AVERAGE HOSPITAL BILL SIZE PER PATIENT DAY

Dr Aline K. Wong asked the Acting Minister for Health what is the average bill size per patient day for representative categories of treatment at restructured, Government and private hospitals.

Mr Yeo Cheow Tong: Sir, the hospital bill size depends on a number of factors. These include whether it is a medical or surgical case, the acuity level of the patients, the type and extent of treatment and investigations carried out, the type of ward accommodation chosen, the rates of hospital charges and also the length of stay.

The average bill size per patient per day for various classes of ward at Government, restructured and private hospitals is summarized in the table (Cols. 481 - 482) that has been handed out to Members. The table also provides some comparison of the average bill size of a typical medical as well as for some representative surgical cases in the Government, restructured and private hospitals for a patient admitted to A Class ward. table - Average Hospital Bill Size Per Patient Day, Comparative Average Bill Size (Cols. 481 - 482)

The table shows that the fees for A and B1 wards in the Government and restructured hospitals are much lower than those in the private hospitals. The fee structure for SGH has been higher than for the other Government hospitals, reflecting the better and newer facilities and equipment and the larger number of medical and other staff available.

Dr Aline K. Wong (Tampines GRC): Sir, from table 2, the NUH charges are much higher than the Government hospitals or SGH. May I ask the Minister why is this so? Does it mean that NUH has been making quite a bit of profit? Or what is the reason?

The second question: for SGH's charges for surgical cases, the patient still has to pay on the average $500-$600 more for the representative treatments quoted. Does this difference in bill size have anything to do with the present practice of SGH to charge by itemizing the bill for every kind of surgical materials used, X-ray test, etc. If so, would the Ministry take steps to inform incoming patients of SGH of this practice so that the patient will know roughly beforehand what he can expect?

Mr Yeo Cheow Tong: Sir, the fees at NUH are higher, but it does not mean that NUH is making profits from the higher fees. In fact, NUH in 1988 had a loss of $2.2 million after receiving a subvention of $21 million from the Government. This reflects the actual cost of providing a high level of services for patients. It also reflects the policy of the Government to charge the full cost to the 'A' and 'B1' class patients. In NUH the 'A' class patients are paying close to the full cost already. Also with NUH being a teaching hospital, the patients tend to be subjected to more extensive investigations, and that partly accounts for the higher per-day fee that is being experienced by the patients.

Sir, the scale of SGH fees has always been higher than for the other Government hospitals. As I said, this reflects the newer facilities, better facilities, and also the much higher level of manning that is available in SGH. Let me give some examples. In SGH the number of doctors to admissions is 1:66 as compared to 1:81 in the Government hospitals. The nurse-to-bed ratio is also higher. In the other Government hospitals the nurse-to-bed ratio is 1:2. In GH, before the restructuring, the ratio was 1:1.4 beds, and because the restructuring programme allows SGH to recruit its own nurses, the nurse-to-bed ratio has now gone down to 1:1.1 beds in order to remedy the shortage of nurses that is being experienced.

As regards informing the patients about the scale of charges, including itemization, the patients will definitely be told about this.

Dr Arthur Beng Kian Lam: Mr Speaker, Sir, I would like to clarify with the Minister what he means by "full cost"?

Mr Yeo Cheow Tong: Sir, patients in 'A' class wards who wish to enjoy the privacy of a single bedded ward, the better and more personalized level of services, will have to pay the full cost that is being incurred in the provision of such services. That means the cost of labour, cost of overheads, including the depreciation costs for the physical facilities that he is enjoying.

Dr Arthur Beng Kian Lam: Does the Minister then mean that the full cost for an appendicectomy is reflected by the NUH cost of $2,670? Or is it the private hospital's cost of $4,300 which, I assume, would include profits of the private hospital and the doctors? So what does he mean by "full cost"?

Mr Yeo Cheow Tong: In NUH the full cost is slightly higher than the figure shown here because, as I stated earlier, NUH is still experiencing some losses. For NUH, the figure quoted is close to full cost, and for private hospitals it will be full cost plus the profit element.

Dr Arthur Beng Kian Lam: Mr Speaker, Sir, one final clarification. Does it then mean that for an appendicectomy to be met at full cost, it will be more than $2,670?

Mr Yeo Cheow Tong: Sir, I have already said that just now, that if NUH were to actually charge the full cost it would be higher than $2,670.

Mr Choo Wee Khiang (Marine Parade GRC): Sir, will the Minister enlighten the House as to the long term pricing policy for all the restructured hospitals, especially the 'B' classes? And also, would the Minister tell the House whether consideration will be given to standardize charges for all the restructured hospitals?

Mr Yeo Cheow Tong: Sir, the policy for private patients or non-subsidized patients is that over the next few years non-subsidized patients should be paying the full cost of their treatment in hospitals. A choice is made available to all Singaporeans whether they wish to opt for the better accommodation and the high level of services in the 'A' and 'B1' wards or, for those who cannot afford it, to go to the subsidized facilities, like 'B2' and 'C' class wards where the facilities are more basic, although the medical services are similar.

As to whether we should standardize the fees for all the restructured hospitals, Sir, one of the objectives of the restructuring programme is to allow all the hospitals to be run autonomously so that each can then compete with the other in terms of value for money. It means that they will have to compete on the level of efficiency, compete on the level of quality of services provided and compete on pricing.

Dr Aline Wong: As to where a patient should go to, is it a matter of free choice of the patients? Actually we hear that where a patient should go to for hospitalization is upon the recommendation of the doctors who are consultants to these Government hospitals or private hospitals. And also, when they go into A&E wards, will the ambulances actually take them to the designated regional hospitals?

Mr Yeo Cheow Tong: Sir, patients who are referred by doctors, for example, general practitioners, have a choice of which hospital they wish to be referred to. For A&E cases, yes, we have catchment areas, and the reason is that it is in the best interest of those patients who are in an emergency to be taken to the nearest hospital rather than to the hospital of their choice. Of course, after admission, if they wish to be transferred, the patient is free to choose to do so.

Mr Choo Wee Khiang: Sir, following the Acting Minister's reply, I would like to ask the Acting Minister precisely what is the long term pricing policy for 'B' wards, and indeed 'C' class wards? If I may add, after the restructuring of the other two hospitals, I would presume that there would not be any 'C' class wards left. I think that is the concern of most common people in Singapore.

Mr Yeo Cheow Tong: Sir, the Member should remember what was stated in the last budget debate. I assured the House that 'C' class beds will always be available as long as there is a need for them. So in the older hospitals that are going to be rebuilt, the 'C' class beds in those new hospitals after redevelopment will still be available.

In terms of the longer term policy, Sir, the policy of the Government is that those who can afford to pay should pay for the services that they are receiving. Whilst those who cannot afford should not be deprived of the medical care that they require.

In terms of the level of subsidy for the 'B2' beds, the level of subsidy at the present moment is 69%. This will gradually be decreased as the average Singaporean's ability to pay improves with our improving economy. For the 'C' class patients, it will still remain highly subsidized so that 'C' class will be available and affordable to the low income group. Of course, we will still retain the policy of waiver of fees for the indigent.

Mr Choo Wee Khiang: I am very pleased to hear from the Acting Minister that for the 'B' class and 'C' class, the basic facilities are bare and are not as good as the 'A' class. However, the medical services will be exactly the same as the 'A' class. But I would like to bring to the attention of the Minister that yesterday on the Forum Page, he would see ---

Mr Speaker: Mr Choo, can you ask your question?

Mr Choo Wee Khiang: Yes, I will ask my question. Sir, patients are referred to 'A' class services rather than 'B' class services, and invariably when patients want to opt for the 'B' class wards, they are forced to go to the 'A' class. Would the Minister explain?

Mr Yeo Cheow Tong: Sir, the specialists in the hospitals are meant to be referral doctors, not family practitioners. Patients who are sick should first see their own general practitioners or the doctors in our polyclinics. If the acuity of the illness warrants it, the GPs or the doctors in the polyclinics will then refer these patients to the specialist departments in the hospitals or in the private sector. Such patients who are referred to the hospitals by our polyclinics will then be treated as subsidized patients. However, they will be referred to the department and they will be seen by the doctor on duty. If a patient insists on seeing a particular consultant, then the patient will have to make his own appointment as a non-subsidized patient.

Dr Dixie Tan: Sir, would the Minister tell us what was the 'C' class expenditure in SGH and NUH? And if there was no 'C' class there, how was the absence of 'C' class ascertained in regard to demand?

Mr Yeo Cheow Tong: Sir, the availability of 'C' class beds is seen at the national level. That means for patients who can afford only the 'C' class beds, there are many empty 'C' class beds available in our other hospitals. They can opt for that. However, for those who are referred to NUH or SGH, depending on the complexity of the case and if they cannot afford to pay for the 'B2' rates, they are given waivers or partial remissions. In fact, in a previous sitting of Parliament I had given information as to the rate of remission or waivers in SGH as well as NUH.

Dr Arthur Beng Kian Lam: Mr Speaker, Sir, I first declare my pecuniary interest as a GP. May I ask the Minister why is it that when a patient is referred by a GP to the Specialist unit, he must be considered as a 'B2' or 'B1' patient or an 'A' patient, and not a 'C' class patient? He may well be present to the GP as having a stomach ache, diagnosed as an appendicitis. Just because he goes through a GP, why should he be classified as a higher class patient and be asked to pay more? Or would the Minister prefer that these cases be referred to a Government outpatient clinic, waste the outpatient clinic's time and also endanger the life of the patient?

Mr Yeo Cheow Tong: Sir, the policy of the Government is based on affordability, that is, those who can afford to pay for care in the private sector should then not be asking for subsidies. Those who can afford to see the practitioners in the private sector should be prepared to pay for the services at the non-subsidized rates. But, of course, if they are referred by the GPand they wish to receive the subsidized fees, they can make a request, and these requests are always looked into.

Prime Minister: Carefully.

Dr Arthur Beng Kian Lam: Mr Speaker, Sir, how does a patient make a request?

Mr Yeo Cheow Tong: Sir, he makes a request when he arrives at the counter and tells the nurse, "Look, I cannot afford to pay." He will still receive the treatment. If he cannot afford, he pays what he has and we will investigate carefully. If it is true that he cannot afford, the remaining fees will be waived. But, of course, if we find that he can afford, the remnant will then be billed to him.

Dr S. Vasoo (Tiong Bahru GRC): Can I ask a supplementary question?

Mr Speaker: It is end of Question Time. The answer to your Question No. 10 will be circulated to you and to hon. Members. 1.30 pm