How much is that doctor in the window? 3

angry doc is actually quite surprised to find that the SMA's decision to withdraw its guidelines of fees has become frontpage news on Today today.


No fee guidelines – what's up, doc?
Medical association says it had 'no choice' ; MOH to publish fee schedule online

DESPITE the weighty ramifications of freeing up private doctors to set their own fees, few expected the Singapore Medical Association (SMA) to take that step so soon.

So the suddenness of the decision to withdraw its guideline of fees, taken at Sunday's annual general meeting after a year of bandying the possibility about, caught patients — and even some doctors and health officials — off-guard.

Yesterday, Health Minister Khaw Boon Wan expressed surprise that the SMA's fee guide, started 20 years ago to make transparent private medical charges, should be seen by lawyers as contravening the year-old Competition Act. The good news is that his ministry is now planning to publish doctors' fees online to help patients make comparisons.

But, as SMA president Wong Chiang Yin emphasised to this newspaper several times yesterday, the move to axe the guideline was made with "great reluctance". The SMA felt it had "no choice" in the matter.

It was, in effect, a choice of scrap the guideline now — or cough up $200,000 for a decision from the Competition Commission of Singapore that might simply lead to the same result.

Since the Competition Act was enacted last year, the SMA's consultations with its in-house legal counsel had indicated that the guideline was "probably" illegal.

But to get a definitive answer from the Competition Commission, the SMA would have had to foot a hefty bill, said Dr Wong.

Getting guidance alone from the Competition Commission to file paperwork would have cost $20,000, while getting a decision would have cost the non-profit organisation $30,000. In addition, the SMA would have had to cough up some $150,000 in legal fees.

"The penalty (for contravention of the Act) is 10 per cent of turnover for every year of infringement. That's quite a lot," said Dr Wong, who had written to the Competition Commission and requested to meet with them.

The commission did not take up the offer, he said, but merely responded to his four-page letter, noting that the SMA had "received legal advice that the guideline of fees may contravene Section 34(2)(a) of the Competition Act".

Said Dr Wong: "As the penalties are accrued on a daily basis, we had no choice but to withdraw the guideline of fees."

But the move was not taken lightly as it has "huge" ramifications on Singaporeans who typically see a doctor five to six times a year, said Dr Cheong Yeh Woei, first vice-president of the SMA.

Ripples will be felt in a wide range of medical services, such as surgical operations, consultations by specialists and doctors, emergency situations and house calls, as well as fees for court attendance and the retrieval of medical reports.

Apart from obvious concerns about overcharging, there is even the issue of undercutting, said Dr Cheong. Medical insurance claims may also be affected.

Dr Cheong said the association is telling members not to vary fees, keeping in mind that the Goods and Services Tax is also set to rise. Doctors and private medical groups this newspaper spoke to agreed that fees would not rise in the short term.

According to Mr Khaw, the Health Ministry intends to publish fee schedules online "before the end of this year", after it collates data on average bill sizes for general practitioners.

Patients will have to play their part — such as being aware if they are being "over-serviced" and ensuring that private clinics display their fees as required.

"If you go to a clinic and find those things are missing, then vote with your feet. Go to another clinic. Providers will react if consumers are demanding and discerning," he said.

One problem, however, is that there is now no clear recourse for victims of overcharging — under the guideline, they could complain to the SMA. The Consumer's Association of Singapore, or Case, might have to "pick up the slack", said Dr Cheong, "but they have not sufficient know-how".

Despite the medical community's misgivings, the Competition Commission said it welcomed the SMA's move. "This would permit greater flexibility for fees to be set by the medical practitioners in line with their business costs. Such a move is more in line with today's circumstances," it said.

"Consumers would therefore benefit from the greater transparency and competition of prices."

But GPs like Dr Clarence Yeo felt a reference was needed. Ultimately, he said, "we mustn't forget that healthcare is a basic necessity. The basic economics of things shouldn't be extrapolated to healthcare".


Given the apparent enormity of the issue, angry doc wonders why the SMA did not decide to go ahead and spend that $200,000 to get a decision from the Competition Commission; afterall, if the guidelines served the dual-purpose of preventing GPs from undercutting each other and specialists from over-charging patients, and the withdrawal of them would impact all Singaporeans and affect "a wide range of medical services, such as surgical operations, consultations by specialists and doctors, emergency situations and house calls, as well as fees for court attendance and the retrieval of medical reports", wouldn't a once-off expenditure be worthwhile in the long term? Or, if the amount was deemed too big, would it not have been a viable idea to seek help from the Ministry of Health?

The SMA took it upon itself to formulate and publish a set of guidelines it believed to be of benefit to all stakeholders in healthcare, and it apparently still believes in the relevance and importance of these guidelines. It seems a shame now to withdraw them instead of defending them and seeking to obtain a favourable a decision on the issue.

angry doc still thinks that the withdrawal of the guidelines will not mean any significant change in medical fees in the short term: GPs will continue to undercut each other as they have been doing all along, and specialists who can command the premium will continue to impose a surcharge and see a steady stream of patients.

What angry doc sees as significant is how the Competition Act directly challenges the assumption of those of us in the medical circle who believe, as Dr Yeo does, that "[t]he basic economics of things shouldn't be extrapolated to healthcare".