REVISION OF HOSPITAL, OUTPATIENT AND DENTAL CHARGES

Mr Howe Yoon Chong: Mr Deputy Speaker, Sir, permit me to make what must be deemed a rather unpopular statement regarding the increase of hospital, outpatient, and dental fees and the rationalization of the way some of these fees are charged. For as long as my Ministry of Health is required to provide up-to-date and progressively better medical and health services to keep pace not only with the rapidly advancing medical science and technology but also to satisfy increasingly sophisticated public demands, and for as long as there is inflation causing escalation in wages and running costs of hospitals and clinics, I am afraid regular revisions of hospital, outpatient, and dental charges will be necessary.

I have circulated to Members of the House a Schedule (Cols. 295 - 304) setting out the main changes in hospital, outpatient and dental fees that will be implemented with effect from 1st January, 1984. When my Ministry announced the last revision of fees which took effect on 1st January, 1983, it stated that fees should keep pace with improved services and rising running costs, as otherwise there could not be any improvement in our health care services. Fee increases, however, would be gradual and would take into account Singaporeans' capacity to pay for health care. Schedule - REVISION OF HOSPITAL, OUTPATIENT AND DENTAL CHARGES, MAXIMUM FEES PAYABLE BY CLASS B2 AND C PATIENTS PER ADMISSION OR SPECIALIST OUTPATIENT ATTENDANCE (Cols. 295 - 304)

Reason for fee increase

For this reason and taking into account the increasing recurrent expenditures on medical and health services, which expenditures are likely to exceed $340 million for the current financial year and estimated to increase to $390 million for the next financial year 1984, it is necessary for regular upward revisions to be made to the fees and charges for services provided by our hospitals, outpatient clinics, and dental clinics.

For this revision minimal increases will be made in respect of fees charged at the outpatient and dental clinics. These slight increases are set out in items 9 and 10 on pages 3 and 4 of the Schedule that has been circulated to Members.

Itemized charges for hospital services

There will also be readjustments of fees and charges for the various services pro- vided by our hospitals. I must emphasize that in the Government hospitals, with the exception of the daily meals that are different, all the medical services, investigations, X-rays, laboratory tests, surgical operations, and treatment are the same for all classes of patients. Currently Class A and Class B1 patients are charged fees in respect of professional treatment and prescriptions, X-rays, laboratory, and other investigative tests and services.

Class B2 and Class C patients have hitherto been paying only an all-inclusive daily ward fee which covers all these services. This implies that the daily ward fee includes the cost of meals and all the other services whether supplied or not. For proper accounting purposes, each item of service rendered should be costed and charged. With effect from 1st January, 1984, a separate daily meal fee will be charged. The principle is that while Government can continue to subsidize heavy health care services, the Ministry of Health should not be burdened with the job of subsidizing the provision of meals in the hospitals.

Class A and Bl patients will pay a separate daily meal fee of $15, while Class B2 and C patients will pay a daily meal fee of $5. This daily meal fee, however, will not be levied on patients in intensive care units, neither will it be levied on the chronic and mentally ill patients.

Same services for all Classes

Apart from the separate daily meal fee, logically for all classes of patients only one scale of fees should be levied in respect of professional services, investigations, surgical operations, and treatment. But this will clearly cause much hardship to people, many of whom may not be able to afford the full Class A medical treatment and surgical operation fees in the public hospitals. Present Government policy is to ensure that the hospital fees for Class A should reflect actual recurrent costs. This means that our hospitals can recover run- ning costs but will not be able to recover capital and equipment costs even from the Class A patients.

In respect of Classes Bl, B2 and C patients, they will be subsidized up to 25%, 75%, and 85% respectively of Class A rates for the various treatment, surgical operation, X-rays, laboratory, and investigative services.

Further, it is likely that even after such heavy subsidies some hardship can still be caused to a small number of patients. Because of this, for the next few years at least, my Ministry will fix maximum levels of charges for Class B2 and Class C patients, beyond which levels the charges will be borne by the Government. Class Bl patients will not enjoy this privilege, but they will pay at the reduced rate of 75% of Class A charges. Thus Class B2 and Class C patients should not be put to excessive difficulty in meeting the revised hospital charges.

Fees payable by Class B2 and Class C patients

It is necessary that I elaborate on the increased hospital charges that affect Class B2 and Class C patients. For a long time now these patients have paid a minimum all-inclusive fee per day in our hospitals. But with effect from 1st January, 1984, this will change. A separate daily meal fee of $5, as I have said, will be levied in addition to the present daily ward fee of $20 for Class B2 in hospitals other than the Singapore General Hospital, (where the daily ward fee is $30). Class C patients will pay a daily meal fee of $5 in addition to the daily ward fee of $10. In respect of professional treatment, prescriptions, X-rays, laboratory tests and other investigations, Class B2 and Class C patients will pay 25% and 15% respectively of Class A rates.

To lighten the burden of Class B2 and Class C patients, they will pay only up to a fixed maximum on a per admission or per specialist outpatient attendance basis as specified in Appendix I (Cols. 303 - 304) to the Schedule circulated to Members. This maximum ceiling will apply to the groups of services and investigations, tests, irrespective of the number done per admission or specialist outpatient attendance. Appendix I - MAXIMUM FEES PAYABLE BY CLASS B2 AND C PATIENTS PER ADMISSION OR SPECIALIST OUTPATIENT ATTENDANCE (Cols. 303 - 304)

As regards surgical fees and medical treatment charges, Class B2 and Class C patients will pay up to a maximum of $200 and $120 respectively for an operation; and $40 and $25 respectively for all the necessary tests and investigations per admission regardless of the complexity of the operation or the number of X-rays, laboratory procedures, investigations and tests that were carried out. In the Singapore General Hospital, Class B2 and Class C patients undergoing surgery will pay up to a maximum of $215 and $129 respectively due to higher operating theatre and equipment costs.

Perhaps a simple illustration will bring out the extent of subsidy to Class B2 and Class C patients. A Class A patient staying for six days in hospital to undergo surgery of a serious nature will be charged in excess of $2,200 in a hospital. For the same kind of surgery and treatment a Class C patient need only pay $248. The treatment and operation are exactly similar, so too is the length of stay in hospital.

In the same way, while a Class A patient will be charged $4,300 (or $4,900 at SGH) in surgical operation fees alone for a major operation; but for a similar major operation a Class B2 patient need only pay the maximum surgical fee of $200 (or $215 in the SGH) while a Class C patient pays $120 (or $129 in the SGH).

Assistance for the poor

Mr Deputy Speaker, Sir, I wish to emphasize that no Singaporean will be deprived of medical treatment merely on the ground of financial hardship. The genuinely poor can continue to apply for remission of medical fees and for welfare assistance.

A medical social work service is available in all our hospitals. The Child Psychiatric Clinic and the School Health Services as well as the general psychiatric outpatient clinics will also have medical social workers to assist patients with their emotional, social, and financial problems. Accouchement fees

Accouchement fees have been raised to reflect increased costs. To discourage large families, there will be an increase of $50 for the third order birth and $100 for the fourth and subsequent birth for all classes of patients. Item 8 on page 3 (Cols. 299 - 300) of the Schedule sets out the various charges in respect of accouchement fees.

Reduction of fees

In respect of certain laboratory tests and investigations where automation and electronic technology have replaced laborious manual work and thus drastically reducing costs and saving time, the benefits achieved will be passed on to the patients. In this respect, many of the laboratory and investigation test fees have been reclassified and lowered. There has also been a rationalization of these investigative and laboratory test charges into eight groups with a range from $5 to $40.

Concessions

Mr Deputy Speaker, Sir, my Ministry is conscious that some categories of patients will require more assistance.

Radiotherapy patients, for instance, will need treatment daily. Such patients will with effect from 1st January, 1984, no longer be required to pay the attendance fee of $12 at each radiotherapy session. This fee will only be paid when they attend the designated specialist outpatient clinic for review by a doctor periodically. My Ministry estimates that this concession will result in a reduction of revenue of $1 million a year, but as a consequence many patients will be able to save between $240 and $480 in attendance fees depending on the length of treatment.

Patients who require follow-up attention at the outpatient dispensaries (OPDs) for minor procedures, dressings, or injections without the need to see the doctor in attendance, currently pay the full attendance fee of $4. This OPD fee will now be raised from 1st January, 1984, to $5. But where patients are not attended to by the doctor and only receive minor procedures, dressings, and injections from the nurse in attendance, the fee is reduced to half, i.e. $2.50 per attendance. Patients who attend the hospital specialist outpatient clinics (SOCs) will be advised to obtain their dressings or injections at the outpatient dispensaries nearest their homes. This will save them considerable time, money, and travel expenses. If, however, they choose to return to the specialist outpatient clinics in the hospitals for dressings and injections, they will have to pay the full specialist outpatient clinic attendance fee of $10 (or $12 at the Singapore General Hospital). The intention of the Ministry of Health is to reduce the congestion and long queues at the specialist outpatient clinics and to make better use of the outpatient dispensaries nearer the patients' homes where the running costs are lower.

Senior citizens aged 65 and above and children under 18 years of age who are not employed, as well as students in schools and junior colleges, will continue to enjoy a 50% concession in respect of outpatient dispensary fees. They will also enjoy similar concessions for dental treatment.

No change in A & E and SOC fees, and charges for the mentally and chronically sick

In spite of increasing running costs, the current Accidents and Emergency Units. Specialist Outpatient Clinics and other prescription fees at these clinics have not been increased.

Treatment of the mentally and chronically sick will continue to be heavily subsidized by Government. They will pay the nominal daily fee of $2 and $5 respectively now levied on Class C mentally and chronically sick patients.

Mr Deputy Speaker, Sir, these increases that I have outlined are minimal in order to ensure that the subsidies that are paid out for hospital and health care will not be increased beyond the policy guidelines that are laid down by the Government. Regular revisions in fees will be unavoidable if we are to improve the services provided by our hospitals and clinics in the light of rapidly changing and improving scientific and medical discoveries and in view of continuing increases in recurrent expenditures. My Ministry, as I have said earlier, will take special steps to ensure that these increases will be gradual and will bear in mind the Singaporeans' capacity to pay for health care.

Mr Deputy Speaker: May I remind hon. Members that they may only raise questions but not debate on the statement?

Mr Jeyaretnam: Mr Deputy Speaker, Sir, may I put all my questions to the Minister at this one rising? Is the Minister aware that contrary to what he has told the House -that in the present charges, the ward fee was only $6 and there was a prescription fee of $2.50 and laboratory fee of $1.50, making in all $10 - is he aware that the Ministry has been collecting $10 regardless of whether there were any laboratory or X-ray tests done?.

Is the Minister aware that these fee increases are staggering for Class C patients, without even taking into account the laboratory and X-ray fees which are 15% of Class A fees? They represent something like 85% increase on the present fee.

Does the Minister know how much revenue the Government now hopes to collect? I have had this answer from the Minister for Finance - how much revenue the Government hopes to collect from the increase in the registration fees for cars and in the road licences -

Mr Deputy Speaker: Mr Jeyaretnam, that is not relevant to the Statement.

Mr Jeyaretnam: I wish to ask why is it not possible for some of the charges for Class C patients to be met out of the substantially increased revenue which the Government is now collecting? Has he thought about that? Has he consulted the Minister for Finance about using some of those monies to pay for these Class C costs? The Minister for Finance's answer was that these monies would be used for the provision of services.

Mr Deputy Speaker: Could you please confine your questions to the Statement?

Mr Jeyaretnam: These are the questions that I have asked, Mr Deputy Speaker, Sir.

Mr Howe Yoon Chong: Mr Deputy Speaker, Sir, as far as I know there are only two questions. One is whether I am aware that the current fee of $10 is made up of $6 for this, $2.50 for that and $1.50 for the other. That might have been in the colonial times. But now, ever since 1st January, 1983, the $10 was just an all-inclusive charge for Class C. And I have explained just now in my Statement that this is unsatisfactory because in order to control costs we have to itemize and cost every item so that we can decide what to charge. Otherwise there will be no financial control of the subsidies.

He also asks whether or not I am aware that this is 180% of the present charge. I am more than aware of this. But, as I explained to him the last time, his reference to percentages i& totally irrelevant. If I were charging 50 cents before and I now raise it to $1.50, 1 will be increasing it by 200%, making it 300%. It is irrelevant. If last year I did not charge anything, and this year I increase it to 1 cent, I will be charging one billion per cent or maybe more. So all these are irrelevancies.

Then he brings up the question of taxes for motorcars. I have nothing to do with those things. So I cannot answer him,

Then he asks what is the increase in fees. I have given you the figures. This year the cost to the Government or the Ministry of Health is $340 million. Next year it will be $390 million. And I am quite sure that the year after, it will be more. So every year it will be more, We are saying that since these are the people receiving the treatment and the services, they should bear part of the cost.

He asked one relevant question. What will be the amount of increase in revenue that will arise from these increases in charges for hospitals and clinics? The figure is in the region of $15-$16 million which does not contribute to make-up the increase between $340 million and $390 million.

I hope he is satisfied.

Dr Augustine H.H. Tan (Whampoa): Mr Deputy Speaker, Sir, all fee increases are painful to bear but my questions to the Minister are designed to find out whether these particular increases are bearable to the patients involved.

The first question is: since the Medisave is not to be introduced until April next year, why can he not wait until then to implement his fee increases? Why is he so impatient?

Secondly, what is the rate at which he is reclassifying the wards from C to B1, B2, A and so forth? Because this would have a direct bearing on the people who can enjoy the Class C wards at the lower rates.

Thirdly, does he have any figures to show this House what is the percentage of workers and their families who are covered by company medical insurance schemes?

Yet another question is: when does he intend to implement the means test whereby patients will not be admitted to Class C wards because they are able to pay for the higher class wards?

Mr Howe Yoon Chong: Mr Deputy Speaker, Sir, as regards the increase in fees, I am well aware that there will probably be people who feel that they are being charged too much. But, as I tried to explain, if you want the services to improve, it is unavoidable that these fees will have to increase.

As regards the question why we are so keen to implement it even before the Medisave comes into force, I have indicated that we will try to make regular but gradual increases. Since the last one was 1st January, 1983, it is a good date to have it on 1st January, 1984. The difference is three months.

In my Statement, I have also referred to the assurance that I gave that medical services will be provided to people even though they cannot pay, Those who are poor can ask for write-off of their medical charges and we have done this regularly. I think the Member for Whampoa has experience in writing to my Ministry and some of the appeals that he made on behalf of the patients have been very sympathetically considered. We are not the monsters that you imagine us to be. In any case, every appeal for help goes directly to the medical social worker stationed in the hospital. And -I am quite sure the medical social worker has been trained to be sympathetic to the poor. So that assurance having been given, we will probably meet with some people who claim that there will be difficulty. But I think that these problems can be ironed out.

As regards the question, what is the reclassification of wards from C to B to A, our decisions are more dictated by the demand. And paradoxically, there is more demand for A and B1 wards than for C wards. At the moment, 70% of our hospital wards are C and we find that we cannot satisfy some of the B1 wards and better B2 wards. So there will be gradual reclassification. But I can assure him that even after all the reclassification, there will be 50% C wards.

As regards the means test, we are not very sure whether we want to introduce it at all. It depends on how this present increase works out and whether or not many people who claim that they want to go to C, although we know that they come in big cars, still insist on C. But with this rationalization of rates, there may not be the kind of people who want to go to C. My feeling is that they want to go to C now because the present rate structure is totally inequitable. I go to A. I want to save face. I pay $4,900. If I go to C, I pay only $248. The rate structure is totally skewed, lopsided. So we are not very sure when or even if we want to introduce the means test.

Dr Toh Chin Chye (Rochore): Mr Deputy Speaker, Sir, it was my past experience to announce the Ministry of Health's increases and charges, but I would like perhaps to assist the Minister for Health by asking him a few pertinent questions. Can he inform us what proportion of the Ministry of Health's revenue will arise from patients after the revision from taxes paid into the consolidated fund, what is the estimate in percentage increase in revenue after the revision and the percentage increase in MOH expenditure? If I calculated correctly, he said it was estimated to be 14.7% in 1984.

Could his Ministry, perhaps from the point of good housekeeping and accounting as well, inform the House whether bills would be itemized according to bed charge, meals, professional fee, prescriptions, laboratory fees, X-ray fees, operation fees, radiotherapy, physiotherapy? Would he also indicate the percentage increases in expenditure for maintaining wards, for maintaining dietary services, prescriptions, laboratory and X-ray services, operating services, radiotherapy and physiotherapy services? In this way we have a clearer idea whether the increases in fees in these different items are proportionate to increases in expenditure.

Mr Howe Yoon Chong: Mr Deputy Speaker, Sir, I would like to say that, apart from the last question asking for details which are not yet available, the other three questions can be answered; except, of course, the part about the tax revenues that are paid into the consolidated fund. That is not within my purview. With the increase in fees, instead of collecting a revenue of $91 million from the patients, the estimated collection will be $97 million when we upgrade certain wards, and $106 million when we impose the new charges. Therefore, it is slightly more than the 14.7%.

We intend first to cost every item - bed space charge, meal charge, prescription charge, nursing attention charge, X-ray, laboratory, various other costs and then itemize them and charge the A-class to expect at least recovery of costs. So the A-class will reflect the actual cost. For the B1 we will charge 75% of the cost. For the B2 we will charge 25% of the cost. For the C we will charge 15% of the cost. But, in addition, as I say, the B2 and the C-class patients will have the cut-off so that it will not give the charges an extra burdensome character.

As to what percentage of total revenue these various tests will constitute, I cannot give him the answer. I probably will want to work it out before giving it to him later.

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