Tag: healthcare

LPPL Insurance Situations

Recently, our Health Minister launched four short social media clips to educate the public about health insurance, in particular riders for IP policies. The take-home message is that riders are expensive and get more expensive as the policyholder gets older. It may be better, especially for an older policyholder, not to buy riders or to buy cheaper riders. Of course, cheaper riders mean less coverage and more deductibles and co-payment. All very sensible. I urge you to watch the clips.

At about the same time, Singapore’s “Blogfather”, aka “MrBrown” aka “Kim Huat” also posted two clips to explain what some colloquial short forms mean. In the second of 2 posts so far, he explained what “LPPL” stands for1.

According to him, LPPL stands for “Laugh Please, Please Laugh”. It can also stand for Log-Periodic Power Law in the field of economics and finance.

To this hobbit, it can also mean a certain location in the human body, namely “Longitudinal Perineum Permanent Location”.

For example, the government introduced the Cancer Drug List (CDL) in 2022. This was introduced ostensibly to empower the government to negotiate for better prices from drug companies and to discourage the use of certain cancer drugs for non-mainstream indications so as to curb rising costs of cancer treatment.

However, many IP insurers then quickly introduced riders to cover for the use of non-CDL drugs. Of course, such riders2, while generating more work and income for some medical oncologists in the private sector, has the downstream effect of encouraging what the introduction of the CDL was meant precisely to discourage  – more use of such drugs which will lead to an unnecessary and avoidable rise in prices and overall healthcare consumption and expenditure

The quick introduction of non-CDL riders by IP insurers effectively negates the policy intent of CDL. And we are back to square one and the government is caught in an LPPL situation. The only consolation is that such riders must be paid with cash.

Why does this happen and why do we allow it? This hobbit doesn’t have the answer. Or even if he thought he knew, he won’t say it here, that’s for sure.

The first thing to know is that we often (if not always) buy insurance because we want peace of mind. Peace of mind is a wonderful thing. But really, if you think about it, the flip side of peace of mind is fear. Fear and peace of mind are but two sides of the same coin. We buy riders for peace of mind, and we buy riders out of fear. The fear that in case we need these non-CDL drugs, we have no access to them and even if we had access, we can’t pay for them. So we buy these riders.

The IP insurers are making lots of money selling these LPPL non-CDL riders in return for giving us peace of mind, or feeding on our fear (depending on one’s perspective).

And as any psychologist will tell you, fear is a great driving force for animals with some intelligence (and that includes humans). The response to fear is a primal one, hard-wired into the human condition through hundreds of thousands of years of evolution, or adaptation, call it what you may.

While this hobbit really likes the Health Minister’s video clips on riders and that he is a great communicator, this hobbit is not sure the clips can countervail the power of fear and the natural response to fear. Especially when this fear and the response to it is also being actively cultivated and reinforced by many insurance companies and insurance agents who get to make a buck or two out of selling such LPPL riders.

Let us move on to another insurance-related matter that has garnered many eyeballs recently. While this matter is about a motor insurance claim, it is nonetheless medically-related.

It was reported that the Courts awarded $417,000 in damages in a traffic accident case. Unfortunately, this decision was arrived at some 5 years after the accident occurred, and only after the traffic accident victim had passed away. The son of the victim, who is his main caregiver for the many years the victim was incapacitated until his death, was the plaintiff.

The sheer callous temerity of the insurance company was most telling. In the opening paragraph of the Judgment3 given by the District Judge, it was stated, “This is a judgment that documents NTUC Income’s wholly unreasonably behaviour”. This hobbit has read quite a few Judgments before, but none has come close to such a resolutely damning statement right at the start of a Judgment document.

In summary, the case involved a person who was seriously injured by a traffic accident. This victim then made a claim against the driver that caused the accident.

It was noted by the Judge that NTUC Income effectively took over the defence of the case because it would have to foot the bill should the courts decide in the plaintiff’s favour.

NTUC Income efforts to deny the claim was akin to “the sort of casually impersonal  stonewalling that some would associate with the worst administrative processes” (Judgment, para 3).

Some particularly galling examples of this impersonal stonewalling –

  • Claims for pain and suffering and amenities was denied because the victim was comatose and could not have appreciated any pain and suffering at all, even though the victim was intermittently conscious until his death (Paras 14 and 17, Judgment)
  • Claims for loss of income was denied, even though the victim was working at the time of the accident (Para. 34)
  • Claims for ambulance-related expenses was denied (Para. 36 of Judgment)
  • Claims for milk powder for the patient was denied because it was too expensive as the patient could have used a cheaper brand such as “Ensure”. (Para. 61 of Judgment). This hobbit is not so sure if “Ensure” appreciates such publicity from NTUC Income.

And if you think this unreasonable behaviour was arrived at because NTUC Income received poor legal advice, the judge made it clear that the lawyers were merely conveying their clients’ instructions. The judge added that the lawyers’ “advocacy was candid, well-organised and fully in line with their duties to the court”.

Against the backdrop of the furore that ensued, the CEO of NTUC Insurance (NTUC Income was rebranded as NTUC Insurance recently) issued an internal memo addressed to “colleagues”. This hobbit obtained a screenshot of this memo, in which he explained the company’s position and then signed off with “Cheers”.

This hobbit must say he has no clue what is there to be cheerful about.

I think the incident shows publicly that the local insurance sector is truly now in a new era of American-style climate of “delay, deny, defend”, which many doctors are already familiar with while caring for IP policyholders in the private sector. So far, the private patients in A1 and B1 class have largely been spared of such agony because IP insurers generally do not question or apply friction to claims for care delivered in restructured hospitals. But who knows what will happen in the future? This may occur sooner than we think.

This case also illustrates the inadequacy of scope in what is offered by the financial and insurance industry to adjudicate claims before it reaches the courts in the form of civil suits. Today, if someone is aggrieved by an insurer, he can take up his case with the Financial Industry Disputes Resolution Centre (FIDReC) which is a platform to adjudicate disputes involving financial institutions (which includes insurers).

However, this is a platform that is only open to the insured (i.e. policyholders who make claims) and their beneficiaries as well as to those parties who have a “customer relationship” with the insurers

It also only covers disputes of up to $150,000.

In this case, neither the victim nor the plaintiff (the victim’s son) is the insured. They don’t have a customer relationship with NTUC Income either. Strictly speaking the plaintiff is not even a beneficiary of the policy as well. What is more, the amounts accumulated over a four-year period far exceed $150,000. So he can’t use FIDReC and so, he has no choice but to sue. But not many people have the financial resources to mount a civil suit. And of course, there is a lot to lose if he does not win the suit. The plaintiff’s legal costs may be easily six-figures if the suit is protracted, and in a worst-case scenario, costs may be awarded against him, i.e. he has to pay for the other party’s costs too.

The plaintiff in this case has obviously weighed his chances, examined his financial resources and then decided to pursue the civil suit route.

As for healthcare-related or IP-related matters, the situation is even worse off in at least three ways.

  • FIDReC is not open to service providers that provide a service or goods to the insured. So, hospitals and doctors who experience unreasonable delays and denials of claims cannot use FIDReC.
  • FIDReC also only handles complaints when a claim has been made, and not before. So FIDReC does not handle issues such as pre-authorisation or how doctor panels are constructed, because no claim has been made.
  • FIRDeC also only handles disputes that are clinical in nature on a voluntary basis. When such a dispute occurs, IP insurers can choose NOT to participate, even if the policyholder has lodged a complaint with FIDReC.

To use a partially real-life example. A patient has an anal fistula abscess. The panel doctor seeks pre-authorisation but is denied. Inexplicably, the case manager suggests that he tries to manage the anal fistula abscess “conservatively” (doctors and nurses reading this, please don’t laugh). This advice to treat an abscess conservatively is not made-up. It actually happened.

If you think the insurer’s case manager should and could be held accountable for making medically unsound and unsafe suggestions and recommendations, you are wrong. Insurers and their employees are not regulated at all for making recommendations and decisions that impact on the clinical aspects of healthcare delivery to their policyholders. For all you know, the case manager has a degree in art history and has recommended the use of Chlorox bleach to treat strangulated piles, and he can get away with such an unsafe recommendation with no consequences to himself or the insurer that he works for. Actually, I exaggerate. I know a few art history graduates who know more about healthcare and medicine than many IP insurers’ case managers. Let’s not unjustly belittle art history grads. They are good people doing good work, which is more than what I can say for many case managers.

OK, this is where the real part ends. We go on to the hypothetical part.

Suppose the surgeon and patient agrees to surgically drain the abscess anyway (because as any 2nd year medical student will tell you, abscesses must be drained – just in case any case manager is reading this and is confused). However, for reasons beyond anyone’s control, the 70 year-old patient with well-controlled diabetes gets pneumonia post-op and gets hospitalised for longer than expected, and the hospitalisation includes 2 days in the ICU.

The claim for the hospital stay is denied because the doctor and patient did not first try “conservative” treatment. The patient/policyholder then files a complaint before FIDReC. The insurer declines to take part in the FIDReC process citing that this is a clinical matter.

What is the patient, surgeon or hospital now to do? The total bill could be say, about $30,000. The aggrieved parties may think that well, the legal fees for bringing this to court alone could well be close to or exceeding $30,000. The surgeon may be fearful that should he pursue the civil suit route, the insurer may well remove him from the insurance panel after this. After all, no reasons need to be given for selecting or removing a doctor from the panel.

And so, all the other stakeholders are again stuck in a LPPL situation, with the insurer being the only party to benefit from such LPPL situations.

Whether we want to admit it or not, “Delay, Deny, Defend” works most of the time. Such is life. LPPL.

1 https://www.youtube.com/shorts/RCSvZUgOCgM

2 https://www.singsaver.com.sg/blog/best-ip-riders-and-supplementary-coverage-for-cancer-protection

3 https://www.elitigation.sg/gd/s/2025_SGDC_150

Grape Cistern Insurance Company: Operation Great Pincer

(For the avoidance of doubt, it is hereby stated that this post is a satire)

Board Memo

To the Chairman and Members of the Board of Directors

Operation Great Pincer (OGP)

I wish to update you that we have begun a major strategic initiative against a hospital service provider – Most Excellent Hospital or MEH in short. This hospital has been a great source of frustration and annoyance to our Company.

This initiative is called Operation Great Pincer (OGP) and its aim is to bring this hospital service provider to its knees and to yield to our Company.

Background

We have to first understand that a hospital needs three other parties to survive: patients, attending doctors and payors. In times past, the payor is often the patient. But nowadays, with bills getting larger, bills are often settled by insurance products which the patients or their employees buy from companies such as us.

Usually, the patient doesn’t really choose the hospital but instead chooses the doctor he wants to consult with, and the doctor happens to work in this hospital or chooses to admit the patient to a hospital where he has admission or attending rights. The doctor is NOT an employee of the hospital but an “attending physician’. In other words, the patient has a choice, and the doctor also has a choice.

Finally, when services have been rendered, the bill will be settled by the payor, I.e., insurance company that sold the insurance policy to the patient/policyholder some time ago.

Once you understand this, you can now proceed to develop a pincer strategy that squeezes the life out of MEH by getting the two other parties to be aligned with the Company: the doctors and the policyholders.

The Pincer Attack

Similar to what we know of a crab claw or crab pincer, a pincer attack must have two limbs or two prongs. Here, as you may have already guessed, one limb or prong is the doctor and the other prong is the policyholder.

A pincer attack or pincer offensive is nothing new. It has been used since the beginning of human warfare and if well executed, is highly effective and deadly. The difficulty lies in getting the two limbs to pivot and close around your prey or enemy until it is encircled and crushed.

A most famous example is the Stalingrad Campaign in World War Two when the Soviet Army managed to mount a counteroffensive by using the pincer attack to squeeze and finally encircle the German 6th Army in Stalingrad in the winter of 1942. By the time the Campaign ended, it was estimated that the Axis forces (led by Germany) lost between 600,000 to 1.1M men (killed, injured, missing or captured). It never recovered from this and it has been said that this was the pivotal moment when Nazi Germany began its inexorable march to ruin and ultimate defeat.

OGP: Our Two-pronged Pincer Attack

Let us now return to OGP and the MEH.

The Build-up

We will first manipulate one of the two prongs to be on our side. And of course, we will choose the weaker prong – the doctors who admit patients to MEH. To this end, I have in my armamentarium the weapon of preferred physician panels. I have already weaponized this by telling these empanelled doctors that they are strongly encouraged to admit to other hospitals and not MEH. To sweeten the deal, I put in place small incentives such as free parking and fruits baskets for my policyholders. Finally I carry the big stick called “depanelment”, which means removal of the doctor from the preferred physician panel. Actually, there is no such word called “depanelment” in the English language. It was probably invented by some insurance executive of antiquity who did not achieve a good grade in English when he was in school; but you get the idea. In any case, I have started the fear rolling like a ball last year by depanelling many doctors.

Launching Operation Great Pincer With The First Prong

In order to maintain the element of fear and uncertainty among panel doctors and to ensure they remain subservient to the Company like groveling dogs, the criteria of depanelment will remain quite opaque and the depanelment process is subject to our whim and fancy. To this end, I have formed a nice sounding department called Provider Management Department and I have instructed it to issue a statement explaining a few of the many reasons for which a doctor can be depanelled. These reasons are ultimately meaningless because it is followed by the one and only factor that really matters, something akin to a Ring to control all other rings (sounds familiar?). This all-powerful clause states “ the Company may or will exercise its sole discretion to make any decision regarding depanelment reasons”. In other words, all the reasonable sounding factors the Provider Management folks have mentioned earlier on in the aforesaid statement are just smoke and mirrors. What really matters is that the doctor’s continued existence on our panel is decided by the Company only. With this, I expect the panel doctor, to toe the line and NOT admit to MEH. But if the doctor still does admit to MEH, then it is time to say “Adios” to him on the panel. It’s not personal, it’s just business.

The Second Prong

Getting doctors to cooperate is the easy part, because doctors are weak. Getting the other party, the policyholders, to work as the second limb of the pincer is more difficult. This is because unlike the doctors who don’t pay our Company, we need policyholders because their insurance premiums keep this Company going. Pincer attacks must be executed quickly and in a coordinated way if you are to trap the enemy and prevent it from escaping. So just one day after our minions have issued the above statement to our panel doctors, the Company will issue another statement saying that we no longer issue pre-authorisation certificates (PACs) to MEH. And without PACs, the issuance of Letters of Guarantee (LOG) will either be very delayed or even not happen at all.

This again has the effect of sowing fear and uncertainty in the second target group, the policyholders, just as we had sowed fear and uncertainty in the first target group, the empanelled doctors.

Without pre-authorisation, policyholders will in all likelihood not get their LOG in time or at all. This leads to two possible consequences for the policyholder:

  1. The policyholder has to stump up cash for his hospital deposit, and also make progress payments along the way during his admission as his deposit is used up to pay mounting bills; and
  2. After the hospitalisation or treatment episode, there is an increased risk that the insurer will not pay his claims since there wasn’t any PAC or LOG issued beforehand.

The first consequence is a matter of cashflow for the insured since his policy is now run on a reimbursement basis. I submit that the hospital can help to alleviate the cashflow burden of the policyholder by waiving the requirement for a deposit or progress payments.

The second consequence is more serious as it is a matter of risk. Without a PAC and LOG, there is an increased uncertainty that the insurer can and will deny the claim. This is something that the hospital cannot address on its own.

To make it sound even more nebulous and scary, our minions will issue statements that obviously run contrary to experience and common sense, like “there is no change to your coverage or benefits when you submit claims or receive treatment with this initiative”. Obviously, cashflow of the policyholder is affected when one has to stump up cash for a deposit when one did not have to do so previously with a PAC. Also, the probability of having a claim denied is obviously higher without a PAC and LOG than when a policyholder has these documents. It has to be so, because if not, then why did we even come up with stuff like PAC and LOG in the first place?

Consequently, all these superficially balmy statements do little to assuage the fear and uncertainty that the policyholder feels when they are told PACs will no longer be issued for certain hospital(s). The trick is that we choose our words carefully, because cashflow and probability of claim denial is not a contractual term or feature of “coverage” or “benefit”. Therefore, while coverage and benefits remain constant in a legal sense, fear and uncertainty in the policyholder increases when a PAC and LOG is not issued.

Encirclement

With this, our second prong, the policyholders, will likewise fall in line with us. Like our panel doctors, they too will also not choose MEH.

With both prongs in place and aligned with us, the Operation Great Pincer (OGP) attack is well underway, and the enemy is choked off from the business that we have previously brought to them. We have entered the final and decisive phase of a pincer attack – encirclement and probable decimation.

The art of the pincer attack is not really the actual decimation of the hospital. But rather, the threat of decimation is sometimes more frightening that the actual act itself. One insurance company cannot decimate a hospital. But many can. As such, the real and great fear of the hospital is that our competitors may do likewise to them.

And so, in time and out of fear, the hospital will yield to us and give us the prices and discounts that we want. We will no longer be price-takers from MEH but instead we will be price-setters. We will then replicate the same strategy with other private hospital operators and be able to cut our payouts to these hospitals drastically, just as we have done so with the doctors using preferred physician panels and fee schedules.

Significant Threats to OGP

At this juncture, it is my responsibility to also point out and evaluate the downside risks of Operation Great Pincer. There are at least two significant threats to OGP that we have to be cognisant of: (1) our competitors and (2) our regulators

Our competitors may steal a little of our market share as new customers who want to buy a health insurance may not choose us, since OGP does limit their choice of hospitals and our repeated depanelment exercises have left our preferred physician panels smaller than before.

But this is a considered downside that we are prepared to stomach. This is because

  1. We are already an insurance company with sufficient heft, with a large pool of policyholders
  2. The market penetration of this sector is already high with a large majority of the potential policyholder pool having already bought health insurance either from us or from our competitors. Future growth is therefore limited
  3. Most of our policyholders will stay with us anyway, since some brilliant minds have already decided that there won’t be full portability in our line of business.
  4. Which means the only real options many of our policyholders have are either to stay with us or stop buying any kind of private health insurance altogether. Those that leave us may not be such a bad thing because they are likely to be older policyholders who are more likely to make claims. This is business we can afford to lose.
  5. Having a slight smaller market share but significantly higher profit margins and actual profits can be a desirable thing.

We have little to fear from our regulators as well. Our primary and first regulator empowered by the relevant legislation, the National Agency for Snooze (NAS) continues to be in a somnolent state. Our other regulator is awake but in truth has few legislation tools under its belt to be of concern to us. We will continue to help them in all earnestness to understand us better. Our strategy is to foment better understanding with our second regulator while avoiding regulation from the first.

Conclusion

Our overarching strategy to increase shareholder value continues to be based on the time-honoured precepts of our industry, which is to Delay, Deny, and Defend. With fear and uncertainty as our allies, we will continue to employ tactics of delay and denial (or threats thereof) against healthcare providers and policyholders, while keeping our regulators far, far away. As long as NAS continues to slumber, there is no need to even defend. Indeed, when one is under-regulated, there is little to defend against.

I remain optimistic about our industry and our company’s future

Finally, if any of you (or your family and close friends who are our policyholders) require medical care from any private specialists and any private hospital, please reach out to me. I will process your requests with the utmost confidentiality and rest assured that your treatment options and insurance coverage are not restricted in any way to any preferred physician panels or preferred hospitals list that the Company may have issued to our policyholders.

Yours sincerely,

Hobbitsma
CEO
Grape Cistern Insurance Company

An Insurer Can Do Many Things

I read with interest this rather long opinion piece by an ex-ST journalist in The Straits Times “Some practical ways to rein in rising healthcare costs, premiums” (Claire Huang, 21 May 25, The Straits Times)

In particular, one section highlighting Integrated Plan (IP) insurer Great Eastern Life deserves scrutiny.

Let’s reproduce the section here,

“What an insurer can do”

“IP insurers are constantly looking for ways to sieve out doctors and hospitals that like to maximise profits.

In this area, Great Eastern Life might have found an achievable and pragmatic way out.

In October 2024, the insurer launched its own medical care concierge, where its in-house officers help match patients to doctors, based on their IPs.

These 10 officers, who are experienced in handling patients or are medically trained, are employed by the insurer and receive a fixed salary.

They first determine what benefits apply based on the policy the patient has, then they recommend specialists who are on Great Eastern’s panel.

Patients can also choose to seek treatment from specialists who might not be on Great Eastern’s panel.

In such an instance, the co-payment amount will logically be higher and some benefits may be moderated if the specialist is not on the panel.

The cost estimates and differences will be made known to the patient.

Those who opt for panel doctors will receive pre-authorised certificates and their claims will be guaranteed by the insurer.

Already, the scheme has worked for Great Eastern, whose concierge team has processed more than 1,100 policyholders so far.

Besides preferred doctors, insurers also have their preferred hospitals.

The preferred hospitals approach functions on the basis of the insurers’ bargaining power, which has grown as medical tourism here dries up.

Some insurers secure bill discounts for patients by agreeing to send these patients to preferred hospitals.”

Let this hobbit now comment and offer another perspective on this subject in addition to this piece of awkward journalism.

In particular this statement, “IP insurers are constantly looking for ways to sieve out doctors and hospitals that like to maximise profits”.

This is true to a certain extent. But then, to be fair to both doctors and hospitals, aren’t the insurers, as companies responsible for maximising shareholder value, almost always trying to maximise profits too? Why only focus only on doctors and hospitals? Should IP insurers also be sieved out when they maximise profits?

Anyway, in this hobbit’s opinion, let us look at some past behaviour and practices as well as the track record of GE to see if it is as good as it is made out to be by this article.

In the 2022 IP Providers’ Ranking Survey conducted by SMA which was published in the SMA News June 2023 Issue, GE did not do so well: (https://www.sma.org.sg/news/1953/June/SMA-Integrated-Shield-Plan-Providers-Ranking-Survey-2022).

In fact, of the 4 largest IP insurers, (Income, AIA, Prudential and GE), it regularly came in last on many fronts. The Survey involved respondents who were doctors. Out of a scale of 1 to 5 (5 being the best), it achieved an overall score of 2.5, which was only higher than the two smallest IP insurers: Singlife and Raffles (which has an employee-physician model). Overall, it was placed 5th out of 7 IP insurers.

In terms of doctor-panel management, GE did pretty well in the 2022 Survey, in terms of inclusiveness and transparency of criteria for doctor selection, scoring 2nd out 7.

But for 5 out of the remaining 6 questions asked, it ranked a poor and consistent 5th place out of 7 insurers, above Singlife and Raffles but consistently below Income, AIA or Prudential. These 5 questions are: ease and timeliness of pre-authorisation, timely payment to doctors and appropriateness of fee scales and putting up obstacles to dissuade policyholders to see non-panel doctors.

Of course, one may say well, this is all about doctors’ perspective which may be biased. Well, let’s look at MOH data then.

Lest we think that panel management is something that GE is good at, and maybe that is the case in 2022, latest and official MOH data suggests otherwise: (https://www.moh.gov.sg/managing-expenses/schemes-and-subsidies/integrated-shield-plans/about-integrated-shield-plans/)

Let’s look at what happened in 2024 for the Big 4 IP insurers according to MOH data

PanelNo. of Private Specialists (Total)No. of Private Specialists Who LeftNo. of Private Specialists who Joined
AIA5942512
GE77912674
Income8073793
Prudential81416154

The data provided by MOH claim with this footnote/disclaimer:

“The higher private specialist attrition in 2024 was due to Great Eastern Singapore’s planned panel review. Great Eastern Singapore continues to maintain a large pool of private specialists on its panel”.

I would hazard a guess that this footnote was inserted at the insistence of GE but to be fair, one does not really know who wanted it to be there. But the MOH numbers speak for themselves.

Adding on new specialists is always a good thing for policyholders because it gives them more choice. But removing specialists may not be a good thing. It leads to loss of choice and more importantly, continuity of care probably suffers. 126 out of 779 is a turnover rate of 16%. The footnote only states that it was due to a “planned panel review”. The statement doesn’t state how often such planned panel reviews occur. Could it be yearly, or more frequently or less frequently? Anyway, if you remove 16% of specialists each year, you can effectively turn over the entire panel in 6.25 years, and that is assuming you top up each year with the same number of new specialists that you remove, which is not even the case here. The panel size actually shrank in 2024, because GE only added 74 private specialists while it removed 126. The panel size of GE for 2022, 2023 and 2024 were 764, 831 and 779 private specialists respectively.

As a policyholder, one should assess an IP insurer’s panel management not just on the absolute number of specialists and whether the panel size is increasing, but also the amount of turnover (number of specialists leaving and joining). The worst scenario is when panel size decreases and at the same time the panel experiences high turnover. You have less choice and continuity of care suffers as your preferred doctor is removed from the panel.

One can easily access MOH data from the link given above and see for yourself and come to your own conclusions as to which IP insurer is better managing their panels for the benefit of policyholders and not just for other reasons, e.g. profit maximisation.

Next, we come to look at some examples of how GE (or rather their appointed third party administrator, Adept Health) communicates with some of their panel specialists. Several specialists have surfaced essential copies of the same letter to this hobbit sent out in Aug 24. An excerpt from this letter reads

“XXH Privileges, Great Eastern (GE) is pleased to announce that XX Hospital (XXH) has been designated as the priority and preferred hospital for Great Eastern Life customers. This selection is based on XXH’s commitment to delivering exceptional care, which aligns with the goal of providing the best possible healthcare experience for the customers”

If the panel doctor does not play ball and admit GE policyholders to XXH, then they may receive another letter several months later. Excerpts from this letter (which this hobbit received with the doctor’s name redacted, so the doctor’s identity is unknown even to this hobbit):

“We have recently noticed that the clinic has not been prioritizing admissions to GE preferred hospitals, such as the XXH. This may result in non-compliance with our guidelines.

As a result, Dr. YYY name is currently removed from the Health Connect website.

If you are accredited, we kindly request that you prioritize admitting patients to GE preferred hospitals during this 3-month observation period.

Should you have any questions or require clarification, please do not hesitate to contact us.

Dr YYY, apparently appealed, because a month later, the TPA replied with an email. Again, excerpts from this email,

“Thank you for allowing us the time to review this matter.
 
Based on our PAC issuance data of Year 2024, we do observe there are patient admission from Dr YYY mostly at ZZ Hospital (You can refer to the PAC data captured at DA Adept records for your reference). As we are also informed by GE side of data (for non PAC cases) it was observed with similar trend as well.
 
We are open to understand more from Dr YYY if there are any challenges or concerns in supporting this initiative.
 
Please note that despite the temporary removal of Dr. YYY’s name from the website, Dr YYY still remains as a panel specialist under GE Shield. This change will not impact Dr. YYY’s PAC requests”.

Finally, Dr YYY was terminated from the panel recently by email:

“We regret to inform you that we’re serving this termination notice on our Health Connect Provider Agreement”. No specific reasons were given for the termination, but one can reasonably come to your own conclusions from the sequence of events and previous communication the reasons for the termination.

A few points are worth discussing here. As an insurer, it is free to source for the best deal from private hospitals, generally speaking. But as a doctor, I can tell you, there are hospitals and then there are hospitals. This is the same for restructured hospitals. There are things that SGH can do, that well, Sengkang General cannot support well as a hospital. There are complicated stuff that NUH can do, that NTFGH cannot. MOH acknowledges this as much – different restructured hospitals have different levels of capability.

And so it is too with the private sector. There are complicated procedures that XXH cannot support, that another private hospital can. Of course these better equipped and staffed hospitals are often more expensive. To simply say that one must admit their patients to a certain hospital just because an insurer has a special arrangement with that hospital ignores the complicated nature of medical practice and hospital capabilities, and may even promote unsafe clinical practice just to satisfy an IP insurer’s commercial interests.

Please also note in the above correspondence that the TPA did not once claim Dr YYY was expensive and did not follow GE’s fees schedules. The professional fees charged by Dr YYY was never highlighted as an issue.

More importantly is the whole idea of transparency. Has GE informed its policyholders in the first instance that panel doctors who don’t use their preferred XXH hospital will be penalised? And perhaps even eventually removed from the panel? One must tell the good news with the bad news. One should not only tell policyholders that they will get free parking and a free fruit basket etc if they go to XXH. They should also tell them that there is a risk of their preferred panel doctors being removed from the panel if they do not agree to being admitted to XXH, leading to a loss in the continuity of care.

In fact, the IP insurer should tell potential customers of their IP plans upfront that their choice of care is largely limited to certain preferred hospitals, or rather private specialists admitting to these preselected hospitals before IP policies are sold or purchased. Then folks shopping for an IP policy can then make an informed choice of which IP insurer to use or buy their IP policies from. What GE is doing is essentially selling a “bundled” IP product, with preferred specialists and preferred private hospital(s) bundled together. Nothing wrong with that, but they need to tell everyone upfront, including existing policyholders and potential customers who are seriously considering buying their IP policies. They can then compare the price of a bundled product with the price of another IP product that gives them more choice of not just doctors, but hospitals as well.

Back to the subtitle in the opinion piece in The Straits Times, “What an insurer can do”. There are many things that an insurer can do. Perhaps too many. This is because the clinical aspects of the IP sector are largely unregulated while the assigned regulator, the Monetary Authority of Singapore (MAS) is interested mainly in ensuring that an insurer is financially viable and does not go bust. Indeed, the insurer can do many things legally. But should they?

Now, based on the above information, would a hypothetical construct called “the reasonable lay-person” still buy an IP policy from GE? Perhaps he will, perhaps he won’t. This hobbit doesn’t know. Perhaps Ms Claire Huang may know and you can ask her.

How You Pay Affects How Much You Pay (and How Much Taxes We Pay)

Last month, DPM Gan Kim Yong and Health Minister Ong Ye Kung gave an interview to The Straits Times’ Ms Salma Khalik (Healthcare financing in Singapore: 10 Questions for DPM Gan and Health Minister Ong, 10 April 25). These are two persons who collectively have run MOH for 14 years and they really know what they are talking about.

But for the avoidance of doubt, the serious smart money is on the interviewer, Ms Salma Khalik, who has been covering health for ST since BC times (Before Clustering) and possibly even before there was Internet and the smartphone. This hobbit thinks only Senior Consultants can safely claim they were already born when she started covering health matters for ST.

A few things struck me in that interview, which includes lightning, since it was so near to the General Elections 2025 when the interview was given. The first notable point is that by 2030, the MOH Budget likely to approach the eye-popping figure of $30B. To revisit the first of Minister Ong’s two truisms of healthcare which he mentioned last year in Parliament (6 March 24) – the people always pay. This $30B will be paid by the taxpayers, since MOH Budget is mainly funded by government revenue.

Another important point made in the interview and also previously on other occasions is that one in two persons with Integrated Shield Plans (IPs) and riders opt for subsidised care.

These two points are worth mulling over especially in the context of Minister’s Ong’s second truism – How you pay affects how much you pay.

Personally and selfishly speaking, I do hope that people with IPs and riders do not opt for subsidised care. The logic is simple: – subsidies are always paid by every taxpayer, and that includes me. But if folks use more insurance to pay for their healthcare expenses, then the taxpayer pays less. It’s almost literally a zero-sum game because insurance is funded by policyholders and returns from investments by insurance companies using the premiums collected.

However, whenever folks do NOT utilise their IP entitlement and go to the subsidised classes, taxpayers end up paying most of the bill. Even for B1 class, taxpayers pay because B1 class is subsidised a bit. Only A class is unsubsidised.

The next question to ask is then why are so many people with IPs and riders opting for subsidised care? There are many reasons but one of the most often quoted reason is that they worry about difficult access to subsidised care after a hospitalisation or procedure. Current IP plans all cover the patient at the outpatient level only for a very limited period after a hospitalisation or a procedure. After the coverage expires, the patient has to pay the expenses himself. And once a patient opts for private hospital care or A or B1 care in the restructured hospitals, he will continue outpatient follow-up care with either private specialists or the private (unsubsidised) clinics in the restructured hospitals. Many such conditions are chronic ones and they require a long, if not life-long, outpatient follow-up and many people need subsidies due to the high cost of such long-term follow-up.

The end result is that many people then opt for subsidised care despite having bought IPs and riders so that they can avail themselves to these subsidies during follow-up.

To better understand this flight to subsidy safety among IP policyholders with riders, we can conceptually divide policyholders into three groups:

• Group 1: Folks who will always use private sector services for inpatient and outpatient care
• Group 2: Folks who will select between private sector and subsidised services depending on insurance coverage and subsidy policy
• Group 3: Folks who will always use subsidised care (basically, they didn’t really know what they were buying when they bought an IP)

For the avoidance of doubt, “private sector services” refer to services that are completely unsubsidised – private sector hospitals and clinics and also A class inpatient and private (unsubsidised) specialist clinics in restructured hospitals (RH) since the latter do not consume government subsidies.

The 2nd group is what concerns us today. As aforesaid, because of the bundling of subsidised inpatient care with subsidised outpatient care, many policyholders forgo the use of private inpatient services so that they can enjoy subsidised care during follow-up. And as our population ages, the follow-up of chronic conditions discovered during before or during an inpatient episode can be for a long time, if not life-long.

This results in unnecessary consumption of the MOH Budget (i.e. taxpayers money).

This policy has been in place for a long time because policy wonks are worried that folks will game the system. I.e. these folks want the best of both worlds: by consuming inpatient services paid for insurance and then using subsidised services when insurance coverage ceases. But in reality, as we shall see, this worry has been downgraded somewhat in recent years.

If one thinks about this again, by continuing with this policy or practice, many people end up using subsidised, inpatient services unnecessarily which generally speaking, are a lot more expensive to the taxpayer than outpatient services. Again, we have to remember it is better if policyholders finance their healthcare needs with insurance monies than with tax revenue.

However, if we truly allow patients to cherry-pick (by using insurance-funded inpatient services and taxpayer-funded subsidised services), then a problem will arise with the first and second groups. The attraction of subsidies is so great that some folks in these groups will migrate towards outpatient subsidised services.

There is already some pre-existing friction put in place to discourage this because one cannot choose the specialits of his choice in subsidised services, whether inpatient or outpatient. Also, appointment times for private SOCs are significantly shorter than subsidised SOCs. But this hobbit readily admits this friction or obstacle is not really big enough to prevent overconsumption of subsidised services. Further trade-offs may be therefore necessary.

Moreover, access to subsidised specialist outpatient clinics (SOCs) and services have been made much easier in recent years with the CHAS, Pioneer and Merdeka Generation benefits. It used to be that only polyclinics and A&E referrals will give a patient access to the subsidised SOCs. But now any Healthier SG family physician can make referrals to the subsidised SOCs and their patients will enjoy subsidy levels according to their CHAS, Pioneer, Merdeka Generation card status. This is what I mean when I say the worry of overconsumption of subsidised services have been downgraded somewhat in recent years.

This hobbit doesn’t have the data, but it would be good if someone with the data does a simulation on how much of the MOH budget is used to finance subsidised inpatient cases that come from IP policyholders who voluntarily downgrade at the inpatient level. These are the potential savings from that could have been realised if inpatient subsidies were not doled out to this group.

This hobbit would like to suggest that to reduce the number of IP policyholders voluntarily downgrading to subsidised services without using their IP benefits, it is worthwhile to just allow IP policyholders to choose a private service for an inpatient stay and then let them have the option of choosing subsidised SOC services when they go for follow-up. If the policy wonks are worried that this would lead to everyone choosing subsidised SOCs, then we can perhaps strike a compromise – we would limit this option to conditions that had been newly diagnosed (i.e. just before or during the inpatient stay) for the purposes of this inpatient or procedural episode.

For example, if a patient goes for a Total Knee Reconstruction (TKR) at a private hospital or as a Class A patient in a RH, but is diagnosed to have diabetes just before admission as he is being assessed by the anaesthetist, then he should be given the option after the operation to be followed up at the subsidised SOC at a RH. The subsidised SOC can then decide to follow-up this patient or discharge him to the polyclinic when his diabetes stabilises.

Today, certain RHs already allow for downgrading to subsidised SOCs after B1 or A class inpatient episode. But to further discourage unnecessary downgrading, we should maybe allow private hospital inpatients (not just RH’s inpatients) to use subsidised SOCs as well after IP coverage expires.

If the patient or IP policyholder is given this optionality of delinking outpatient subsidy from the inpatient episode, we can perhaps get more IP policyholders to use their IP benefits at the inpatient level and rely less on funding via subsidy, i.e. how much the government or taxpayer pays.

What Our Healthcare Can Learn From DeepSeek

This hobbit came along this article in The Straits Times recently, “How did DeepSeek build its AI with less money?” by Cade Metz. The original article was first published in New York Times on 12 Feb 25.

Some points mentioned in this article hold lessons for us working in healthcare and is certainly worth mulling over by the big shots who design and implement our health care systems and policies.

The overarching theme of DeepSeek’ success was that it achieved just as much by using less. The big American AI companies typically used 16,000 specialised chips (i.e. Graphics Processing Units, or GPUs, produced mostly by Nvidia) to train their LLM (Large Language Model) chatbots. DeepSeek only used about 2000. In doing so, it saved on a lot of resources, including not just chips, but energy as well, because these chips consume a fiendish amount of energy and sending data between these chips consumes even more energy. Such activities release a huge amount of heat in the process. These chips are housed in huge data centre buildings that produce so much heat that they need another building to cool the data centre building.

The article claimed that DeepSeek’s “engineers needed only about US$6M in raw computing power, roughly one-tenth of what Meta spent in building its latest AI technology. It is no exaggeration to say that DeepSeek has demonstrated a quantum leap in efficiency that has completely changed the game in town. Here are a few lessons we can learn from the development of DeepSeek that we can perhaps consider for healthcare:

Lesson 1 – Spread out the work, pair the expert with the generalist

The first strategy and technology DeepSeek employed was to use a method called “mixture of experts”.

“Traditional” (if there is such a word) AI companies employed a single neural network to learn literally everything under the sun. This monolithic approach takes many chips, time and energy. The designers of DeepSeek split the system into many neural networks, each learning one area of expertise. Each smaller neural network concentrated on one particular field. In itself, this is nothing special. What made DeepSeek special was the designers then paired these specialist neural networks with a “generalist” system. This generalist system then helped to coordinate interactions between the many expert neural systems.

Now, it is not uncommon for a single patient, whether inpatient or outpatient, to generate several referrals to other specialists in the hospital or specialist outpatient clinics. There is no generalist involved. Once the polyclinic or family physician makes a referral to the specialist or hospital care system, the patient is then often stuck in the environment for a long time, if not forever. There is no generalist coordinating care there or interactions between specialists. The family physician or generalist only coordinates care when the patient leaves the hospital system. Perhaps we can consider having generalists in the hospitals and specialist outpatient clinics to coordinate care and cut down on unnecessary processes that consume lots of time and resources.

Lesson 2: Do not aim for perfection

We are told that the training of AI neural networks basically relies on multiplication of numbers: “months of multiplication across thousands of computer chips”. These chips pack their numbers into 16 bits of memory. But DeepSeek developers managed to squeeze these numbers into only 8 bits of memory, thereby lopping off “several decimals from each number” and saving a lot of memory space in the process. The answer so produced was less accurate but it did not matter. The article stated that “the calculations were accurate enough to produce a really powerful network”.

But that’s not the end of this story. One now has to multiply all these 8-bit numbers together. DeepSeek now stretched the multiplication answer across 32 bits of memory, and in doing so, made the answer more precise. Which is why DeepSeek performed just as well if not better in certain areas that other AI platforms consuming far more resources.

In healthcare, doctors and other healthcare professionals are reminded that we owe the patient a duty of care. Arising from this duty is the concept of standard of care. What is the standard expected of us in every instance of care we deliver? This used to be determined by our peers, but somewhere along the way, the concept of “best practice” crept in.

Best practice is laudable and of course something we should aspire to give. But does the required standard of care necessarily equate to best practice? This hobbit thinks not but many others think so. When a doctor is found wanting in a disciplinary inquiry, the standard of care quoted is often best practice. And when what was done does not quite qualify as best practice, the doctor can be found to be guilty of negligence or professional misconduct etc.

For example, should a doctor be punished when he did not see the patient personally but relied on his registrar’s assessment, (even though he did see the patient eventually, albeit 12 hours later), or when he did not order a CT scan one day earlier than when he actually did, and relied on blood tests and an erect Chest x-ray in the meantime to detect an intestinal perforation? Somehow along the way, our medico-legal environment has conflated required standard of care with best practice, the equivalent of the 16-bit number, when what is needed (or what we can afford) is really the 8-bit product.

We need to learn that “good enough” care is what we should be delivering most of the time, especially in situations where resources are limited and public funds are used. Of course, when one is paying for their own care out of their own pockets and if they can afford it, they can ask for best practice care all the time. Elon Musk and Jeff Bezos can ask for and pay for best practice care all the time. But in reality, most of the time and for most people, “good enough” care is all that the person or the system can afford.

This can also be seen in how we choose our healthcare IT systems. Do we have to choose the most comprehensive (read: expensive) system with all the bells and whistles that costs not just an arm and a leg but all four limbs to implement and maintain? When most of the time, these additional features are either not required or used at all? Why should we choose the most “perfect” IT system for our hospitals? Could we not have settled for less, i.e. settled for an 8-bit product and not 16, and maybe tried to stretch the output to a 32-bit after we are familiar with the system? Could we not have chosen a good-enough system instead of the best system?

Lesson 3: Prioritise your work

Not mentioned in the aforesaid NYT or ST article but mentioned elsewhere is that DeepSeek uses a new way of prioritizing data which uses far less memory space than older methods. This is known as Multi-head Latent Attention (MLA) as opposed to the traditional Multi-head Attention (MHA) method. MLA has been demonstrated to use only 5 to 13% of what MHA uses and in doing so, allows for far more efficient training and deployment. The multiplications we mentioned earlier results in much data produced. These data are stored in the form of fundamental data structures known as Key-Values, (KVs) which are then stored in the memory cache.

MLA allows for low priority KVs to be compressed into what is known as latent vectors and in doing so, MLA reduces the KV cache size dramatically. When these low priority KVs are needed, they are decompressed again for use.

Sometimes in healthcare, we attempt too many things at once. Our in-trays (physical or virtual) are loaded to the brim with different things that demand our attention at the same time. They can range from service requirements to teaching responsibilities to research projects. The myriad of demands we make on the system and on our healthcare professionals, in the end creates so much complexity and consumes so much attention that the system slows down or even gets paralysed.

Another good example is how we structure our subsidy system with layers and layers of schemes that makes things so complex that our hospitals’ IT and billing systems cannot cope. The result is slower and unsatisfactory performance of both the staff and the IT systems.

We could perhaps look at all the balls we are trying to juggle in the air and prioritise the work. Schemes that have marginal impact would be merged or even dispensed with altogether. Focus on only the few things that matter. Often, a person or an institution cannot be good at all things all at once. Less important things need to be compressed and cached, maybe even disposed.

If your institution’s waiting time is now a year, perhaps it is time to focus on service delivery and minimize other non-essential stuff. Getting your doctors to run ad-hoc clinics can help in the short run, but it may not help in the long-term, as job satisfaction decreases and more people quit, leaving the organization in a vicious cycle of attrition and more work. It is far better to prioritise your work (and your people) and cut back on the non-service delivery work. Compress and cache these non-essential work for now.

The above are just three simple examples of how we can learn from DeepSeek. There are many others. The underlying principle of why DeepSeek is revolutionary is that its developers experimented with solutions to real problems and obstacles. The solutions they tried are not just incremental in nature or doing more of the same thing. By many accounts, most of the folks who worked on DeepSeek were young people fresh out of college and they looked at things with a fresh perspective. They undoubtedly experimented many times and failed but by thinking out of the box, they came up with something that was faster, better and far cheaper that what had come before them.

Likewise, healthcare system planners should be bold and not think of doing more of the same, because seeking out and getting incremental change is just not good enough anymore.

The Sure and Quiet Death of Duty of Care

As reported in The Straits Times, MOH recently published data that showed Integrated Shield Plans (IPs) varied widely in terms of coverage and lifetime price (Integrated Shield Plans lifetime premiums vary widely across insurers, MOH comparison shows” (1 July).

This is hardly surprising and shows that there is some form of competition between insurers and collusion does not exist, which is good.

However, as Saw Swee Hock School of Public Health Associate Professor Wee Hwee Lin noted, “This is clearly useful for people to review their existing insurance policies but with caveats. It is not possible for people with existing medical conditions to switch providers.”

Price is easy to understand, but coverage less so. As journalist Ms Salma Khalik noted in the above article, “To confuse matters further, the lowest coverage may not come from the insurer charging the lowest premiums”.

Understanding coverage requires much more technical knowledge and research effort than comparing price or premiums.

Or for that matter how insurance companies operate.

To understand this, the hobbit would like to point you to another Straits Times article published on 19 June 2024 written by a CEO of a financial advisory firm, “When it comes to financial advice, do your own homework” (by Chuin Ting Weber). This hobbit must confess that he has found this to be one of the most illuminating articles published this year. Here is what she wrote,

“The truth, or the whole truth?

Financial advice, like medicine and law, is a licensed profession, Professionals know more than the people they serve. Often, clients don’t know what they don’t know. This knowledge asymmetry imposes an ethical responsibility on a financial institution (FI) and its representative to go beyond basic honesty, to care about their clients’ interests.

How far this responsibility goes, however, depends on the standard applied. In Singapore, FIs are held to the “suitability” standard (emphasis mine); financial products recommended must be appropriate to the consumer’s financial situation and goals…..

….However, this still falls short of a higher “fiduciary” standard adopted by some countries. A fiduciary must make recommendations in the best interest of the client, even if it means decreased remuneration for the FI or the adviser”.

She then gave the example that a retiree seeking a stream of income was given a recommendation by a financial adviser or FI to buy an insurance product when she should have gone for a higher CPF Life payout by getting the retiree to top-up her CPF Retirement Account. Recommending her to buy the insurance produce was not untruthful, but “the more complete truth” would be recommending her to consider topping up her CPF Retirement Account.

She adds “If fact, FIs can even argue that their advisers should not do that (recommending the retiree to top up the CPF Retirement Account). Because while their responsibility towards the consumer (i.e. the retiree) is on a suitability basis, their responsibility towards shareholders is on fiduciary basis”.

After reading this article, this hobbit was deeply troubled. But this also explains why the medical profession is often at logger heads with the insurance companies and the twain shalt never meet (at a place of peace) given the gulf in fundamentals.

Doctors owe a duty of care to our patients. This is to be found in the SMC Ethical Code and Ethical Guidelines. In reality, duty of care is really fiduciary duty in medical-speak. That means we must do our best and put the interests of our patients before our own interests.

On the other hand, Financial Institutions (all insurance companies that sell IPs are FIs licensed by the Monetary Authority of Singapore) puts the interests of its shareholders above that of its customers. As aforesaid by Weber – the FI owes a fiduciary duty to its shareholders but not to its customers/policyholders; it only has to offer “suitable” insurance products to its customer, which may not be in their best interests.

When “suitable” is not good enough

Contrast this to an actual case that went before SMC and the Courts. In 2017, a prominent private sector oncologist was suspended by the Courts for 8 months after an appeal was filed for a SMC case. In fact, the Courts said that had it not been for the long delay by SMC to hear the case, the suspension would have been 16 months.

What did this oncologist do to be punished so heavily? Answer: He had “wrongly held out false hope” to the family by claiming that there was a 70% chance of the cancer patient responding to medical chemotherapy and for not offering surgery as the preferred option for treatment of the patient’s cancer.

That is not to say that chemotherapy was quackery. In this case, chemotherapy was an accepted form of treatment. It was just that surgery was supposed to be better and it wasn’t offered as an option for the patient to consider.

Now if the standards of regulation for FIs were applied to this oncologist, he probably would have gotten away with offering chemotherapy as the (only) option although he may be still found to be guilty of giving the patients’ family false hope.

This is because while surgery was the better option, chemotherapy cannot be considered to be unsuitable; similar to the logic behind the example given in the abovementioned Straits Times’ article – topping up of the CPF Retirement Account was the best option, but recommending the retiree to buy an insurance policy was also “suitable”.

We owe a fiduciary duty or duty of care to our patients, while FIs and financial advisors and insurance agents only need to offer something that is suitable. Which is also why Weber recommends that when it comes to the matter of financial advice, do your own homework!

A wise crack may counter that isn’t it the same with subsidised healthcare in our public healthcare institutions (PHIs)? As a subsidised patient, one has no right to choose their own attending specialist physicians. The hospital will just assign you a specialist. It’s your good luck if you get assigned the professor or Head of Department. Tough luck if you get assigned an Associate Consultant instead. Certainly, an Associate Consultant is “suitable” (because he is indeed a specialist), but he or she can hardly be considered to be the best option the PHI can offer.

Well, there is a difference here. If the case turns out to be complex and beyond the abilities of the AC, he is also duty bound to seek the input of a more senior specialist or even refer the patient to the more senior specialist. This happens at no extra cost to the subsidised patient. If the case is simple and does not warrant the input of more senior specialists, then it can be argued that the outcome is likely not to be significantly different whether the case is handled by an AC or a SC.

The FI test of suitability is a tradeoff between enriching self (the shareholders of the FI and/or the financial advisor) and doing what is best for the policyholder. This is in contrast to the duty of care or fiduciary duty that we owe our patients whereby enriching oneself at the expense of the best interest of one’s patient is NOT allowed.

The triumph of the standard of suitability

Now let us look at another real-life example in the form of an incident involving medical oncology that has happened recently. A medical oncologist was dropped from a preferred provider of an IP panel. No reasons were given, as usual. Any IP insurer will tell you that they don’t have to give any reasons whatsoever for including or dropping a doctor from their panels.

This oncologist began to reflect over why was she (and her colleagues in the same practice) dropped by the insurer. She had heard from reliable sources that her group’s rates were quite reasonable and in fact, she hadn’t raised her rates for 5 years.

She surmised that the reason she was dropped was that she had sometimes used cancer drug treatments which are not on the MOH’s Cancer Drug List (CDL) on a few patients after conventional drug treatments had not worked. She is a domain expert in her area and often gets referrals from other doctors for difficult and complex cases. When the usual options are not effective, she would try something not on the CDL if the patients had bought riders that explicitly allowed for such use (Class A to E of Non-CDL Treatments) as described in the circular issued on 2 September 2022 by the Life Insurance Association, Singapore (LIA). In some of these cases, due to the high cost of treatments, she has often given discounts as well.

If what she suspects the reason behind her being dropped by this insurer is true, then this is a good example of what can happen when fiduciary duty meets the test of suitability. She had tried doing what she thought was best for the patient, given the patient’s dire situation and what the patient’s IP policy is supposed to cover. But by doing so, she will suffer financially going forward because she is no longer a panel doctor with this insurer, i.e. her patient’s best interest has been served at a loss to herself.

On the other hand, the insurer, despite providing coverage for non CDL treatments, may also be sending out a message to other panel doctors that they do not encourage doctors from trying their best (even when it is permitted under the terms of the policy) but instead should just do what is suitable and sufficient, and that the interests of the insurer come before the patient.

The suitable slope to perdition

The future of medicine in especially the private sector will therefore be a contest between a doctor trying to fulfill his duty of care/fiduciary duty to the patient and also funders of healthcare such as insurers trying to impose a lower standard of “suitability” on doctors. The balance of power is clearly on the side of the insurers because they control the funding and they are also accountable to no one on how doctors are chosen to be put on or dropped from preferred provider panels.

In the short term, this is not a bad thing because if everyone just dishes out suitable care, healthcare costs will probably be lower and therein lies the temptation. But in the long run, the patient will suffer as doctors align themselves with their funding masters –  the insurers. This is because the obvious knowledge asymmetry between insurers, providers on one side and the patient/policyholder on the other side is so great that it is not easy for the patient/policyholder to discern he has been given just “suitable” care instead of the best care that owing a fiduciary duty/duty of care requires.

Clearly, in the face of the enormous power and financial resources wielded by FI insurers that are only expected to operate on the standard of suitability, doctors in the private sector must align themselves with the insurers to survive. The tenet of duty of care that we teach in medical schools and to our young resident doctors must eventually yield to such great a countervailing force (of the insurers and their test of suitability) when many of them leave for the private sector.

And before we know it, we may already be well on a fast and slippery but surely suitable slope to perdition.

POSTNOTE (Dated 23 Aug 24): since the publication of this post, a lawyer, presumably linked to the case involving the oncologist that was quoted in this article has contacted SMA more than once with regard to what he or she considers to be a factual error in this post. This lawyer (with reference to the Disciplinary Tribunal’s findings and the C3J’s Decision) has stated that the use of the word “preferred” is incorrect to describe surgery as an option and that the adjective used should be “viable” instead.

There are a few things that need to be stated or restated here

This hobbit was merely quoting the mainstream media (aka The Straits Times) when he used the word “preferred”. Instead of asking lowly me to correct this word, maybe the mighty Straits Times should be asked to make this correction instead. (The news article was published in 2017 and written by Ms Salma Khalik). https://www.straitstimes.com/singapore/health/prominent-cancer-doctor-ang-peng-tiam-given-8-month-suspension-by-supreme-court

All readers should also note for historical reasons, this hobbit is known as “hobbitsma”. But really, this hobbit has been an independent blogger for years and this is clearly stated in the first post on this wordpress platform. So while certain equally old coots in SMA know how to contact me (usually by smoke signal or using the middle-earth equivalent of a mail pigeon), SMA doesn’t tell me what to write or not to write.

Finally and most importantly, the main subject matter of this post is comparing the test of suitability with the duty of care or fiduciary duty doctors owe their patient. And really, it doesn’t matter whether surgery is “viable” or “preferred”. The crux of the matter is that under the duty of care he owes the patient, the doctor would be found wanting if he had not offered surgery as an option, whether surgery was viable or preferred is irrelevant to the outcome at the SMC or C3J level. On the other hand, under the test of suitability, the doctor would probably be found to be OK if he had only offered chemotherapy as the only option offered because chemotherapy is a “suitable” option. Under the test of suitability, one does not have to offer ALL suitable options; the doctor has to offer only one – and that was the thrust of the ST article by Weber.

Therefore, the key point of this hobbit’s discussion that affects the outcome of this case is NOT whether surgery is a viable or preferred option, but which test was applied or is applicable – Duty of Care or Test of Suitability.

So, really, this Postnote is unnecessary. But I have to write this to get my life back. Maybe it is about time to retire and sail off to Valinor

SQUIB GAME AND THE DYAD OF MEANNESS

squib – (noun) A short humorous or satiric writing or speech (Merriam-Webster’s Dictionary)

Since my last post, “Letters to Hobbit 2024” (https://hobbitsma.blog/2024/02/15/letters-to-hobbit-2024/), many more alert and mythical readers of this column have stepped forward to give me further examples of stupid questions and requests from high priests of the Insurer Order. While we politely call them high priests, I have been told these chaps have all the charisma, intelligence and persistence of a lice-infested orc.

Further examples of stupid questions:
• “Why do you follow-up the patient every six-monthly instead of 12-monthly” and “Why do you follow-up the patient 12-monthly instead of six-monthly (same insurance company)
• “Did you attempt conservative treatment for this patient before deciding on surgery?” (For a patient with anal fistula). Purported but unverifiable answer: No. Because like his insurer, he wants to be a perfect ass-hole.
• Why did you do a mammogram only on the left breast? (breast cancer found in the right breast and a right mastectomy had been done)
• Please give a memo describing the indications for and results of the colonoscopy done three years ago (for a claim on an operation for a fracture of the right ankle)

And the list goes on…..

This has become so big a problem that there are anecdotal reports that nurses now coming for job interviews with private specialist clinics not infrequently state up-front that their job scope must not include dealing with insurance companies and insurance claims; if not, they would rather not get the job. So private specialist clinics must now hire separate staff just to deal solely with insurance companies and claims.

Dealing with stupid questions invariably is very demoralising and mood-sapping. Other than perhaps an unreasonable patient or family member, there are few things that can ruin a healthcare worker’s mood more than a stupid question from an insurer. And since we are talking about better mental health and mental well-being for all, including healthcare workers, we should really help them by trying to minimise stupid questions. Stupid questions can be considered to be a kind of psychological abuse of the healthcare worker by certain inconsiderate members of the insurance industry. And since we do not even tolerate verbal or psychological abuse of healthcare workers from patients and their families nowadays, why should we tolerate abuse from these inconsiderate members of the insurance industry?

Time and resources spent answering (often repeatedly so) stupid questions could be better spent on more productive tasks like seeing more patients, not to mention the intangible costs of consequent low morale and poor mental well-being of affected healthcare workers.

All this leads to a less efficient healthcare system and higher healthcare costs because well, stupidity is expensive.

And so, in line with the constructive nature of this satirical column, this hobbit would like to propose that the relevant stakeholders of the health insurance industry start a forum or body to look into stupid questions posed by insurance companies and their staff to healthcare providers. We can call this the “Stupid Questions Under Investigation Bureau” (SQUIB). The administrative support of SQUIB will be funded by hopefully, MOH.

This is how SQUIB can work. The SQUIB Panel can consist of perhaps the following:

• A senior MOH doctor (maybe the Director-General of Health (DGH) or Deputy DGH to chair the SQUIB Panel. He will have the casting vote in the event of a tie
• A representative from Life Insurance Association (LIA) to represent the insurance industry’s interests
• A representative from either a Medical School (like a professor from YLLSOM) or a Professional Body like the Academy of Medicine Singapore to provide the doctor’s perspective on what is good practice of medicine
• A representative from the Consumers Association of Singapore (CASE) to represent patients’ interest

We can also hope that the SQUIB Panel will have a voting representative from the (somnolent) regulating authority for insurers. If this happens, this hobbit will buy 4-D, TOTO and Big Sweep all at one go.

SQUIB will process complaints from doctors about stupid questions from insurance companies. To discourage frivolous complaints from doctors against insurance companies, doctors will have to pay a non-refundable admin charge of say, $100 to SQUIB for each complaint filed.

SQUIB will then consider if the complaint is justified or not justified by its members voting. Whether a question is stupid or not will be decided by a majority decision by its members.

If the complaint is not-justified, nothing happens to the insurance company. If the complaint is justified, then the insurance company has to donate $1000 to a registered charity of the doctor’s choice, in the doctor’s name. If the registered charity is also an Institute of Public Character (IPC), then the doctor can claim a tax break from the donation.

There has been informal feedback that doctors are generally afraid to complain against insurance companies or use a forum like the Multilateral Healthcare Insurance Committee (MHIC) because they think they will be thrown out of the preferred provider panels of these insurance companies they had complained against. And it is indeed a fact that today, insurance companies can remove any doctor from their panel without giving any reasons – when it comes to whether a doctor can be on any panel, insurance companies are the judge, jury and executioner. Hence this climate of fear among panel doctors about bringing unfair insurance practices to light.

To allay these fears and promote transparency, the MHIC and SQUIB should require insurance companies to file a yearly list of doctors that have been removed from their panels and check if these doctors are also registered complainants to MHIC and SQUIB. Should they be, then MHIC and SQUIB can request a full report from the insurance company to justify why these doctors have been removed from their panels. If MHIC or SQUIB is not satisfied with the report, then they can refer the case to the insurance regulator for further investigation for possible victimisation of or retribution against complainants by insurance companies.

Finally SQUIB can publish a ranking of insurance companies according to the number of (proven) stupid questions complaints received by SQUIB. They should even publish the stupid questions themselves, if nothing but for a good laugh.

OK, so much for stupid questions. We move on to more latest developments in the health insurance sector. And yes, they are getting murkier by the minute.

Dyad Of Meanness

Recently, there has been feedback from a galaxy far, far away on quite a few incidents involving this insurance provider which we shall fictitiously call “I-come-steal”. Now, I-come-steal has not always been so coveting. They had been quite kind and cooperative previously and they had reimbursed doctors well, often up to the top end of benchmarks, giving doctors very decent income. But they have since left their cooperative stance and gone to the dark side.

Things got even darker when they appointed this claim administrator which happens to be owned by a major facility provider. We will likewise give this claim administrator a fictitious name, “I-am-strange”. There is obviously a potential conflict of interest with I-am-strange. I-am-strange can deny claims from doctors and then benefit from this denial at two levels. Firstly, they get the usual fees from the I-come-steal for services rendered. Secondly, they can shift the money they had squeezed from the doctor to the facility bill side, which will benefit their owners. Basically, they can swop or “exchange” the doctors bill to the hospital bill component. This hobbit has no evidence this has happened, but many doctors this hobbit has spoken to have brought up this potential for double benefit and potential conflict of interest. And apparently, bills incurred at other facilities do not incur the same kind of intense scrutiny as the ones incurred at facilities owned by I-am-strange’s shareholder, which only serves to reinforce this perspective on the ground. All this hobbit can say is I-come-steal and I-am-strange form a formidable Dyad Of Meanness, like The Emperor and Darth Vader.

Next, we move on to another purported example of this Dyad’s shenanigans. They are very quick to explore loopholes in our healthcare system. An example fee is the loophole found between Table of Surgical Procedures (TOSP) and fee benchmarks. In the interests of keeping up with progress in medical science, and to reflect current practice, there is a committee overseeing TOSPs that comes up with new TOSP procedure codes from time to time. So for example, a new surgical code may be created to reflect a combined operation involving two procedures. But the well-meaning TOSP committee’s creation of new codes is not link to the Fee Benchmarks Committee’s work. So this new code does not have an official MOH fee benchmark.

I-come-steal/I-am-strange then conveniently tells the surgeon that the use of an old code (for an operation he has performed for years) is now not accepted. He has to use the new code. The old code may have a fee benchmark (issued by MOH) that is from e.g. $10,000 to $20,000. As a result, the mid-point for the benchmark is $15,000, which is what the surgeon is claiming for, and also what he has been paid in the past. He is now told that he must claim under the new code, for which there is no MOH benchmark. Instead, I-come-steal/I-am-strange now issues their own benchmark of say, $11,000 to $15,000 for this new code. The midpoint is now only $13,000 and the doctor will be reimbursed as such. Which is kind of ridiculous when the new code is supposed to cover an operation which is more complex and involves more resource utilisation but which the insurer has conveniently given an internal reimbursement value that is lower than the old code (for a simpler operation), just because MOH hasn’t issued a fee benchmark for this. This surreptitious move to use new codes with no fee benchmarks is something policymakers should look out for. At the very least, perhaps a new TOSP code can be issued only if it comes with a fee benchmark, to prevent abuse by any insurance provider.

That’s all for this month. This hobbit really hopes someone in MOH will take up the proposal to organise SQUIB. SQUIB Game will be fun and charities will also benefit, which is a very good thing. In the meantime, let’s hope someone keeps a close watch on the unpleasant stuff being dished out there in spades by the Dyad.