PATIENTS IN ACUTE HOSPITALS (Fees for overstaying)

Dr Lily Neo asked the Minister for Health how many patients, who have overstayed in acute hospitals, have been charged with higher fees since the policy was implemented from March 2002.

The Minister of State for Health (Dr Balaji Sadasivan) (for the Minister for Health): Mr Speaker, Sir, the hon. Member for Jalan Besar GRC, Dr Lily Neo, has asked how many patients who have overstayed in acute hospitals have been charged with higher fees. It is a policy that the Ministry of Health introduced in March 2002.

Mr Speaker, Sir, to-date, only one patient has been charged full cost for four days of overstay in Class B2 ward of Singapore General Hospital (SGH). Despite financial counselling given to the patient, she chose not to be discharged home after she was certified medically fit. The reason she gave was that she did not want the hassle of returning to SGH for her daily outpatient radiotherapy treatment.

Let me take this opportunity to explain our policy on overstayers in acute hospitals. Patients should be discharged from the acute hospitals when it is medically assessed that they no longer require inpatient medical care. Patients who still insist on staying in the hospitals should pay the full cost of their extended stay. In this way, we ensure that the heavily subsidised beds are taken up by patients who require inpatient care.

In implementing this policy, I would like to reassure Singaporeans that we have put in place several safeguards. First, our hospitals certify patients that they are medically fit for discharge based solely on medical grounds.

Secondly, my Ministry is aware that some families may face difficulties in looking after patients at home upon their discharge for various social reasons. Some patients may also require step-down care. As such, the hospitals will assist the patients and their families to arrange for placements in step-down facilities, or home medical, or home nursing, for these patients. Patients and their families will be given sufficient time to make the necessary domestic adjustments. Full cost would only be charged from the seventh working day after the patients have been certified medically fit and after the hospital has placed them in appropriate step-down care facility, if necessary.

Dr Lily Neo (Jalan Besar): May I ask the Minister of State whether it is appropriate to implement the new subsidy for overstayers ruling as there is, at the moment, still a shortage of nursing homes and community hospital beds to discharge these patients? Moreover, the home care services are not adequate presently to have them sent home.

Dr Balaji Sadasivan: Mr Speaker, Sir, where step-down facilities cannot be found for the patient, or where the home nursing arrangement has not been arranged, the patient will not be discharged from the hospital, even if they are medically fit and even if the seven days have been exceeded.

Dr Teo Ho Pin: Sir, may I ask the Minister of State what is the average occupancy rate of the acute hospitals?

Dr Balaji Sadasivan: Mr Speaker, Sir, the occupancy rate depends on whether the patients are in the subsidised or the paying class wards. Currently, in the subsidised wards, particularly in the C class wards, the occupancy rate is close to 100%.

Dr Lily Neo: May I ask the Minister of State who certifies the discharge of overstaying patients?

Dr Balaji Sadasivan: Mr Speaker, Sir, the certification that the patient is medically fit will be done by a doctor. As in the acute hospitals, these patients are in departments that are under the care of consultants. The consultant in charge will be responsible for the patient being certified fit for discharge.

Dr Lily Neo: May I ask the Minister of State whether it is right to put the onus on the doctor to certify the discharge of his patients? Do the doctors have enough time to investigate whether, socially, these patients are ready for discharge? Will he not agree with me that a patient cannot just be assessed physically, but also in totality?

Dr Balaji Sadasivan: Mr Speaker, Sir, the doctors will only certify on the medical grounds whether the patient is fit to be discharged. There are social problems involved in many of these cases and the social problems will be handled by the medical social worker. Where the medical social worker cannot solve the problem, meaning that the home nursing or home medical services cannot be arranged, then the patient will not be discharged. It is only when all arrangements can be made, and there have been seven days since the time the doctor has certified that the patient was medically fit to leave, it is only at that point will the patient be charged full rates.

Dr Tan Cheng Bock: Mr Speaker, Sir, with regard to discharging of patients, is it because of the present case mix policy, meaning there is a specific period of stay that a patient will get subsidy from the Government, after which there will be no subsidy? So I am wondering whether the patients are being discharged for this purpose to make sure that the hospitals do not have to pay on their own to treat those overstayers.

Dr Balaji Sadasivan: Mr Speaker, Sir, this policy has nothing to do with case mix. At this point in time, case mix has not been introduced for purposes of reimbursement of the hospital. So they have no reason to take case mix into consideration when discharging patients. And should case mix be introduced at some point, we will ensure and insist that decisions on whether patients are discharged home or whether they are medically fit must be decided purely on medical criteria, and not on financial or case mix criteria.

Dr Amy Khor Lean Suan (Hong Kah): Sir, regarding the allocation of the medical social worker to a case where step-down care is needed, when does the medical social worker come into the picture?

Dr Balaji Sadasivan: Currently, it is the policy in many hospitals that looking at discharge of the patients and placement of the patient starts very early, sometimes even soon after admission, particularly with stroke patients. So the medical social workers may be involved very early in the management of the patients.

Dr Lily Neo: May I ask the Minister of State whether it is correct to say that many overstayers are old people with no income or from families with low income and many of them with no family members who can look after them. May I ask whether this new ruling will jeopardise this group of people further financially and socially.

Dr Balaji Sadasivan: Mr Speaker, Sir, the policy has been implemented for only a month and only one patient so far has been charged. In her case she had financial counselling and, for convenience, she wanted to stay in hospital. We will monitor the effects of this policy over the next few months. If there are any cases that have been discharged and it has caused undue suffering to the family or to the patient, they can bring it up with my Ministry or they can bring it up with me and we will look at it. But as this is a new policy that has been implemented for only one month, I cannot at this time tell the Member whether or not there will be anybody affected in such a manner. But we will monitor this.

Dr Teo Ho Pin: Mr Speaker, Sir, may I ask the Minister of State, since the average occupancy rate for the subsidised wards is 100%, is there any plan to increase the number of beds for the subsidised wards?

Dr Balaji Sadasivan: Mr Speaker, Sir, currently there is a great demand for C class beds. We are reviewing the matter and, at this point, we have not made any decision on that.

Mr Steve Chia Kiah Hong (Non-Constituency Member): Mr Speaker, Sir, may I ask the Minister if there are plans for more step-down care services to be provided.

Dr Balaji Sadasivan: Mr Speaker, Sir, yes, there are plans for more step-down facilities, there are plans for new nursing homes and new step-down facilities to be built.

Dr Lily Neo: Sir, may I ask the Minister of State whether it is correct to say that Medifund cannot be used for nursing homes and step-down care. Therefore, may I ask him whether his Ministry has created a group of people with special needs that cannot be met by our present schemes, in other words, have we created a group with no safety net for them? How would the Minister of State assure Singaporeans that nobody would be deprived of medical care as a result of lack of financial means?

Dr Balaji Sadasivan: Mr Speaker, Sir, the first premise that we have when a patient is discharged from the hospital is that the patient is medically fit to leave the hospital. So the question of the patient not receiving medical care does not come in. As long as a patient is in the acute hospital requiring medical care, Medifund will be available for the patient.

Dr Lily Neo: Would the Minister not agree with me that many patients with disabilities are as a result of diseases? A good example he mentioned earlier was stroke. Therefore, how can he then refer to such cases as not medical-related cases and not needing Medifund?

Dr Balaji Sadasivan: Mr Speaker, Sir, I think we need to make a distinction between medical problems and social problems caused as a result of medical illness. When a patient comes to the hospital, the patient is ill, he is treated and medical care will be provided for him. But as a result of the medical illness, there are real social problems that may occur in that the person may be left disabled, without work and may have to make alternative financial arrangements to look after themselves. These are the social problems as a result of a medical illness. Where the social problems arise, they are referred to the medical social worker, who will then liaise with the various bodies responsible for taking care of providing support for people with financial problems, to help these people.

Mdm Cynthia Phua (Aljunied): Mr Speaker, Sir, regarding the 100% occupancy rate of the C class wards, can the Minister of State assure us that those who are on the waiting list would be given the relevant medical attention and also at the C ward charges?

Dr Balaji Sadasivan: Mr Speaker, Sir, I said close to 100% because the occupancy rate fluctuates from day to day. Any patient who requires treatment will not be delayed. The patient will be admitted, put into a bed in another class, but the charges would remain, depending on what class the patient is admitted. So the various hospitals have contingency plans to deal with the situation when at one point in time there are not enough beds in that particular class.

Mr Sin Boon Ann (Tampines): Sir, will the Minister of State tell whether a comatose patient is ever fit enough for discharge from the hospital?

Dr Balaji Sadasivan: The decision on when a comatose patient is fit to leave an acute hospital will be a decision to be made by the doctor in charge. But there are comatose patients who leave the acute hospital to be transferred to a nursing home where they may remain for several months until they recover.

Mr Sin Boon Ann: If the family of a comatose patient insists that the patient be kept in the hospital, will this patient then be subjected to the policy of full charge?

Dr Balaji Sadasivan: If an appropriate step-down facility is available for the patient and the arrangements have been made and there is a step-down facility that is available for the patient, it would make sense to move the patient to the step-down facility, because the cost of looking after the patient in an acute hospital is much higher than in a step-down facility. And that is the purpose why step-down facilities are built. So where a patient has an appropriate facility available for him and the family does not want the patient to move to that facility or the patient does not want that to happen, then the full charge will come in.

Mr Steve Chia Kiah Hong: Mr Speaker, Sir, if I may ask the Minister of State, when will plans for the additional step-down facilities be implemented? When can we see the step-down facilities be done and in what percentage are we talking about?

Dr Balaji Sadasivan: Mr Speaker, Sir, I do not have the figures with me at this point in time on the details of the step-down facilities and when they will be available. But I will make this information available to Mr Steve Chia.

Mr Ong Kian Min (Tampines): Will the Minister of State not agree with me that the difference between the step-down facility and an acute hospital is one of subsidy, and will the patient not be put in a position where he is forced to take up an alternative provider of care where he does not enjoy any subsidy from the state in a situation like this?

Dr Balaji Sadasivan: Mr Speaker, Sir, I do not agree. There is a difference between a step-down unit and an acute hospital. In an acute hospital, the level of medical care is more intensive and the patient is more acutely ill. The patient goes to a step-down unit when his condition is stable and needs medical care or nursing care of a lower intensity, and that is why the cost of providing care in a step-down unit is much lower than in an acute hospital. And, in a step-down unit, they are subsidised too.

Dr Michael Lim Chun Leng (Pasir Ris-Punggol): Mr Speaker, Sir, I practise in a hospital, so I understand the system very well. The problem of overstaying, if I may ask the Minister of State, if I am correct, is very subjective because, really, medicine is as much a science as it is an art. So, are there going to be very clear fixed parameters in which you can determine that a person has already reached a stage where he should be home and therefore if he stays any further he should be considered an overstayer? I think this is going to be very, very difficult to determine. So I am not sure on what sort of criteria or whether there are certain international guidelines he is going to use to determine that a patient has overstayed his due period of stay in the hospital.

Dr Balaji Sadasivan: We have left the decision to the doctor in charge because it is not possible to draw a guideline that you can apply across every case. Every sick patient is unique. So we will leave it to the doctor who is looking after the patient to make the decision. As a rule, and in fact all the doctors are very compassionate people, I cannot imagine that they would want to discharge a patient who is not fit to be discharged. What we will make sure is that there is no financial, social or administrative pressure on the doctors to make a decision that is not in the interest of the patient.

Dr Michael Lim Chun Leng: Mr Speaker, Sir, I would like to ask the Minister of State, in that case, if the Ministry's thinking is that everything should be left to the doctors to decide when a patient is fit for home, then why is there a move over the last one or two years for the Ministry of Health to ask professional bodies to draw up clinical practice guidelines. I happen to chair one of these as well. Obviously, the Ministry's purpose is to ensure that there are perhaps clear guidelines for the management of certain diseases. So I would like to ask the Minister of State, if that is the thinking of the Ministry, then why are they asking doctors to draw up practice guidelines? Obviously, the reason is that medicine is very subjective and it is very, very difficult to determine when a patient is well enough to go home or how he should be treated.

Dr Balaji Sadasivan: Mr Speaker, Sir, we are fully aware that, in medicine, there are subjective decisions to be made and the guidelines are drawn up by the doctors for themselves. So when the guidelines are drawn up, it is the specialists within a certain area who draw up guidelines to help them make the correct decisions. And most of the guidelines are clauses to ensure that it is not rigid, such that the doctor involved can still use his own discretion to make the final decision.

Dr Ong Chit Chung: Mr Speaker, Sir, the Minister has stated that a decision on such overstayer cases is left to the hospital doctors. But who reviews the doctors? Is there an avenue for a second opinion? As he said, doctors may differ in opinion. Will he care to put a mechanism for appeal or review of any cases? Where families are not happy, could they bring it up through some channel, rather than come to our MPS, then we appeal to the Minister? It will be too late, it will take too much time.

Dr Balaji Sadasivan: Currently, the consultants in charge of the patient are responsible. But this is a suggestion that we can take up, ie, as to whether or not, when an appeal is made, another doctor within the hospital can review the case. This is a suggestion that we will take up in the Ministry.

Dr Michael Lim Chun Leng: Mr Speaker, Sir, I would like to ask the Minister of State, in the acute hospitals where there is great pressure on the beds, doctors are often asked to do what we call "discharge rounds", in other words, doctors will go and do a round in a ward to discharge patients primarily to have new beds to admit acute patients and some of these patients are not again what we would determine as optimally cured or treated at that point in time. In the light of this, how is the Ministry going to prevent this practice from happening where you discharge patients primarily because you want to free beds to take in acute patients?

Dr Balaji Sadasivan: Mr Speaker, Sir, we do not want our doctors to discharge any patients who are medically unfit. This is not acceptable. If there is any case that anybody knows, please let me know.

Mr Gan Kim Yong (Holland-Bukit Panjang): Mr Speaker, Sir, the medical condition on whether a patient is fit to be discharged is decided by a doctor but could the Minister of State consider whether the decision to charge him fee for overstaying can be determined in consultation with the medical social workers to take into consideration the financial and social aspects? The medical condition is decided by a medical doctor but the decision to charge a fee should be decided including other elements as well.

Mr Speaker: Mr Gan, I think the question has been asked. Dr Khor.

Dr Amy Khor Lean Suan: Mr Speaker, Sir, my supplementary question is actually similar to Mr Gan's. Following the question from the Member for Jalan Besar, the decision to discharge should be based on totality, that means, he may be medically fit but there may be social problems, so we should involve the medical social worker.

Mr Speaker: That question too has been answered.

Dr Michael Lim Chun Leng: Mr Speaker, Sir, I would like to ask the Minister of State that since there is such a great pressure on subsidised beds and since lately, the Ministry of Health has also openly announced that they will go all out to court private patients as well, there seems to be mixed signals. On one hand, are we trying to say that there are a lot of extra paying beds and therefore we should go out to court paying patients but the subsidised beds are very full and we should try to discharge so-called "perceived overstayers"? Should the Ministry then not consider converting more paying beds to subsidised beds and ease the pressure on subsidised beds?

Dr Balaji Sadasivan: I think the Ministry will periodically review the demand for subsidised beds and looking at the trend, if there is a necessity in future where beds have to be converted, that is something that we will have to consider.