Medical assistance and healthcare provision in Singapore

Size matters, and so does ability
There’s a general consensus that public and private facilities in Singapore provide an exemplary standard of care. Zeller; Krishnan, and Dr Ulrike Sucher, Medical Director for Allianz Care customers, all agree that Singapore General Hospital and the National University Hospital are among the best public healthcare facilities in the island state; and that Mount Elizabeth Novena Hospital, Farrer Park Hospital, and the ‘ever-popular’ Gleneagles Hospital are some of the best private hospitals.

While, generally, people tend to agree that the quality of service between the public and private sphere is negligible, some … note that public hospitals tend to have longer wait times

In addition, Zeller notes that public hospital KK’s Women’s and Children’s Hospital is the major tertiary referral centre for other medical providers, including private hospitals, for a number of specialisms – in some cases, he adds, it is also the only place that can provide specialised care for young children. Dr Sucher insists that Singapore in general is considered to be the referral medical centre for the whole of Asia Pacific.

In addition to the considerable number of public and private facilities, access to care is greatly augmented by Singapore’s size. Krishnan notes that Singapore has a total land mass of 724.2 square kilometres; and Zeller notes that a large number of Singapore’s public and private hospitals are ‘strategically’ located in the Central region of Singapore. Due to its small area, and meticulously laid out healthcare facilities, healthcare is easily accessible to any patient from any region. “Especially in the case of an emergency, where speed of care is vital,” Zeller added.

But distance is not the only indicator of healthcare accessibility, and some providers note that the geographical structure of healthcare in Singapore is also calculated to accommodate social classes, with the cost of healthcare increasing as you move closer to neighbourhoods packed with expat families, as well as closer to Singapore’s central business district. But before we dive into cost issues, let’s take a look at how the healthcare system in Singapore functions for international patients.

Government-restructured hospitals
A State of Health Insurance¹ report from Pacific Prime cites that Asia hosts the largest number of international migrants, a factor that drives demand for international health insurance plans in the region. It also cites that Singapore, as a financial hub for the region, is fast becoming Asia’s preferred destination for expats, as Hong Kong has begun to lose its lustre for foreign executives. For the climbing number of foreign nationals, healthcare is an important factor of their daily lives.

Expats who are permanent residents or citizens have access to Singapore’s universal coverage system, Medisave, which requires both employees and employers to make monthly contributions to the compulsory state insurance scheme in return for subsidised, affordable hospital coverage. For those working in and visiting Singapore from foreign countries, healthcare is expensive, and so private insurance (either obtained independently or provided through an employer) is a necessity.

Many of Singapore’s public hospitals, including Singapore General Hospital and the National University Hospital, are government-restructured hospitals, meaning that they operate as a private company, but are wholly owned by the Singapore Government through the Ministry of Health, through which they receive a government subsidy for the provision of subsidised medical services. Zeller notes that these government-owned public sector hospitals also operate as private limited companies to compete with the private sector on service and quality, and offer separate treatment rates for non-residents who do not have access to subsidised care.

Zeller explains that these government-structured hospitals can sometimes be problematic for international insurers, who often struggle to get the information required to process international insurance claims. He adds that insurers can find it difficult to convince their members to use the public system to help manage the claims spend. This may have something to do with the perceptions around service quality: while, generally, people tend to agree that the quality of service between the public and private sphere is negligible, some, including Zeller, note that public hospitals tend to have longer wait times – a factor that can lead to care delays at emergency rooms during peak hours, he says.

Further to this, Allianz Care’s Dr Sucher adds that in public facilities, while foreign patients are given priority for life-threatening situations, local citizens are given priority for all conditions. This means that for elective cases, foreign patients have to wait for appointments. “This can make it challenging to get foreign patients access to public hospitals for appointments,” he said.

Still, Zeller reasons that the excellent quality of care and support in public facilities, teamed with the latest and advanced medical technologies and equipment, and their world-renowned vast area of specialities such as cardiology, oncology, gynaecology and paediatrics, compensates for these minor shortfalls.

Doctor-insurer conflict creates challenges
While Carmen Poehlmann-Wolfe, Director of Business Development and Client Accounts at GMMI tells Hospitals & Healthcare that Singapore is generally a well-regulated market for healthcare, in the private healthcare sphere, Zeller divulges that Pacific Prime increasingly notices these facilities recommending members expensive, ‘experimental’ treatment. “Once the doctor has recommended this, it is very difficult to convince members that they can’t have this treatment, and [this] often leaves the member blaming the insurer for hampering their medical care,” Zeller said, comparing this issue to a similarly recurring problem in China. “The main way for us to overcome these challenges is via continued education of members, as well as incentivising members to use the public system, allowing the knowledge of quality of care to spread via word of mouth.”

Zeller adds that making members aware of the overall impact they have on an organisation by choosing the ‘expensive option’ stretches far beyond increased hospitalisation cost claims. It goes both ways, he explained: “It also flows into outpatient claims, where continuing to drive members into the insurer’s panel and offering additional services such as telemedicine can be seen as enhanced service, but also benefits the client overall on a claims performance side.”

Singapore’s ageing population was expected to cause healthcare costs to rise nearly ten-fold over the next 15 years

In addition, while direct billing is commonly available in Singapore (although Dr Sucher notes that for foreign-based insurance companies, local representatives or companies are required to support direct billing arrangements), Zeller says that with members being drawn (sometimes unknowingly) to more expensive treatments, or even being over-prescribed drugs, hefty costs can be immediately passed onto insurers. This ultimately hurts the member too, as it can lead to increased premium costs.

Because of this, says Zeller, insurers are starting to strictly apply the ‘Reasonable & Customary’ rule/clause to their policies, which specifies that they would only pay up to the standard cost for a procedure. “So, if an OB-GYN charges S$10,000 for a procedure that is commonly charged at $3,000, we start seeing some insurers refusing to pay more than $3,000,” explains Zeller. “This obviously leads to frustrations from members having purchased health insurance with high limits of coverage (say $20,000) as they do not understand why the insurer ‘negotiates’ the cost of treatments.”

In these instances, brokers such as Pacific Prime can offer additional services, as they can help mediate. “One of the solutions is also to always pre-authorise your treatments in advance to make sure you do not have bad surprises and the full extent of your upcoming treatment is guaranteed as paid, in advance,” advises Zeller.
GMMI’s Poehlmann-Wolfe insists that, in all cases, accurate communication with providers is key. She said: “GMMI’s medical team is continuously involved in the approval process for services, providing assurance that the ask is clear (what services are covered) and avoiding any potential claim rejections.”

Singapore’s rising cost of healthcare driven by a ‘hyper-ageing’ population
In Asia, Pacific Prime’s report detailed that Singapore witnessed the highest premiums inflation rate, at nine per cent between 2018 and 2019, coming in fourth (out of 100 locations) for the location with the most expensive premiums. “This is reflective of Singapore’s healthcare system, which has seen prices skyrocket in recent years, with the country’s healthcare inflation rate hitting 10 per cent, 10 times the economic inflation rate in 2018,” Pacific Prime wrote.

While the State of Health Insurance report reasons that for the individual buyer, rising medical insurance claims are often driven by poor lifestyle choices, population ageing looks set to play a major role in the rising cost of healthcare in the coming years – especially as it is predicted that by 2050, one-third (33 per cent) of the population is predicted to be over the age of 65 in Singapore².

Indeed, Pacific Prime’s report details that lower fertility rates and ageing populations have become worldwide concerns, especially in developed countries such as Singapore. “This continuous trend creates a burden on local healthcare providers due to the increased spending on welfare and healthcare,” the report said.
Elsewhere, a 2018 report in the International Journal for Equity in Health³, which studied the effect of income disparity on Singapore’s health status, found that Singapore’s ageing population was expected to cause healthcare costs to rise nearly ten-fold over the next 15 years – and this would increase the healthcare disparity gap between the poor and the wealthy in the island state. “With high levels of income disparity, increasing healthcare cost and a decreasing old-age support ratio, elderly persons with poor social support are at the highest risk of having poor health outcomes.” the report read.

Digital healthcare responds to Singapore’s changing healthcare needs
A more pressing factor affecting access to care has obviously been the Covid-19 pandemic. Zeller told Hospitals & Healthcare that while the Covid-19 outbreak has caused some of Singapore’s hospitals to take steps to ramp up capacity (such as increasing bed capacity by more than 30 per cent), all doctors in the public and private sector have – since lockdown measures were enforced – been advised by the Ministry of Health to stop or defer accepting new foreign patients who do not reside in Singapore.

Still, as The State of Insurance report details, a great number of foreign nationals already reside in the Garden City, and for these individuals, much like others across the world, the pandemic has altered the way that they engage with healthcare, so that they access it through an increasingly digital approach.

Zeller notes that the demand for, and usage of, telemedicine is growing in Singapore. Like many other destinations, it experienced considerable uptake during the Covid-19 pandemic⁴, and will likely continue to do so for some time to come. What’s more, thanks to its Smart Nation government initiative – which aims to harness infocomm technologies, networks and big data to create tech-enabled solutions – and it’s strong presence of IT infrastructure (Singapore ranked first in the World Economic Forum’s Global Information Technology Report 2016⁵), digital health solutions look set to become a key feature of Singapore’s healthcare landscape.

Moreover, a report from Consultancy.asia argues that both telemedicine and assistive tech are viable solutions to the looming issue of an ageing population⁶, so it’s likely we’ll see even greater adoption of digital health platforms here in the coming years.

A league above the rest, but for how long?
The provision of healthcare in Singapore continues to advance. Zeller tells Hospitals & Healthcare that the government is increasing healthcare access via its plans to erect additional healthcare institutions by 2030 – four of which will be public hospitals. But, with an increasingly ageing population, and a growing disparity between the poor and the wealthy, the issue of healthcare cost in Singapore looks likely to get worse.

For now, as Krishnan points out, medical case management for international patients here is generally ‘smooth sailing’, thanks to the abundance of quality medical treatments available across the island state, and the recent surge in telemedicine, despite being largely driven by the necessity for remote healthcare during the global pandemic, seems indicative of a growing integration of digital health initiatives.

However, it is worth noting that neighbouring Malaysia’s rapidly improving reputation as a medical destination is something to keep an eye on in the coming years. As a less-saturated market, Malaysia could become a preferred destination for cheaper medical treatment, and could affect Singapore’s monopoly on international patient referrals. Currently, Singapore sits leagues above its Southeast Asian counterparts as a superior destination for healthcare, but as the wheels keep turning, there’s still everything to play for.  ■