Letters to Hobbit 2024

This month, we continue with the tradition of publishing some completely nonsensical letters from our alert but fictitious readers. For the avoidance of doubt, this column is written in the spirit and form of satire. If anyone is offended by this satire, go and suck your thumb. Trust me, it helps. To at least ingest some germs, if nothing else. Your microbiome needs it, since you are so uptight.

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Dear Hobbit

Why do second ward round?

Recently I have been asked by an insurer called Stinklife to justify why I was doing two ward rounds a day for my inpatients. In her email to me, this Assistant Manager of Shield Operations Team (sounds like a person from Marvel Avengers, hence I am very afraid) wrote, “Could you please further elaborate the medical indication/reasons for the justification on why the patient is required 2 visits per day from admission till discharge day. Also kindly state the timing for each visit on each day for our further review”.

I am very perplexed and upset. When I was a young MO working in public hospitals, I was told by my boss that a hardworking and good doctor always tried his best to do two ward rounds a day; a morning round and an evening round. I remember my more conscientious consultants doing their evening rounds with me before they went home.

Now it would appear Stinklife is trying to tell me that my evening round is unnecessary. 24 hours is a long time before an inpatient is seen again, the patient’s condition can turn for the worse in this period.

Dr Chin Du Lan

Cardiologist

Mount Noveau Hospital

Dear Colleague Du Lan,

I am with you all the way here. But it would appear that in our current climate in Middle-earth Healthcare, there is one ring to rule them all – and this is the Ring of the Insurer. This Ring is more powerful than what we learn from textbooks, research papers, CMEs and our professors and role models in the profession. It may have been two ward rounds a day in the past, but since the Wearer of the Ring of the Insurer has spoken, it is now only one round a day. This is mainly because the Wearer of the Ring of the Insurer Regulator sat on his ass for the last 10 years before sailing off into the sunset. The folks holding on to the Ring of the Healthcare Professionals cannot stand up to the wearers of the Ring of Insurers

On a more serious note, I do note that the standard of English from the Shield Operations Team is very bad. Really gave me a ogre-sized headache just going through those two unwieldy sentences.

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Dear Halfling

$5.99 Telemedicine

Greetings in the Year of the Smaug. May you HUAT all the way this year, win TOTO 12 million and your Healthier SG patient enrolment hit the roof!

Recently, I received this EDM tilted “Consult for a Medical Certificate”, the EDM further stated “Teleconsult for Minor Illnesses” – Get a medical consultation started in 5 minutes for $5.99 nett”, “No Video Consultation Required” and “SMC Registered Doctors”

Apparently, the medical consultation may just consist of filling up a form. The doctor will review your case (via the form you filled up online) and decide whether to give you an MC or not. They may get in touch with you if they need further information.

Doesn’t this smell of selling MCs? How does one determine a patient is deserving of an MC without a video consultation and apparently by just filling a form?

Can I do likewise?

Dr Chao Geng,

GP, Eat Snake Clinic

Dear Dr Chao Geng

Since you are also a SMC Registered Doctor, you can of course start a service similar to what is mentioned in the EDM. But a word of friendly advice- you should not charge this odd figure of $5.99. You should charge according to how our CDC Vouchers are designed – in multiples of $2, $5 or $10. This would facilitate faster transactions because your payer, I mean patient, doesn’t have to Paynow you the remaining 99 cents. We need to be more payer-centric, I mean, patient-centric.

You should also do a side business of selling snake soup in the shop lot adjacent to yours. I suspect your patients may have a certain predisposition to eating snake-derived products.

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Dear Shorty

Most Trusted Centre

Recently I have been approached by a person claiming to want to give my practice Tulang Orthopaedic Clinic an award for being one of the “Most Trusted Orthopaedic Centres Adopting Evidence Based Practices and Cutting Edge Treatments in 2024”

This award comes with other benefits, including two full-page exclusive story about Tulang Orthopaedic Clinic which will be designed with images, the issuance of a Certificate of Leadership Excellence, two authored articles written by any person representing the practice, among other things.

All of the above will come as long as I paid them USD2500. If I can buy trust and more patients for USD2500, why not? What do you think?

Dr Hoh Seng Lee

Emeritus Senior Consultant Mentor

Tulang Orthopaedic Clinic

Dear Dr Boh Seng Lee, I mean Dr Hoh Seng Lee

I can see why you want to improve your standing and branding in the market. However, you should really ask yourself if anyone reads this publication or website that gives out this award. And how many recipients of this award will there be? Maybe also 2,500?

You may be better off doing a 15 second dance routine on TikTok that highlights the joy of sucking marrow out of a long bone found in a bowl of orc soup. With today’s woke generation, that may get you more patients than getting an award for being “Most Trusted….”.

The Short One

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Dear Adik the Pendek

Who is Responsible?

I performed a haemorrhoidectomy on a 62 year-old in September last year. After sitting on my claim for some 4 months, I received a letter from the insurer last month asking me to give a memo to justify why a pre-operative ECG and Chest X-ray were needed for this patient. To add insult to injury, the email stated, “Please submit a referral letter/doctor’s memo for our review. Kindly note that the doctor’s memo fee (if any) is not payable under the policy”.

The patient is a 62 year-old. Isn’t it routine to do an ECG and Chest X-ray to assess anaesthetic risk? I am wondering who is asking such basic questions? More importantly, if we do not do a proper pre-anaesthesia workout and something bad happens, who is responsible? The insurer or the doctor?

Dr Tan Kah Chng, Giles,

Giles the Piles Clinic

Dear Kah Chng,

I sense much anger in you. That leads to the Dark Side. Anger leads to pain, and pain leads to suffering.

Please see my above reply to Dr Chin Du Lan. Unfortunately, a standard accessory item to the Ring of the Insurer is the Pendant of Non-Accountability. Wearers of this Pendant cannot be held accountable to any clinical outcome, good or bad, even though they can decide how healthcare services are priced, who can perform and get paid for these services. In short, you, the doctor is still responsible if some disciplinary tribunal decides you have not given professional services of a good enough standard by not ordering an ECG or a Chest X-ray for a 62 year-old patient, and then censures or suspends you from practice.

I need to caution you that the person who asked you to justify the investigations may also be a High Priest of the Insurer Order. These High Priests have developed the ability to ask an infinite number of stupid questions that are designed to frustrate and anger you and also to generate more and more paperwork to justify higher and higher management costs for the insurance company they work for.

Yeah, life in Middle-earth sucks for us doctors. Truth be told, if I can be reincarnated, I will want to come back as an Insurer. I am told the wearer of the Ring of Insurance Regulator has been cursed with the Spell of Somnolence by the dark Sauron, the effects of which seem to be permanent. It doesn’t seem the wearer will wake up anytime soon.

Your friendly neighbourhood, Adik the Pendek

Do We Have Too Many or Too Few Doctors?

A New Year brings new hopes and aspirations. And new worries and fears, unfortunately. In this new year, the hobbit wants to wish all readers of this nonsensical column a very ungratifying year and may all of you remain as ingrates.

This is because in 2024, the scariest word is gratification. Woe be unto you should any of you (especially those in the public sector) be suspected to have received gratification. Gratification can be displayed in many different forms; these include free concert and F1 tickets, or may even be just letting off a loud burp or two after a heavy meal or an upsized cup of bubble tea.

So remember, in 2024, stay ingrate.

Having dispensed with this New Year Greetings and leaving all ungratified, let us now set our eyes on this post’s question: Do we have too many or too few doctors?

As the cliché answer goes – it depends on who you ask

If you ask the public sector folks – they will say too few. The public healthcare clusters are desperately trying to recruit new doctors to fill vacancies that are created when new hospitals and polyclinics are launched. And the government are building these public health institutions (PHIs) rather quickly, in anticipation of increased healthcare needs of an aged population. The frequent complaints about waiting times and appointment times at polyclinics and specialist outpatient clinics reinforce the view that we don’t have enough doctors in the public sector, at least.

But if you look at the MOH Singapore statistics, in 2022, we have 2.8 doctors per 1000 population or about 1 doctor to 357 persons. This figure is in line with those of many developed Anglophone countries, including USA, Canada, UK, Australia etc and better than most countries in the region, including Korea and Japan. Also, Singapore is a small city-state that does not suffer from difficulty of having physical access to doctors that sparsely populated large countries may experience. In other words, even we may not have too many, we probably have enough or near enough doctors, going by national and international statistics and norms.

Then again, if you ask doctors in private practice, they will say the situation is rather saturated and we have enough or even too many doctors. Apparently, seven ENT surgeons have left or are leaving for the private sector in 2024. And we are in January. Prices and rentals for specialist clinic space in private hospitals are shooting up again, suggesting that demand far outstrips supply.

The Public Sector

But let us go back to the public sector again since the public sector employs the majority of doctors. In the latest SMC Annual Report (2022), it is stated that there are a total of 16,633 doctor in Singapore, of which 10,938 worked in the public sector and the remaining 5,695 working in the private sector. (i.e. 65.8% working in public sector or about two-thirds)

Of the 10,938 doctors in the public sector, 4,536 were specialists while 6,402 were non-specialists.

According to a recent article in the Straits Times, (9 Dec 2023), there were 624 doctors working in our polyclinics. These are in all probability not specialists registered with the Specialist Accreditation Board (SAB). That leaves about 5778 non-specialists working in the public sector less polyclinics. There were also 624 house officers in 2022 who need close supervision.

There are a relatively small number of public sector doctors who work in MOH, the statutory boards such as HSA, HPB, and agencies such as MOHH, AIC, Synapxe etc. If we ignore this small group, and take away the 642 polyclinic doctors and 624 house officers, there are 9690 doctors in the public sector. Of which the 4536 specialists would make up 46.8% of all doctors in the public sector.

In other words, there are almost as many specialists as there are medical officers working in the clusters’ hospitals and national specialty centres.

Obviously, this was not the case in our restructured centres long ago. Older doctors can all testify that specialists were a rare thing. In fact, even registrars were a rare thing. Once you pass your M.Med, you are either a Registrar or a MOS (Medical Officer Specialist), and you are given that prized object – the black name tag, which you proudly wear (if you are male) on top of your shirt pocket. You are now officially known as a “Tua Lo Kun” (Big Doctor in Hokkien) and you can now strut down the ward corridor with a spring in your step. Even senior nurses like ward sisters (aka ward managers) treat you with deference. You also get a respectable night call allowance (i.e. more than forty bucks). You gladly buy your on-call team supper. Actually, the registrar paying for supper was almost an obligatory thing, mainly because the more junior doctors were paid peanuts or nothing.

When you become a consultant, you have reached minor warlord status with your small team of registrar, medical and house officers. A consultant cannot be left alone when he or she visits the ward to see patients. A nurse and a house or medical officer will rush to the consultant’s side when he reviews his patients, to take instructions and to update the case-notes.

And finally, when one reaches the demi-god status of senior consultant, junior staff who are not in your team actually now avoid you or at least your stare while those who are, fawn over you, or least pretend to. The air thickens around you wherever you go, and now you are accompanied by the ward sister and at least a registrar when you review your patients. The ward doctors and staff hold a mini-conference before they make the decision to page you, or not. (For young readers, please be informed that there was this thing called a pager and “page” is both a verb and a noun).

Well, all that has changed with the above distribution of medical manpower currently in our restructured hospitals and national centres. As the numbers show, almost half the doctors are specialists. And this hobbit has been told that about half of the specialists are senior consultants (this hobbit has not been able to verify this claim). In other words, if this is true, then about 1 in 4 doctors are senior consultants, another 1 in 4 are either consultants and associate consultants.

There are no more entourages for senior consultants, except maybe the head of department or previous heads of departments. There just aren’t enough junior doctors to accompany every specialist that comes around in the wards. In some departments, the senior consultants outnumber the house officers.

It is therefore a “top-heavy” distribution of medical manpower. Obviously, we have to work in new ways now. But in the long run, one must ask, is this distribution of medical manpower sustainable from a cost-effectiveness point of view? Yet, at the same time, as aforesaid, we often hear of a large number of public sector specialists resigning for the private sector. One wonders, are they mainly senior consultants or more junior specialists?

It is a very complex situation but it would be nice to know what are the planning norms for medical manpower in our public healthcare clusters? E.g. what percentage of doctors should be specialists? And of these, what is the desired proportion for Associate Consultants, Consultants and Senior Consultants? Of course the tertiary hospitals and national centres could have a larger percentage of senior consultants etc.

This hobbit doesn’t know how many doctors and specialists the public sector needs as a whole, but the gut feel is that we probably either have too many senior consultants, too few junior doctors, or both.

The specialist manpower planning in our clusters is also inextricably linked with the private sector and national situation. It has been said that specialists should comprise 40% of all doctors in Singapore. This target has already attained currently with 40.3% of all doctors being specialists.

The Private Sector

This figure would include the significant number working in the private sector and especially the private hospitals. In our private hospitals, almost all doctors are specialists. But a closer look at the private sector would reveal that only about 38% of doctors in the private sector are specialists, (2163 are specialists out of 5695 private sector doctors). One would assume (wrongly) that the bulk of the remaining non-specialists would presumably be family physicians (FPs).

There are 3532 non-specialists working in the private sector of which only 1707 are registered FPs. That leaves 1805 non-specialist doctors in the private sector who are not on the family physician register. One wonders what do they do? Locums? Working in pharmaceutical companies? Resident MOs in private hospitals? Aesthetic GPs? This hobbit confesses he doesn’t know how this diverse group of doctors can come up to 1805, outnumbering the number of FPs.

Ideally, this group of “undifferentiated” non-specialist doctor in the private sector should be deployed where they are needed most. Perhaps more can be retrained as FPs through the GDFM (Graduate Diploma Family Medicine) route?

Let’s return to the specialist manpower situation again. The recent announcement by MOH (8 Jan 24) that it is interested in exploring the idea of setting up a not-for-profit private acute hospital should be supported. Another Mount Alvernia-like hospital would allow for more specialists to go into private practice without incurring the costs associated with the astronomical price for for-profit private hospital land in Singapore.

Perhaps this not-for-profit private acute hospital would address the possibility that we are having relatively too many specialists and especially senior specialists in the public sector.

But for this to happen, there needs to be a national and professional-wide consensus on the following:

Do we have enough doctors nationally? (with a doctor-patient ratio of 1:357)
Are we getting enough doctors every year (both locally and from overseas, ~ 600 to 700)?
Are we training enough of these doctors to be specialists? (~40%)
Do we have enough specialists nationally, now and going forward (in terms of percentage and in absolute numbers)?
Do we have enough specialists in the public sector (in terms of percentage and in absolute numbers) compared to junior doctors?
Do we have enough senior consultants in the public sector (in terms of percentage and in absolute numbers)?

In line with this New Year’s theme of avoiding any form of gratification, this post ends with more questions than answers……

Not So Merry A Season

It’s that time of the year when practically everyone you know is on holiday overseas. They are taking full advantage of the almost almighty Singapore dollar and standing up for Singapore by chirping “cheap, cheap” from Tokyo to Tasmania and from Seoul to Sao Paulo. Of course, most people do not realise that there are zero-sum games in this world after all – if we find everywhere else cheap, then everyone else also probably finds us expensive. Which probably explains why Orchard Road is rather quiet nowadays, when compared to other shopping districts in the major cities of Asia. But it’s OK, in the meantime, just enjoy the almost almighty Singapore dollar and almost all-conquering Singapore passport.

It’s the season to be merry, after all. But not for quite a few folks

The first group of folks would be the board of directors, management, shareholders and customers of Cordlife Group Limited. In a shocking revelation, several storage tanks in its Singapore operations for stem cells were found to have been exposed to temperatures exceeding that which is deemed allowable. This calls into question if the cells and tissues stored therein are still viable should they be needed. In any case, an accreditation body called FACT (Foundation for the Accreditation of Cell Therapies) has suspended their accreditation of the bank. Most if not all reputable hospitals who can perform stem cell transplants will only take samples that have been stored in cord blood banks that are accredited with internationally reputable accreditation agencies – FACT is one of them. In other words, even if the cells stored are viable, they may not be deemed usable because the accreditation status is now suspended.

Anyway, the incident calls into question a few things, including

When and how much did the management and board know about the shortcomings?
What was done to uncover the full extent of these incidents to get a full picture of the number of incidents in tank(s) were exposed to higher than allowed temperatures?
What were the reasons for these failures in operations, escalation and disclosure?

This will entail probably the Mother of all RCAs (Root Cause Analysis)…..And we haven’t even talked about how this incident affects Singapore’s reputation as a healthcare hub.

The next unmerry thing on the radar is the alleged corruption of the AON Singapore CEO, who has been accused of taking a bribe amounting to $240,000 from Fullerton Healthcare. At first glance, two things are interesting about this case. First, this hobbit doesn’t know how much an insurance broker like AON pays their Singapore CEO, but it is probably well in excess of $240,000 a year. The fact that he was willing to risk his entire well-paid job and possibly end up as a criminal for $240,000 defies common sense. Also no present or past employee or director of Fullerton Healthcare has been charged yet by CPIB. Watch this space carefully.

We move onto something else pretty interesting developing in the Third Party Administrator (TPA) Scene. An unnamed TPA was said to have offered new fee scales to its panel of ophthalmologists. These new scales are so low that they fall well below that of the MOH Fee Benchmarks. In fact, an older ophthalmologist was said to have remarked that the new fee scales are even below what he was offered more than 10 years ago by the same company. Apparently, in 2011 a Table 4A operation was reimbursed at ~$2800. In 2024, the same Table 4A was to be paid ~$2200.

This hobbit is also hoping his bowl of Bak Chor Mee in 2024 will be cheaper than what he paid for in 2011, but that is wishful thinking bordering on the mythical, like Santa coming down the chimney bearing gifts.

But myths and wishful thinking will remain just what they are. Reality, on the other hand, bites. Apparently, more than 90% of the original ophthalmologists who were on this TPA’s panel came to their independent and individual conclusions that it was unwise to remain on this panel for reasons best known only to them and they then quit one by one; leaving just a handful left on the panel. It’s a free world and a market economy we live in. Payers have a right to offer fee scales as they see fit and service providers have a right to independently reject them for whatever reasons. But if I were this TPA’s clients, I would ask why did my panel of ophthalmologists shrink by more than half in 2024 when compared to 2023?

Finally, its squeaky-bum time for the Integrated Shield Plan (IP) providers. On 9 Dec 23, Mr Han Fook Kwang wrote in ChannelnewsAsia (CNA) this commentary titled, “Amid ever-raising premiums, let’s make for no-claim individuals to switch private health insurers”. Now Mr Han is the Michael Owen-equivalent of Singapore journalism. He was the Editor of The Straits Times for many years but now writes for CNA, not unlike how Michael Owen played for Liverpool before playing for Manchester United, both periods to wide acclaim.

In this commentary, Mr Han has come to the conclusion that:

The IP providers want to collect premiums when you are young but are happy for you not to be covered by them when you are old (i.e. the concept of cherry-picking or adverse selection)
There is no real competition between IP providers once a person has chosen to stay with one IP provider due to pre-existing diseases
Smaller IP providers charge higher premiums and also make financial losses

He then recommends:

(More) government supervision and action
Beyond ensuring the financial viability of insurers, there should be someone (or some government agency) out there to look after the interests of the customers
There should be “closer oversight of the premiums charged and what they cover”.
Allowing for “portability for those who have not made any claims for a certain number of years”.
So as to facilitate “a gradual migration to more efficient companies charging lower premiums”
Three to four IP providers will suffice for a relatively small market like Singapore so that real competition exists, instead of seven providers

Many of the above points have also been covered by this Hobbit previously in this Blog over many posts but of course nobody pays attention to mythical me. Hopefully the guys in MAS, the stated regulators of insurers, will pay more attention to what Mr Han is saying. Even though going by the past record of MAS, this is most likely going to remain a hope and nothing more. But’s it is Christmas and Christmas is the season of hope. The hope that MAS will do more than pay attention to financial viability or health of insurers, but also do what Mr Han said about looking after “the interests of customers”.

Finally, we move on to the ongoing Public Consultation of the Health Information Bill (HIB). It’s interesting how this Consultation is carried out – which is in the form of a survey or a questionnaire. The survey consists of a number of questions that demands the respondent to answer in a binary-outcome fashion, either a “yes” or a “no”. Each question is followed by an optional free-text box for you to elaborate, should you so wish.

I think whoever designed this survey should be sent either to the Civil Service College or the Saw Swee Hock School of Public Health for a short course in survey or questionnaire design, because enforcing a binary outcome does not lend itself well to understanding and analysing the nuances in attitudes of diverse stakeholders in what is now usually a complex policy environment. Many respondents may not use the free-text box provided and even if they do, the free text cannot supersede the “yes” or “no” response.

You are conducting a consultation to receive feedback so as to draft bills and fine-tune policies. You are not conducting a referendum like in the Scottish Referendum of 2014, when the Scots were asked whether they wanted to be an independent country or not, in which case a “yes” or a “no” answer is fit for purpose.

Indeed, a “yes” or “no” answer makes for easy analysis later when the consultation process is over. But what will be the quality of the analysis of the survey outcomes that can possibly come out of such a blunt approach?

Don’t Make Things Complicated

Life as a GP used to be simple. But it’s not so simple anymore. And this hobbit is not even talking about Healthier SG and the NEHR. We are just talking about signing up as a member of the Royal College of GP in the UK.

As expected, you need to fill up a form when you apply to be a member. The link to the form is as given below at the end of this post. You are asked to declare your gender identity and you are given the following choices:

Prefer Not To Say
Man
Woman
Transgender
Genderqueer
Agender
Genderless
Non-Binary
Cis Man
Cis Woman
Trans Man
Trans Woman
Third Gender
Two-Spirit
Bigender
Genderfluid

The form does not say you have to choose only one out of the above choices. Presumably you can pick more than one?

This hobbit is not making this up. I think when society gets this complicated, it is time to leave where you are and live out your days in a tiny hamlet or a remote island. So that you can figure out what is the difference between “Agender”, “Genderless” and Non-Binary”. Seriously, perhaps the RCGP can conduct some very meaningful CME on what each of the above options mean. I hope our CFPS doesn’t follow RCGP’s footsteps in making the world a more complicated place than it already is.

Thankfully, life in Singapore is much simpler. Most of the time. All the folks need to know is whether your clinic has signed up as a Healthier SG clinic or not and whether your clinic system is NEHR-ready or not.

Speaking of NEHR, the recent Distributed Denial-of-Service (DDoS) cyberattack on Synapxe (formerly IHIS) resulted in public healthcare institutions websites being down for seven to eight hours on 1 Nov 23.

This is a very unfortunate event which has been summarised by The Straits Times’ Senior Health Correspondent Ms Salma Khalik on 2 November as “Having the websites of nationwide public healthcare institutions go down may not be severe, as critical services were not affected. But people’s trust in the efficiency and high level of security of government IT platforms may be shaken as a result. That is the real fallout”.

Synapxe issued a press release on 3 November 23 stating that “Patient data and the internal networks remained accessible and unaffected. Patient care was not compromised”. However it did also state that “On 1 November 2023, an abnormal surge in network traffic was detected at 9.15am. This surge circumvented the blocking service, and overwhelmed Synapxe’s firewall behind the blocks. This triggered the firewall to filter out the traffic, and all the websites and internet-reliant services became inaccessible”.

The press release further noted that “DDoS attacks cannot be prevented, and the defences against DDoS attacks will have to constantly evolve to keep up with advancements”.

The public sector Electronic Medical Record (EMR) and NEHR systems were unaffected and hence “patient care was not compromised”. This is because since the Singhealth Cyberattack of 2018, the EMR and Health Information Systems (HIS) in public healthcare institutions have been delinked from the Internet. The government and the public healthcare clusters have the enormous resources to implement this. Today, there are separate computers for clusters’ clinical staff to access the internet for research and other purposes that are totally delinked from the EMR or HIS systems. It would be beyond the resources of private sector clinics, whether GP or specialist, to run a Clinic Management System (CMS) that is not internet-based or -linked.

In fact, most, if not all of the HSG/NEHR-compliant CMS being offered on the market are cloud-based and use existing internet browser interfaces. Gone are also the days when the clinic database is stored on a hard disk located inside the clinic.

If “DDoS attacks cannot be prevented” and somehow the “blocking service” could be “circumvented” by a surge, then how would private sector clinics continue working in the event of a determined and massive DDoS attack if the attack targets the private sector? Indeed, while patient care in the public sector wasn’t affected, many GPs will tell you that the Patient Risk Profile Portal (PRPP) could not be accessed on 1 Nov and hence vaccination information could not be submitted on that day. You can still submit this on another day I suppose, but one cannot say patient care was entirely unaffected in the private sector, as was the case with the public sector.

Could a doomsday situation happen when all private sector clinics’ CMS are knocked out by a Mother of All DDoS Attacks on the several IT systems that can link up with the NEHR and have been pre-approved as HSG-compliant? And if so, what happens? What is the backup plan to keep private sector clinics running if this happens on a nationwide scale? Are we prepared for such a scenario? On another note, do private hospitals also face similar risks with their EMR and HIS systems in the context of DDoS attacks?

This hobbit is no IT expert and these are tough questions that obviously this hobbit does not have the answers to. But he certainly hopes some folks in MOH and Synapxe do.

Since we are also on the subject matter of forms and making things complicated, let us move on to talk about a local example of a misguided use (or rather, denial of use) of forms. A private sector doctor who wanted to opt out of the NEHR told this hobbit that he has found out the only way to do so is to obtain the opt-out forms from public healthcare institutions (link below). Which is kind of a strange arrangement. This probably has come out of some super-bright, savant-level mind who has deluded/convinced himself/herself into believing that ONLY the public sector can be trusted with the simple task of ensuring that the person who wants to opt out of NEHR is provided with the relevant information to make an informed decision.

The private sector can be allowed to do organ transplants, offer proton beam therapy and separate conjoint twins but cannot be entrusted/empowered to tell a person what he needs to know in order that he can make an informed decision whether to stay in or opt-out of NEHR? The private GP can be empowered to be MOH’s main partners in delivering HSG but cannot be entrusted/empowered to tell the patient what he needs to know about the consequences of opting out of NEHR? If a person opts out of NEHR, he is automatically disqualified from enrolling onto HSG. No enrolees, no HSG, no business for the GP. If there is one thing consistent about private sector GPs – they don’t do stuff that is bad for business. Enrolling patients for HSG is good for business, which is why we see healthy enrolment numbers now.

It makes this “opt-out of NEHR form” sound like a weapon of mass destruction that has to be kept in a sealed bunker or vault that can withstand a nuclear attack and is guarded round-the-clock by commandoes.

Seriously, in Singapore, you can obtain birth or death certificates, submit your tax returns just by simply logging on to government websites using SingPass on your handphone but you have to visit a public healthcare institution in person just to obtain this mystical form so as to opt-out of the NEHR? What is more important in life than birth and death and taxes??

The genius who came up with this policy really needs to think again and do better. Why make life so unnecessarily complicated?

RCGP online application form:

https://www.rcgp.org.uk/getmedia/d194bd03-14d2-4bfb-b41f-9d2588c66393/RCGP-UK-membership-application-form-2018.pdf

Opting out of NEHR:

https://www.synapxe.sg/healthtech/national-programmes/national-electronic-health-record-nehr/faq

Beware the Middlemen

The Fattest Cats

On 9 October, The Economist published an article, “Who profits most from America’s baffling healthcare system”. The sub-heading read: “Hint: it isn’t big pharma”.

The article began by saying that on 4 October, 75,000 employees of Kaiser Permanente went on a 3-day strike. Kaiser Permanente is a name that many public sector senior management in Singapore may be familiar with. It was the go-to place for study trips and was touted as a model of care that we could learn from, even before the idea of population health became popular or anyone thought about Healthier SG (HSG). The article also noted that in April this year, Kaiser had acquired Pennsylvania-based Geisinger Health, yet another name that many public sector leaders in Singapore may be familiar with.

The Economist article went on to state “Pharmaceutical firms and hospitals attract much of public ire for the inflated costs. Much less attention is paid to a small number of middlemen who extract far bigger rents from the system’s complexity. Over the past decade these firms have quietly increased their presence in America’s vast healthcare industry. They do not make drugs and have not, until recently treated patients. They are the intermediaries – insurers, chemists, drug distributors and pharmacy-benefit managers (PBMs) – sitting between patients and their treatments. In 2022, the combined revenue of the nine biggest middlemen – call them big health – equated to nearly 45% of America’s healthcare bill, up from 25% in 2013”.

It seemed rather ironic to this hobbit that the biggest and fattest cats in America healthcare now are neither the folks that made the drugs and equipment that patients need, nor the hospitals or folks that actually gave the care. The fattest cats are now (drumroll please), “the middlemen”.

Thank goodness there is little chance of that happening in Singapore. For primary care, with the advent of HSG, the third-party administrators (TPA) who sat between the GPs and the patient are largely redundant and will be replaced by the one TPA to rule them all – the government. There is a lot of pain and angst with HSG, especially when it comes to the IT part (such as syncing with NEHR) and worries over drug pricing, but at least the government pays on time and pays adequately when compared to many TPAs. This hobbit does not think that the government will ever become the biggest or fattest cats making money in the primary care sector, but it needs to be said that bureaucracy does have a tendency to becoming fat and unwieldy, although not in a feline or profitable sense.

The government also makes up the lion’s share of the hospital sector, with some 80% of all acute hospital beds, so the middlemen can’t really sink their teeth there too. But when you look closer at the private hospital and specialist sector, the signs are there that we may be walking down the American path.

We need to just look at the profits insurance companies make in Singapore, as well as the increasing amount of money going to management salaries and bonuses as well as the commissions paid to insurance agents and you can see where the proverbial train may be heading.

On top of this, on the provider side, be they at the hospitals or doctors’ end, more and more resources are being spent on insurance-related matters, which include:

obtaining pre-authorisation in a timely manner
appealing against denial of pre-authorisation
filing of claims after service and care has been provided
handling denial of claims
processing of requests for discounts from insurance companies

It used to be that hospital and clinic staff took on these insurance-related tasks in addition to the regular responsibilities they had. But no more. Now it is not uncommon for a staff nurse to tell the specialist upfront that his/her responsibilities do NOT include dealing with insurance-related matters if he/she is to work for the specialist The consequence is that the doctor now has to hire another staff just to deal with insurance-related matters.

And we wonder why healthcare spending is going up. Soon, we will end up like the USA, where folks on both sides hire legions of staff to frustrate one another in the private hospital sector.

On 10 October 2023, MOH announced that through its Claims Management Office (CMO), it was issuing Claims Rules. Medishield Life (MSL) claims deemed potentially unreasonable are now subject to adjudication by an independent panel appointed by the MSL Council.

“If the claim is found to be inappropriate, the medical institution and/or doctor will be asked to rectify and refund the inappropriate portions of the claims and not recover the monies from the patient”….”MOH is stepping up our monitoring of inappropriate claims and will not hesitate to act against the small minority of doctors who are found to be repeatedly non-compliant despite warnings. Repeat offenders may have their accreditation status under the MSL and Medisave schemes suspended or revoked”. (MOH press release dated 10 Oct 2023).

All well and good. In a population of thousands of specialists, there will be a few who don’t play by the rules or reasonableness and they have to be managed actively, if not managed out.

The press release also stated that speciality-specific claims rules have been and will be developed. These rules are based on “evidence-based literature, prevailing clinical practice and cost-effective guidelines”. It was also stated in the same release that the first set of claims rules for gastrointestinal endoscopy was released in August 2022. Two more sets of claims rules were released in September 2023 for ENT and cardiology.

All these efforts are to ostensibly primary protect the interests of the patients and to keep MSL financially sustainable in the long-term. This hobbit has nothing against supporting practices that are “cost-effective” and “evidence-based”.

However, what about the other side of the equation with the insurance companies who sell Integrated Shield Plans (IPs)? IP premiums and claims sit on MSL premiums and claims. Who ensures IP providers are “cost-effective” and “evidence-based”?

Cost-effective?

Does anyone in Singapore set a minimum limit on how much of the premiums collected are spent actually on paying for healthcare? Or IPs can spend as they like on management costs and commissions and also on amassing profits?

USA’s Affordable Care Act or “Obamacare” states that 80 to 85% of premiums collected should be spent on healthcare costs. But in Singapore, between 2016 and 2019, the corresponding figure is only 75%, with the rate of rise for management costs and commissions being faster than claims (i.e. payment for claims for healthcare provided) between 2016 and 2019. Can such a state of affairs support the aim of being “cost-effective”?

Evidence-based?

As for “evidence-based”, what is the evidence for some IP providers selecting certain doctors to be empanelled over others?

It was stated in the SMA’s Position Paper on Troubled IPs (May 2021) that “The Health Insurance Task Force (HITF) Report stated ‘To enhance and ensure transparency of the arrangement (e.g. disclosures on the healthcare provider selection process)’, that is, IP insurers should state the criteria used to select doctors to be on a panel. The fact remains that no doctor or policyholder knows what the actual quantitative or qualitative measures that make up these secret criteria are”.

This was the state of affairs in 2021 and remains so today.

In other words, the exercise of selecting doctors for empaneling is a completely opaque exercise with no accountability to regulators, policyholders and of course the hapless healthcare providers who do not get selected.

But this is just the tip of the iceberg about evidence-based. What is far worse is the exclusion clauses and denial of claims that are inflicted on policyholders that are not evidence-based. Policyholders are not healthcare professionals armed with the knowledge to understand and appreciate the true impact of these clauses up-front. Only years later, when they need to make claims for conditions that are excluded, they then experience dismay if not devastation when they receive notice that their claim has been denied. Some IP providers also indulge in semantics to get away with paying for claims. The examples of non-evidence-based exclusion clauses and denial of claims are many. Some of the commonest or egregious ones include:

A history of breast cysts leading to an exclusion clause for all breast conditions, including breast cancer. (The evidence is that breast cysts do not become cancerous)
A history of piles or anal abscess that leads to an exclusion for all colorectal conditions. Some insurance companies even state that all gastrointestinal conditions are excluded! What has an anal abscess got to do with stomach or colorectal cancer?
A major branch of the Left Anterior Descending Artery (LAD: a major coronary artery) is the diagonal artery. A claim for a stent inserted for a almost completely occluded diagonal artery is denied on the grounds that the diagonal artery is NOT the LAD, it is a branch. (That is like saying your car insurance policy only covers you for the main Singapore island but not Sentosa). Well for the record, a heart attack involving the diagonal artery can lead to death and disability too.

No Two-way Street

This hobbit can go on and on. But at the end of the day, one of the major conclusions from this exercise that this hobbit has arrived at is that while healthcare providers, such as doctors, are compelled to practise in a cost-effective and evidence-based way (and rightly so) when MSL is involved, there is no such requirement for IP providers although IP premiums and claims sit on the MSL framework. IP providers just need to be seen to be financially sustainable to their regulator and when things get rough for them, they can resort to that one usual and effective trick they have up their sleeves: – the ability to get away with squeezing healthcare providers and policyholders ever harder by raising the spectre of premiums increasing for policyholders if they are not allowed to get their way. (I gotta admit, this is a beautiful strategy that works like a charm, something almost akin to a kid throwing tantrums when he realises that he always gets what he wants by doing so)

But one should perhaps wonder: for how long more can this lop-sided state of affairs continue?

And while we may reassure ourselves that the private hospital and specialist sectors constitute a small part of healthcare delivered in this country, the fact that about 70% of Singapore residents have bought an IP policy means that there is great potential for this to mushroom into a big problem later on.

Previous posts on the subject of IP:

https://wordpress.com/post/hobbitsma.blog/914

https://wordpress.com/post/hobbitsma.blog/865

https://wordpress.com/post/hobbitsma.blog/773

https://wordpress.com/post/hobbitsma.blog/757

https://wordpress.com/post/hobbitsma.blog/749

https://wordpress.com/post/hobbitsma.blog/731

https://wordpress.com/post/hobbitsma.blog/709

https://wordpress.com/post/hobbitsma.blog/664

Things We Should Really Be Teaching Our Medical Students Today

It was announced recently that a new common curriculum for incoming NUS dentistry, medicine, nursing and pharmacy students will be introduced (The Straits Times, 16 Aug 23)¹.

The Straits Times reported that the aim of the common curriculum covering five modules was to “imbue in students a greater awareness of social issues and their impact on health, as well as cultivate teamwork, communication skills and digital literacy. Students will also learn about working and communicating in multidisciplinary teams, as well as the legal and ethical principles underpinning the practice and delivery of health services”.

“The curriculum combines healthcare, data science, artificial intelligence and information technology to equip students in using data effectively to improve patient outcomes and information flow across healthcare IT systems”

The above stated purposes are indeed laudable. Let’s hope they can achieve what they set out to do. But why stop here? As this hobbit looks back on his medical education received from the local medical school as well as what is happening around him now, he cannot but think that there were some things that the School can do to improve things further.

Here are a few suggestions as to how the curriculum can be improved even more with the introduction of a few more fresh modules….

The IHIS/Synapxe Module

On 27 July 23, the organisation called IHIS (IHIS – Integrated Health Information Systems) was renamed, or to be exact, given “a new identity”, as Synapxe. In his speech on that day, Minister for Health said that IHIS/Synapxe “is a 4000 strong organisation today”².

IHIS has been in existence since 2008. It is therefore NOT a new organisation, and it is a big organisation that is responsible for providing IT support to the public healthcare system and rolling out the NEHR to the private sector as well. Its influence permeates every aspect of care in the public sector, which consists of the three healthcare clusters that contain 10 restructured hospitals, 23 polyclinics and as well as community hospitals and national specialty centres.

From the many conversations this hobbit has had with quite a few young doctors, they don’t seem to be aware that IHIS/Synapxe exists even though it has been around for 15 years and what it is actually supposed to do. All these young doctors know is that they have to grapple with an EMR that is so important that the restructured hospitals and polyclinics are almost paralysed when the system is down. Even specialists in the public sector don’t know what this organisation is supposed to do. So it is important that we educate our medical students about Synapxe comprehensively and how big and important it is.

To put things in perspective, there are some 4000 people working in Synapxe. From the SMC 2021 Annual Report (the latest available on the SMC website) there were 4,368 specialists employed in the public sector. That means for every public sector specialist providing care to our patients, there is also one Synapxe employee working behind the scenes.

To put things in even bolder relief, according to the 2022 Allied Health Professionals Council Annual Report, there were 1485 diagnostic radiographers, 1003 physiotherapists, 154 radiation therapists, 249 speech and language therapists and 520 occupational therapists working in our restructured hospitals, national specialty centres and polyclinics (i.e. the three public healthcare clusters) in 2022. This makes a grand total of 3411 Allied Health professionals from these five groups employed to deliver important care in the three public healthcare clusters, but this number is still significantly less than the number of people employed by Synapxe! Come to think of it, our medical students should really learn how to work with Synapxe employees since there are more of them than there are allied health professionals.

Medical Law Module: Lawful, Unlawful and Lawless

The aforesaid Straits Times report stated that medical students will learn about the legal and ethical principles underpinning the practice and delivery of healthcare services. Presumably, they will learn about legislation such as the Medical Registration Act, Medicines Act, Healthcare Services Act etc as well as the SMC Ethical Code and Ethical Guidelines (ECEG). This is excellent because this hobbit didn’t think he was taught any of these laws while in medical school. We need to teach medics more than the science and art of medicine, they need to know what is lawful and ethical and what is unlawful and unethical.

But this is also not enough. We need to teach them about what is lawless too. There are organisations such as third-party administrators (TPAs), insurance companies, such as Integrated Shield Plan (IP) providers that can influence, organise and even direct healthcare provision but at the same time do not come under any law that regulates how they do so and ensures that they do not undermine the practice of ethical or lawful clinical medicine.

For example, IP providers are regulated to ensure they are sound financially, but there is no law that can stop or punish an IP provider from suddenly stopping coverage for something as fundamental as a colonoscope, or for denying coverage to a policyholder for colon cancer because he had bleeding from piles 10 years ago. These are the lawless aspects of our healthcare environment that every medical student should learn early – the sordid facts of life that a doctor will face sooner or later as a doctor.

Patient Confidentiality and Privacy Module

We always talk about patient confidentiality in our medical ethics lessons and when teaching our students and young doctors about the dos and don’ts when accessing and using EMR and NEHR. But we never talk about patient privacy rights. In fact, there is nothing on patient privacy and their privacy rights in official documents that this hobbit is aware of. Hence, there are also no established standards to articulate what is a patient’s right to privacy.

Which is kind of incredible for a first-world country such as ours.

Every ethicist worth his salt will tell you that it is almost impossible to define a patient’s confidentiality rights well before we have some clear idea about what are the patient’s privacy rights. How does one define a patient’s confidentiality rights when there are no privacy rights standards and therefore he has no established and expressed rights to information privacy in healthcare? Confidentiality is built on the foundation of privacy. But somehow, we have been able to talk about ensuring patient confidentiality by suspending it in thin air without anchoring it to the principle of privacy.

This hobbit wonders how much longer can we continue to ignore teaching the principles of patient privacy and privacy rights to our medical students (and for that matter, to all healthcare professionals as well) and just continue to harp on only ensuring patient confidentiality. Its like trying to teach medical students histopathology without first getting the student to learn histology and anatomy

The Expectation Module

We really need to educate our medical students that they have to moderate their expectations of the good material life that they think they will have. This should be done right after matriculation.

Here are the numbers. As of 2021, there were 16,044 doctors licensed to practise medicine in Singapore, of which 6,431 were specialists. The number of doctors increased by 776 over the previous year.

Twenty years ago, in 2001 (SMC Annual Report 2001), there were 5,922 doctors in Singapore, of which 1930 were specialists. The number of doctors increased by 345 from 2000.

Over 20 years (2001 to 2021), the number of doctors increased by 2.7 times and the number of specialists increased by 3.33 times.

The doctor-population ratio in 2001 was 1: 678. In 2021, the ratio had fallen to 1:369³.

Our medical profession is growing a lot faster than the general population. The population in Singapore hasn’t increased by 2.7 times in 20 years, even though they have aged and should consume more health care per capita. But the fact remains that doctors are fast losing any rarity effect that they used to enjoy.

Unfortunately, the number of freehold housing properties and Certificate of Entitlement (COEs) have not increased as quickly as the number of doctors here. In fact, the vehicular population is now at almost zero-growth. The end result is that most doctors of the future will not be able to enjoy the so-called finer things in life that their predecessors did: large cars, freehold condominiums and landed properties, golf club memberships etc.

Going forward, the median income of doctors will move more and more towards the median income of the general population. The end result is that things that can only be afforded by say, the top 5 to 15% of income earners will be out of reach of many doctors unless they have parental assistance to purchase these things or they are at the top of their game in terms of earnings. This would include private housing and it won’t be long before we see large segments of the profession staying in HDB flats. Hopefully, doctors in the future should still be able to afford HDB Prime and Plus HDB flats.

Our medical students need to know that given the numbers, this scenario is all but a certainty due to the inevitability of statistics. And we should really tell them the whole truth as early as possible. Of course, there will be still be a very few within each cohort that can end up in big houses and own very expensive sports cars, but these will get rarer and rarer as long as the doctor population is growing at a much faster rate than the general population.

Don’t get this hobbit wrong, there is nothing wrong with staying in HDB flats like 80 to 85% of the population. This hobbit grew up in a HDB-shire and thoroughly enjoyed his 30 years living there. He may yet return to one when he gets older to enjoy the amenities and subsidies that HDB dwellers enjoy. But he is worried that many young doctors and medical students may set out with material expectations which are misaligned with the eventual reality that many of them will experience.

¹https://www.straitstimes.com/singapore/new-common-curriculum-for-incoming-nus-dentistry-medicine-nursing-and-pharmacy-students

²https://www.moh.gov.sg/news-highlights/details/speech-by-mr-ong-ye-kung-minister-for-health-at-the-integrated-health-information-systems-15th-anniversary-and-launch-of-new-identity-27-july-2023-9-40am-at-singapore-expo-hall-3

³https://www.moh.gov.sg/resources-statistics/singapore-health-facts/health-manpower

Going Private 2023

Recently I received in my email an EDM about a seminar organised by the SMA, “Taking the Plunge – Going Into Private Practice” which will be held on 26 Aug 2023. That set me on thinking of what it means to go into private practice in the post-Covid world of 2023.

Specialists

I was just chatting with some young surgeons the other day and was astonished to find out that apparently, at least 12 orthopaedic surgeons have left for the private sector in the first six months of 2023! From anecdotal evidence, this exodus is not just limited to orthopaedics but extends to other specialties as well.

There are several interesting new trends in the current round of private sector entrants in the specialist sector. For one, very senior people, including folks in their fifties are leaving when in the past, it was those in their late thirties and early forties who usually quit. You hardly if ever hear of a fifty-something year-old leaving. Secondly, folks now don’t leave one at a time from one department. They often leave in twos and threes.

This sudden surge in folks leaving for private can be another unwanted aftermath of the Covid-19 Pandemic. Few people dared to leave for private in the Covid years of 2020 to 2022, and so now there is a rebound, as in the number of people who normally would have left for private over three years have now been compressed into a one-year period.

Of course, when folks go private, they have to go somewhere in private. And this somewhere has translated into sky-high prices and rentals in popular private hospitals. Clinic space in a big freehold-lease private hospital have reached $12,000 to $13,000 per square foot. In another large hospital in town where only about 60 years remain of its 99-year lease, prices are going at about $9000 per square foot. Rentals in both these hospitals are now frequently in the $23 to $25 per square foot range.

All this may suggest that the environment is hunky-dory outside in the private sector but this cannot be further from the truth. Firstly, severe manpower constraints, especially in nursing, have meant that private hospitals often cannot be operating at full capacity. Wards and especially operating theatres are not infrequently closed. Unless absolutely urgent or it is an emergency, one frequently cannot find a bed to admit a patient. OT slots are even harder to find and many surgeons have told this hobbit that they consider themselves very lucky if they can find an elective OT slot within three weeks for their patients. So there are some serious capacity issues that limits one’s earnings in the private sector, even though demand for their services may remain high from both local patients with integrated shield plans (IPs) and overseas patients.

Which brings us to the next topic of the day, IPs. IP reimbursement remain parsimonious and clustered at the lower half of the MOH Fee Benchmarks. MOH has just released the second edition of the Benchmarks last month. It remains to be seen if the IP providers will revise their reimbursements upwards to keep pace with the newly-revised Benchmarks.

Another perhaps even more discouraging trend we are seeing is that IP providers are seemingly very reluctant to admit new specialists to their preferred panel of providers. The common lament of new private sector specialists we hear is that they find it extremely difficult to get into IP panels. Older and more established doctors may belong to four or five panels but newer ones consider themselves lucky to be in more than one panel.

Therefore, there is possibly a “dual ossification” happening here. The first ossification is that of reimbursement rates as IP providers drag their feet to pay more to be in line with the new benchmarks, resulting in specialists’ earnings per patient or per procedure unlikely to increase significantly anytime soon (if ever). The second ossification is of preferred provider panels where these panels are largely frozen in time with very limited number of new entrants resulting in new specialists being shut out. Frankly, this hobbit thinks that regulators should state some standards for preferred panels. The size of panels should be in line with the number of policyholders an IP provider has. For example, an IP provider with 1M policyholders should have 2x the number of preferred providers that another IP provider with only 500,000 policyholders has. And it should be stated that no matter how small the pool of policyholders are, every IP provider should have at least have a bare minimum X number of preferred providers.

These two phenomena are actually known to the specialists who are contemplating going private.

If you think about it, a specialist going private now have to face up to a quintuple-whammy of:

Reimbursement rates by IPs not increasing fast enough or at all
Getting acceptance into an IP preferred provider panel is getting more and more difficult
Rapidly rising prices for purchase or rental or clinic space/medical suites
Workload constraints due to healthcare facility capacity limits and/or manpower shortage
Increased competition among increasing number of private sector specialists

Yet, they are still going private. Why is this so?

This hobbit thinks that this may have to do with expectations:- Things are bad, but if you are convinced that if things are not going to get better, then even if things are bad now, it is still better to leave sooner rather than later.

Will workload and waiting times in restructured hospitals get better? Will the EMR get easier to use? In a mistake-intolerant environment, will the trend to get consultants to do more and more work that were previously done by medical officers and residents reverse itself? Will private hospital clinic space get cheaper when no one knows when will land for a new private hospital be made available?

If the answer to the above questions is a consistent “No”, then people will still leave. In other words, whether the going is good or not is not as important as whether the going is going to get worse; i.e. staying on is not tenable.

A simple example of the importance of expectation is that of private hospital and private hospital clinic or medical suite space. The last private hospital land was released 15 years ago, around 2008. No one knows when the next piece of land will be released for building a private hospital. This is exacerbated by the precedent of sky high prices paid for the last private hospital land that was put up for sale. This leads to the current situation where specialists will pay an arm and an leg to secure medical suite space. The uncertainty of when new hospital co-located medical suites will be made available in the market leads to the persistent expectation that demand will outstrip supply which in turn feeds higher prices for such assets. This can been seen by the fact that 15 years after the last release of private hospital land here, the 2008 price for that piece of land is probably still the most expensive hospital land on this planet (on a per square foot built-up area basis) today!

Things would be different if the relevant authorities are publicly committed to releasing land for say, a 300-bed private hospital every 10 or 12 years. Specialists and hospital operators will then plan accordingly with that certainty in mind, instead of pushing up prices for land and medical suite which in turn leads to more and more expensive private healthcare.

Family Physicians (FPs)

On another note, let’s turn our attention to FPs. Healthier SG has been largely welcomed by the current generation of FPs. But among younger doctors still in the public sector, many are also thinking of going private as well; either to set up their own GP clinics or groups, or to join an existing group. The reasoning is quite simple – Enrolment under Healthier SG is truly underway now. However, in a few years, it is expected that everyone will be enrolled with a FP under Healthier SG. In fact, this is one of the stated aims of Healthier SG – Everyone should have a FP. Will there be many people who still need to be enrolled with a FP in five years’ time? The only folks that may require enrolling in the future may be new PRs and citizens, who did not enjoy Healthier SG benefits when they were previously not residents in Singapore.

In other words, the Healthier SG pie for new FPs will be getting smaller rapidly as the pool of people without Healthier SG shrinks. It is also likely that future generations of Singaporeans will sign up with the same Healthier SG providers that their parents have enrolled with. Or rather, they may have already been signed up when they were kids, and they will likely continue with the same providers when they grow up. Not unlike why this old coot is still using the same POSB bank account that he has had since Primary 1 when some nice bank officer came and signed up practically everyone in the class.

In business school, they call this “first mover advantage”. Indeed, the first mover will almost always have an advantage. But it cannot be to the point that future generations of FPs will be existentially disadvantaged. Young FPs and FPs- to-be now in the public sector are right to worry about this and policymakers could pay attention to this so as to make Healthier SG attractive for future generations of FPs.

Follow The Money Trail

Doctors In The Crosshairs

On 2 May 23, a certain financial advisor by the name of Francis How Chee Kuen wrote to The Straits Time Forum stating, “Many years ago, IPs (Integrated Shield Plans) were more affordable, but doctors have been charging high prices for their services, leading to insurers increasing their premiums. Premiums will continue to rise if doctors overcharge or mark up prices”. The letter was titled, “Holistic approach needed to tackle cancer care costs”.

He gave an example of one his clients having to pay $3000 out of $5000 a month when the new Cancer Drug List (CDL) is enforced in February 2024. He ends off the letter by saying “In our battle to contain cancer treatment costs, we can’t just be targeting the insurers and capping coverage. Instead, the whole issue needs to be addressed holistically and from all angles”.

“Holistic” is a very politically-correct word nowadays, but using such a big word doesn’t make one’s argument any more complete and persuasive than making a monkey wear a skirt or a pair of pants and calling it human.

What this Mr How is actually saying is, doctors overcharging and making mark-ups to their services is the root of the problem. He also said in the same letter that pharmaceutical companies should be subject to scrutiny as well. And the system should not be just targeting insurers and insurance coverage in an attempt to contain costs.

Just Being Human

This hobbit’s answer to Mr How is quite simple – Everybody wants to make a good living and put bread on the table. These includes doctors, employees of pharmaceutical companies such as pharma reps and insurance agents (now called financial advisors).

So let’s cut to the chase. Everyone wants to defend or maintain if not increase the money they are making. Because doctors, insurance companies and their financial advisors as well as pharmaceutical companies and their sales representatives are humans and no one wants to suffer a loss of earnings. This is true for a communist society and even truer for a market and capitalist economy like Singapore. It is true whether you are making $4,000 a month or $4,000 a day. Nobody wants to then earn $3,000 a month when he was earning $4,000 a month or $3,000 a day when he is used to earning $4,000 a day. It’s human nature.

Let’s start with the insurance industry itself and their financial advisors. In the four years leading up to the Pandemic (2016-2019), the growth rate in management costs and commissions (paid to insurance agents and financial advisors) was actually faster than payments made to the healthcare providers. This could be easily inferred from a study made by the Singapore Actuarial Society. (https://actuaries.org.sg/sites/default/files/2021-01/SASResponseMSHLReview2020FINAL.pdf) (Table A4 of Medishield Life 2020 Review: SAS Comments). From this data, we can reasonably conclude that insurance companies and financial advisors are not exactly doing this for charity. They also want to make money, and probably as much as legally possible.

Now, let’s turn to the doctors. According to the 2021 SMC Annual Report, there are about 50 medical oncologists in the private sector. These 50 will prescribe the bulk of cancer drugs in the private sector, although there are also many other specialists who prescribe cancer drugs.

So it is probably expedient to focus on these 50 specialists and say they overcharge or have mark-ups and use ineffective cancer drugs. Especially if many of them are big earners. Are all 50 completely blameless? Probably not. But that’s not the point. By the way, no medical oncologist has actually been convicted of overcharging by SMC or in the courts.

Moreover, Mr Frances How used the case of his patient from a restructured hospital, which to this hobbit, makes no sense because as everyone knows, a doctor in a restructured hospital has no input on decisions of drug price. He does the work and the hospital decides on the prices based on costs. Unless he is thinking that even restructured hospitals unreasonably mark-up their services.

Which means that he is either illogical, uninformed or he must think the problem lies elsewhere – i.e. the pharmaceutical companies. Well, pharmaceutical companies are for-profit companies that will expectedly maximise their profit. Why do you want to sell a cancer drug for $3,000 when you can sell it for $5,000? Especially in this case, your customers have paid insurance premiums that will fund most if not all of the $5,000.

So, there is no use in pointing fingers at doctors or pharmaceutical companies. Everybody is behaving as expected. It is more fruitful to, as the saying goes, “follow the money trail” by revisiting why people pay for IPs, especially pertaining to IP cancer care coverage.

We Should Be Anti-social

Since the introduction of the CDL, the IP providers have come up with riders for coverage of cancer drugs that the CDL either does not cover or where the CDL-based reimbursement caps are perceived to be insufficient to cover the actual cost of treatment. These riders are to be paid for in cash. There is a concern in some circles that if too many people buy these riders, the issue of expensive cancer drugs gets “socialised” to a huge segment of society, thereby undermining the efforts of introducing the CDL and claims caps etc to control costs.

In an article published in The Straits Times on 24 April 23, it was reported that the Minister for Health said “now that riders provide higher cancer coverage, their premiums will need to be priced higher. If this results in fewer people buying riders, “I think we have addressed the problem”. But if riders continue to be in high demand, notwithstanding high premiums, that would be a problem and MOH and the MAS are prepared to step in.”

This reporting by Ms Salma Khalik is a relief to this hobbit because it shows that MAS, the body empowered by law to directly regulate insurance companies (not MOH) is now finally prepared to step in on matters that are medical-related. This hobbit does not remember MAS stepping in to regulate IP providers in any meaningful way other than for non-medical issues and have appeared to be content to let MOH to do the heavy lifting in this area. Perhaps they have finally crossed over to a higher plane of enlightenment, which is good.

However, this hobbit thinks many people will buy these riders, which means the problem is likely to persist. We will look at this issue from both the demand and supply sides.

Demand Side

First, on the demand side, there will be a healthy interest in buying these riders:- The whole purpose of buying IP is to finance a person’s medical expenses in the private patient classes (A1 or B1 class) of a restructured hospital or in a private sector hospital when he gets a catastrophic disease. Cancer is an example of a catastrophic medical event and more than a quarter of Singaporeans will die from it and more than 40% will get it in their lifetime, i.e. getting a cancer is NOT a remote and rare event.

So it usually makes little sense if I have an IP but it is perceived that the IP is insufficient to fund private oncology care (Restructured B1 or A1 or private hospital patient). If I have an IP now I would be inclined to buy the rider, just for peace of mind and the high probability that I will need and use the rider, unless I find the rider really quite unaffordable.

There are also secondary factors that contribute to uncertainty and hence create more demand for riders (and for peace of mind):

The current messaging is not good for IPs that are sold without a rider. The new limit of paying only for the most expensive cancer drug (should more than one be used at the same time) gives the impression that a IP policyholder sans cancer rider has to pay out of pocket for the remaining drugs, should the policyholder need more than one drug, even though the reimbursement limit is actually quite generous.

The monthly limit for CDL claims can be seen to be archaic when chemotherapy cycles are now commonly 6 weeks along, leading to unutilised claim limits in some months and bursting the limits in other months, in which case the policyholder may have to top-up the difference in these other months.

Supply Side

On the supply side, there are two structural problems with the current IP environment that leads to the situation where the IP sector is unable to effectively complement Medishield Life (MSL). As this hobbit will show you, it can even undermine the policy intent of MSL. By design, the IP policy sits on top of MSL so the two are entwined like Siamese twins. If one of the twins are unwell, the other feels it too.

Problem #1: MSL Is For Life While IP Is An Annual Plan

Being an annual plan means the IP sector is in permanent dissonance with MSL. This dissonance is not just structural, but strategic, financial and behavioural as well. While MSL looks at the lifetime needs of its policyholders, IP executives and financial advisors are incentivised to think mainly short-term.

The executives who run IP providers are rewarded mainly for the IP’s financial performance on a year-by-year-basis. Financial advisors’ commissions are also heavily front-loaded and diminish very significantly after a policy is sold after say, about 2 to 3 years.

Problem #2: Too Many IP Providers

According to the financial advice website Singsaver, there are close to 3 million IP policyholders. This is about right if you consider the oft-quoted claim that close to 70% of Singapore residents (i.e. citizens and PRs) have bought IPs. Most insurance experts will tell you that 3M is a rather small pool to be shared among seven providers. It is quite unlikely that market penetration will rise much beyond 70% because the poorest 30% will probably find IP premiums very unaffordable.

To sustain seven IP providers, each IP provider will have to look for new customers to sign up. These new customers can come from either other IPs’ customer base or those that have not signed up with any IP, especially young adults entering the workforce and earning a decent salary. In any case, because of the relatively small pool of addressable IP customers, there is intense competition for new customers among all IP providers so that the IP providers can maintain or grow their market share.

One of the most important determinants of selecting an IP is of course, price. IP providers have to compete on price. But an interesting facet of the IP industry is that price competition is only critical when a person decides to buy an IP and when he renews his IP while he is still young with no pre-existing diseases. Once an IP policyholder has pre-existing diseases he is basically stuck with the same IP provider if he wants to continue having IP coverage for these diseases. He then effectively has only two choices – stay on and pay the increased premiums with the same IP provider or drop out of the market completely.

In other words, once pre-existing diseases kick in, IP is a very sticky business. Which is why despite some IP providers periodically “cry father, cry mother” about how tough and unsustainable the IP market is, no provider has exited the scene yet. Customer stickiness is a good thing when you are a business owner or operator.

And So….

In summary, this culminates in a situation whereby IP providers compete aggressively for customers up front by slashing prices but do not similarly compete so intensely on “after-sales” service and care quality later. That is why they do not have to respect MOH fee benchmarks in its entirety and also seek not to have more doctors empanelled. When you’re stuck to your IP provider because of pre-existing diseases, you’re stuck real good.

We say that healthcare is ultimately determined by the Golden Triangle of Affordability, Accessibility and Quality.

But in reality, the business model of IP is probably based on maximal affordability up-front and denial or limitation of accessibility later with minimal if any respect for quality, so that profits can be maximised.

This can be largely attributed to the two features described above:

IP policies is an annual plan while MSL is for life, resulting in multi-faceted dissonance between the two and
There are too many IP providers fighting for a small pie up front which paradoxically becomes a sticky business post-sales.

So it is likely that cancer riders will be popular because there are factors on both the demand and supply side that lead to such a fertile milieu for the sale and purchase of these riders.

But what if the revenue from these riders cannot adequately pay for the cancer services incurred later on? As usual, IP providers can raise premiums to a limited extent before policyholders drop out, or restrict accessibility by empanelling as few specialists as possible.

They also have a third trick up their sleeves – which is to blame service providers such as doctors and hospitals for being expensive as well as chastise pharmaceutical companies for excessive mark-ups. And then the cycle may repeat itself – there may be some task force or committee formed that will try to control costs by introducing measures that mainly target healthcare providers while IP providers pay lip service to the recommendations that would have been put up, which is essentially what happened with the HITC’s work (Health Insurance Task Force) a few years ago.

If you think about it carefully, the interests of IP providers and their financial advisors are almost diametrically opposite to that of the government. The government is always about long-term sustainability while the IP sector is short-term. The government doesn’t want too many buying such riders lest the problem gets socialised. The IP sector on the other hand wants more and more people to buy riders, thereby indirectly socialising the issue. This applies to cancer care and can be applied to the whole IP industry as a whole. The money trail starts with the how the IP sector is structured while at the same time there are too many IP providers for a relatively small market. And these lead to other consequences when other stakeholders also want a piece of the pie. The trouble is everyone wants the biggest slice of the biggest pie. And somehow the insurance industry has been the most adept at this game so far, by blaming others and positioning itself as mostly blameless.

But the truth is, everyone is human and human nature prevails. Unless you’re a hobbit.

Previous posts on the subject of IP:

https://wordpress.com/post/hobbitsma.blog/865

https://wordpress.com/post/hobbitsma.blog/773

https://wordpress.com/post/hobbitsma.blog/757

https://wordpress.com/post/hobbitsma.blog/749

https://wordpress.com/post/hobbitsma.blog/731

https://wordpress.com/post/hobbitsma.blog/709

https://wordpress.com/post/hobbitsma.blog/664

In Search Of A Better Life

In the 10 years preceding Covid-19, from 2009 to 2019, MOH Budget tripled from S$3.7B to S$11.7B. In FY2022, MOH Budget peaked at 19.29B, understandably so, due to the demands brought on by fighting the Pandemic. In the current FY2023, the MOH Budget has shrunk a bit to S$16.8B, as we gradually leave the Pandemic behind us. S$16.8B is still 44% more than what was budgeted in the year preceding the Pandemic, in FY2019. That’s still a lot of growth. And if we extrapolate back to 2009, the 2023 MOH budget is 4.5 times larger than what it was in 2009, a mere 14 years ago.

In any other country that this hobbit can think of, if the government pumped so much money so quickly into the system, you would imagine that there would be better morale amongst healthcare workers in the public sector, because ultimately an influx of such magnitude so rapidly would lead to better pay or more staff to share the workload, or both.

However, when this hobbit talks to young doctors, the mood cannot be more different. It is not uncommonly a spirit of resignation and defeat. Many are heading for the exits, or at least seriously contemplating so. And this is very worrisome. Because as this Hobbit grows older, he needs more and more medical care and he would like to treated by doctors who are at the very least satisfied with their professional lives.

There are many reasons given for this unhappiness. Many of these reasons have been discussed in detail before – excessive and unsatisfying paperwork and administrative duties, unreasonable patients and family members who may even abuse them, bosses who are overly demanding, an environment intolerant of mistakes and even underperforming hospital IT systems etc.

As this hobbit approaches the autumn if not winter of his medical life, he has the luxury of looking back. If he had to live his life again, would he have chosen to apply for Medicine in the local university when he turned 19 so long ago? The answer is still a “yes”. I cannot say the same thing for folks turning 19 now in 2023, though. And that’s the difference.

Wanting and choosing a career in medicine involved many things that haven’t changed much since then: it is a calling, hard work, long hours, sacrifice, satisfaction, status etc.

Over the years, there is also another constant that medical school admission interviewees don’t mention much, but many want to be doctors because they were in search of a better life. I’ll be honest here, one of the bigger reasons why this hobbit chose medicine as a career was that he believed this career would lead him to a better life. A career in medicine has largely delivered on this count for me.

In itself, there is nothing wrong with wanting a better life. One can even say it is a human right to want a better life, similar to the pursuit of freedom, happiness and human dignity.

But what is a better life? To answer this question, we must first recognise “better” is a word that has connotations of relativity. Better than what or who?

• Better than your peers who after A levels or junior college went on to choose other careers?
• Better than what your parents managed to provide for you when you were growing up or that you can provide for your children better material comforts than what your parents provided for you?
• Better than what your seniors in the medical profession could achieve?
• Better than what your classmates in medical school could achieve?

Whether we like it or not, most of the time, this “better” involves material possessions and wealth. Of course, there are a few who do not consider measures of material wealth being pertinent at all; these include admirable folks who go on to work in NGOs, become missionaries etc. But these are the exceptions.

Also, a lot of what a better life depends on where is your starting point. If you grew up in a 2-bedroom rental Singapore Improvement Trust flat or a 3-bedroom HDB flat and taking the bus to school, then buying your first executive condominium at 32 or your first small second-hand car at 30 usually means medicine has indeed given you a better life, materially speaking.

But if you grew up in a freehold landed property in Districts 9, 10 or 11 and you were fetched to school by your parents or even chauffeured in a nice big car from Primary 1 to JC2, then ending up in an executive condominium and buying that small second-car car as a medical officer is not a big thing. In fact, you may start to wonder if being a doctor will ever lead you to a “better” life, without parental assistance in the form of paying for the down-payment of the condominium and/or helping you with paying for that $100,000 Category A COE. And then you may even start to doubt if you will ever make it to a Category B COE vehicle in your lifetime, given how things are going.

What constitutes “a better life” is a tough question that each generation of doctors have to face and answer themselves. Because no one can answer these questions for them.

But the facts are not on young doctors side. 30 to 40 years ago, 150 to 200 students were chosen to read medicine locally out of a cohort size of about 60,000. Another maybe 30 to 50 kids were rich enough to go overseas. In other words, about 200 to 250 medical graduates were produced a year from local and overseas medical schools. Today, a total of 700 medical graduates are produced a year (500 local and 200 overseas), out of a cohort size of about 35,000 to 39,000.

Put it another way, when this hobbit entered medical school, there was one doctor to 1000 persons in Singapore. Now there are 2.7 doctors to 1000 persons. This figure is likely to reach 3 in a few years’ time. While an ageing or aged population will create more demand for medical services, it is unlikely to fully offset the effect of a quickly growing medical profession. In other words, there will be less work for each doctor, which will likely translate into less earning power.

You can see it especially in the private specialist sector. 30 to 40 years ago, nobody really worried about not enough work when they went private. 20 years ago people worried a little but in the end, nobody was short of work either. Today, not having enough patients is a real concern.

The public sector is not spared either. Recently, a senior public sector doctor posted in social media that 25% of doctors in public hospitals were senior consultants. Senior consultants used to be a rarity, now no longer. I hear in some top-heavy tertiary hospitals some consultants only have half a day of operating theatre time a week.

Doctoring is no longer an uncommon thing, like in the past.

We always say medicine is a calling. Only those that receive that calling should become a doctor. This hobbit still believes this to be true. But we need also to be honest and admit if we use the old perceptions and definitions of what a better life is, then medicine is unlikely to deliver the goods for many doctors. And young men and women who aspire to be doctors today should know these hard truths before committing to a career in medicine.

They will need to decide for themselves what are the new norms for defining a better life. And that may already be taking place even as we speak. Maybe that’s why young doctors now talk about better work-life balance and quality of life. Because these are the ingredients for a better life that they can still hope for today.

Could We Or Covids Have Done Better

The Covid-19 White Paper was released on 8 March 23. This hobbit thinks this was a very commendable effort to look back at what happened that was led by a former Head of Civil Service that is known for his frankness and clarity of thought.

It correctly identified the two major shortcomings made by the government – the U-turn in mask policy and the blow-up in cases that happened in foreign worker dormitories. And this in itself, is a win for transparency and humility. Two very rare commodities in the world nowadays. It is also noteworthy that the two errors arose from essentially the heuristic error of anchoring. Just because the coronavirus in SARS was infectious only when the patient had fever doesn’t mean that another coronavirus will behave likewise. We were anchoring on our past experience with the SARS virus and hoping the Covid-19 virus will behave likewise.

But enough big talk. Now for the small talk that regular readers of this column seem to enjoy much. There are some episodes during the pandemic that are worth remembering but not mentioned in the White paper, just for laughs, if nothing more. These include:

The Virus Vanguard. These are official superheroes no less, since they first appeared in government Facebook webpages, albeit for about only a day in April 2020. We remember our disappeared champions – Circuit Breaker, Care Leh-Dee, Dr Disinfector, Fake News Buster and the (drumroll please) MAWA Man (Must always walk alone, the very antithesis of Liverpool fans). This hobbit hopes that they have NS liabilities, so that in the next pandemic or epidemic we can serve the SAF100 on them to return.

Pivot to F&B Sector. The KTV cluster in 2021 was a result of several KTVs that have “pivoted” to the F&B sector (with assistance and sometimes even grants from the relevant authorities). A good and well-meaning idea in itself except that these newly pivoted F&B outlets did not have any commercial kitchens. So obviously they had to cook up something else on these premises which resulted in the cluster.

Strangers Sharing Same Hotel Room during Quarantine. At the start of the Omicron wave around December 2021, some folks were made to quarantine in the same hotel room with complete strangers. Naturally, this nutty idea was quickly panned by many. Between a full-height walled cubicle in Singapore Expo and sleeping with a stranger in the same hotel room for about 7 to 10 days, most folks will prefer the former. C’mon, even in an SAF exercise, I have my personal basha tent. This hobbit thinks the guy who came up with this probably liked Frank Sinatra’s “Strangers in the Night” a little too much.

CB and Tightened CB. Kudos to the wordsmiths who were always on top of the word game during the pandemic. These include calling a lockdown a circuit breaker or CB in short. This evolved to a Tightened CB later on. And at about the same time, the government was putting out Chinese-dialect short videos to get the message out to the elderly in the Chinese community. Whoever came up with the tightened CB bit should also be sent for some dialect classes.

Die Another Day. This incident arose also in late 2021 when a MOH Director said mortuary directors could handle dead bodies when the cause of death was Covid-19. This was refuted by the Secretary of the Association of Funeral Directors’ Singapore the next day in The Straits Times Forum which stated clearly that MOH guidelines prohibited them from handling such bodies outside of hospitals. This is clearly NOT a case of Everything Everywhere All At Once as the left hand didn’t know what was happening with the right hand. It is also nice to know the Association was given a President’s Certificate of Commendation for exceptional effort and significant contribution to fighting Covid-19. Incidentally, organisations such as SMA, CFPS, AMS, SNA, SDA and PSS weren’t. Obviously someone either forgot about or doesn’t like these guys?

Let us now get down to the White Paper proper and move back into the serious stuff. What really hit home for this hobbit. The White Paper really had their finger on the pulse when it stated on Page 67:

“However, some of the (i.e. SMM) measures were overly elaborate, difficult to operationalise and explain, and therefore confused the public. Re-opening the economy in phases while limiting the spread of community infections turned out to be a more complicated, and emotionally affecting, journey than expected. All this highlights the need for us to exercise greater flexibility in a crisis, go for broader brush but more implementable measures, and to guard against the instinct to aim for unrealistic standards of perfection”.

On Page 74, the White Paper essentially put out the same message again:

“With future pandemics, we will also need to exercise more flexibility. During COVID-19, at times we allowed the perfect to be the enemy of the good, for example the over-calibration of some SMMs and treatment protocols. In striking the right balance between achieving precision and ease of implementation in our public health protocols, we should guard against leaning too much in the direction of the former”.

Very important points that were most eloquently articulated. Beyond these wise words, this hobbit would like to draw attention to this graphic that was put out in late 2021 by Lianhe Zaobao which told vividly how wrong can matters get:

https://www.zaobao.com.sg/news/singapore/story20211004-1199797

Like what this hobbit has said before, you don’t have to know Chinese to appreciate the ludicrous complexity the “system” had become before thankfully someone decided to implement Protocols 1, 2 and 3.

It is perhaps importantly to go one-step further to discuss why the “system” went off the cliff in terms of complexity and impossibility (rather than ease) of implementation, especially in the area of public health and healthcare.

First, let us remember, whether we like it or not, that protocols, circulars, instructions, directives etc, are written and put in place by people (i.e. real humans, not halflings, elves and orcs). And what drove these people to do what they did? This hobbit can proffer several possibilities:

The people who wrote these protocols really have no real on-the-ground experience running healthcare facilities such as hospitals, nursing homes or clinics. They probably grew up in a nice white building; from sitting behind a desk to sitting in a cubicle, before finally being holed up in an office and adorned with a personal assistant to show they have arrived. Hence, just armed with a little theoretical knowledge and no frontline experience, they write protocols the way novelists write fantasy stories.

These people are more afraid of losing their jobs more than solving real-life problems, and think that the best way to keep their jobs is to cover their backsides and to write protocols and directives that cover every possibility and exception without thinking how the people on the ground will cope. Never mind you cannot possibly comply with what they wrote. That’s your problem, not these people’s.

They are just plain stupid (which is unlikely, since they can write such complicated protocols. Maybe they have spectrum disorder, but they are probably high-functioning ones rather than stupid).

Various combinations and permutations arising from the above three possibilities.

There are of course other possibilities, but it would be impossible to explore all of them in the interests of time and readers’ attention. Of course, this hobbit is NOT about to excoriate old wounds, start a new round of fault-finding or try to settle old accounts. But it is important to state that these people have written and issued protocols and directives that have caused untold grief and profound degradation of morale among front-line healthcare workers during the pandemic. This hobbit thinks the morale hasn’t quite recovered fully even now. Quite a few people are still scarred and angry.

So, in the name of all that is good and true, this hobbit beseeches those that are in the high places of power that they do not assign very important tasks such as writing of protocols and directives to these same dangerous people again. Put them somewhere else where they can still earn a living off taxpayers’ money but do less harm, like dress them up as MAWA Man, Care-leh-dee and Dr Disinfector etc and send them to Cosplay conventions. Better still, we can put them onto a Chingay Parade float that has a big overhead banner which has the words “CBs”.