Written by  2014-01-05

Singapore Healthcare: Can we achieve a peace of mind when we age?

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I am not trained in public health or policies, nor am I an accountant or insurer or have any training in business and finances. However, during the course of my work in the long term care setting, and with my past rotations in the restructured hospitals, polyclinics, private GP clinics, community hospitals, nursing homes and long term home care services; I do very much like to share some insights from my past decades as a clinician and as a fellow average HDB dwelling Singaporean. Like some of you, I do have dementing, dying grandparents and parent with malignancy to care for and pay for. It is already not easy for me as an insider to arrange and manage the health services needed and to contain the costs involved. It must be doubly hard or even impossible for the rest of you out there.

 I have summarized most of the health services needed in one’s life and the biggest costs would be both in the tertiary and long term care setting. (See Annex 1) Many studies have shown medical costs at the last year of life is very much more and with good medications, and efficient and effective care services in Singapore, I dare say we will stretch this last year of life to a few more, hence the cost involved will all escalate.

To me as a physician, all our restructured hospitals are providing very good standard of care and subsidized wards are generally quite affordable. However, due to the constant bed crunch attributable to a sudden population increase, aging population and effective medical treatments, we are always in a hurry to discharge patients. Those who can walk out of hospitals are usually fine and everyone is happy with lesser days hospitalised. However, those that cannot walk out of hospitals may be faced with placement problems and recurring admissions when not well supported in the community. With recurrent admissions, it will further strain the system and escalate costs. Unfortunately, the system favours hospital admissions since it is well subsidised, and able to use private insurance, MEDIFUND, MEDISHIELD and even mobilise MEDIFUND!

On the primary care end, although the cost is usually acceptable and attainable, the biggest problem is still the lack of adequate resources and integration. But that is a discussion for another day. Polyclinic will be the last line of defence and it has been holding up, with more in the pipeline in the near future from the current size of 18.

On acute hospital end, average savvy Singaporean can get private insurances, Medishield with Integrated shield plans and other rider programs etc. Those really cannot pay with no insurance etc can get MEDIFUNDed and VWO support.

On the long term care, it is an issue since not much emphasis has been place in the past and the government has let the charities and private sector take over. Hence, in step down care facilities, just a few years back, there is no government built community hospital or nursing home, rather these facilities survive on its own or services are partially funded by MEANS testing. There is not much insurance when the patient cannot walk out of the hospital for continue care and planning to keep them out of hospitals, hence our readmission rates and heavy workload in the emergency department.

So how much does it cost to maintain a dependent patient in the community? What sort of insurance policies can they tap on at the moment? Apart of the IDAPE/ELDERSHIELD scheme and eSMF which was recently introduced to include consumables, I guess we are on our own. One of the issues is drug cost which is not subsidized when you leave the restructured hospital system but then, there is no so-call hospital system in the long term care setting in the community. We can break down the cost of the patient into a few simple aspects:

1.      Healthcare manpower, including the caregiver, doctors, nurses and therapist

2.      Hospital furniture

3.      Consumables

Let see the cheapest possible cost for a bed bound patient on nasogastric tube feeding (which I can personally do, and which I do for many patients -  for the poorest)

Cost to be cared at home:

90 year old grandmother staying in 3 room HDB, born in 1924, bed bound on nasogastric feeding. This in what I will do usually:

MEANS tested 80% since she lives alone in a 3 room HDB with $0 income, Cost:

1.      Hospital bed at 10% cost (just the single cranking type – new) $690 x 10% = $69,

2.      Air mattress 4 inch $400 x 10% = $40,

3.      Diapers (Tena etc) 5 pieces/day x 30 = $200 to $300

4.      Ensure milk 5 cans/day = $2.00 x 5 x 30 = $300

5.      Care giver – Daughter = Free

6.      Other consumables – NGT set, laxatives, barrier creams, moisturisers, dressing etc = $100

7.      Medications: Dr Tan Jit Seng decided to stop all medications apart from some laxatives

8.      Dr Tan Jit Seng’s review under charity $30 per once in 3 months plus cost of flexiflo $20 = $50. I will include the insertion the NGT and all other possible procedures as well for free.

 

Total for 3 months (maintenance excluding initial hospital furniture =

$200 x 3 + $300 x 3 + $100 x 3 + $30 +$20 = $1850)

One year average = $1850 x 4 = $7400

 

Subsidies eligible:

IDAPE $250 monthly x 12 = $3000

eSMF funding for MEANS tested 80% annually allowed = $2000

 

Total: $7400 - $3000 - $2000 = $2400/12 = $200/monthly.

 

This is the absolute absolute cheapest case scenario and can form the backbone for any further calculations. I see the poorest to the richest and to perhaps maintain a patient from richer family with paid caregiver(s) the cost may be between $1000 to $5000 monthly, inclusive of the medications and without any subsidies or insurance claim.

Cost to be cared in nursing home:

Same patient, nursing category CAT 4:

Nursing home bed norm cost from $1200 to $5000 per month excluding consumables and extra charges/administrative charges depending on the class of stay and before any MEAN tested subsidy. Hence, at maximal 75% subsidy, so the cheapest bed at $1200 will set the family back by $300 before adding the cost of milk feeds/diapers etcs

The cost will only go UP In future.

Hence, I am hopeful that MEDISHIELD Life may be a partial answer for the funding for this group of patient in future. My suggesting would be to either get CPF board or a new government board (even AIC) to run this insurance and for the insurance to include long term care as well in proper accredited nursing homes or home care services. It is stated to be covering all Singaporean citizens and with pooled resources it may be possible. MEANS testing are not as mean as before but can still be quite mean since those middle class who have worked hard for Singapore past 5 decades and achieve a reasonable standard will not get any subsidy and add more liabilities to their younger and growing families. So it depends what are policy makers are leaning towards, it was pretty right in terms of old and frail before but since 2011 GE it has shown to be going towards more left with more mentioning of chronic and eldercare services. 

There are many different healthcare policies in the world, ranging from both extreme ends like universal healthcare in the British NHS, to all private in term of paying out your own pockets for insurances etc. There are countries with state insurance programs, like Taiwan, Switzerland and co-payment programs like 10% of monthly salary for hospitalizations in certain European countries.

Which program is best suited in Singapore? We will see!

So what we can hope to do is to aim for compression of mortality model, where everyone is fit with little healthcare expenditure from year 0 to year 99, get sick and die within 1 year at year 100. This will start from health education from young and change our unhealthy and stressful lifestyle. Possible? Well, I guess we have to continue to fight fire…

Drafted by
Dr Tan Jit Seng
Senior Home Care Physician
Lotus Eldercare Pte Ltd
Read 5240 times Last modified on Friday, 02 January 2015 09:39

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