Subsidy and Other Preoccupations 20

It's not fair, is it? Making angry doc angry on a Sunday morning...


(emphasis mine)

Means testing on track for implementation in January 2009
By May Wong, Channel NewsAsia

SINGAPORE : The government is on track to implement means testing in January next year at all public hospitals.

Health Minister Khaw Boon Wan said preparations are on-going to link up with agencies like the Central Provident Fund Board and the Inland Revenue Authority.

Means testing helps to focus healthcare resources to needy Singaporeans, with low-income citizens receiving higher government subsidies.

Mr Khaw was speaking to reporters after launching a campaign on colorectal cancer on Saturday.

[snip]

Means testing will ensure lower-income Singaporeans have access to subsidised wards like C-class hospital beds.

This scheme will also ensure such beds are not overcrowded by those who can afford higher medical bills.

Mr Khaw said: "I expect a January implementation which is hassle free and ought to be uneventful. (The) majority will not have a problem with means testing and (for) a small minority of high-income patients, the criteria are very generous, so they'll be expected to pay a little bit more, but not a lot more. (It will be) well within their affordability level. So Singaporeans need not worry."

[snip]


It doesn't quite add up, does it?

Let's look at the statements angry doc highlighted in turn.


"Means testing helps to focus healthcare resources to needy Singaporeans, with low-income citizens receiving higher government subsidies."


While the statement is technically true, it is misleading: "low-income" citizens are not going to enjoy higher subsidies than they already do now; instead, "high-income" citizens are going to enjoy lower subsidies than they already do now.

As the minster put it:

"a small minority of high-income patients... they'll be expected to pay a little bit more, but not a lot more."


How much more is "a little bit more"?

A patient with monthly a income of $5,201 and above will receive a 65% subsidy for Class C instead of the usual 80%, while a patient whose income falls between $3,201 and $5,200 will receive a subsidy of between 65-80%.

Given that "the scheme will not affect 80 per cent of Singaporeans", this means that (assuming similar bill sizes between the two groups) even if we assume that the 20% of patients who fail means testing all receive only 65% subsidies instead of 80%, we stand to 'save' 6.25% of spendings in terms of subsidies*. angry doc agrees with the minister that this is "not a lot".

If we take into account the fact that some of these 20% of patients would not have chosen to stay in a C-class bed to begin with, means testing or no, then the 'savings' will be even less than 6.25%.

So let's say means testing allows us to "focus" this 6.25% in "resources" to low-income patients; will it "ensure such [subsidised] beds are not overcrowded by those who can afford higher medical bills"?

angry doc doesn't think so, since according to the FAQ on Means Testing on the MOH site:

"Patients will still retain their freedom to choose their ward class. Any patient, regardless of whether they are rich or poor, can choose to be admitted to a Class C or B2 ward. They will still be heavily subsidized, but at different rates."

So they are free to choose their ward class, they are "heavily subsidized", but the MOH nevertheless expects them to *not* choose a C-class bed. Interesting.

And if they are still free to choose a C-class bed (and who wouldn't? It *is* "heavily subsidized"!), will means testing still "ensure lower-income Singaporeans have access to subsidised wards like C-class hospital beds"?

angry doc will leave his readers to answer that question for themselves.


* - angry doc's maths is poor, so do let him know if he made a error there.

Subsidy and Other Preoccupations 19

After a long period of speculation, we now know how means-testing for inpatients will take:

(emphasis mine)

Healthier coffers, rising costs
MOH gets 19% budget boost to meet subsidy and manpower needs
Tan Hui Leng

AS Singaporeans grapple with medical costs that shot up by 7.4 per cent last year on the back of imported inflation, the Ministry of Health (MOH) is getting a rare 19-per-cent boost to its budget this year — a necessary prescription to meet the need for more manpower, rising expectations and subsidies to help patients cope.

For one, $1.9 billion will be spent over the next five years to grow the pool of doctors, nurses, pharmacists and allied health professionals by 40 per cent.

"Our doctors and healthcare professionals are overworked and at some point, they need a life too," said Health Minister Khaw Boon Wan, noting how director of medical services K Satku was "sleeping less and less", juggling between surgeries and meetings, while younger doctors were "working day and night to meet the needs for increasingly more demanding patients and relatives".

Apart from overseas recruitment — last year, 438 doctors came from abroad, nearly twice the 230 who graduated locally — the bigger budget allows for twice the number of scholarships for allied health professionals this year, plus a new overseas degree-conversion scholarship for Nanyang Polytechnic graduates.

More competitive salaries, too, are needed to retain those enticed by competitive posts abroad and even from the booming local hospitality sector.

But the bulk of the $421-million increase in the MOH's coffers will go towards subsidised patients. Indeed, direct subsidies for class B2 and C ward patients will likely exceed $1.7 billion this year, said Mr Khaw, who unveiled the finalised details of the means-testing scheme to kick in next January at public hospitals.

Sporting "more generous" criteria following feedback from public dialogue sessions and Members of Parliament (MPs), the scheme will not affect 80 per cent of Singaporeans — including all housewives, retirees and children living in HDB flats as well as lower-annual value private properties.

Patients with a personal monthly income of $3,200 or less will continue to enjoy the full subsidy of 80 per cent in class C and 65 per cent in class B2 wards. The higher up the salary scale one is, the smaller the subsidy entitlement.

"We will be flexible at the margins to help those who may appear to be of high income, but who have exceptional financial liabilities," said Mr Khaw.

Similarly, at the other end of the income scale, many of the people in need "end up paying nothing" after some help from Medifund, he said to Nominated MP Siew Kum Hong's suggestion to give an even bigger subsidy to such patients.

And while the minister acknowledged that — as some MPs pointed out — per capita household income was a better gauge of financial ability than personal income, this would be costly to implement and "intrusive to every patient". Should one feel unfairly treated, a thorough means-test can be done upon appeal.

Rising costs will continue to be a worry as health spending goes up from 4 per cent of GDP to as much as 6 per cent in the medium term, said Mr Khaw.

"Last week, (MP) Dr Ahmad Magad related a personal experience during which his daughter was hospitalised in a private hospital. He said he almost fainted when he saw the bill of $2,300 for a two-day stay."

But what is contributing partly to cost increases are Singaporeans' higher expectations. Take the 11-per-cent jump in attendance at emergency departments last year, said Mr Khaw, which creates the need for prices to be adjusted to deter non-emergency patients.

Likewise for subsidised wards, the continual upgrading of services is drawing more higher-income patients — hence, the need for means-testing.

But while the MOH's bigger budget will result in improved clinical care and hopefully shorter waits for medical services, Mr Khaw had some words of caution. Don't expect "on-demand service" like that in five-star hotels. And beware that it does not lead to a vicious cycle of even higher expectations and more cost spikes.

Non-constituency MP Sylvia Lim asked if the MOH shouldn't in fact moderate such expectations. Mr Khaw responded that even as he would be "the last one to be fanning expectations", he could not ignore the growing demands for better public healthcare standards.

For instance, one such improvement will see the bed-to-patient ratio, which stands at 1.6 per 1,000 population now, improve to 1.8 by 2015.


The news article on the CNA site gives more details, and tells us that:


"Higher income earners will get subsidies on a sliding scale of one percentage point, depending on their income range. This is capped at 65 per cent for Class C wards and 50 per cent for Class B2 wards for those earning more than S$5,200.

Economically inactive patients will also receive full subsidies unless they live in a property with an Annual Value exceeding S$11,000.

...

As for those who feel the simplified approach has treated them unfairly, a thorough means-test will be conducted upon their appeal and will be based on the approach that is currently used by nursing homes."


angry doc must say that he is impressed by this new scheme. It leaves a large proportion of patients unaffected, and still gives those who earn more than $3200 a month a substantial amount of subsidy (essentially they may pay B2 prices for a C class bed, or B1 prices for a B2 bed).

There are still a quirk or two in the system, like say how a family with the father as the sole bread-winner earning more than $3200 may be better off if the mother or a child fell sick since they will enjoy full subsidy, than if the father fell sick, since he will not pass the means-test and it will at the same time leave the family without income.

The actual savings in terms of subsidy not given out will probably not amount to much, especially if those who find themselves faced with a large bill and failing the means test can appeal for a 'thorough means-test'. angry doc also notes that the actual amount of money the ministry expects to save is never mentioned in any of the news articles on the subject.

At the end of the day, angry doc suspects, this scheme is probably not aimed so much at reducing government healthcare expenditure by subsidy saved alone but - despite what the minister said - a way to 'moderate expectations'; if this step in introducing the concept that one's inpatient subsidy entitlement is tied to one's wealth is accepted, then it may in the future be easier to implement it in other levels of healthcare, as it has been for nursing homes.

Whether that is a good thing or not will depend on your point of view.

Inertia

I know I promised to be back end of this month but frankly it is a bit hard to get started again after such a long break.

So for a start I will just link to this article on means testing on The Online Citizen. Do have a read.

Subsidy and Other Preoccupations 18 or Edited 3‎

Yesterday Gerald posted the text of a letter he had sent to the ST Forum on the bed shortage situation on the comments section of an earlier post, thinking that they have decided not to publish it.

After reading the letter, angry doc agreed with him - the tone of the letter was... less than complimentary, he thought. But it turns out angry doc is wrong; he had forgotten about the tireless editor of the ST Forum page...


Means test won't resolve social-overstayer issue

I refer to Ms Khalik's [the] article "Means Test the Solution to ease hospital bed crunch" on 25 May 2007. I agree with the Health Ministerthat public hospitals are designed for the acute care of patients, and that patients who are fit for discharge may be better served by step-down facilities such as community hospitals.

However I disagree that means testing is the solution to ease the hospital bed crunch. As currently envisaged, it will apply to everyone [every subsidised patient] staying longer than 5 days, regardless of whether they are fit for discharge or not [1]. As the Minister himself brought up, an elderly patient may need weeks to recover. Is it fair to penalise a patient who needs the bed, but takes longer to recover?

Furthermore, means testing applies only to a subset of patients, namely those who can afford to stay in private wards but choose to stay in subsidised wards. It will not apply, for example, to the destitute old man who qualifies for C class and is fit for discharge, but whose family refuses to bring [take] him home. Means testing will not help free up beds occupied in such a way.

Lastly, inpatient means testing has yet to be implemented, and difficulties are already anticipated. We should concentrate onfulfilling its basic objective (namely to ensure that subsidies go tothose who need them), rather than tack on additional goals.

Therefore I would like to bring to your attention [highlight] a policy that directly addresses the problem of social overstayers and is already in place in our public hospitals. It is available on the he.citizen.gov.sg website, and can be found (aptly) under the "Social Overstayers" heading at http://he.ecitizen.gov.sg/health_dollar_charge_sgh.htm - I quote "Patients who are fit for discharge but insisted on staying on will be charged the full cost of the period of their overstay, from the 7th working day after the hospital has assisted in finding a placement ina step-down care facility."

Rather than use the bed shortage to justify the introduction of means testing, the Health Minister should instead familiarise himself with [we should tap] methods that are simple and already available, and ensure that they are carried out smoothly.

Gerald Chen Zexin

Subsidy and Other Preoccupations 14

An article from The New Paper brings angry doc back to the topic of means testing.

As he has mentioned many times, angry doc is not a fan of means testing in its current proposed form, but here it is not so much the idea of means testing that troubles him as much as the poor arguments for means testing presented by the journalist here. angry doc will interspace his comments (in blue).


Monthly salary $9,300 Hospital ward C CLASS
S'pore's top earners make up 1 in 10 patients in subsidised wards. Time to start means testing?
By Leong Ching

WOULD you give public assistance to the boss of a multinational corporation?

Free meals to a lawyer living in a District 10 bungalow?

Subsidise the Lexus of a coffeeshop towkay?

No?

Then why would you be against means testing? It is just a way of making sure that anyone who needs a subsidised bed will get one.


Wrong, because means testing in its current proposed form will not make sure that anyone who needs a subsidised bed will get one. A rich man can still stay in a C-class ward even if he fails means testing, provided he is willing to accept the fact that he will receive less subsidy than someone who has passed the means test.

And wrong also because means testing does not test "need"; it tests "means". A poor man who passes means testing can still stay in a C-class ward and enjoy the full subsidy even if there is no compelling medical reason for him to be there.

So between a rich man who needs a bed and a poor man who does not need a bed, who is denying the poor man who needs a bed his bed?


Without means testing, some of the rich, and even the very rich, are enjoying government subsidies by choosing to stay in lower-class wards.

Yesterday in Parliament, two vital pieces of information emerged about health care here. First, we are short of hospital beds. Second, we are throwing government subsidies at certain well-off people.


The two issues are actually not directly related: a rich man who needs to be admitted will take up one bed regardless of how much subsidy we give him, just as the poor man. The amount of subsidy a man receives has no direct impact on the total number of beds in the system.


Said Health Minister Khaw Boon Wan: 'Our current bed situation is tight, particularly in the Tan Tock Seng Hospital as it is the only hospital serving the large population in the north besides its own catchment area.

'The over-crowding in TTSH in turn causes spill-over to the other hospitals, especially National University Hospital and Changi General Hospital.'

There will be relief, he noted, when the new general hospital in Yishun opens in three years' time. There is also another general hospital in the west being planned.

Each year, Singapore will need another 60 to 100 new beds - many in subsidised wards.

Beds in B2 and C Classes are heavily subsidised, the latter to the tune of 80 per cent.

How do we make sure that these wards go only to those who need them?

Another way of saying it - how can we make sure that those who can afford it, do go to the less-subsidised wards?

The policy objective is the same - but the political nuance is vastly different.


Nuances indeed. Here the writer continues to make the error of equating ability to pay with (non-)need, and that the bed situation is a result of "those who can afford it" taking up the beds of "those who need them".


The second way of saying it leaves it open to those who want to score political points.

'Sure, I can afford to go to a better class, but I don't want to,' they say. 'And you are wrong to make me.

'I may get a higher pay, but I want to spend less on health care.

'And if the next guy doesn't pay taxes and I do, I would be even more entitled to a C Class bed.'

These arguments are very appealing to the sandwiched middle class, who may be struggling to raise kids, care for ageing parents and find hospital bills an onerous expense.

This by itself does not contradict the principle that the rich should not get handouts. It merely tells us that we ought to be careful whom we call 'rich'.

For example, a family may earn $5,000 from two incomes, but they might deserve some subsidies if there are three little children and four old folks to take care of.

The devil is in the details. And here are more details to light the way.

The Ministry of Health yesterday released numbers to show the profile of the people who used CClass wards in 2004.

They were startling - they showed that 9 per cent of C-Class patients were from households whose earnings were in the top 20 per cent.

That is to say, nearly one in 10 patients who used C-Class wards came from a household earning close to $10,000 a month.

One-third of all C-Class patients were from the bottom 20 per cent of households.


Ironically, these statistics suggest to angry doc that we have too many C-class beds, not too few. Otherwise, why are only one-third of the beds occupied by the poor people?


According to the Department of Statistics, the top 20 per cent of households earned $9,300 a month, whereas the bottom 20 per cent earned $1,180.

So, in the democratic environment of a C-Class ward, a man who earns $9,300 a month enjoys the same handouts from the Government as the one who earns $1,180.

Is this fair?

Another quarter of C-Class patients come from the lowest 20th to the 40th percentile.

So, by and large, more poorer Singaporeans are using the most highly-subsidised ward.

But why are rich Singaporeans there as well, and in numbers as high as 9 per cent?

ALLOTMENT VS RIGHT

Some may argue that they are there because they are as frugal as the next guy. Why deny them the right?

Well, because a government subsidy isn't a right - it is an allotment, in the same way that public assistance and food rations are.

One MP asked Mr Khaw yesterday whether he was going to implement means-testing.

He replied that it was 'at the back of my mind' but that he had many other issues to deal with - including the reform of Medishield and Eldershield.

'I will come to it,' he said.

One reason for the long percolation could be the political price. After all, the $9,300-a-month man would not take kindly to his low-priced hospital stay being taken away from him.


Except the "$9,300-a-month man" may end up with a $300,000 bill, which even at 65% subsidy (but before Medisave) will take "$9,300-a-month man" a full year's income to pay off. Hardly "low-priced", is it?


Madam Halimah Yacob, who chairs the Government Parliamentary Committee on Health, had warned that an extensive public debate was needed 'so that people are adequately prepared and are not caught by surprise by the change in policy'.

Last month, the Health Ministry said there would be some kind of means testing within a year.

I would say - let's start now, and start with the $9,300 man first, followed by the $5,000 man.


angry doc would say: start with looking at more aspects of the issue first, followed by getting your logic right, then start thinking about whether we should even implement means testing in its current proposed form.

Subsidy and Other Preoccupations 13

Yet another letter to the press on the subject of means testing:


By all means, add subsidised beds
Letter from Lan Zhong Zheng

I concur with the opinion of the reader who wrote the letter, "More hospital beds the remedy" (April 26).

Indeed, from my fleeting hospital attachment at one of the restructured hospitals in Singapore, I managed to catch a glimpse of the crunch faced by government hospitals here.

There was an appalling paucity of available beds in the heavily subsidised wards, while the exact opposite was obvious in the "paying patient" wards.

There were even instances where subsidised patients in the Intensive Care Unit (ICU) were transferred to a Class A ward, just to squeeze out a bed in the ICU for someone whose condition was believed to be more dire and life-threatening.

The ultimate solution is not to carry out means testing on Singaporeans but to increase the supply of beds in the subsidised wards in hospitals here. Implementing means testing infringes on the right of the people to choose.

Does it mean a tycoon should be barred from a superior room and can only stay in a suite? Similarly, why should the middle-income not be given the option of staying in a Class C ward? Being in the middle-income group does not definitely mean one has the money to splurge on a class B1 or A ward.

Looking into supply should be the long-term solution in addressing this shortage. However, as we all know, land is scarce and government hospitals are stretched to their full capacity in terms of facilities and resources.

Rather than diversifying interests by trying to usurp a slice of the burgeoning medical tourism market, the Health Ministry should draw on the HDB model, which sets out to provide public housing to Singaporeans first, especially the less well-off ones. Drawing on this model, healthcare should be focused on catering to the individual needs of Singaporeans, in particular the subsidised pool of patients rather than having to attract foreign wealthy "paying patients" at the same time.

Means testing may bring instant temporal relief to the current situation but with an ageing population and such uncertain times, no one knows when epidemics like Sars will rear its head again. The bed crunch in hospitals may pose a more serious problem then.


Despite our low beds ratio, angry doc is still not convinced that the root problem here is an absolute bed shortage. In fact, the account given in the letter of subsidised patients being lodged in A-class wards tells us that there are beds available in the hospital.

Nor is the problem one of relative bed shortage alone.

In its currently proposed form, means testing does not forbid one from staying in a C-class ward: it merely reduces the percentage of subsidy a patient who fails the means test receives (to less than 80%, but presumably more than 65%). If the patient accepts the lower subsidy, he may still stay in a C-class ward.

So what is the purpose of means testing then?

Is it "to better target our subsidies at those who need them most"?

If so, does that mean that subsidy for those who pass the means test will be increased to more than the current 80%?

Or, is it to achieve "right-siting"?

If so, means testing seems to be too imprecise a tool to achieve that, since it does not take into account whether or not a patient needs to stay in an acute hospital.

angry doc is, once again, confused. Perhaps all the letters to the press published in the past few weeks will prompt a reply from the ministry which will answer all his questions.

Subsidy and Other Preoccupations 12

An interesting letter to Today today which attempts to look at the issue of means testing using statistics:


More hospital beds the remedy
Means testing: Are S'poreans abusing medical system or is capacity just insufficient?
Letter from Tony Tan Kok Tee

I read with concern recent news articles on the planned means testing in hospitals here, presumably because our lower-class hospital wards are overcrowded.

The question is, what is the root cause? Is it due to Singaporeans abusing the system, or insufficient hospital beds?

According to the World Health Organization's World Health Report 2006, the number of hospital beds ratio in Singapore (in 2004) is only 28 per 10,000 population. Countries with similar Gross National Product (GNP) per capita as Singapore have a much higher hospital beds ratio than Singapore.

In the 2007 PriceWaterHouseCoopers study on global cities, Singapore also scored badly in this area.

Among the four Asian dragons, the Republic of Korea led the way with 89 hospital beds per 10,000 population, followed by Taiwan (48 beds), Hong Kong (47 beds) and Singapore (28 beds).

Among the countries with US$20,000 ($30,200) to US$40,000 GNP per capita as indicated by the International Monetary Fund, only five countries had fewer than 30 hospital beds per 10,000 population in 2003/04. They are Kuwait (21 beds), the United Arab Emirates (22), Brunei (26), Bahrain (28) and Singapore (28).

Since Singapore has been benchmarking itself in many areas against advanced countries, I think we should do likewise in the hospital beds ratio.

If our hospitals are indeed overcrowded, then building bedrooms carved out from wards for loved ones to stay, as reported in a newspaper article, will only worsen the problem.

If there is a genuine need for such accommodation, our Government may wish to allocate nearby land for such purposes and encourage private enterprises to build and manage them to complement the hospital services.

Our Government has also done a fantastic job in marketing Singapore as a medical hub and I fully support the initiatives. But if our public hospitals are also targeting the foreign patients, will there be pressure to convert the already limited wards to better-class wards/facilities at the expense of lower-class wards?

If we have insufficient hospital beds for our current population, it will be a bigger challenge to handle the additional 1 million foreign patients without compromising on Singaporeans' increasing medical needs.

Our Health Minister mentioned that means testing is to prevent Singaporeans from abusing the system. But, is that the case?

Is the "sandwiched" middle class abusing the system if they choose to stay in lower-class wards even if their income is above average? They may have two sets of elderly parents, ailing loved ones plus school-going children to care for. I would like to think they are being prudent.

Should we force them to stay in upper-class wards and deplete their savings faster?

Compared to the lower income earners, these middle-class earners may seem "well-off", but the reality may be the opposite. Every family is unique and means testing will not be able to accurately capture the increasing financial constraints of this middle class.

Another solution to the overcrowding problem, rather than adopting means testing, is to increase the number of hospital beds — beyond the planned Jurong and Northern General hospitals.

The increased capacity will not only give all Singaporeans a choice and not deprive them of the opportunity to stay in these lower-class wards especially if they are financially constrained, but also help us service the increasing foreign patients.

Our Government will have to decide whether all Singaporeans — regardless of financial health — are entitled to basic, low cost, no-frills healthcare services.

We're not asking for free medical treatment or hospital stay like in some countries, but to have a fair system for all Singaporeans.


Comparing our bed ratio to those of the other developed Asian countries, angry doc is tempted to conclude that we do suffer from bed shortage.

But wait.

Mr Tan goes on to tell us that the countries with the lowest bed ratios include Gulf states like Kuwait, UAE, and Bahrain.

Now Kuwait, UAE and Bahrain are not exactly Third World countries, with what the oil bursting out of the ground, so why would they have bed shortages? Moreover, healthcare in Kuwait, UAE and Bahrain are actually quite good, so their low bed ratios do not seem to translate to poorer healthcare for their residents either.

So what's happening here?

Well, disease patterns and health-seeking behaviour differ from country to country. A low bed ratio does not necessarily mean that the people are sick and unable to get a bed in hospital; it might just mean that they are mostly healthy and do not need to be hospitalised. On the other hand, a high bed ratio may also not mean that everyone who needs a hospital bed will get one, if access to hospital is difficult, hospitalisation fees are high, or if the beds are 'oversubscribed'.

What we perhaps need to do in asnwering the question of whether we have a problem of bed shortage is to look at data other than bed ratios.

What is the occupancy rate of beds by ward class like?

What are the waiting times from the emergency department to the ward?

What are the waiting times for elective admissions like?

Those statistics, angry doc believes, will give a better picture of whether or not we do have a bed shortage problem here.

But even if we do have all those figures, and even if we do have a proven bed shortage, it does not answer Mr Tan's question of whether the root cause is that of a fundamental bed shortage, or whether it is that of abuse. A hospital with a high occupancy may have a high abuse rate if most of the patients in fact do not require hospitalisation, just as a hospital with low occupancy may in fact have a zero abuse rate if all the patients are there for medical reasons.

We cannot have a system that will prevent abuse unless we have a system that has the moral courage to identify abuse and to stop it. Until we do that, everything else we do is just penalising people who genuinely require healthcare.

Subsidy and Other Preoccupations 11

The ST Forum published a letter from Gerald today:


Have disease-specific time limits for means testing

I REFER to the editorial, 'Means testing a minefield' (ST, April 19). Most people would agree with the principle that the less well-off should receive more subsidies. However, follow-up questioning would likely reveal that none of them would consider themselves as 'well-off', and therefore they, too, should be deserving of subsidies.

Therein lies the difficulty of means testing - everyone agrees with the principle, but the devil is in the details of the implementation. I would like to make the following suggestions for the public and Health Ministry to consider.

Firstly, on the qualifying criteria for subsidy, no matter how the cut-off line is drawn, there will be unhappiness among those above the line. The use of a sliding scale, so that everyone enjoys at least some subsidy, is to be commended.

Furthermore, the criteria should keep pace with healthcare inflation. For example, the current maximum of $500 per capita family income for downgrading to C class was implemented in 2001. Data from Statistics Singapore shows that health-care costs have risen by almost 10 per cent since then, and only 238,000 households met this limit in 2005.

Secondly, the proposed limit of five days' stay in a public hospital is too simplistic. Certain conditions, by their very nature, necessitate a stay of more than five days, e.g., colon-cancer operation. It is also for these very conditions that we worry about chalking up large bills, rather than one-off admissions like childbirth, hernia surgery or knee replacement. With disease-specific data readily available from Casemix, the ministry should instead set disease-specific time limits.

Lastly, the public is apt to view this exercise as a cost-cutting measure. To assure us otherwise, the Government should channel the projected savings back to us, especially to those who will be affected adversely by means testing. This could be in the form of an upgrade of our MediShield packages, to assure us that although we may no longer qualify for C-class subsidies, we would still be able to afford the necessary health care when the need arises.

Gerald Tan Jit Shen


Setting disease-specific time limits sounds like a way to fine-tune means testing. Perhaps we can go one step further and implement different cut-off income levels for different diagnoses too. The background work will probably be a nightmare, but it does sound like something the ministry should look into.

Rational Rationing

"Healthcare has to be rationed. The only question is how best to do it."

So writes Dr Crippen in his latest post is on the subject of, well, rationing healthcare.

Dr Crippen believes that one of the causes for the long waiting time in the NHS is abuse of healthcare by "people who do not understand that health care is expensive", and advocates a front-end charge for healthcare.

"There needs to be a front end charge for health care. Yes, a “charge” at the point of entry. That charge needs to be a percentage of the costs of care that each patient needs. And yes, that means that some will pay more than others; that those with poor health will pay more. The system must be properly safety netted by means testing so that none will be denied health care because of cost but all must pay something."

It's a controversial idea for those used to the 'free at the point of delivery' NHS, but here in Singapore we are already familiar with the concept of co-payment.

Unfortunately, in angry doc's experience, co-payment does not always eliminate abuse; it merely imposes a fee for abusing healthcare.

People will continue to use the healthcare system inappropriately as long as they can afford it, and means testing will not be a satisfactory tool in discouraging people from abusing the system.

Let's look at a couple of hypothetical scenarios.

Mr A makes $4500 a month. He lives with his elderly mother who had a stroke, his wife, and their two children.

Mr A wants to bring his family for an overseas trip for a week, but does not want to bring his bed-bound mother along. He brings her to the emergency department and 'requests' that she be admitted. As his monthly per capita household income is $900, he passes the means test and his mother is warded into C-class.

Mr B makes $2200 a month. He is unmarried and lives with his elderly mother, who also had a stroke. His bed-bound mother gets a urinary tract infection. He brings her to the emergency department, where the doctor advises her to be admitted for treatment. As Mr B's monthly per capita household income is $1100, he fails the means test and his mother is warded into B2-class.

Is that fair?

But what if Mr A pays B2 rates for his mother's admission?

What if Mr A pays A-class or non-subsidised rate? Does that mean he is not abusing healthcare?

angry doc believes what determines abuse of healthcare is not whether one pays for it, but whether one actually needs it. Setting arbitrary income-levels to decide who gets how much subsidy is not going to change the fact that fundamentally, most of us feel that given a situation where resources are limited, they should go to those who need them most.

Subsidy and Other Preoccupations 10

An anonymous doctor made this comment on an earlier post which angry doc thinks is worth replying to in a separate post:

My wife is currently pregnant. 25 weeks gestation at the moment.

She had premature contractions.

We went to KKH.

Thoughts ran through my head about what would happen if our 25 week old baby were to be delivered.

Mortality is high. Morbidity is high. A several month stay in Neonatal ICU would cost a lot of money if we were not in C class.

These issues are real. Even for a doctor myself earning a comfortable income, a several hundred thousand dollar hospital bill followed by having to bring up a child with possible disabilities is a very sobering thought.

Luckily for us, no premature delivery occurred.

I hate to say this to you angry doc, but perhaps you need to have a loved one close to you be struck down with illness and then have the government tell you that you can't go to C class because you do not earn <$1000 a month and then later on be saddled with debt of several hundreds of thousands of dollars.

I know someone has to pay for it. But I am still happier paying higher taxes so that all of us do not have to worry so much about the cost of saving our loved ones.

To be frank at one stage I was thinking, it might be better if my soon to be born permature son die swiftly rather than for KKH's neonatologists try to save him.

Certainly isn't a good thought but it did cross my mind. :(

Certainly if angry doc's loved one needed expensive treatment, he would like to receive as much subsidy as he could.

And that's exactly the point of means testing.

Let's look at some figures.

Let's start with a total hospitalisation bill of say $300,000, which is close to the figure in the example provided by LuckSingaporean and the (in)famous KKH premature baby case.

With C-class subsidy, the final bill will be 20% or $60,000.

Assuming a 2-month stay (again using the figure from LuckySingaporean's example and assuming that a baby delievered at 25-weeks gestation is discharged at 34-weeks), at a daily withdrawal limit of $400, Medisave can be used to pay for $24,000 of the bill, leaving an out-of-pocket bill of $36,000.

At B2-class rates, the final bill is 35% or $105,000, with an out-of-pocket bill of $81,000.

Failing means testing does not mean that a patient has to pay the entire sum of $300,000.

Of course, $81,000 is still a lot of money, and if angry doc had to come up with that kind of money, it would mean working harder and scrimping. But can he, in all honestly, say that it is unaffordable?

Assuming angry doc makes $100,000 a year, do you think it is fair that he gets C-class subsidy, and lets tax money take care of the $45,000 difference?

Do you think it is fair for someone who earns more than angry doc (say $600,000 a year) to let tax money pay for the difference?

When looking an extreme example of a $300,000 bill, it is easy to think that anyone but the richest should be entitled to subsidy. However, most hospitalisation bills come up to (only) several hundred or thousand dollars. Is it fair then for angry doc to let tax money pay for the several hundred or thousand dollars in difference, when he can (presumably with his doctor's pay) easily afford it?

angry doc returns to his point that means testing, when it comes to something as variable as hospitalisation in the acute hospital, is a crude tool. At a lower end of the spectrum we may be able to accept saving more tax money by giving people who can afford it less subsidy, but at the higher end of the spectrum I think we can all agree that it can be hard even for those whom we would usually consider well-off. Means testing in its current proposed form does not consider this, and angry doc believes this is why many fear it.

Or maybe it's just that we all just don't want to pay more when we can pay less.

Added: angry doc would once again like to state that he believes subsidy should be tied to a patient's need for treatment rather than a patient's income level.

Subsidy and other Preoccupations 9

Another letter on the subject of means testing in the ST Forum today:


Means testing: Allow less well-off to pay less

WHILE I agree fully with the intention of means testing to bring about a more equitable health-care system, the operationalisation of the aim should not be to make the better-off pay more but to allow the less well-off to pay less.

The Health Ministry's decision to stick with the former indicates that health care is a zero-sum game.

All indicators point towards economic prosperity, so why the need to cut costs now instead of just boosting subsidies from the bottom?

Means testing for long stayers in hospital seems to be based on the following assumptions:

• Patients with more money are not spending as they should on health care.
• They are able to spend but they choose not to for reasons which the ministry feels are invalid.
• These patients deprive the more needy of their subsidies.
• Patients' ability to pay for health care correlates positively to their family income.

Although affordability is an important consideration when deciding on nursing homes versus hospitals or A-class versus C-class wards, I find it rather presumptuous to assume that elderly patients who can afford much better would choose a hospital over a nursing home with a better environment. For the elderly who have lived out a large portion of their lives, costs would probably be a lesser factor over environment and comfort, especially if they can well afford it.

Another debatable assumption in means testing seems to be definite familial support for the patient. Family income alone is not a good indicator of how well a patient is able to afford his hospital bill. A family that willingly supports an elderly patient would necessarily give him the best health care and comfort within its means. However, immediate family members have their own family units to take care of.

Furthermore, not all families follow the 'seniors first' rule. In the event of having to choose between paying for one's child and one's parent, many would choose to support the child.

Health care is an essentiality which no one should be deprived of, regardless of the patient's supposed ability to afford higher fees. Policies should not be made based on assumptions of familial support or dubious claims that high-income patients choose to stay in a poor man's ward.

Fang Shihan (Ms)


Ms Fang makes some valid points, but angry doc thinks some of her assumptions are wrong.

"Although affordability is an important consideration when deciding on nursing homes versus hospitals or A-class versus C-class wards, I find it rather presumptuous to assume that elderly patients who can afford much better would choose a hospital over a nursing home with a better environment."

It makes sense to think that a patient who does not need to stay in a hospital would choose to go to a nursing home instead, but in practice patients resist this as it actually costs less to stay in a C-class ward in a hospital than in a nursing home if one fails the means test. This is in fact one of the reasons given for extending the means test to hospitals (see item 13.).

"For the elderly who have lived out a large portion of their lives, costs would probably be a lesser factor over environment and comfort, especially if they can well afford it."

Again, it makes sense, but in angry doc's own experience this is not always true. In fact, many of the elderly patients he has met are obsessively thrifty when it comes to healthcare expenditure. Patients have asked for 'standby' medication to be added to their subsidised prescription for their overseas trip to China or Korea (thus helping them save a few dollars for a trip that costs them a few thousand dollars).

"Health care is an essentiality which no one should be deprived of, regardless of the patient's supposed ability to afford higher fees."

angry doc would once again like to state that he is not a fan of means testing in its current proposed form, but he nevertheless thinks that we should as far as possible be precise and accurate when we discuss this issue. Means testing in its current proposed form does not "deprive" anyone of healthcare. It does not even "deprive" anyone of subsidy, but just reduces the amount of subsidy they receive. If we misrepresent means testing in an effort to discredit it, we stand to lose credibility ourselves.

"Policies should not be made based on assumptions of familial support or dubious claims that high-income patients choose to stay in a poor man's ward."

Here angry doc agrees with Ms Fang. angry doc would like to know how much we stand to 'save' if means testing was implemented. Perhaps there should be a data-gathering phase where patients who stay for more than 5 days in the C-class ward are subjected to the proposed means test questionnaire. Perhaps it is already being planned or implemented.

Subsidy and other Preoccupations 8

Sometimes angry doc has difficulty deciding whether letter-writers to the ST Forum are cleverly subtle, or just clueless.


Worry and questions about means testing

I REFER to the article, 'Means testing in hospitals within a year' (ST, April 8).

The problem that means testing is trying to resolve is the 'abuse of subsidised health care'. I disagree with this approach.

By applying for C-class wards, a patient is sacrificing level of service, comfort and reduced waiting time. Hence middle-class citizens who can afford better wards must be applying for C-class wards for pure cost savings.

This should be a personal choice. Why can't middle-class citizens elect to get subsidised health care?

Imagine securing a C-class ward, and, after enduring the long queues and a more crowded environment, having to pay B-class prices after five days.

Furthermore, the definition of what a person can afford may vary. Do we use taxable income? Or disposable income? What about the number of dependants? There are many complexities in this financial decision, and devoting the Health Ministry's resources to perform credit assessments on everyone may generate a substantial cost in itself.

If the patient load in C-class wards is getting heavier, wouldn't it be more efficient if more B-class wards are converted to C-class wards?

With the reduced number of B-class wards, their prices can be subject to market forces. Citizens can hence freely elect to pay B- or A-class prices to enjoy better service. I believe this would be a better way of reducing patient load.

The same argument against middle-class citizens enjoying health-care subsidies can be applied to education subsidies. Do we really want to move in that direction?

Soo Kuo-Ooi


What do you think?

Subsidy and other Preoccupations 7

One of the shortcomings of means testing which Mr Chang did not bring up in his letter featured yesterday is the fact that means testing, when it comes to subsidy for hospitalisation, is a crude tool.

Patients are admitted to the acute-care hospital for a variety of reasons, and the costs can therefore vary very much depending on the condition and treatment. Under the proposed means testing scheme a patient who passes the means test will enjoy an 80% subsidy, while a patient who fails the means test will receive something perhaps closer to the B2 class subsidy level of 65%.

At the lower end of the scale, say a 5-day admission for chronic obstructive lung disease at Alexandra Hospital, this 15% difference translates to something in the region of $300.

At the higher end of the scale, say a 12-day admission for a coronary bypass at National University Hospital, the difference is in the region of $2000.

So while the percentage differences are the same in both cases, angry doc believes that it is the absolute amount that patients are worried about.

Further, angry doc believes that the absolute amount needs to be seen as a percentage not just of the total hospital bill, or against the per capita household income, but as a percentage against the total hosehold income and what it means in terms of the reduction to the per capita household income.

Let me illustrate this with a couple of examples, using a threshold of $1000 per capita per month (see here for why I chose this value) and two patients whose incomes are $100 above and below this threshold respectively.

Mr A, who has a wife one child, earns $3300 a month. His per capita houshold income is $1100 and he fails the means test.

Mr B, who lives with his parents, wife, and two kids, earns $5400 a month. His per capita household income is $900 and he passes the means test.

Mr A and Mr B are both admitted for coronary bypass. Mr A's bill comes up to $4844, while Mr B's bill is $2768.

Mr A's bill translates to 12% of his total annual income, and Mr B's bill translates to 4.3% of his total annual income.

In other words, Mr A, whose absolute total annual income is lower than that of Mr B, pays a higher fee than Mr B, both in terms of absolute amount, as well as in percentage terms.

angry doc can easily see why Mr A will think means testing is an unfair system.

Subsidy and other Preoccupations 6

As expected, a letter on the ST Forum on means testing.

Mr Chang sounds angry, and his letter looks a little disorganised (and angry doc had to rearrange a couple of paragraphs to make his commentary below). He uses many arguments that people use when faced with the prospect of paying more for healthcare. Let's have a look at them together, shall we?


"I STRONGLY disagree with the plan to introduce means testing in public hospitals ('Means testing in hospitals within a year'; The Sunday Times, April 8).

Why are Singaporeans paying more in income tax, based on earnings, and getting less or no subsidies in hospitals? Isn't this a double whammy? Middle-income earners are likely to be the hardest hit again.

What is the justification for taking away subsidies because of a heavier patient load in hospitals? The heavier load should be managed through beefing up health-care staff and more funding from the Government. This is especially so in the face of an ageing population."


At first glance Mr Chang's argument makes sense: why should one tax-payer receive less subsidy compared to another tax-payer who has a lower income, since he, by virtue of the fact that he has higher income, pays more taxes? Let the government government rather than tax-payers pay for the required funding and staffing, he argues.

Now assuming that the other government expenditure remain static, any increase in government funding in healthcare will necessarily come from taxation. And if we assume that this taxation will come from income tax with the same exemption for people who do not make the minimal taxable income, such a system will benefit the lower-income group, and 'penalise' the middle income group who do pay income tax, and also all tax-payers who do not utilise the subsidised healthcare system.

So at the end of the day, unfortunately, a middle-income earner will still have to pay for his healthcare, either out of his pocket or through his taxes.

(If you are interested, angry doc has previously tried to estimate how much increase in taxation a fully funded healthcare system will mean.)


"Hospitals already have a first-line check. The minimum entry level is B2 class. Downgrading to C class involves much red tape, which prevents people from abusing the system."


angry doc is not sure that the minimum entry level is B2 class, but downgrading to C class is difficult, although there are ways to beat the system...


"Having a child with a critical long-term medical condition means having to visit the hospital on average once a week, be it inpatient or outpatient.
...

The Government has been encouraging young parents to have more children but its actions are not in sync with this drive."


One can in fact utilise the same argument to argue against an increase in the cost of almost everything: petrol prices because children need to go to school, food prices because children need to eat, property prices because they need a place to sleep, and so on. O! won't somebody please think of the children?

To be fair the government does provide many things in the form of free healthcare for children, such as free immunisation and free screening by the School Health Service Division, and until recently free weight reduction programme in the form of the TAF Programme.


"As a Singaporean and a taxpayer, I would expect to be taken care of and not have to compromise on health care because of uncertain financial support.

...

Medical subsidy should not be given on a case-by-case basis. It should be an entitlement of the Singaporean taxpayer, who should not have to 'beg' for it during trying times.

Chang Kiang Meng"


These two paragraphs give the two key obstacles to the implementation of means testing: that it offends our sense of entitlement, and that it can be demeaning.

angry doc believes that most Singaporeans do view healthcare subsidy as an entitlement - something they earned just by being a citizen and a tax-payer - and so it seems like a perversion of justice when those who pay more taxes should be denied benefits from the very system they have contributed towards.

angry doc is no fan of means testing, but he nevertheless thinks he might need to re-examine this sense of entitlement. Means testing in its current form does not deny one subsidy altogether - it merely reduces the amount of subsidy one receives - nor does it deny one affordable healthcare. If we all make the connection that the subsidy being given comes from the taxes we pay ourselves, perhaps the idea of means testing will become more acceptable?

The final sentence in Mr Chang's letter tells us the other reason for resistance to the implementation of means testing: people do not like to beg.

Being subjected to means testing can be a demeaning experience. One is required to provide proof of one's poverty, as it were.

angry doc has seen some patients who would rather give up on their applying for financial assistance than to turn up for the interview and provide the required income data. Perhaps they didn't really need the financial assistance or would not have made the cut. Perhaps their per capita household income was too high, but their family did not give them enough money to see the doctor. Perhaps their pride did not allow them to go through the whole process.

Whatever the case, angry doc imagines that the means test is one test that a patient wouldn't feel good about whether he passes or fails it.

Subsidy and other Preoccupations 5

Seeing as how means testing is likely to become a hot topic over the next couple of weeks, angry doc would like to draw his readers' attention to this excellent repository of news articles and letters on means testing in Singapore.

Subsidy and other Preoccupations 4

After years of anticipation and uncertainty, we finally have a projected date for the implementation of means testing.


(excerpt)

Means testing may kick in within next 12 months: Health Minister
By Hasnita A Majid, Channel NewsAsia

Means testing may kick in within the next 12 months, says Health Minister Khaw Boon Wan.

And the first to be affected will be patients in C-class wards who stay more than five days in hospital.

Patients in C-class wards now enjoy an 80 percent subsidy.

But the Health Ministry realised that not all patients need such a subsidy, as there are some in the high income bracket who choose to be hospitalised in such wards.

To ensure that there is no abuse of the system, the Health Minister says means testing must be done on those who stay more than five days in hospital - the average length of stay.

Means testing, which is a way to determine how much subsidy a patient should get, is already done in nursing homes and community hospitals.

Mr Khaw says: "We are in this business where all of us want to constantly improve our service level. But if your prices are wrong, if they are heavily subsidised or free or whatever, you are going to attract more and more patients to you, including those who can go to Gleneagles Hospital and Mount Elizabeth and so on. And we have very good doctors, very good specialists. So we know that at the end of the day, means testing are important.

"And until you introduce proper means testing, I'm afraid all these problems will remain, will simmer. I'm seriously thinking about all those who are long stay, who should now be discharged to community hospital, we should do means testing on them. Now they are saying that if they go to nursing homes they will be means tested but if they remain at SGH they are not means tested, therefore it's cheaper - then we will never solve this problem."

Mr Khaw says for those who can afford to pay more, their subsidy may be reduced to less than 80 percent but they will not be asked to move to a higher class ward.

However, he is not keen to extend means testing at the polyclinic level for practical reasons.

Mr Khaw says: "It's not just looking at your personal income - we are talking about family income here. The whole family should be supporting the patient. So therefore I need to know how many children you have and how much are they earning. And we cannot have self-declaration because everybody will say they are poor, they earn $800 when actually it may not be so. So you begin to see the complexity of means testing.

"We know that at our polyclinics, waiting time is already very long. If at the counter we are going to start asking all these questions, you know, I think we cannot do business. We will end up doing only means testing and no treatment. So it's not practical unfortunately."

Mr Khaw was speaking at a dialogue session on on Saturday with unionists in the healthcare sector, where he answered several questions.

(click here to read rest of article)


Announcing the decision at this time is really bad timing.

Timing aside, angry doc wonders what life in a C-class ward where not everyone pays the same fees will be like. Will those who receive say 70% subsidy feel that they are entitled to better care and service compared to those who receive 80% subsidy, since they pay more? How will the staff and 80%-subsidised patients feel towards them? Will they simply decide that they should just upgrade to B2 class and receive 65% subsidy instead?

angry doc is still ambivalent about the whole concept of means testing; he believes that the right way to control government healthcare spending should be rationing based on need (for the treatment) rather than ability to pay.

For angry doc to embrace the concept of means testing, it will require him to make a paradigm shift and see subsidy not as a form of entitlement which all citizens should enjoy equally if they wished, but as a form of, well, subsidy for those who need them.

Parkinson’s

No, not the talk show host, not the disease, nor even the dirty joke about how old men in the old-folk’s home prefer old women with that disease, but this letter from the ST Forum today:


Dec 7, 2005
Review doctors' working hours, for safety's sake

I refer to the article, 'Checks in place to manage stress, fatigue' (ST, Dec 2), which stated that pilots are not allowed to fly more than 100 hours in any 28 consecutive days. This is to ensure that they fly with full concentration and deliver passengers safely to their destinations.

I wish to relate this to the plight of doctors here. Not long ago, an article in Time magazine reported that in the United States, around 98,000 deaths each year are the result of medical errors. Could some of these errors be due to fatigue or poor concentration?

I have friends who are junior doctors. They tell me their workday typically starts at around 7am, when they prepare to do ward rounds, after which the rest of the day is spent mostly in the wards carrying out instructions given by senior doctors. Their day theoretically ends at 5pm, but they do not usually leave before 6pm.

And when they have night duty, they work continuously from 5pm till the next morning. Thereafter, they continue the morning's duties like in any other day. They are allowed to leave only when they have completed the tasks for that morning. Many a time, it can be as late as mid-afternoon. That means they would have worked non-stop for close to 24 hours. And these night duties can occur up to six times a month.

These junior doctors are always stationed in the hospital wards and if their concentration and competence are affected by fatigue, are we not placing patients at risk?

Are we so short of doctors? Or are the hospitals swamped with too many patients? As with passenger safety, when there are patients' lives at stake, it makes sense for doctors' working hours to be reviewed.

Chris Tan


The opening analogy is interesting, not least because junior airline pilots earn more than junior doctors, and few patients are worth as much as aeroplanes. But the bit I would like to rant on is the last paragraph.

I believe that Parkinson’s First Law, which states that:

Work expands to fill the time available for its completion

also applies to subsidised healthcare.

The cost of unsubsidised healthcare is so high and hence the subsidy so attractive, that people will continue to seek subsidised healthcare and stretch it to its capacity unless one or both of two things happens:

1. It becomes so dangerous or unpalatable that people would rather spend the extra money than to receive it.

2. A system is in place to deny people of subsidised healthcare, based on whatever criteria as the case may be (e.g. means testing).

It seems that the author of the letter is arguing that we should do something about doctors’ work hours before 1. becomes a reality (some would argue that it already is a reality), without implying that 2. is the solution.

I don’t think anyone is actually perpetuating the current system of night-calls which really means six or more 36-hour shifts per month just to torture junior doctors. A simple calculation will tell you that to have separate night-shift doctors will mean a doubling of manpower requirement if after-hours are to be fully-staffed, or a 50% increase if it is on half-staff.

The current manpower shortage simply does not allow that, even if we had the money to employ the staff. Or is it a distribution problem? Can we increase the manpower pool by luring GPs in the private sector to work as junior doctors for a five-figure salary?

It might work, but that will drive healthcare costs up to an amount we are not willing to bear. Plus from Parkinson's Law, one can predict that people will continue to consume as much healthcare we can provide.

Something has to give.

I don't really wish to see 1. happen, so I guess I have to root for 2.

I'm not a fan of means testing as it stands though - it allows for a situation where a poor person may over-consume healthcare he does not need with impunity, while a rich person who needs it for a major illness can quickly become no-longer-rich from having to pay for it.

Even though this is theorectically a question of economics, as doctors we see this being played out so often you wonder if there is a fairer way of doing it.

Other People's Money 3

I nearly missed the reply from Touch Home Care:

Nov 15, 2005
Care for elderly: New fees allow more access to wider range of services

I refer to the letter 'Government should relook at the means test for medical subsidy' by Ms Wendy Teo (ST Online Forum Nov 9). We thank Ms Teo for bringing this matter to our attention.

The means test is commonly used by agencies for individuals who wish to apply for subsidies. The objective of the test is to ensure better allocation of resources in providing financial assistance to the people who need it most.

Although the means test has been used by the government to determine its subsidy level to our clients since 2002, TOUCH Home Care (THC) only started charging fees at the beginning of this year as it was able to sustain its free services in the past.

In Ms Teo's case, her mother had enjoyed free services, fully subsidised by THC, for the past three years. However our client base has doubled over the last few years.

To effectively meet the needs of our existing and future clients and to sustain our services, it has become necessary for us to charge fees. We hope to ensure the prudent and efficient use of resources while meeting the needs of the elderly under our care.

We fully empathise with Ms Teo's situation and wish to assure her that THC is committed to do its best to help the elderly enjoy greater independence and better quality of life at home.

We are constantly reviewing our policies to improve our services to those in need and we welcome feedback. For this reason, we have recently developed a new fee structure in which a client pays a flat rate instead of being charged on a per visit basis.

This new structure allows our elderly clients to have access to a wide variety of services, including occupational therapist support, counselling services, visits by doctors and nurses, at a flat rate.

The new fee structure is partially subsidised by THC as we are mindful of the financial challenges faced by families which do not pass the means test.

We are glad that Ms Teo has found our services useful. We invite Ms Teo to meet us for a discussion so that we can better understand her situation and explore alternative arrangements.

Kavin Seow
Programme Manager
TOUCH Home Care

Other People’s Money 2

This letter is from the ST Online Forum yesterday, but I thought I would comment on it relation to today’s ‘Clues for the Clueless’.


Nov 9, 2005
Govt should relook at the means test for medical subsidy

My mom suffered three strokes and was bedridden since 2002. Ever since her discharge from the hospital, Touch Home Care (THC) has been taking care of her. It started with free service provided by THC.

Beginning this year, I had to pay for each visit ie. $29 for a nurse and $88 for a doctor. When the nurse comes, she checks my mom's blood pressure, cholesterol and conduct other tests.

When the doctor comes, it is a routine check on my mom's heartbeat etc and he writes a prescription for her medication. The nurse and doctor rotate to come once every month. So on average I have to fork out $58.50 per visit per month.

But starting next year, I have to pay a monthly premium of $148 regardless of the number of visits. This is because THC has implemented a new fee structure and I failed the means test. So I am not entitled to any form of subsidy, which comes directly from the government.

Why I failed the means test? It's because my family head-count consists of only two members ie. my mom and I. I am the only child in the family.

I am earning over $2,000 a month. I hired a maid to look after my mom full-time. Therefore I am not entitled to any subsidy. Subsidy provision is only for those who pass the means test with $750 and below per head. In this case, my means test is $1,000 per head.

It does not take into consideration my hiring a full-time maid to look after my mom. This costs me $300 (salary) + $200 (levy). It does not take into consideration that my mom has to wear adult diapers, which cost $100 a month.

It does not take into consideration that my mom's medication costs $35 a month. It does not take into consideration the daily expenses incurred ie. three meals a day for my mom and the maid, about $10 a day or $300 a month.

How about my own personal expenses? I have to work, eat and pay for transportation, insurance, etc. Or maybe I should not work, just so that I can pass the means test to enjoy the subsidy from the government.
Sure, I can look after my mom without the maid. But without any income, who's going to pay for my mom's diapers, medicines, food, etc? Can the government provide these necessities as well?

On one hand, our government encourages its citizens to work even beyond retirement age. Our government also encourages us to stay with our parents to help look after them in their old age.

Does this include sending our aged parents to an old folks home when they are no longer of help to the family and considered 'useless' when they are helpless? Is this the only solution?

Can we as their children provide some form of filial piety at home instead of sending them to a lonely and cold home? Even if we choose to send them to a home, it doesn't come cheap. Again, depending on the means test, we may have to pay between $1,500 and $2,500 a month.

So what is this means test all about? To turn away people who may really need the government's aid? Is this a fair measure? Maybe the government should weigh the means test on a case-by-case basis. Or maybe the government is inflexible about handing out subsidies?

I guess my family is not the only one affected by the new fee structure implemented by THC. But then, other families may not voice their woes like I do.

Ever since I received the 'service agreement' letter from THC, I have been calling many 'home medical service providers' for help. Most of them were helpful in answering my queries but they were of no assistance.

That's because my mom's case is under THC, and THC is the only community provider in the precinct which my family resides. Given no choice, I have to continue with THC, which I feel is unjustifiable.

It's not because of the money problem, but I feel 'cornered'. If I do not continue with THC, my mom would not be able to get her medicines unless I 'force' her to go to a (polyclinic). In this case, I have to pay for the ambulance service to fetch my mom there and back.

Or maybe my mom should just forget about taking any medicine if she thinks it is becoming too troublesome, which she might just do. But being filial, being the only child, I have to continue providing my mom the best when she is alive and it's not fair for her to suffer.

Probably that's why there is this saying that goes: 'You can die here but cannot fall sick.' Dying is so easy and it is a one-off payment, whereas when one falls ill, the amount to spend is without limit.

I sincerely hope the government will relook at the means test. Is this really the fairest way to measure one's wealth? I wonder.

Wendy Teo Whee Chin (Miss)


Ms Teo’s situation is as she said by no means unique, and I hope she gets the help she needs.

Means Testing is by no means perfect, and letters like hers highlight the deficiencies should be taken seriously by the policy-makers. The letter must also have made many readers aware of this entity called 'Means Testing'. Being aware of it is the first step towards understanding it and having an opinion on whether it should exist, and if so in what form.

However, I take issue with the tone of her letter in the form that it appeared. (The editors are sometimes over-enthusiastic in their duties.)

She gives no word of thanks for all the time when she and her mother had received the care free of charge, and in fact dismisses the doctors’ and nurses’ visits as 'routine', which she only accepted because she wanted the medication. The polyclinic, which also provides subsidised healthcare, is a place so unpalatable to her that her mother has to be ‘forced’ to go to.

Ms Teo does not ask why THC is the only service available in her precinct. The answer is THC is part of a not-for-profit voluntary welfare organisation. With every visit they make, they LOSE MONEY! Believe me, if they were making money, there would be more than one service vying for her customs. The money that funds such community services comes from somewhere, and in this case it’s donations and grants. One should be thankful for receiving even if it doesn’t cover all one needs.

It's one thing to criticise and question policies (in fact I think we all should), but another to dismiss the efforts of voluntary welfare organisations and the men and women who work in them, some of who could actually command a higher salary elsewhere but choose to do this work instead.

Charity is not an entitlement.

(angry doc is not affiliated with Touch Community Services)