A Commentary on SMA’s Position Paper on Troubled Integrated Shield Plans (IPs)

It is not every day that SMA hits the front page of three newspapers: The Straits Times, Business Times and Lianhe Zaobao. But that’s exactly what happened on 29 March 2021 in response to the abovementioned Position Paper. The paper was already released to SMA members I think about a day earlier.

The reporting on 29 March focused on “Future SMA Initiatives” which involves ranking of IP insurers and setting up of a SMA Complaints Committee for IPs and Health Insurance.

But this Hobbit thinks this this is not the real main thrust of the paper.

The main narrative of the paper is how and why we got to where we are, and draws a BIG question mark on whether IPs, the way it is structured, sold and managed, is sustainable at all.

Blameworthy or Blameless IP Insurers?

The first point made in the paper is to debunk the narrative that doctors and patients are the chief cause for overservicing, overcharging and overconsumption that are seen more commonly in as-charged plans and comprehensive first-dollar riders. They are bad, but the SMA puts a large part of the blame back at the IP insurers who first offered these insurance products. SMA is right. The IP insurers narrative of assigning blame to doctors and patients is like saying the cigarette companies are complaining about rising rates of lung cancer amongst smokers and blaming the smokers for this and that the cigarette companies who created and sold the cigarettes are themselves blameless.

The HITF Report Recommendations

The SMA clearly draws the line in the sand with how it sees the Health Insurance Task Force (HITF) Report’s recommendations vis a vis LIA.

In her letter to the ST Forum on 18 March, The Life Insurance Association’s Executive Director, Ms Pauline stated that “The HITF, which included the SMA, recommended a suite of measures to do so, including panels, pre-authorisation, fee benchmarks and co-pays”, in an apparent attempt to infer what the IP insurers are doing has/had the blessings of SMA through both parties’ membership in the HITF.

In this Position Paper barely 10 days later, the SMA resolutely states (para 18) “the SMA council wishes to make clear that it is unable to support the way how the LIA and many of its members have implemented these recommendations”.

It is clear that from SMA’s perspective, LIA and many of its members have misinterpreted and misapplied the HITF recommendations. Which party is right here? This is a point that is worth mulling over.

The Cookie Monster

This is going to take a bit longer to explain but please bear with this Hobbit. The HITF was formed in 2016 and the Report released in October 2016. Buttressing this Report is a 26-Page “LIA Study On the Cost Of Health Insurance In Singapore” (Annex D of HITF Report). It is with this study that LIA made the case that healthcare costs with respect to IPs were increasing at an alarming pace and measures to control this increase were urgent and necessary. The Study used data mainly from 2012 to 2014, a three-year period or a Compound Annual Growth Rate (CAGR) over 2 years.

Now what did this LIA Study actually say?

For the study period, it showed that IP inpatient bill sizes increased by a CAGR of 8.1% vs 2.1% for A class beds in Restructured Hospitals (Page 8: Table 1). According to LIA, this 8.1% is a very bad thing.

The Study then broke down the inpatient bill further into Room and Board Charges, Surgery Charges and Implant Charges (Page 11: Chart H). The CAGR for the same period (2012 to 2014) for the three categories were 8%, 10% and 13% respectively for private hospitals. The corresponding figures for A class were 4%, 1% and 0%. Doctors are responsible for surgery charges and 10% CAGR was held up to be a very bad thing as well.

So this was the starting point or platform for the HITF which the LIA had constructed in 2015. They obviously did their homework and credit must be given when credit is due.

Unfortunately, they stopped their homework after the HITF Report was published. Or at least if they didn’t, they chose to ignore some very significant and odious trends that were building up post-LIA Study (2015) and post-HITF Report (2016).

They probably thought everyone bought their “Insurers are sibeh cham” narrative. As recently as 18 March, in the aforementioned letter to ST Forum, Ms Pauline Lim mentioned, “(the HITF measures) are collectively intended to address overcharging, overservicing and overconsumption of healthcare services”. She was implying clearly that the HITF recommendations (implemented in the manner that LIA’s members see fit) were necessary because the three evils of overcharging, overservicing and overconsumption still existed.

Then came the Singapore Actuarial Society’s 100 mega-ton warhead “SAS Comments: Medishield Life 2020 Review” document (https://actuaries.org.sg/sites/default/files/2021-01/SASResponseMSHLReview2020FINAL.pdf)  which was published just in January this year. The Review used more recent data and a longer period covering 2016 to 2019.

It countered LIA’s claim that (at least in this period) there was overcharging, because Average Payout Per Claim went down by 1% (not up!) over this period.

It also completely countered LIA’s claim there was overservicing because the claims incidence rate for IPs (9%) was actually 1% lower than for Medishield Life (10%). It is noteworthy that this is a good comparison because Medishield Life (and Medishield before this) is well designed with copayment and deductibles being a part of the product design as compared to the as-charged and comprehensive riders being offered by IP insurers in the past

Overconsumption = overcharging X overservicing.

If there is neither overcharging nor overservicing, then it is nigh impossible to have overconsumption.

But hang on folks. There is more.

From the table given in SAS’ Comments (Page 20: Table A4), it can be inferred that the CAGR in Management Fees (16%) and Commissions (15%) were growing at much faster rates than that of Gross Premiums (10%) and Gross Claims (11%).

Gosh, how the tables have turned! The 16% and 15% are much higher than the numbers used in the 2015 LIA Study to justify their call to control doctors’ fees (10% for 2012 to 2014)  through fee benchmarking and over-provision of services through panelling and pre-authorisation. This hobbit won’t say it’s disgraceful, but these figures collectively interpreted are pretty embarrassing for LIA.

In case anyone thinks that a few percentage points do not make a big difference, please note these are COMPOUNDED rates, and they tend to have a multiplicative, explosive effect with time. This can be seen by the fact that Gross Claims increased absolutely by 35.9% over four years (when its CAGR was 11%) and Management Expenses increased absolutely by 56.6% (when its CAGR was 16%). A five-point CAGR difference translates into an absolute 20.7% difference over a four-year period. And this absolute difference will increase more rapidly with time as long as the gap exists.

As it turns out, the SAS Comments paper have revealed why there seemingly aren’t enough cookies in the jar – there is a cookie monster helping itself to more and more cookies. And the greatest irony is that the one party complaining most loudly and frequently about not enough cookies is the cookie monster itself!!!

Expensive Tradeoff Between Risk-Pooling And Cost Of Running IP

Another snippet is that that Gross Claims accounted for 75% of gross premiums collected. This means for every four dollars collected, one dollar goes to non-healthcare cost items. Insurance, at its core, is a construct that is supposed to extract more funding efficiency through risk-pooling. But if the “funding efficiency” is only 75% (i.e. only 75% goes to healthcare providers to pay for healthcare), one must wonder is this risk-pooling worth the bother at all. In the Affordable Care Act (i.e. Obamacare), it is mandated that 80% to 85% of premiums must go to healthcare providers, so as to maintain a baseline efficiency in the system. This is also why SMA calls for a 85% to 90% Gross Claims figure to be imposed on IP insurers so as to “instill cost discipline”.

One Payor To Rule Them All

Which leads us to the last point SMA was trying to make – the prospect of a single-payor system that can extract far more efficiency than the current IP sector involving seven players. In 2019, $363M was spent on management costs and commissions. This is a huge sum. If a single payor can run the whole IP system for say $63M, that is $300M in savings. This hobbit is told $300M is the ballpark figure a ‘smaller’ restructured general hospital receives in operational subsidies a year. In other words, the savings so gained can be used to fund another general hospital the size of KTPH or maybe even NTFGH. Alternatively, the money can be put into Medifund to help poor patients in the subsidised healthcare sector. This hobbit can think of no better single payor system operator than MOH. If MOH can run Medishield Life, it can certainly run IPs.

The counter argument to all this is that market competition is good and market forces must be allowed to play themselves out. But as experience has shown, the IP market is hugely imperfect as policyholders cannot freely switch IP insurers once they have pre-existing disease(s). That is why IP insurers can raise their share of the pie in terms of management costs and commissions with relative impunity.

Bad Apples and Dirty Linen

Finally, we come to some of the concerns raised about SMA’s big pushback against IP insurers. People are concerned that with SMA’s Position Paper, the LIA, its members or just their sympathizers will push back with horror stories of unethical doctors overcharging, overservicing etc. In other words, they will publicise all our bad apples and wash our dirty linen in public.

There are some 2000 specialists in the private sector and there will always be bad apples to show and dirty linen to wash. In fact, this hobbit knows quite a few examples too. But that is NOT the point. No matter how many bad apples we have (and this hobbit would like to think there are but a few) and dirty linen to wash, they are ALL encapsulated in the 11% CAGR in Gross Claims. That’s it.

This 11% is just one percentage point higher than the CAGR for Gross Premiums. It means that Gross Claims growth is very close to growing in tandem with Gross Premiums, which is the first precondition to making the IP environment financially sustainable. Now contrast this 11% to the 15% to 16% figures for commission and management costs and one will quickly realise who is the main culprit in this whole issue of IP sector being unsustainable.

Conclusion

The 15% to 16% CAGR for commissions and management costs makes IP unsustainable. Period. Extracting more friction through pre-authorisation, higher deductibles and copayment when using non-panel doctors or having highly restrictive panels won’t address the root cause of the problem. Reimbursing doctors at even lower rates than now may help, but at current rates how much lower can you go? MOH might as well throw in the towel and concede defeat to LIA and its members by withdrawing its Fee Benchmarks if the IP insurer fee scales go any much lower than now.

The SMA Position Paper highlights the findings of the SAS Comments on Medishield Life, and points the way to where we should look for solutions. With payout size stable and claims incidence rate for IP being 1% lower than Medishield Life, the focus of efforts to make IP sustainable must now be on the IP insurers themselves.

The numbers don’t lie….

The 6ME FDW or Maid Check-up

The recent case of the tragic death of a Myanmese maid has led to calls for doctors to be tasked to report cases of maid abuse. Actually this requirement already exists, in small print, in the current form after the doctor ticks off the results for the VDRL and pregnancy tests:

“If you notice signs of abuse, refer the helper immediately to the Police or MOM for help”.

It was also noted that “the doctor had seen bruises around the maid’s eye sockets and cheeks, but Gaiyathiri (the late maid’s employer) claimed that the victim fell down frequently as she was clumsy” (CNA website, 25 Feb 2020; Myanmar maid’s death: MOM reviewing how doctors report potential abuse). It was also reported that Gaiyathiri turned down the doctor’s suggestion for further tests on the victim’s swollen legs in case of underlying conditions.

MOM said “Nothing adverse was flagged to the authorities’ attention on either occasion (when the doctor saw the deceased maid)”.

This hobbit is all for doctors’ playing a greater role in the detection of foreign domestic worker abuse. But to go beyond the present state of affairs, we need to answer a few questions.

The first question that needs to be answered is whether the doctor is supposed to detect abuse in this statutory medical examination using clinical examination or forensic examination methods?

Let us first talk about statutory medical examination. A statutory medical examination is simply a medical consultation and physical examination (and sometimes includes investigations) to demonstrate that the examinee is fit for a purpose as required by law (i.e. statute). Examples include heavy vehicle examination, pilot examination etc. The Six-monthly medical examination (6ME) for foreign domestic worker (FDW) required by MOM is another such example.

The purpose of this examination when it was first instituted was to detect if a FDW was pregnant or if the FDW had contracted sexually transmitted diseases. These questions can easily be answered objectively and in a binary fashion (yes or no) by simple laboratory tests.

Detecting abuse was a later addition to the 6ME that was added on only a few years ago. The case for detecting physical abuse is slightly different. There are no simple laboratory tests with binary outcomes for physical abuse. It is a matter of judgement and therefore more subjective.

Every doctor is trained to conduct a clinical examination. However the clinical examination is based on certain assumptions of a social compact between the patient and the doctor. A clinical examination entails history-taking and physical examination to elicit clinical signs and symptoms. Undergirding this is that the patient must cooperate by telling the truth. I think all doctors would have had the unfortunate experience of being waylaid to some extent by patients not telling the whole truth after many years of practice.

A forensic examination is different. The underlying principle here is that the doctor is trying detect some crime that has been committed. The patient should preferably cooperate with the doctor but the forensic examination is not dependent on this cooperation. After all, a forensic medical examination is a comprehensive examination looking for injuries and taking samples that may be used as evidence in a police investigation and any subsequent prosecution. Doctors will have to be trained to perform forensic examinations if this is the standard expected of them in the 6ME.

It would be helpful if MOM can state if they expect doctors to conduct a clinical or forensic examination when they carry out the 6ME FDW.

Be it clinical or forensic examination, a key point is that the employer or any other person should not be present, if the intent is to detect abuse. However, there is no such stated requirement now, despite the fact that the doctor is to refer the maid to the Police or MOM if the doctor notices “signs of abuse”. It is hard to do a proper examination to detect abuse when the criminal may be right there standing next to the abused. The doctor is also not empowered by statute to confirm his suspicions of abuse by ordering tests.

A second and equally difficult question is how will a doctor be judged? If there is truly abuse and a doctor missed it, to borrow a legal term, what is the “burden of proof” that will be applied to the doctor?

There are three common standards used:

  • Prima facie, i.e. enough evidence to support a case
  • On the balance of probabilities
  • Beyond reasonable doubt

Is a doctor supposed to report abuse because

  • There is just some evidence that the event happened? (“prima facie”)
  • More likely than not that the event happened (50.1% probability that something happened)
  • Very strong evidence that the event happened (beyond reasonable doubt)

If the doctor is informed beforehand what is the applicable standard, then the doctor will also likewise respond appropriately to the standard expected of him or her.

The third question is that of costs. Presently, a 6ME costs anything from the region of $25 to $45 (depending on whether you use urine or blood to detect HCG). In reality, most doctors do nothing more than a cursory physical examination and the whole process takes 5 to 10 minutes or so. A detailed clinical examination (let alone a forensic one) will entail far more time and resources than what is presented committed to the 6ME. It would also mean employers have to probably pay a higher price for the 6ME. But if society is determined is stamp out maid abuse, then it must be so.

Integrated Shield Plans: The Veneer Of Choice

Empanelling: Trust Me, You Will Take The Blue Pill

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

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

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

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

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

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

Nothing Personal, It’s Just Business

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

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

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

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

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

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

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

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

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

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

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

LIA’s Letter to ST Forum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Summary

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

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

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

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

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

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

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

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

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

Let there be light.

2021 Hobbit Awards

2020 was a year with no comparison for healthcare. Of course, Covid-19 was the every visible elephant in the room but there were other memorable incidents and people that managed to share some of the limelight as well. This hobbit recaps this momentous year with the 2021 Hobbit Awards. And the winners are……

Circular King Award

A total of 244 Circulars were issued by MOH in 2020. They were issued by either our new DMS, Prof Kenneth Mak or his lieutenants. If you think about it, there are 366 days in 2020 (leap year), 104 weekend-days and 11 public holidays. That leaves us with about 251 working days (give or take a few). In other words, we had to keep abreast with about one new MOH circular per working day! That’s incredible. I think the current DMS has issued more circulars in one year than any of his predecessors. He is this hobbit’s choice for Circular King Award.

Superman Baby Award

In the beginning of every version of a Superman movie, the opening scenes invariably involve the parents of Superman putting the Superman baby into a spacecraft. The spacecraft then blasts off planet Krypton for Earth and within seconds Krypton explodes.

That about sums up the previous DMS, Prof Benjamin Ong. The first case of Covid-19 hit Singapore on 23 Jan 20. His last day in MOH as DMS was 31 Jan before the current DMS took over and MOH promptly exploded with the Covid-19 outbreak in Singapore. Prof Ong is a deserving winner of the Superman Baby Award.

Best Communication Award

This goes to our wordsmiths in the civil service and political leadership for coming up with the term “Circuit Breaker” in lieu of the commonly used “lockdown”. The acronym “CB” is now widely used. More interestingly, on 21 Apr 20, it was officially announced that CB measures would be tightened. Only in Singapore do we tighten already a very tight CB.

Most Useless Relic Award

Remember long, long ago, in a galaxy far, far away, there was this one colour code to rule them all – DORSCON? Well nobody talks about it anymore. Although it has a few colour grades to the Code, no one takes it seriously when we realised ‘Red’ is a hypothetical, mythological colour that will NEVER be used even when we faced the closest thing to Armageddon (aka a tightened CB – please see above) and more than a thousand new Covid-19 cases were popping up a day.

DORSCON should be thrown into the fires of Mount Doom to be destroyed forever like all useless relics.

Best Witchcraft Award

This prestigious award goes to the Ministry of Trade and Industry’s GoBusiness Portal for deciding in an incomprehensible and opaque way who is an essential worker and how many staff is a clinic entitled to. How is a GP clinic assistant deemed to be an unessential worker is just beyond this hobbit.

Animal Advocate of the Year Award

This goes to the genius that decided that “basic” pet grooming services could resume on 1 June 2020, even before the resumption of “human” aesthetic medicine.

Best Cartoon Comedy Award

This award undoubtedly goes to the folks who approved the Virus Vanguard, who existed for about a day before it was disbanded. Even so, the timeless superhero legends of Circuit Breaker, MAWA Man, Care-Leh Dee, Dr Disinfector and Fake News Buster will remain etched in the collective psyches of Singaporeans forever. It shows that some decision makers in the government have a (strange?) sense of humour/reality.

This hobbit confesses that he may still be suffering from Virus Vanguard’s Dissolution-related PTSD.

The Special Destiny Award

This goes to the Minister for Manpower and her team for pitching to us the seminal point that the outbreaks in our foreign worker dormitories were inevitable. This hobbit now believes that we were just fulfilling our destiny when 47% of workers (152,794) living in foreign worker dormitories were infected.

Best Educator Award

This definitely goes to Minister Chan Chun Sing for educating a younger generation of Singaporeans on the use of the term “sia suay”. Even an old coot like me hasn’t used that in a long time.

He also educated us on the unnecessary use of masks and hoarding of toilet paper, eggs and instant noodles, amongst other things.

Evidence-Based Infection Control Award

This very relevant and timely Award goes to the Elections Department of Singapore for demonstrating with strong evidence during General Elections 2020 what most healthcare workers already knew – you can’t put on gloves when your hands are wet with disinfectant/alcohol/water etc.

Best Voodoo Healthcare Award

This goes to the Health Insurance industry, in particular the Integrated Plan (IP) providers for

  • Not respecting fee benchmarks that were issued by MOH
  • Selling IPs to 70% of Singaporeans when the combined hospital beds market share of private hospitals and A and B1 bed classes restructured hospitals is only about half of that
  • Empanelling only about 20% of specialists in the private sector and not telling potential IP customers that they can only choose from a very limited pool of specialists.

On the other hand, they are still telling the public to buy more IPs when there is really no capacity to fulfil demand down the road.

If this isn’t voodoo healthcare, this hobbit doesn’t know what is.

Company of the Year Award

DoctorsXdentists (DXD) won this hands down. In this one year, they managed to achieve the following:

  • Misrepresented MOH compliance officials
  • Irritated the hell out of several professional bodies such as Academy of Medicine, SMA and CFPS
  • Used information from the SMC doctors’ directory without SMC permission

This is the most breath-taking healthcare company we have seen in a long time.

The Basket Case of Doctorxdentist (DXD)

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

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

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

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

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

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

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

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

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

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

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

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

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

Misrepresentation of MOH’s position

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

Refusal to issue an erratum, let alone apologise

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

Flip-flopping

DXD can flip their position faster than a prata.

Incident 1:

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

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

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

Incident 2:

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

Unauthorised Use of SMC Website and Data

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

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

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

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

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

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

Sequence of Events

3 Nov 20

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

4 Nov 20 (DXD Blog)

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

7 Nov 20 (DXD Blog)

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

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

10 Nov 20 (DXD Blog)

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

13 Nov 20 (DXD Blog)

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

13 Nov 20 (SMA update to members)

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

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

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

19 Nov 20 (DXD Blog)

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

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

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

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

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

22 Nov (DXD Blog)

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

25 Nov (SMC website)

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

26 Nov (Various Newspapers)

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

The Curious Case of DoctorXDentist (DXD)

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

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

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

Examples of these packages:

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

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

SMC Directory

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

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

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

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

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

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

Non-Manageable Risk to Doctors

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

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

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

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

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

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

DXD: The Special One?

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

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

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

Wow.

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

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

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

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

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

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

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

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

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

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

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

The SMC-DXD Bundle

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

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

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

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

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

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

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

The IP Titanic

Question 1:

How does a health insurance company make money?

Answer:

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

Question 2:

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

Answer:

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

Question 3:

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

Answer:

The threat of higher insurance premiums.

Current Situation for Integrated Shield Plans (IPs)

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

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

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

This hobbit does.

Under-utilisation and Structural Under-capacity

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Young Policyholder Pool

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

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

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

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

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

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

Incredible, isn’t it?

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

So why are IP insurers losing money?

What Can “Affordable” IPs Really Afford?

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

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

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

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

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

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

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

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

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

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

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

2https://www.moh.gov.sg/resources-statistics/singapore-health-facts/beds-in-inpatient-facilities-and-places-in-non-residential-long-term-care-facilities

3https://www.moh.gov.sg/home/our-healthcare-system/healthcare-services-and-facilities/hospital-services

The “Unbalanced” Hand of the Private Health Insurance Market

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

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

He said,

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

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

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

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

History

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

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

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

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

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

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

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

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

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

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

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

The Current Situation

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

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

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

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

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

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

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

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

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

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

What is really the point of having IPs?

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

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

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

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

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

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

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

Regulatory Lacunae

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

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

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

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

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

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

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

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

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