own tail, and everyone is just getting worse off eventually”.
This hobbit largely agrees with what the Minister has said. However, this race to the bottom is largely of the IP insurers’ own making. Nobody asked them to offer as-charged plans or first-dollar coverage riders. You made the bed you now lie in.
While it is easy to blame doctors and patients for the buffet syndrome (the more “professional” term for this in health economics is “moral hazard”), it should be stated here that the Minister himself has said this is “human nature”. With the exception of this mythical hobbit, doctors and patients are humans. Can we change human nature resolutely and permanently? Probably only with great and sustained effort. If it were not so, there will be world peace and everyone will have a healthy lifestyle. But instead, we have to wage war against diabetes and now against instant noodles as well.
More importantly, doctors’ professional fees as a component of the total hospital bill have been decreasing over the years. In other words, in terms of dollars and cents, the doctor is NOT the main beneficiary of this buffet syndrome. Private sector specialists who have been out there for some time now often remarked that their professional fees have fallen from about one-third of total hospital bills 15 years ago to about 25% or even 20%. Hospital component of bills have increased significantly. But since there are so few private hospitals out there, they have pricing power and IP insurers cannot or aren’t willing to pressurise them to lower their charges. Hence, IP insurers continue to pay for lobsters and steaks found in inpatient bills while they hire armies of case managers to ask doctors stupid questions and deny insurance claims from policyholders.
But these are at best peripheral questions. Ultimately, the Minister’s observation that “with escalating claims, insurance companies are hardly making profits on their health insurance portfolio” needs to be reflected upon. Against this backdrop, there are a few noteworthy points that bears highlighting:
The implementation of the MOH fee benchmarks a few years ago means it is very difficult for private specialists to overcharge. There are a several imaginative ones that over-service and multi-code. But with MOH Claims Management Office now in place, it will be even harder for these shenanigans to occur going forward. And as aforesaid, with doctors’ professional fees becoming a smaller and smaller component of total bill size, the key factor responsible for growth in total bill size must lie elsewhere. This is borne out by statistics released by MOH: the Compounded Annual Growth Rate (CAGR) for Median Total Private Bill Sizes from 2007 to 2021 was 4.3%. The CAGR for median private hospital bill size was 4.5% for the same period while the CAGR for Median Total Private Doctors’ Professional Fee was only 2.7% (as reported in The Straits Times on 14 June 2023). This is a point that no IP insurer or facility operator mentions, much less acknowledge.
The claims ratio in Singapore was 73% during the Covid years of 2019 to 2022. In the few years preceding this period it was 75% (2016 to 2019).
The claims ratio is the percentage of insurance premiums that is actually paid out to healthcare providers when claims are made. In USA, Obamacare demands that the claims ratio must be at least 80 to 85%. If IP insurers cannot make money with a claims ratio that is only 75% or less, then it stands to reason that the other costs are too high. Other costs would include distribution costs (i.e. commissions etc.) and management costs. Another factor could be too much of the premiums collected are parked in reserves. Some IP insurers also made large investment losses. https://hobbitsma.blog/2024/04/26/the-quest-for-value-based-insurance/
And here’s the rub – it was observed that “about half of holders of IP and riders actually end up using subsidised healthcare in public hospitals”. In other words, half of the IP policyholders did not utilize the IP benefits they paid for but instead went back to subsidised healthcare so as to be subsidised by the government (which in the end means largely subsidised by taxpayers).
So, this hobbit asked an old friend who has migrated to Australia a long time ago and is now involved in insurance oversight and regulation work Down Under. He was very absolutely floored when he found out that IP insurers cannot make money when only half of those who are insured actually make claims when they require healthcare that is insured by the policies they had bought.
He remarked wryly that any commercial insurer in the real world would love to be an IP insurer where only half of the entitled policyholders actually made a claim and the claims ratio was around 75% – This is the closest to “insurance heaven” one can get. But that is the “real world” we are talking about, not the world or narrative that IP insurers would like the public and the government to believe – which is it is very difficult to make money when claims ratio is 75% and only half of the entitled policyholders actually make claims.
The numbers speak for themselves: A 75% claims ratio implies there is a lot of headroom for the insurers to manage the issue of increasing bill sizes and the insurers are getting a free lunch out of half of their policyholders since only the other half make claims that they are entitled to with their IP policies.
This race to the bottom is therefore really a well-cushioned race for the insurers. The proof is in the pudding in that no one has dropped out of the race yet. If we are to believe that capitalism still works, (i.e. the efficient deployment of capital) there should have been some blood on the streets by now with insurers exiting this race amid this vicious cycle. But we haven’t even seen a bruised buttock yet in this well-cushioned race, let alone any IP insurer packing their bags.
But in the larger scheme of things and policy intent, we must still return to the original purpose of having an IP industry. Letting and having IP insurers remain viable as a business is not an end in itself from the national perspective. The whole purpose of the IP industry is that IPs is a health financing tool for the majority of Singaporeans, based on the principle of risk-pooling. The whole idea of the IP industry is to serve the public, not the insurers or healthcare providers.
From the looks of things, the conclusion must be that the IP framework has failed as a risk pooling and healthcare financing tool when IP insurers find it hard to make money even with such odds stacked in their favour. (i.e. Only half of entitled policyholders actually make IP claims and the claims ratio is at best 75%)
Maybe it is time this sector undergoes a big “policy reset” as well, to borrow and paraphrase a term that was used by our new Prime Minister in his first National Day Rally.
A Brief History of Medical Indemnity Cover in Singapore
Younger doctors may not know this. There was a time when all doctors in Singapore had to buy their own professional medical indemnity plans. MOH or MOHH did not arrange for coverage for public sector doctors. Whether you were a medical officer or private sector specialist, you bought your plans through SMA, who acted as the agent for these providers.
Prior to 1999, there were two providers: MPS (Medical Protection Society) and MDU (Medical Defense Union). There both originated from the UK. They actually were not licensed by the local regulatory authority (i.e. Monetary Authority of Singapore, MAS) to sell policies locally. These medical indemnity plans or policies were issued directly out of UK and SMA was paid some fees in the process for the administrative work done.
MPS still exists today and the arrangement between SMA and MPS is still largely in place. However, in 1999, MDU decided to pull of Singapore for reasons best known to themselves. They had struck an agreement with MPS whereby MPS will continue to offer coverage to ex-MDU customers for a fee. In an article written by Past SMA President Goh Lee Gan in the September issue of SMA News in 2002 titled, “The Inside Story of UMP Singapore”, he said he received the news of MDU’s pulling out and handing over of their business to MDU on the rather auspicious date of 9 September 1999 or 9/9/99.
The SMA leadership then decided that it was imprudent to have only one provider for medical indemnity services in Singapore (and a foreign-based one at that) and decided to introduce another provider. This came in the form of the largest medical indemnity provider in Australia at that time – UMP.
However, UMP’s presence in Singapore was very short-lived because back home in Australia, quite a few court judgments went against doctors (especially in its home state of New South Wales [NSW]) and these cases came with huge damages awarded. UMP was declared insolvent and went into provisional liquidation. It was subsequent revivedly with government funds to the tune of A$260M accompanied by tort reform. But the end result was that UMP could only operate in Australia and UMP’s presence in Singapore lasted only 2 years. It has to be said in that short period, there was no evidence that UMP’s business in Singapore was unviable.
Once again, the Singapore medical profession faced the prospect of having only one foreign-based professional medical indemnity provider. This time, SMA approached NTUC Income. In the aforesaid SMA News article, it was reported, “A/Prof Goh spearheaded the venture with NTUC Income, and held discussions with Mr Tan Kin Lian, CEO of NTUC Income, about providing medical indemnity cover for doctors”.
And so, since 2002, NTUC Income (or should I say, Income, since the prefix of “NTUC” was regrettably dropped in 2022 when NTUC Income was corporatised) has been a medical indemnity provider in Singapore.
The market share of Income in providing medical indemnity cover is probably very small and the profits attributable to this business line, if any, are probably insignificant to Income. Many doctors may not even realise it is a provider, but it’s there: (https://www.income.com.sg/commercial-insurance/medical-indemnity-insurance)
The negotiations between Prof Goh and Mr Tan obviously went well because in 2002, NTUC Income stepped into the breach to ensure that medical profession was not subject to the crutches of a potential monopoly situation. The impact of this strategic move should not be taken lightly, because should the remaining, foreign-based provider also pull out, or raise its premiums to very unaffordable rates, then healthcare provision in Singapore will be at peril. This was the situation NSW faced in 2002 when UMP folded which left thousands of doctors without cover. The NSW government of the day had to use public funds to bail UMP out, so that doctors could continue to be covered and healthcare could continue to be delivered.
In short, NTUC Income did “national service” in 2002 and continues to do so even today.
The Deal
In this historical light, this Hobbit, like many others, received the news that Allianz was buying 51% of Income Insurance for $2.2B with much discomfiture, if not apprehension.
Since then, the Chairman of NTUC Enterprise, Mr Lim Boon Heng has come up with several reassurances that things will be alright. These include “NTUC Enterprise will continue as an active shareholder of Income Insurance to keep it to its purpose and deliver social commitments to its policyholders” (24 July, “Income will still provide affordable insurance for lower-income customers after Allianz deal: NTUC Enterprise chairman”, CNA).
However, not all are convinced and the logic is simple. A 51% stake is a majority or controlling stake. It is no coincidence that Allianz wants 51% and not 49%. It intends to control the way the acquired entity is run. Unless there is some written contractual term in the acquisition document that enables the minority shareholder to influence or demand that the majority shareholder behaves or acts in a certain way, the majority shareholder will call the shots. These contractual terms are commonly called “reserved matters” in which e.g. despite Allianz having a 51% share of the company, minority shareholder NTUC Enterprise can compel Allianz to manage Income Insurance in such a way that Income Insurance will continue to “deliver social commitments” and “still provide affordable insurance for lower-income customers” beyond the $100M committed for 10 years from 2021 (as stated in the Clarification issued on 25 July 24)? We are already in the second-half of 2024….
The Clarification on 25 July also states that Income Insurance will “provide access to insurance for seniors, people with mental health concerns and those with special needs, such as Down Syndrome and autism”. That sounds good. But it remains to be seen at what price such coverage will be given and if there are any strings attached. The devil is in the details, as the saying goes.
Anyway, if there are such reserved matter clauses in the agreement, let’s see it. If not, this hobbit will take such reassurances with a large pinch of low-sodium chloride (Healthier SG and our Health Minister promotes the use of low-sodium salt, so this hobbit has to follow too).
In any case, this hobbit speculates that should this deal go through, it is unlikely that Allianz-controlled Income Insurance will continue to provide medical indemnity services. I don’t think German-origin Allianz is in the business of doing national service in Singapore, unlike NTUC Income, which has its (although now probably severely-mutated) DNA in Singapore’s labour movement. In any case, Medical Indemnity is not mentioned in the aforesaid Clarification.
Nonetheless, this hobbit declares that he does not obtain medical indemnity cover from Income and so, even if it does cease to cover such services, he will not be adversely affected in the short term.
Me and My Incomeshield
On a personal note, this hobbit is more concerned with his Integrated Shield Plan (IPs), which he had bought from NTUC Income years ago and continues to pay the premiums. This hobbit is probably not alone in the situation he has found himself to be in.
Let’s do another recap of the history of Medishield and IPs. In 1990, Medishield was introduced to cover B2 and C class inpatient bills. In 1994, IPs were introduced. Actually, this hobbit isn’t sure if the term “IP” existed then. But in any case, insurance products providing cover for restructured hospitals’ B1 and A class services were introduced. This happened at about the same time when the government took away inpatient healthcare benefits from civil servants. This was in the Jurassic age when all NUS medical graduates were bonded and employed directly by MOH itself as civil servants (except for a small group of graduates who were directly employed by NUH to serve out their bond).
After our inpatient medical benefits were removed (in return for 1% more CPF employer contribution), many of us bought Income’s Incomeshield products. If my memory doesn’t fail me, there were only two products: Incomeshield A and Incomeshield B. The former covered A class charges while the latter covered B1. An IP product to cover private hospital charges had not been yet created then.
It is important to note that NTUC Income virtually enjoyed a monopoly in this product segment from 1994 to 2000. This hobbit, like many of his contemporaries, did not have a choice between providers. It was either buying NTUC Income’s Incomeshield or self-funding for inpatient services.
It was only sometime between 2000 to 2002, that two other providers were introduced to provide IP or IP-like products: AIA and Great Eastern.
In other words, it is not unreasonable to think that there are now large numbers of people who had bought Incomeshield A and B in those years where NTUC Income was the only provider of IP products and now continue to be their policyholders. They are probably now in their fifties and sixties. If they had not switched out of Income when they were younger, they are probably stuck with Income now, because by now, many of them would have developed medical problems and no other IP insurer will take them as policyholders because of their pre-existing disease(s).
And so, just as you are about to more likely claim from Incomeshield plans when you are now in your fifties and sixties, you are now also faced with the prospect and uncertainly of Income being controlled by a for-profit foreign insurer whose loyalty, and indeed fiduciary duty, is to its shareholders. Post-acquisition, will my Incomeshield premiums still be affordable? Or will they go up significantly, because the majority shareholder needs to recover its $2.2B investment and also to profit-maximise?
In this hobbit’s opinion, in all likelihood, this Income deal will prove to be a bad outcome for many Singaporeans, but a good deal for the investment bankers, management consultants and lawyers paid to see the deal through.
As reported in The Straits Times, MOH recently published data that showed Integrated Shield Plans (IPs) varied widely in terms of coverage and lifetime price (Integrated Shield Plans lifetime premiums vary widely across insurers, MOH comparison shows” (1 July).
This is hardly surprising and shows that there is some form of competition between insurers and collusion does not exist, which is good.
However, as Saw Swee Hock School of Public Health Associate Professor Wee Hwee Lin noted, “This is clearly useful for people to review their existing insurance policies but with caveats. It is not possible for people with existing medical conditions to switch providers.”
Price is easy to understand, but coverage less so. As journalist Ms Salma Khalik noted in the above article, “To confuse matters further, the lowest coverage may not come from the insurer charging the lowest premiums”.
Understanding coverage requires much more technical knowledge and research effort than comparing price or premiums.
Or for that matter how insurance companies operate.
To understand this, the hobbit would like to point you to another Straits Times article published on 19 June 2024 written by a CEO of a financial advisory firm, “When it comes to financial advice, do your own homework” (by Chuin Ting Weber). This hobbit must confess that he has found this to be one of the most illuminating articles published this year. Here is what she wrote,
“The truth, or the whole truth?
Financial advice, like medicine and law, is a licensed profession, Professionals know more than the people they serve. Often, clients don’t know what they don’t know. This knowledge asymmetry imposes an ethical responsibility on a financial institution (FI) and its representative to go beyond basic honesty, to care about their clients’ interests.
How far this responsibility goes, however, depends on the standard applied. In Singapore, FIs are held to the “suitability” standard (emphasis mine); financial products recommended must be appropriate to the consumer’s financial situation and goals…..
….However, this still falls short of a higher “fiduciary” standard adopted by some countries. A fiduciary must make recommendations in the best interest of the client, even if it means decreased remuneration for the FI or the adviser”.
She then gave the example that a retiree seeking a stream of income was given a recommendation by a financial adviser or FI to buy an insurance product when she should have gone for a higher CPF Life payout by getting the retiree to top-up her CPF Retirement Account. Recommending her to buy the insurance produce was not untruthful, but “the more complete truth” would be recommending her to consider topping up her CPF Retirement Account.
She adds “If fact, FIs can even argue that their advisers should not do that (recommending the retiree to top up the CPF Retirement Account). Because while their responsibility towards the consumer (i.e. the retiree) is on a suitability basis, their responsibility towards shareholders is on fiduciary basis”.
After reading this article, this hobbit was deeply troubled. But this also explains why the medical profession is often at logger heads with the insurance companies and the twain shalt never meet (at a place of peace) given the gulf in fundamentals.
Doctors owe a duty of care to our patients. This is to be found in the SMC Ethical Code and Ethical Guidelines. In reality, duty of care is really fiduciary duty in medical-speak. That means we must do our best and put the interests of our patients before our own interests.
On the other hand, Financial Institutions (all insurance companies that sell IPs are FIs licensed by the Monetary Authority of Singapore) puts the interests of its shareholders above that of its customers. As aforesaid by Weber – the FI owes a fiduciary duty to its shareholders but not to its customers/policyholders; it only has to offer “suitable” insurance products to its customer, which may not be in their best interests.
When “suitable” is not good enough
Contrast this to an actual case that went before SMC and the Courts. In 2017, a prominent private sector oncologist was suspended by the Courts for 8 months after an appeal was filed for a SMC case. In fact, the Courts said that had it not been for the long delay by SMC to hear the case, the suspension would have been 16 months.
What did this oncologist do to be punished so heavily? Answer: He had “wrongly held out false hope” to the family by claiming that there was a 70% chance of the cancer patient responding to medical chemotherapy and for not offering surgery as the preferred option for treatment of the patient’s cancer.
That is not to say that chemotherapy was quackery. In this case, chemotherapy was an accepted form of treatment. It was just that surgery was supposed to be better and it wasn’t offered as an option for the patient to consider.
Now if the standards of regulation for FIs were applied to this oncologist, he probably would have gotten away with offering chemotherapy as the (only) option although he may be still found to be guilty of giving the patients’ family false hope.
This is because while surgery was the better option, chemotherapy cannot be considered to be unsuitable; similar to the logic behind the example given in the abovementioned Straits Times’ article – topping up of the CPF Retirement Account was the best option, but recommending the retiree to buy an insurance policy was also “suitable”.
We owe a fiduciary duty or duty of care to our patients, while FIs and financial advisors and insurance agents only need to offer something that is suitable. Which is also why Weber recommends that when it comes to the matter of financial advice, do your own homework!
A wise crack may counter that isn’t it the same with subsidised healthcare in our public healthcare institutions (PHIs)? As a subsidised patient, one has no right to choose their own attending specialist physicians. The hospital will just assign you a specialist. It’s your good luck if you get assigned the professor or Head of Department. Tough luck if you get assigned an Associate Consultant instead. Certainly, an Associate Consultant is “suitable” (because he is indeed a specialist), but he or she can hardly be considered to be the best option the PHI can offer.
Well, there is a difference here. If the case turns out to be complex and beyond the abilities of the AC, he is also duty bound to seek the input of a more senior specialist or even refer the patient to the more senior specialist. This happens at no extra cost to the subsidised patient. If the case is simple and does not warrant the input of more senior specialists, then it can be argued that the outcome is likely not to be significantly different whether the case is handled by an AC or a SC.
The FI test of suitability is a tradeoff between enriching self (the shareholders of the FI and/or the financial advisor) and doing what is best for the policyholder. This is in contrast to the duty of care or fiduciary duty that we owe our patients whereby enriching oneself at the expense of the best interest of one’s patient is NOT allowed.
The triumph of the standard of suitability
Now let us look at another real-life example in the form of an incident involving medical oncology that has happened recently. A medical oncologist was dropped from a preferred provider of an IP panel. No reasons were given, as usual. Any IP insurer will tell you that they don’t have to give any reasons whatsoever for including or dropping a doctor from their panels.
This oncologist began to reflect over why was she (and her colleagues in the same practice) dropped by the insurer. She had heard from reliable sources that her group’s rates were quite reasonable and in fact, she hadn’t raised her rates for 5 years.
She surmised that the reason she was dropped was that she had sometimes used cancer drug treatments which are not on the MOH’s Cancer Drug List (CDL) on a few patients after conventional drug treatments had not worked. She is a domain expert in her area and often gets referrals from other doctors for difficult and complex cases. When the usual options are not effective, she would try something not on the CDL if the patients had bought riders that explicitly allowed for such use (Class A to E of Non-CDL Treatments) as described in the circular issued on 2 September 2022 by the Life Insurance Association, Singapore (LIA). In some of these cases, due to the high cost of treatments, she has often given discounts as well.
If what she suspects the reason behind her being dropped by this insurer is true, then this is a good example of what can happen when fiduciary duty meets the test of suitability. She had tried doing what she thought was best for the patient, given the patient’s dire situation and what the patient’s IP policy is supposed to cover. But by doing so, she will suffer financially going forward because she is no longer a panel doctor with this insurer, i.e. her patient’s best interest has been served at a loss to herself.
On the other hand, the insurer, despite providing coverage for non CDL treatments, may also be sending out a message to other panel doctors that they do not encourage doctors from trying their best (even when it is permitted under the terms of the policy) but instead should just do what is suitable and sufficient, and that the interests of the insurer come before the patient.
The suitable slope to perdition
The future of medicine in especially the private sector will therefore be a contest between a doctor trying to fulfill his duty of care/fiduciary duty to the patient and also funders of healthcare such as insurers trying to impose a lower standard of “suitability” on doctors. The balance of power is clearly on the side of the insurers because they control the funding and they are also accountable to no one on how doctors are chosen to be put on or dropped from preferred provider panels.
In the short term, this is not a bad thing because if everyone just dishes out suitable care, healthcare costs will probably be lower and therein lies the temptation. But in the long run, the patient will suffer as doctors align themselves with their funding masters – the insurers. This is because the obvious knowledge asymmetry between insurers, providers on one side and the patient/policyholder on the other side is so great that it is not easy for the patient/policyholder to discern he has been given just “suitable” care instead of the best care that owing a fiduciary duty/duty of care requires.
Clearly, in the face of the enormous power and financial resources wielded by FI insurers that are only expected to operate on the standard of suitability, doctors in the private sector must align themselves with the insurers to survive. The tenet of duty of care that we teach in medical schools and to our young resident doctors must eventually yield to such great a countervailing force (of the insurers and their test of suitability) when many of them leave for the private sector.
And before we know it, we may already be well on a fast and slippery but surely suitable slope to perdition.
POSTNOTE (Dated 23 Aug 24): since the publication of this post, a lawyer, presumably linked to the case involving the oncologist that was quoted in this article has contacted SMA more than once with regard to what he or she considers to be a factual error in this post. This lawyer (with reference to the Disciplinary Tribunal’s findings and the C3J’s Decision) has stated that the use of the word “preferred” is incorrect to describe surgery as an option and that the adjective used should be “viable” instead.
There are a few things that need to be stated or restated here
All readers should also note for historical reasons, this hobbit is known as “hobbitsma”. But really, this hobbit has been an independent blogger for years and this is clearly stated in the first post on this wordpress platform. So while certain equally old coots in SMA know how to contact me (usually by smoke signal or using the middle-earth equivalent of a mail pigeon), SMA doesn’t tell me what to write or not to write.
Finally and most importantly, the main subject matter of this post is comparing the test of suitability with the duty of care or fiduciary duty doctors owe their patient. And really, it doesn’t matter whether surgery is “viable” or “preferred”. The crux of the matter is that under the duty of care he owes the patient, the doctor would be found wanting if he had not offered surgery as an option, whether surgery was viable or preferred is irrelevant to the outcome at the SMC or C3J level. On the other hand, under the test of suitability, the doctor would probably be found to be OK if he had only offered chemotherapy as the only option offered because chemotherapy is a “suitable” option. Under the test of suitability, one does not have to offer ALL suitable options; the doctor has to offer only one – and that was the thrust of the ST article by Weber.
Therefore, the key point of this hobbit’s discussion that affects the outcome of this case is NOT whether surgery is a viable or preferred option, but which test was applied or is applicable – Duty of Care or Test of Suitability.
So, really, this Postnote is unnecessary. But I have to write this to get my life back. Maybe it is about time to retire and sail off to Valinor
A letter to the Forum of The Straits Times that was published on 12 June 24 caught this hobbit’s eye. It was written by a young doctor, Dr Amreena Shamit, who purportedly works in a GP clinic. The letter was titled, “Doctors, don’t be too hard on yourselves when a mistake occurs”. It is a very well written letter, very encouraging and uplifting in tone and substance. She advises how we doctors should learn to live with the mistakes we make and move on so that we can help even more patients. She ends off by saying, “making mistakes is part of the risk of being in the healthcare profession. After all, for every mistake we make how many patients do we actually help? Maybe if we knew the answer, we might not give up so easily”.
But as this old coot of a hobbit is about to tell you, there are mistakes, and then there are mistakes. And while we can and should live with our mistakes and move on, not everyone shares that view. Put simply, mistakes come in all shades and sizes. Like beauty (and ugliness), mistakes often lie in the eye of the beholder. Some mistakes are unfortunately punishable and even career-ending.
Mistaken about Mistakes
There have been also people who have been mistaken about mistakes. The celebratory case of Dr Lim Lian Arn comes to mind. A patient had complained against Dr Lim for not informing her of the side effects of a hydrocortisone and lignocaine injection. Dr Lim pleaded guilty and the SMC Disciplinary Tribunal (DT) subsequently fined him the maximum amount of $100,000 for professional misconduct. The outcome was so unexpected that MOH then requested that SMC appealed against the decision of its own Disciplinary Tribunal. The Court of Three Judges (C3J) overturned the decision of the DT1.
The C3J noted that not all mistakes amount to professional misconduct and are therefore punishable. The Judges noted “As we observed to Mr Chia (SMC’s lawyer) in the course of his submissions, there must be a threshold that separates relatively minor breaches and failures from the more serious ones that demand disciplinary action. Were it otherwise, doctors would find it impossible to practise in a reasonable way. For a medical practitioner to be charged and found liable under the MRA (Medical Registration Act), the misconduct must be more than a mere technical breach of the relevant standards”. (Para. 30 of the Judgment, SMC vs Lim Lian Arn, [2019] SGHC 172). This is a case where the C3J concluded that the DT and the lawyers of both SMC and Dr Lim were mistaken about the nature of Dr Lim’s mistake.
To Err (Even One-off) Is Human and Sometimes Punishable
We now move on to a more recent SMC case, SMC vs Yeo Khee Hong. The Grounds of Decision of the DT was only published on 27 May 242. Dr Yeo, a GP of 38 years’ experience, pleaded guilty and was suspended for one year for failing to diagnose a case of testicular torsion in a patient that was about 15 years old when the incident occurred. Due to the misdiagnosis of epididymitis and orchitis, the patient presented late to the hospital and had to subsequently undergo an orchidectomy.
This has led to some disquiet on the ground because everybody makes a misdiagnosis from time to time. If everyone can make the correct diagnosis 100% of the time, then he would most certainly be inhuman (or not a hobbit as well).
First, this hobbit would like to say that he is in agreement that the doctor should have been found guilty of professional misconduct and sanctioned to some extent. However, the grounds of decision (GD) did not address certain issues that may come back to haunt the profession later.
Para. 26 of the GD stated, “The ASOF (Agreed Statement of Facts) further states that the applicable standard of care is (a) to consider all (emphasis mine) acute scrotal pain as testicular torsion until proven otherwise, and (b) regardless of the duration of the patient’s symptoms or whether the patient had acute or intermittent testicular torsion, to refer the patient urgently (emphasis mine) to the A&E in a hospital or a specialist. The ASOF states that that testicular torsion cannot be conclusively excluded or eliminated on history-taking and physical examination alone….”
Para. 27 further states “The ASOF states that the Respondent failed to act as a reasonable and competent doctor would have done and was in breach of the applicable standard of care”. The same paragraph then when on to describe how the misdiagnosis of epididymitis and orchitis led to the serious consequences and harm to the patient which doctors already know too well.
Para. 28 of the GD then describes how Dr Yeo had breached Guidelines A1(1), A1(4) and A2 of the SMC ECEG, which amounted “to such serious negligence that it objectively portrayed an abuse of the privileges which accompany registration as a medical practitioner, and the Respondent is thereby guilty of professional misconduct under s 53(1)(d) of the MRA”.
This hobbit is not familiar with how the DT works, but one needs to ask, does the ASOF’s applicable standard of care apply to the whole profession henceforth? Already many GPs are saying arising from Para. 26, they have no choice but to refer urgently ALL cases of scrotal pain to the hospital or specialist urgently. And my A&E colleagues are also already shaking their heads at the prospect of being asked to urgently exclude the diagnosis of testicular torsion in geriatric male patients.
When we have an “Agreed” Statement of Facts (ASOF), we have to ask – who is agreeing to what here? Presumably the parties in agreement are the Respondent (Doctor) and SMC’s lawyers, but do what they agree to in an ASOF apply to the rest of the medical profession as a new, universal standard of care?
For example, do we now really regard acute scrotal pain in a 75 year-old man as a case of “testicular torsion until proven otherwise”? Or do we say yes, we regard every case of acute scrotal pain in a 15 year-old as testicular torsion until proven otherwise; but well, for a 75 year-old, testicular torsion may well still be a rare differential diagnosis, but the scrotal pain is more likely to be something else. In other words, would the DT still have suspended the doctor for a year if this was a rare case of testicular torsion in a 75 year-old with the same clinical presentation?
The clue to this may also lie in para. 25, which stated “According to the ASOF, based on the Patient’s history of left testicular pain, the Patient’s profile and age (emphasis mine), and the Respondent’s physical examination finding that the Patient’s left testis was enlarged and tender, the Patient was at risk of testicular torsion on 27 March 2019. A reasonable and competent doctor in the Respondent’s position would have considered the possibility of intermittent testicular torsion as a differential diagnosis without first referring the Patient to the A&E of a hospital or a specialist such as a urologist or paediatric surgeon for urgent surgical assessment or exploration”.
Unfortunately, years from now, people may not understand or realise that para. 26 may have been crafted under the context given in para. 25. This hobbit thinks para. 26 could have been worded in a better way, or paras 25 and 26 could have been merged into one paragraph. Not only must we be careful with our words, we have to be careful with our paragraphing as well. The lone Para. 26 as it stands now, can lead to unnecessary referrals to A&E or specialists if not defensive medicine.
It is also important to note that Dr Yeo was found guilty of professional misconduct under the second limb of the landmark Low Cze Hong case, which is “where there has been such serious negligence that it objectively portrays an abuse of the privileges which accompany registration as a medical practitioner”.
Here, it is important to revisit again the C3J’s Judgment of the Lim Lian Arn case, in particular para. 38 of the Judgment, “Serious negligence portraying an abuse of the privileges which accompany registration as a medical practitioner would generally cover those cases where, on a consideration of all the circumstances, it becomes apparent that the doctor was simply indifferent to the patient’s welfare or to his professional duties, or where his actions entailed abusing the trust and confidence reposed in him by the patient. On the other hand, it would not typically cover one-off breaches of a formal or technical nature where no harm was intended or occasioned to the patient or where harm was not a foreseeable consequence; nor would it ordinarily cover isolated and honest mistakes that were not accompanied by any conduct which would suggest a dereliction of the doctor’s professional duties”.
Interestingly, in para. 66 of the DT’s GD for Dr Yeo’s case, it was stated that this incident was “one-off” and “out of character” for him. Also, in para. 68, the DT considered this to be “an isolated incident”. There was no mention that the doctor was “indifferent to the patient’s welfare or to his professional duties”. While harm was “occasioned”, it was certainly not “intended”. Perhaps the strongest point made in the GD against the Respondent was that missing a diagnosis of testicular torsion would lead to a “foreseeable consequence” of orchidectomy, significant pain, suffering and morbidity.
Would therefore an “isolated” breach of Guidelines of A1 and A2 that was “one-off”, “out of character” for the Respondent amount to serious negligence/professional misconduct and a suspension of one year? The GD described how it arrived at the one-year sentence, but did not clarify how the doctor’s act crossed the threshold of serious negligence, which was unfortunate, especially when there are countervailing factors such as “isolated”, “out of character” and “one-off”.
Perhaps the SMC can follow up with an effort to explain these points so that the entire profession can learn clearly from this incident on how an isolated incident of what is largely of a technical nature can cross the threshold to be considered as serious negligence/professional misconduct.
Make Mistakes When You Are Young(er)
This hobbit would also like to make the observation that seniority is not a mitigating factor when you make mistakes. In fact, according to the Courts and SMC, age or seniority is an aggravating factor. In other words, under the same set of conditions, a more senior or eminent doctor may be punished with a heavier hand than a more junior one.
This was established in the appeal to the C3J in the Ang Peng Tiam vs SMC case ([2017] SGHC 1433). This was stated clearly in para 93 of the Judgment for this case, “Seniority and eminence are characteristics that attract a heightened sense of trust and confidence, so that when a senior and eminent member of the profession is convicted of professional misconduct, the negative impact on public confidence in the integrity of the profession is correspondingly amplified”. The logic for this, as given by the C3J, is that the main aim of disciplinary proceedings is “general deterrence”, i.e. to deter the rest of us doctors from doing things in a similarly bad way. This is a concept that this hobbit has always found it hard to wrap his halfling mind around, but it is what it is. You don’t have to agree, you just have to know that it applies to all of us doctors – seniority sucks when it comes to disciplinary proceedings.
This position was also adopted by the DT in the aforementioned case involving Dr Yeo. The GD stated in para 66, “We accepted that the seniority of the Respondent is an aggravating factor. As noted in the Sentencing Guidelines, there is an overarching need in medical disciplinary cases to uphold the standing of the profession and prevent an erosion of public confidence in the trustworthiness and competence of its members. Against this consideration, we took into account the fact that the Respondent has a long unblemished track record and good professional standing. The present offence was one-off and out of character. In our view, he is unlikely to re-offend”.
Given the fact that the older you get, the higher the stakes are for you when you make a mistake as a doctor, it would be interesting to study if such a medico-legal climate foments an environment whereby more senior doctors are more predisposed to practising defensive medicine than more junior ones. That would make a fascinating study for health policy and medical ethics researchers, don’t you think?
Finally, to be absolutely clear, this hobbit really likes the letter written by Dr Amreena Shamit. It encourages us to take mistakes in our stride, to learn from them and to move on as better doctors so that more patients can benefit.
But it also important to know that for serious mistakes amounting to professional misconduct, there are circumstances and conditions that do not permit us to move on.
A lot of folks are talking about Value Based Healthcare. It’s the in-thing now. Two public health specialists (Drs Jeremy Lim and Jake Goh Jit Khong) joined in the IP debate recently (25 April 24) and wrote in the Straits Times recently that “Ultimately, every stakeholder wants ‘Value’”.
Let’s see if the IP insurers are delivering value. To do that, unfortunately, we have to look at the numbers. This hobbit is not particularly a whiz at numbers but let’s give this a shot. And if the figures given in this post are proven to be very wrong, this hobbit unreservedly apologises in advance.
In Jan 2021, The Singapore Actuarial Society (SAS) produced a paper called “Medishield Life 2020 Review: SAS Comments” based on data between 2016 to 2019. A very illuminative table was produced in that paper which was reproduced by the SMA in its Position Statement which was released in March 2021 : Troubled Integrated Shield Plans. Table 1 is a reproduction of that table in the Position Statement.
Table 1: Combined Profit and Loss of 7 Integrated Shield Plan Insurers 2016 to 2019
Year
Gross Premiums
Gross Claims
Management Expenses
Commission
Change in Reserves and Other Expenses
Underwriting Gain/(Loss)
2016
$1608m
$1190m
$106m
$131m
$279m
(98m)
2017
$1859m
$1390m
$126m
$160m
$329m
(146m)
2018
$1836m
$1399m
$140m
$182m
$153m
(38m)
2019
$2143m
$1617m
$166m
$197m
$206m
(43m)
2016-2019
$7447m
$5596m
$538m
$670m
$967m
(325m)
% of Gross Premiums
75%
7%
9%
13%
(4%)
% Increase from 2016-2019
33.3%
35.9%
56.6%
50.4%
CAGR (Compound Annual Growth Rate
10%
11%
16%
15%
The last two rows are additional observations by SMA. The rest of the table is exactly what was presented by SAS. We can trust that SAS are experts in this field and the figures they presented have not been contested by anyone as being erroneous even though there was some debate as to what conclusions one can draw from these figures.
One of the things that I need to say I am happy with the Monetary Authority of Singapore is that they require insurers to submit data in a form called Form A5. These submitted data is then published online. The link is given at the end of this post 1,.
In any case, this hobbit and his gnome friends have dug deeper into such publicly available sources and mined more recent data.
Table 2: Combined Profit and Loss of 7 Integrated Shield Plan Insurers 2019 to 2022
Year
Gross Premiums
Gross Claims
Management Expenses
Commission
Change in Reserves and Other Expenses
Underwriting Gain/(Loss)
2019
$2143
$1617
$166m
$197m
$206m
(43m)
2020
$2351
$1625
$170m
$202m
$948m
(593m)
2021
$2451
$1807
$177m
$215m
$79m
172m
2022
$2571
$1889
$192m
$215m
$153m
123m
2019-2022
$9516
$6938
$705m
$829m
$1386m
(341m)
% of Gross Premiums
73%
7%
9%
15%
(4%)
% Increase from 2016-2019
20%
16.8%
15.7%
9.1%
CAGR
6.3%
5.3%
5.0%
3.0%
From Table 2, it would appear that things have become stabler from 2019 to 2022 compared to 2016 to 2019. Management Expenses and Commission costs are not increasing faster than gross premiums collected and gross claims paid out.
However, the claims ratio, which is the amount of money disbursed on behalf of policyholders to healthcare providers has dropped from 75% to 73%. As stated in SMA’s position statement, “In USA, the Affordable Care Act or “Obamacare” formally states that Insurers must spend at least 80-85% of premium on health costs; rebates to policyholders must be issued if this is violated. As one can see from the table above, only 75% of premiums collected were paid as claims in 2019 for the IP sector”. We have since gotten even lower than 75% and now stands at 73%, suggesting that the effectiveness or utility of IP as a funding mechanism for private health care has deteriorated further.
The column on “Change in Reserves and Other expenses” is highly variable and subject to individual IP insurer’s actions. For example, in 2020, AIA noted “Long Term Individual Medical Expense: The underwriting result includes a one-off impact of S$(697)m from reinsurance. Excluding this one-off impact, the underwriting result in 2020 is S$(3)m. “. In other words, if we took out this $697m item from AIA, the industry would have made a healthy profit and AIA would not have made a 700m loss in 2020. We do not really know why AIA had to book this one-off 693m item into the books. Is this an accounting treatment and nobody burned through $697m of cash or they really lost all that money in cold, hard cash. This hobbit suspects it is some form of accounting treatment but admittedly, this is just a guess.
The Other Side Of The Coin: Value in Investment (Or the lack of it)
As with all insurance activities, insurers take our money in the form of premiums and surpluses and then invest the premium monies in the quest for good returns (and hopefully these returns will relieve some of the pressure to raise premiums).
In additional to the datasets that SAS has discussed in their 2020 paper, there is actually more information that can be gleaned from Form A5 submissions in the form of Nett Investment Income. This is where the insurer invests the premiums and underwriting gains to generate more income for the company. Whether they are successful or not is another story, as Table 3 will show:
Table 3: Underwriting Gain/Loss and Nett Investment Income: 2019 to 2022
What are the possible conclusions we can draw from Table 3? Here is what this hobbit thinks:
If we ignore or remove the effect of the one-time AIA’s 697m reinsurance figure, then AIA probably made some money from underwriting (?+32M) and only two insurers lost money in underwriting; i.e. the two smallest ones.
Insurers often claim that they know how to grow our money, but judging from the data above, maybe they aren’t so good after all.
Let’s take the example of a real IP insurer. We will call this insurer – Insurer A, a relatively large IP insurer. They were profitable from underwriting activities consistently for the four years in question: from 2019 to 2022. They made money from investment activities from the first two of the four years. Then they lost 13M in 2021 and a whopping 144M in 2022! Basically they had practically lost all their money that they made in underwriting in this period and then some. One can only wonder what they were doing to lose so much in investment activities in one year.
The smaller IP insurers, such as HSBC_AXA, Raffles and Singlife_Aviva are the only insurers that made money from investment activities in all four years. One large insurer only made money in one of the four years, another insurer made money in three of the four years and yet another in two out of the four years. Many of the seven insurers would have been better off putting the premiums in a bank fixed deposits or buying T-bills.
One may counter that insurance premiums are calculated based on actuarial principles and not based on investment outcomes. This hobbit concedes he does not know enough about the insurance industry and maybe that is true. But having said that, if I were the board director of an insurance company or even just a shareholder, one would want to know how will management address the losses arising from investment activities. How does one cover the big hole of say, ($144m)?
Back To Premiums
And now we come back to the issue of IP premiums. Notice whenever anybody wants something more from the insurers, the insurers will respond by saying whatever you ask for will lead to higher premiums? They seem to be looking for every opportunity to repeat this mantra of higher premiums. This is especially so when doctors lobby for more, whether in terms of asking for more doctors to be empanelled or raising fee schedules.
The LIA has just said a few days ago that empanelling more doctors will lead to higher premiums. If every empanelled doctor already sticks to being reimbursed at the rates prescribed by Insurer X’s fee schedule, how can more panel doctors lead to higher premiums for Insurer X’s policyholders? Can the newly-added doctors charge more than the fee schedule? Do more panel doctors mean more over-servicing? Can over-servicing happen frequently when insurers already hire armies of case managers to handle claims and ask questions that range from the clinically unsafe (e.g. why do you do two ward rounds a day instead of one) to the plain stupid (e.g. Why did you not try conservative treatment first before performing surgery on the patient with anal fistula?).
The fact is the majority of IP insurers are making decent margins and profits from underwriting IP policies in the last few years. Prudential, in particular, is doing exceptionally well and it contributes more than half of the underwriting profits of the entire group of seven IP insurers.
And if you look at MOH data released in the June 2023. (Please see chart 1), you will see that doctors’ fees have been rising significantly slower than hospital part of the bill and overall bill sizes.
Chart1 :
(The Straits Times 14 June 2023)
So let’s get things into perspective, the IP insurers aren’t doing badly underwriting IP policies and doctors are not the main culprits for rising healthcare costs in the private sector. Period. And some IP insurers can even do much better if they don’t make bad investment decisions. I think my grandmother can generate better investment returns than some of these folks.
Extracting More Value: Claims’ Ratio Going from 73% to 85%
The slowly declining claims ratio should be of particular concern to policy wonks. I think the world will be a happier place for policyholders and healthcare providers if the government just nationalised the whole IP sector (i.e. like Eldershield becoming Careshield) and raised the claims ratio to 85%. That would mean $1.1B (73% to 85% = 1.1B) more money over four years to pay for healthcare services, instead of now being spent on the supporting infrastructure of “management”, “commissions” and “other distribution expenses” of IP insurers.
On another note, this hobbit has been told that “other distribution expenses” include incentive overseas trips, conferences and celebratory meals for insurance agents, and perhaps even media advertisements to show who are the most successful insurance agents. And these amounts are not small. For example, one company spent $31m on “additional distribution expenses” in 2022. These expenses are reflected under the “Changes in Reserves and Other Expenses” column in Tables 1 and 2 and are separate from the commissions that agents earn directly from the insurers.
If we can raise the IP sector’s claims ratio from 73% to 85% and extract about $275m a year more from the system, we can probably even have policy portability without significantly raising premiums. This would answer the question of “who pays for portability”. The answer would be, “Still the policyholders. Just cut out the middleman costs of private IP insurers and raise the claims ratio”.
85% is not a magic figure plucked from thin air. It is a figure mandated in Obamacare. American healthcare is known to be notoriously expensive and inefficient. If they can mandate a figure of 80 to 85%, why should Singapore settle for anything less than 85%?
Then we can move from value-based healthcare to value-based insurance as well. The current IP milieu is failing on both counts. On one hand, the value in IP underwriting to policyholders can be significantly improved. Instead it has declined from 75% to 73%. On the other hand, it is also obviously not delivering enough value from its investment activities in many instances.
So instead of just talking about getting more value out of healthcare providers and always threatening to raise premiums, lets focus on getting more value out of IP sector and the insurers. The public and policyholders expect and need insurers to deliver value just as much as healthcare providers.
Portability and Choice
On 30 April, the President of SAS, Mr Alex Lee, weighed in on the debate in a letter to The Straits Times Form “Time for an inclusive and informed dialogued about IPs”.
He opined that “The data needed to support an inclusive and informed debate on portability, continuity of care, and other aspects of IP design is not available. That needs to change. Policyholders of different profiles must be heard”. He further commented that portability will lead to increase in costs and premiums because “choices have a cost” and indeed, this hobbit agrees that portability is about having a choice and there is a cost to having a choice, especially when you exercise that choice.
This hobbit has long argued that getting a restructured hospital to run four classes of bed leads to increased costs and less efficiency. It would be far better to have less choice for class of beds. We could derive some savings just by cutting down choice. The term management consultants use nowadays is not to “give a choice” but to “retain optionality”.
So choice indeed costs. Henry Ford implied this truth in his autobiography regarding the production of the Ford Model T, when he said “Any colour the customer wants, as long as it’s black”. The retool his production line to provide for different colours for Model T will raise costs.
Similarly here, why are healthcare providers and some policyholders clamouring for portability? Portability is not an end in itself, it is really a means to the end of extracting more value through competition after a IP policy has been bought and especially if pre-existing diseases have developed.
The government’s disdain for riders is well known. Yet IP insurers still innovate and come up with all kinds of riders nowadays. This is because they need to compete for new business and so innovate to develop more perceived value for the prospective customer to sign up as their policyholder.
But once you have developed pre-existing diseases as a policyholder, you are kind of stuck. No competition occurs and IP insurers see no need to deliver more value, especially when the policyholder gets older. They are probably not very unhappy if you decide to drop your IP plan when are you are 75 years old, having paid IP premiums for decades and are now likely to start making claims.
Portability will force IP insurers to compete post-policy purchase and in doing so, hopefully deliver value. Yes, while this hobbit agrees with Mr Alex Lee, President of SAS that choice costs – But this is from the perspective of the manufacturer (like Ford) or the insurer. From the perspective of the consumer, retaining optionality (i.e. the threat of exercising choice) also leads to better value creation through competition on the other side of the equation.
In Search Of Value: Competition and Regulation
However, competition is not the only way to deliver more value and safeguard the interests of policyholders. Another way is regulation so as to address the “power imbalance” that the President of SMA, Dr Ng Chee Kwan, mentioned about in his letter on 27 April 24.
If some regulator stepped up to the plate and started to do most of the following (non-exhaustive):
Mandate that the claims ratio for IP business should be at least 80%, preferably 85%
Not allow IP insurers to change coverage anytime (remember the incident involving an insurer not covering diagnostic scopes suddenly a few years back?)
Mandate that criteria for empanelment and exclusion from preferred panels be spelled out clearly and publicly
Regulate the size of preferred panels with respect to the the number of policyholders
Regulate on how insurers must grow their preferred panels with time
Regulate what can be put into exclusion clauses for disease coverage. For example, they must be evidence based exclusion clauses. E.g. you can exclude coverage of colon cancer if the patient had colorectal polyps discovered previously, but you cannot exclude coverage of all GI cancers from the oesophagus to the anus just because the person had piles.
Regulate what can be preauthorised and when preauthorisation can be denied
Regulate IP insurers on what questions they can ask or cannot ask. Especially questions that subliminally promote a unsafe practice culture through under-servicing, e.g. “Why do you have to do two ward rounds a day instead of one”?
Appointing a SMC-registered medical practitioner to oversee and be held accountable for decisions by insurers that affect patient safety and clinical outcomes adversely
If the above can be instituted for all insurers, then maybe we do NOT need portability so badly..
Bottomline is, other stakeholders in the IP sector, such as policyholders and healthcare providers are looking for a better deal from IP insurers i.e. they are searching for more value than what insurers are providing.
This can come through either by competition or regulation or both. But at present, both are not present. That is why “the current arrangements are untenable and will come to a boil soon enough” (Drs Jeremy Lim and Jake Goh).
Where’s The Value?
The days where the public and healthcare providers accept that IP insurers
provide a claims ratio of only 73%
do not compete after a policy is bought because there is no portability
and are also at the same time largely not subject to adequate regulation
are probably over. We need to find ways to extract the kind of value from the IP insurers that our people need and deserves.
Postnote: Alert and mythical reader of this column, Dr Harry the Beng has alerted this hobbit that the figure of $1.1B could be extracted by raising the claims ratio from 73% to 85% over FOUR Years, not one year, or about $275m a year. The hobbit is sorry for these errors and has since corrected them. That’s what happens when you post at around midnight, I guess. In any case, this hobbit would like to suggest to the relevant authorities to consider creaming off any excess premiums that exist when the claims ratio falls below 85% and use the cream-off to fund Healthier SG activities Now, wouldn’t that be a much better way of using those excess premiums than letting the insurers keep the money?
There has been some concern over a spate for ophthalmologist resignations from the public sector in the last 12 months or so.
But first, some statistics to put things in context. In the latest SMC Annual Report (2022), it was recorded that there are 314 ophthalmologists in Singapore, of which 122 worked in the private sector and the rest (192) worked in the clusters. Therefore, about 39% of all ophthalmologists are from the private sector.
From 2018 to 2022, a period of 4 years, the number of ophthalmologists increased by 42, from 272 to 314. That’s about an increase of 10.5 per year in this period. I.e. we are increasing the number of ophthalmologists by about 10 a year, nett of the ophthalmologists who retire in the same year.
If we assume that the country produces nett 10 ophthalmologists a year, and to maintain the market share between private sector and public sector at around the current 40%/60% split, then roughly 4 ophthalmologists should leave in a 12-month period for the private sector.
However, In the last 12 months, a total of 15 ophthalmologists have left the public sector or have tendered their resignations and are now serving notice, give or take a few. And interestingly, the vast majority of these 15 are senior consultants, or on the verge of becoming one, since the most junior ophthalmologist of these 15 was already registered with the SAB (Specialist Accreditation Board) in 2016, i.e. with at least 7 years of experience as a specialist before resigning. Three of them are very senior, having graduated in the 90s and collectively have chalked up some 60 years of specialist experience between them.
To better understand why so many ophthalmologists have left or are leaving in the last 12 months, we need to first acknowledge that there are several peculiarities of ophthalmology:
The practice of ophthalmology is not as dependent on hospitals as many other disciplines, not unlike dermatology. Hence there is a less pressing need for one’s practice to be located in a clinic suite that is co-located with a private hospital. Hence, an ophthalmologist doesn’t have to pay sky-high rents.
Secondly the epidemiological trends of eye diseases are firmly on the ophthalmologist’s side. At least 80% of Singaporeans become myopic by the time they reach adulthood, and this translates into a great pool of patients that can benefit from refractive surgical procedures e.g. Lasik. 80% of the elderly will develop cataracts, which again serves as a very large source of patients.
Due to the perceived criticality of sight, patients in this day and age do not wish to be treated by family doctors for eye conditions except for the least complex of conditions that can be treated with just eyedrops and ointments prescribed by the family doctor. Gone are the days when a family physician will routinely attempt to lance a stye or excise a chalazion. Some still do, of course, but they are few and far in between, especially among the younger family physicians. Most GPs are not trained to perform indirect ophthalmoscopy or tonometry and do not have the equipment anyway. All this means that, in comparison to most other disciplines, ophthalmologists take up an inordinately large share of the disease burden.
A secondary factor that needs to be discussed is the role of insurance in private sector ophthalmology. While many other specialties are very dependent on insurance-funded work, ophthalmology is less so. This is because non-insurance work are a plenty in ophthalmology in the form of Lasik procedures and even aesthetic blepharoplasty. That is why despite insurance players resisting recruiting new doctors onto panels and cutting down on reimbursement rates, ophthalmologists have no problem earning a decent living in the private sector sans insurance.
The above can be considered as unmodifiable factors that are particular of ophthalmology that makes going into private practice less daunting when compared to other disciplines.
But it doesn’t quite explain why the sudden exodus has happened. Your friendly neighbourhood hobbit actually went to talk to a few of them. When folks in their fifties and late forties leave, you can be sure that there are significant push factors behind the move. This is in contrast to someone leaving for private practice when they are in their thirties and early forties, when pull factors play a more important role in the decision-making process.
Some of the push factors expressed include:
A relentlessly and sharply increasing workload and punishing work schedule that gets harder and harder to keep up with as one gets older. As one ophthalmologist put it, “At the rate this is going, I can’t see myself growing old and retiring in Institution X, because I don’t think I can keep working at this rate. Might as well go out and work at a less punishing pace now and lengthen my working life”.
Changing of remuneration policies. Each institution has a different work and pay culture. Some are more ‘capitalist’ and some are more ‘socialist’. Not a few said that a particular institution was getting more and more socialist in remuneration policy and yet workload kept increasing. Another ophthalmologist said, “You cannot have your cake and eat it too. If you want to make me work harder and see more patients, then pay me more. The pay structure has to incentivise me to chase after more patients. Communist countries failed economically because socialist-style remuneration did not lead to more productivity”. (Oops. This one really hit home for me)
There is a need to strike a better balance between research, teaching and clinical service. “Some of us are bearing the brunt of the massive workload and bringing home the bacon for the institution but we are getting paid less than folks who see fewer patients and spend most of their time doing research”. This is nothing new, the tension between service needs and academic medicine. But somehow the already-delicate equilibrium between the two has apparently deteriorated lately, probably brought on by the rapidly increasing service workload. The tension is more manageable when the workload is likewise manageable. But when the workload becomes unreasonable, then old wounds concealed by a thin scab may just dehisce again.
The obvious solution of course is to train more ophthalmologists to meet the demands of workload. But it takes a long time to train an ophthalmologist. So, in the meantime, the fastest way to beef up supply in the public sector is to recruit ophthalmologists from overseas. Singapore public sector pays relatively well compared to some other countries and it would not be too difficult to recruit ophthalmologists from e.g. UK. But in the long run, this may not solve the problem either. There have been examples of foreign-trained specialists who likewise leave for private practice once they obtain full SMC registration. For foreign-trained specialists with a basic medical degree that is registrable with SMC, the time taken to convert from conditional to full SMC registration can be as short as 2 to 3 years. Unless we plug this hole and mandate a longer period of service before a foreign-trained specialist can obtain full registration and can therefore leave for private practice, recruiting more foreign-trained specialists may be a just a short-sighted or stop-gap measure at best.
In addition to addressing directly some of the push factors stated above, perhaps a better approach is to better distribute the workload between the private and public sector ophthalmologists. But this would require the cooperation of insurers, especially the Integrated Shield Plan (IP) insurers. Not just particular to ophthalmology, IP insurers have instituted a suite of measures to restrict and reduce IP work in the private sector while pushing more and more work back to the public sector, thereby exacerbating the demand-supply imbalance there. These measures include not just disincentives to seek care in the private sector even though the IP policy provides adequate private sector coverage, but also incentives for the policyholder to go back to the public sector.
There are no easy solutions here but obviously something needs to be done quickly to turn the tide. If not, the dark triumvirate of poor morale, worsening working conditions and more resignations may spill over to the public domain in the form of ballooning waiting times for appointments and surgeries.
squib – (noun) A short humorous or satiric writing or speech (Merriam-Webster’s Dictionary)
Since my last post, “Letters to Hobbit 2024” (https://hobbitsma.blog/2024/02/15/letters-to-hobbit-2024/), many more alert and mythical readers of this column have stepped forward to give me further examples of stupid questions and requests from high priests of the Insurer Order. While we politely call them high priests, I have been told these chaps have all the charisma, intelligence and persistence of a lice-infested orc.
Further examples of stupid questions: • “Why do you follow-up the patient every six-monthly instead of 12-monthly” and “Why do you follow-up the patient 12-monthly instead of six-monthly (same insurance company) • “Did you attempt conservative treatment for this patient before deciding on surgery?” (For a patient with anal fistula). Purported but unverifiable answer: No. Because like his insurer, he wants to be a perfect ass-hole. • Why did you do a mammogram only on the left breast? (breast cancer found in the right breast and a right mastectomy had been done) • Please give a memo describing the indications for and results of the colonoscopy done three years ago (for a claim on an operation for a fracture of the right ankle)
And the list goes on…..
This has become so big a problem that there are anecdotal reports that nurses now coming for job interviews with private specialist clinics not infrequently state up-front that their job scope must not include dealing with insurance companies and insurance claims; if not, they would rather not get the job. So private specialist clinics must now hire separate staff just to deal solely with insurance companies and claims.
Dealing with stupid questions invariably is very demoralising and mood-sapping. Other than perhaps an unreasonable patient or family member, there are few things that can ruin a healthcare worker’s mood more than a stupid question from an insurer. And since we are talking about better mental health and mental well-being for all, including healthcare workers, we should really help them by trying to minimise stupid questions. Stupid questions can be considered to be a kind of psychological abuse of the healthcare worker by certain inconsiderate members of the insurance industry. And since we do not even tolerate verbal or psychological abuse of healthcare workers from patients and their families nowadays, why should we tolerate abuse from these inconsiderate members of the insurance industry?
Time and resources spent answering (often repeatedly so) stupid questions could be better spent on more productive tasks like seeing more patients, not to mention the intangible costs of consequent low morale and poor mental well-being of affected healthcare workers.
All this leads to a less efficient healthcare system and higher healthcare costs because well, stupidity is expensive.
And so, in line with the constructive nature of this satirical column, this hobbit would like to propose that the relevant stakeholders of the health insurance industry start a forum or body to look into stupid questions posed by insurance companies and their staff to healthcare providers. We can call this the “Stupid Questions Under Investigation Bureau” (SQUIB). The administrative support of SQUIB will be funded by hopefully, MOH.
This is how SQUIB can work. The SQUIB Panel can consist of perhaps the following:
• A senior MOH doctor (maybe the Director-General of Health (DGH) or Deputy DGH to chair the SQUIB Panel. He will have the casting vote in the event of a tie • A representative from Life Insurance Association (LIA) to represent the insurance industry’s interests • A representative from either a Medical School (like a professor from YLLSOM) or a Professional Body like the Academy of Medicine Singapore to provide the doctor’s perspective on what is good practice of medicine • A representative from the Consumers Association of Singapore (CASE) to represent patients’ interest
We can also hope that the SQUIB Panel will have a voting representative from the (somnolent) regulating authority for insurers. If this happens, this hobbit will buy 4-D, TOTO and Big Sweep all at one go.
SQUIB will process complaints from doctors about stupid questions from insurance companies. To discourage frivolous complaints from doctors against insurance companies, doctors will have to pay a non-refundable admin charge of say, $100 to SQUIB for each complaint filed.
SQUIB will then consider if the complaint is justified or not justified by its members voting. Whether a question is stupid or not will be decided by a majority decision by its members.
If the complaint is not-justified, nothing happens to the insurance company. If the complaint is justified, then the insurance company has to donate $1000 to a registered charity of the doctor’s choice, in the doctor’s name. If the registered charity is also an Institute of Public Character (IPC), then the doctor can claim a tax break from the donation.
There has been informal feedback that doctors are generally afraid to complain against insurance companies or use a forum like the Multilateral Healthcare Insurance Committee (MHIC) because they think they will be thrown out of the preferred provider panels of these insurance companies they had complained against. And it is indeed a fact that today, insurance companies can remove any doctor from their panel without giving any reasons – when it comes to whether a doctor can be on any panel, insurance companies are the judge, jury and executioner. Hence this climate of fear among panel doctors about bringing unfair insurance practices to light.
To allay these fears and promote transparency, the MHIC and SQUIB should require insurance companies to file a yearly list of doctors that have been removed from their panels and check if these doctors are also registered complainants to MHIC and SQUIB. Should they be, then MHIC and SQUIB can request a full report from the insurance company to justify why these doctors have been removed from their panels. If MHIC or SQUIB is not satisfied with the report, then they can refer the case to the insurance regulator for further investigation for possible victimisation of or retribution against complainants by insurance companies.
Finally SQUIB can publish a ranking of insurance companies according to the number of (proven) stupid questions complaints received by SQUIB. They should even publish the stupid questions themselves, if nothing but for a good laugh.
OK, so much for stupid questions. We move on to more latest developments in the health insurance sector. And yes, they are getting murkier by the minute.
Dyad Of Meanness
Recently, there has been feedback from a galaxy far, far away on quite a few incidents involving this insurance provider which we shall fictitiously call “I-come-steal”. Now, I-come-steal has not always been so coveting. They had been quite kind and cooperative previously and they had reimbursed doctors well, often up to the top end of benchmarks, giving doctors very decent income. But they have since left their cooperative stance and gone to the dark side.
Things got even darker when they appointed this claim administrator which happens to be owned by a major facility provider. We will likewise give this claim administrator a fictitious name, “I-am-strange”. There is obviously a potential conflict of interest with I-am-strange. I-am-strange can deny claims from doctors and then benefit from this denial at two levels. Firstly, they get the usual fees from the I-come-steal for services rendered. Secondly, they can shift the money they had squeezed from the doctor to the facility bill side, which will benefit their owners. Basically, they can swop or “exchange” the doctors bill to the hospital bill component. This hobbit has no evidence this has happened, but many doctors this hobbit has spoken to have brought up this potential for double benefit and potential conflict of interest. And apparently, bills incurred at other facilities do not incur the same kind of intense scrutiny as the ones incurred at facilities owned by I-am-strange’s shareholder, which only serves to reinforce this perspective on the ground. All this hobbit can say is I-come-steal and I-am-strange form a formidable Dyad Of Meanness, like The Emperor and Darth Vader.
Next, we move on to another purported example of this Dyad’s shenanigans. They are very quick to explore loopholes in our healthcare system. An example fee is the loophole found between Table of Surgical Procedures (TOSP) and fee benchmarks. In the interests of keeping up with progress in medical science, and to reflect current practice, there is a committee overseeing TOSPs that comes up with new TOSP procedure codes from time to time. So for example, a new surgical code may be created to reflect a combined operation involving two procedures. But the well-meaning TOSP committee’s creation of new codes is not link to the Fee Benchmarks Committee’s work. So this new code does not have an official MOH fee benchmark.
I-come-steal/I-am-strange then conveniently tells the surgeon that the use of an old code (for an operation he has performed for years) is now not accepted. He has to use the new code. The old code may have a fee benchmark (issued by MOH) that is from e.g. $10,000 to $20,000. As a result, the mid-point for the benchmark is $15,000, which is what the surgeon is claiming for, and also what he has been paid in the past. He is now told that he must claim under the new code, for which there is no MOH benchmark. Instead, I-come-steal/I-am-strange now issues their own benchmark of say, $11,000 to $15,000 for this new code. The midpoint is now only $13,000 and the doctor will be reimbursed as such. Which is kind of ridiculous when the new code is supposed to cover an operation which is more complex and involves more resource utilisation but which the insurer has conveniently given an internal reimbursement value that is lower than the old code (for a simpler operation), just because MOH hasn’t issued a fee benchmark for this. This surreptitious move to use new codes with no fee benchmarks is something policymakers should look out for. At the very least, perhaps a new TOSP code can be issued only if it comes with a fee benchmark, to prevent abuse by any insurance provider.
That’s all for this month. This hobbit really hopes someone in MOH will take up the proposal to organise SQUIB. SQUIB Game will be fun and charities will also benefit, which is a very good thing. In the meantime, let’s hope someone keeps a close watch on the unpleasant stuff being dished out there in spades by the Dyad.
hobbitsma 