The Dive | We have one of the top healthcare systems in the world, but do Singaporeans agree?

TL-DR – We spoke to young Singaporeans, sandwiched class Singaporeans and older Singaporeans.

Mdm Pea, 70, was admitted to a public hospital after she had constant fever for a month and was in pain. Her X-ray showed a black spot near her kidney and she was scheduled to do an ultrasound the next day. Her ultrasound came back with no conclusion and she was then again scheduled to do an MRI. Mdm Pea had fasted and waited at the hospital for several hours before realising that the hospital had no open slot for her MRI but because of manpower shortage, this was not communicated to her. As a result, Mdm Pea had to fast again the next day when a slot finally opened up.

Mdm Pea’s daughter, Mrs Goh, 43, is a full-time PME and married with no children. Mrs Goh was increasingly agitated with the level of care rendered to her mother by the hospital. The MRI incident was just one of a few of a string of unpleasant incidents. There were other miscommunication on the part of the hospital staff that resulted in Mdm Pea having to draw blood an extra time and also being served lunch at 4-5PM on at least two occasions. These, coupled with the anxiety and stress of multiple commute to and fro hospital and home, Mrs Goh and family were losing not just patience, but also confidence.

Out of frustration at how slow things were moving at the public hospital and further miscommunications, Mrs Goh decided to seek a second opinion at Mount Alvernia (private hospital). The hospital had recommended an operation and advised that it would cost around $60,000 or up to $100,000 if complications developed. The same operation would have cost $20,000-$30,000 less at the public hospital.

But Mdm Pea and her family were more confident and comfortable with the private surgeon and decided to proceed. Mdm Pea’s daughter, Mrs Goh, quipped “Thank God we went private, my mum had a complication that required several additional surgeries. The public hospital would not have been able to cope with this drainage of infection and would have had to move her to another hospital. The doctor also came back on a weekend at 3am to check on my mum. Her insurance also covered half of the costs.”

All in, the entire operation to remove Mdm Pea’s growth cost $100,000, inclusive ot the three additional minor surgeries for the drainage. Her insurance with NTUC INCOME only covered 50% if she chose to go to a private hospital. So Mrs Goh and family ended up having to fork out $50,000 in cash.

 

Singapore has consistently been ranked among the top countries in the world when it comes to healthcare system.

According to a 2018 Bloomberg report, Singapore is second behind Hong Kong. The success of Singapore’s healthcare policy has been much studied and featured, with the Lee Kuan Yew School of Public Policy even calling it the “envy of the west”.

Singapore’s health system is the envy of the West (via)

But do Singaporeans agree that our healthcare system is top-notch?

What do Singaporeans think about our healthcare system?

We spoke to several Singaporeans to get their thoughts on our healthcare system, and came across a mixed bag of comments.

Since we started out with the assumption that people at different life-stages have different needs and expectations, we deliberately spoke to people of different ages and demographic profiles. We identified these three groups of Singaporeans, (1) Younger Singaporean adults below the age of 30, (2) Sandwiched class of Singaporeans who are typically middle-income, middle-aged, and (3) Older Singaporeans.

Across the young, middle-aged and old, rising costs and quality of healthcare were common concerns. However the specific grouses varied depending on the life-stage they were in and whether they had safety nets to fall back on, such as adequate insurance and liquid cash assets.

Young Singaporeans: Lousy doctors, nurses, expensive treatments, but thank goodness we have insurance.

Young Singaporeans: Lousy doctors, nurses, expensive treatments, but thank goodness for insurance (via)

With almost three-quarters of direct care workers in Singapore and more than a quarter of doctors in the public healthcare sector here being foreigners, frictions such as miscommunications will happen.

Mr V Samuel, 19, unemployed shared a bad experience with foreign nurses, “The nurses are very rude. I think they are too busy. So I ask them little things they also like very rude. And they are not local. I think they also cannot understand what I’m saying. I got into accident, went to hospital for treatment, but ended up fighting with the nurses.”.

Besides struggling to fill healthcare positions, as Singapore races to train more doctors, this also means there is a higher chance of patients encountering internship doctors on their rounds.

Mr Melvin Ho’s Son, 6, student, went to hospital as he felt ill. The father, Melvin, shared that it took very long to figure out what happened but there was no conclusion. “End up we still have to pay cash and MediSave for a total of $4,000. I feel that because my son’s condition was not exactly life and death, we ended up gotten lousy intern-doctors. I am not happy with the treatment.”

Although some young Singaporeans feel the quality of healthcare is questionable, almost everyone we spoke to were grateful for MediSave and also their personal insurance coverage, even as they mentioned rising costs.

Miss Wong, 29, full-time PME, suffered from a severe and sudden allergic reaction to a medication. She was rushed to Tan Tock Seng Hospital (TTSH)’s A&E department and was warded for two nights subsequently. Her hospital fees for stay in an A class ward was fully covered and subsidised under Medishield Plan and additional private insurance coverage.

Young Singaporeans with chronic issues or who needed outpatient treatment also benefited from the Medisave and insurance payouts, although they found the treatments expensive if without insurance.

Miss Ong, 28, a full time PME working in a consulting firm, suffers from depression. She is prescribed with antidepressants which she takes on a regular basis to help her treat depression. Each visit to her private psychiatrist costs her about $300. She is glad that her current company that she works for has insurance coverage, otherwise she “would have trouble coming up with $300 every visit to the psychiatrist in the long run”.

Miss Ong is amongst the luckier ones. Our checks revealed that most insurers and company health plans exclude outpatient treatment for psychiatric conditions. Each visit can cost $300-$500 inclusive of medication if you visit a private facility. One can always choose to go to a public hospital, but the appointments may not be as immediate whilst the situation might be urgent or even dire.

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What about MediSave, you asked. The Government has started to allow Singaporeans to use up to $500 per year from our MediSave account with 15% co-payment.

Mr J Lim, 21, who is in the army shares, “Coming from a Singaporean’s point of view, healthcare is sufficiently subsidized at all ages. As I was covered since young, all consultation at government hospitals that I’ve attended was significantly cheaper than private clinics. However, the actual cost of it is still steep. A few thousand dollars for colon cleanse and inspection. Without the MediSave coverage, it’ll be very painful ah.”

MediSave also covered the hospital stay of Jon, 30, a Masters student, who was warded for a night at Ng Teng Fong hospital due to gastric. “One night stay was $800+, damn expensive. But all MediSave cover. So never pay anything, but still feels $800+ is expensive and Medisave is still my money.”

Sandwiched class: The standard of care at public hospitals pales in comparison to private hospitals, General Practitioners (GPs) are becoming more expensive, financial issues with unexpected out of pocket costs, having to bear the healthcare burden of looking after children and elderly parents.

The sandwiched class Singaporeans have to take care of themselves and also shoulder the burden of care for their children and parents (via)

The sandwiched class is not just sandwiched between two sets of elderly folks (parents and in-laws) and their children. They are also being sandwiched in both time and money, and this group of middle-income, middle-aged Singaporeans are generally critical of the quality of the public healthcare system and costs of outpatient treatment.

In most cases, sandwiched class Singaporeans have these aspirations, and there are opportunity costs in every spending decision that they make. But in most cases, something’s got to give, right?

  1. We want to be filial, to take good care of our parents to pay them back for the love and care showered upon us.
  2. We want to give our kids the best possible so that they can be happy and to realise their potential.
  3. We also want to sustain or achieve a certain level of living standard for ourselves.

Ms J Lim, 39, shares her experience that two of her friends went through. Both friends had cancer, but the friend who could afford going to a private hospital had everything expedited, from the MRI to the treatment. In contrast, her other friend who went to a public hospital had to wait longer for everything, including seeing the doctor.

Ms HL Chua, 34, is a full-time working mother of three young children. A recent bout of fever that spread from kid to kid to kid set her back by $500. “I brought them to a neighbourhood pediatrician at Ang Mo Kio, and it’s already $100 for a 10-minute consultation with the PD. The more premium type would probably be $160-$180. It’s expensive lah.”

Nevertheless, there are still instances where middle-aged Singaporeans had good experiences with the public healthcare system.

Mr Siow WJ, a 33-year-old PME says, “I think Singapore’s healthcare is very good. The system is very smooth even when transferring between hospitals. It was very easy for my father who recently had an operation. The wait wasn’t long even when we got a date for his operation. It was also heavily subsidised and I did not even need to worry about it.”

The out-of-pocket costs are a big concern for some people in the sandwiched class, especially when it comes to outpatient and hospital deposits.

Mr M Ho, a father of two, shared, “Singapore outpatient costs at GP are ridiculously expensive. Two days’ MC (medical chit) and some medicine I need to pay more than $50. Self-medicating is cheap but no choice, have to see doctor if we need MC. It’s been a long time since I went to a Polyclinic, but my impression is the wait is very long. Sick where got time to go wait so long. And their doctors all feels inexperienced as compared to private clinic GP.”.

Mr N Chew, a 31-year-old in retail concurred, “GP is damn expensive. I do not even visit doctor when I’m sick.”

Even if there is insurance for outpatient costs, usually the patient has to fork out cash before claiming from the insurer, which can be a deterrent for patients to seek outpatient help.

Furthermore, if GP costs are seen as expensive, patients and families get a bigger financial shock when it comes to paying hospital deposits.

Ms J Lim highlighted that a lot of people are not prepared to come up with cash or credit for deposit when being admitted. “When my younger girl needed to be wheeled to the NICU (neonatal intensive care unit) when she was delivered, my husband had to put down a deposit of $10,000 (as the nightly deposit was $2,000 and the hospital estimated she needed to stay about 5 nights). As she was just born, we had no MediShield plans to cover her hospital costs. When we tried to pay using a credit card, the $10,000 deposit crossed the credit card limit, so we had to look for another credit card.”

“The hospital deposit is something that causes sudden debt for quite a number of people especially sandwiched class. If some families do not own a credit card, then they may need to use debit card but they may not have enough money inside their bank account.”

Having adequate insurance, access to subsidies and enough childcare leave are also important factors when sandwiched families cope with inpatient and outpatient costs and caregiving.

Mr S Leong, 35, social media trainer, is fully insured for private hospitals. “When I fell and hurt myself, I just called my insurance agent and went to a private hospital. The insurance even covered after-surgery care. The doctors and nurses were very nice at the private hospital. A&E was with Changi General Hospital (CGH), also no issue with this public hospital, they sent me in almost immediately and solved my problem. The transfer from one hospital to another was almost seamless as well.”

Civil servants like Ms Chris Goh, a teacher, benefit from having a Civil Service Card (CSC), which subsidises her GP visits by $20 per visit and makes GP a lot more affordable despite only being eligible for selected clinics.

She hopes childcare leave can be reviewed, so that parents with younger children can have more childcare leave instead of just six days of childcare leave throughout your child’s first six years, as younger kids fall sick more easily. Nevertheless, she appreciates having maternity and paternity leave and shares that the Baby Bonus is very helpful for parents.

Elderly: Our public healthcare system offers subsidised treatments but there can be a strain on the system (shortage of manpower, shortage of resources), going private is an option. But not all elderly have insurance. The healthcare benefits under the Pioneer Generation (PG) and Merdeka Generation (MG) packages are helpful, but the burden of care-giving for elderly with chronic illnesses often falls on the sandwiched class.

The Merdeka Generation (via)

A study carried out by Duke-NUS Medical School’s Centre for Ageing Research and Education and the Ministry of Health highlighted a worrying trend – 37% of the above 60 year-olds who participated in the study had three or more chronic illnesses. With Singapore’s population moving towards an ageing population, healthcare expenses for the elderly certainly is a topic that needs to be discussed more thoroughly.

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Mr Neo, 74, was diagnosed with Parkinson’s disease three years ago and as with 50% of the sufferers of Parkinson’s disease, Mr Neo also has depression. While his two children can help with the financial cost, his sole caregiver, his wife, has been tending to him nearly 24/7 for the past years. Due to his condition and also his anxiety over his sickness, it has been rough on Mrs Neo for the past few years. She has to be extra careful with his food since he is very particular. He has also become more sensitive and very prone to mood swings and increasingly, he has become demanding and even restricts her movements. These have all taken a toll on Mrs Neo who has been falling sick frequently in the past year. Their two children can cope with the financial burden of their parents’ conditions, but the care-giving and other emotional parts have become immensely challenging.

Mr Leong, 76, currently suffers from diabetes, gout and has prostate cancer. He sees the doctor very often for his chronic conditions and so far has been able to make use of Government’s schemes to pay for his bills. He is unaware of how much the medical costs amount to as the hospital helps to manage and settle the claiming for him. He personally feels that the public healthcare system has been good so far.

We spoke to another chronic illness sufferer who echoes Mr Leong’s thoughts.

Mr Chua, 63, has been a chronic illness sufferer for a few decades. He contracted blood disorder polycythemia in his 30s and has to see the doctor at Singapore General Hospital every month for a check-up, blood tests and medication. He has been unable to buy medical insurance as he had polio since birth and has to pay out of pocket for his treatments. Thankfully, costs are still manageable. “It’s about a few hundred a month, but I was assigned a blood specialist at SGH. The wait times can be long sometimes but I’m okay waiting and doing my own things. I haven’t had too bad an experience with the public healthcare system besides sometimes having trainee nurses use me to practise drawing blood.”

We also spoke to another elderly Singaporean who is relatively healthy, but she does tap on the public healthcare system regularly.

Mdm Tay, 70, recently had been seeing things (flying insects) in her right eye. She went online to make an appointment at the Polyclinic on a Sunday and the earliest available was a Wednesday slot. Since she did not think it was life-threatening, she took the Wednesday appointment instead of walking in to queue on a Monday. She waited a mere 10 minutes on her appointment day and the doctor advised her to go A&E rightaway that evening. Since she is Pioneer Generation Singaporean, the cost at the Polyclinic came to just a few dollars. She had gone to A&E at the Singapore General Hospital (SGH) that evening and waited for over four hours for her turn. Thankfully, it was a benign case of eye floaters which should go away after a while.

Our Pioneer Generation and Merdeka Generation can enjoy subsidies for GP and dental clinics under CHAS (via)

While elderly with chronic illnesses seem to find the public healthcare system manageable in terms of costs and wait times, this is not always the case when it comes to elderly who require immediate medical attention.

An ex-healthcare worker also offered us some insight from her years working in the A&E and pharmaceutical line.

“I seen plenty of elderly unable to pay cash for medicine even though it is all subsidised already. Somehow it is hard to activate their Medisave. One elderly lady had to pay $800 for her medication but she did not have the cash to do so and even though had $40,000 in Medisave, for whatever reason, she was not able to claim.”

While the 3Ms – MediShield, MediSave and MediFund – generally help in terms of subsidising medical costs, there could still be some elderly that fall through the cracks. When an elderly chooses to go private or does not have insurance, it seems the burden falls on their immediate family to pay for the costs.

For instance, in the case of Mdm Pea that we talked about at the beginning of the article, her family had to decide if they wanted to let her undergo the operation at the public hospital where all costs were covered under insurance, or to have it at the private hospital where it set them back by $50,000. This is not a small amount for most families.

In addition, Mdm Pea’s daughter, Mrs Goh, shared the stress of having to juggle her full-time work with daily visits to the hospital. Even after her mother was discharged, she had to arrange to go back to her mother’s home everyday to help deal with daily post-operation injections. Not all companies provide family care leave or generous annual leave.

In spite of the growing trend of elderly getting more chronic illnesses, there are some doing their part to keep fit and live by the mantra “health is wealth”.

The Ministry of Health has plans to get more seniors moving, including building larger daycare centres that offer a range of active ageing and care services (via)

Mdm Ong, 63, attends exercise sessions twice a week with fellow elderly in a bid to keep active and keep illnesses at bay. She is generally healthy, save for high cholesterol. She discovered her condition from a subsidised health check-up organised by the nearby community centre. She was given a referral letter to her nearest polyclinic and now sees her polyclinic doctor every few months for follow ups. “The wait time can be a bit long sometimes but I read my newspaper or play my mobile games so time passes quite fast. The prices of the consultation and medication are also very reasonable. But of course, I try to keep fit so I can cut down on my medication in future.”

Alas, there is no simple answer to whether elderly can afford to fall sick in Singapore as it depends on a variety of factors. But we do know that for the most part, the public healthcare does seem to be a viable lower-cost option. That said, there is room for improvement in terms of manpower shortage and a crunch on the resources.

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For patients who prefer certain specialists or cannot afford the longer wait times at public hospitals, there is the option of going private – although it comes as a heftier cost for elderly without insurance and is likely to burden their children who may be facing increasing healthcare cost pressure on their own. And while the Government’s 3Ms certainly do help with medical costs in Singapore, we need to ask what more can be done for those who fall through the cracks.

Understanding Singapore’s Healthcare System

Singapore adopts the “S+3M” framework for our public healthcare system. The S refers to subsidies and the 3M refers to Medishield Life, MediSave and MediFund, and the Government uses these different components work together to keep healthcare affordable for Singaporeans.

Statistics have shown that in our public hospitals, 7 in 10 subsidised bills are fully paid without any cash outlay by the patient. In other words, 70% of all subsidised bills do not require any out of pocket cash payment by the patient at all. Of the remaining 30% of bills, one-third require payment of $100 or less in cash, and another one-third is paid for using a cash outlay of between $100 and $500.

he Singapore government’s multi-layered approach to healthcare (via)

Subsidies

According to the Ministry of Health, patients in public healthcare institutions enjoy subsidies of up to 80% of their bills.

MediShield Life

MediShield Life is a universal healthcare insurance which provides all Singaporeans lifelong protection against large hospital bills and selected costly outpatient treatments such as dialysis and chemotherapy for cancer, regardless of age or health condition. This basic health insurance plan is administered by the Central Provident Fund (CPF). and is structured so that patients pay less MediSave and cash for large hospital bills.

MediSave

Most working Singaporeans will be familiar with MediSave, since a portion of our monthly CPF contributions go into the MediSave accounts. Basically, Medisave is a national medical savings scheme which helps us put aside part of their income to meet their future personal or immediate family members’ hospitalisation, day surgery and certain outpatient expenses.

MediFund

MediFund is an endowment fund set up by the Government as a safety net to help needy Singapore citizens who are not able to pay for their heavily subsidised medical care at restructured hospitals. Last year, for instance, MediFund provided about $156.5 million through 1,239,578 applications in assistance to patients who require additional help with their bills. (Other schemes are also available for the needy.)

So where are the gaps and challenges?

From the conversations we had with Singaporeans of different life-stages and from different walks of life, we have formed some initial impressions which may be worth a second or deeper look into.

For the younger Singaporeans, it appears that they are more informed about the entire healthcare ecosystem and they tend to plan early enough and are adequately covered in terms of healthcare insurance. One possible gap we can identify is the relatively high occurrence of mental health issues among the 18 to 34 year-old Singaporeans, depression being the top mental disorder and how the typical insurance and company health covers do not include this.

For the sandwiched class of middle-income, middle-aged Singaporeans, the rising costs of healthcare is a key issue. Many have spoken out about the high outpatient costs of seeing GPs, and we also note the financial burden on them for their dependents. It gets expensive when their children need to see the pediatricians, and it is double whammy if their parents and in-laws also require medical attention, aggravated by how many elderly folks are not adequately insured or the lower-income elderly may not have much in their MediSave accounts.

For the sandwiched class, the problem is not just about money. It is also the whole care-giving stress when they need to bring their dependents to the doctors, or when they need to stay home for caregiving duty. The situation becomes worse when the elderly dependents suffer from chronic illnesses.

For the elderly Singaporeans, outpatient costs are largely manageable, especially with the implementation of the Pioneer Generation and Merdeka Generation packages. But for complicated, chronic and/or even sudden medical emergencies, unless these elderly folks have healthy nest egg for retirement and healthcare needs, the burden can be heavy on their children.

Food for thought

We think it is fair to say Singapore has a reasonably effective healthcare system, but there are gaps and also emerging trends that we need to tackle.

  1. Can we do more for the sandwiched class, especially those who are not rich enough and yet not poor enough to qualify for most of the help schemes we have? And it is not just about the money.
  2. How can we better help people who are suffering from mental health issues?
  3. How can the manpower shortage in the healthcare sector be eased? Demand for manpower is going up, especially with the ageing population. Can technology and digital transformation projects help?
  4. What else can we do to attract and retain healthcare talents? What about their mental well-being?
  5. And of course, how can we promote healthier living for everyone? Keeping everyone as healthy as possible can obviously save a lot of money and pain.

So even if we concede and say that Singapore does have one of the top healthcare systems in the world, it is not the best and there is room for improvement.

In particular, our hearts go out to the sandwiched class.

(Featured image via)

The Dive is our new weekend feature where we bring you in-depth news, interesting insights and different perspectives on the latest trends or issues that matter.

 

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The Editor

Author The Editor

Either busy trying to save the world, or poking my nose into other people's affairs.

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