MEDISAVE (Use for angioplasty procedure)

[Mr Speaker in the Chair]

Mdm Halimah Yacob asked the Minister for Health (a) the rationale for disallowing the use of Medisave to pay for the costs of inserting stents in an angioplasty procedure when Medisave can be used for other charges related to this procedure and (b) will his Ministry review this policy.

The Minister for Health (Mr Lim Hng Kiang): Mr Speaker, Sir, I wish to clarify that Medisave can be used to pay for stents in an angioplasty procedure. Surgical implants, including stents, are eligible for Medisave claims as part of the total hospital bill, subject to the daily withdrawal limit of $300. Implants can also be claimed under MediShield and Medisave-approved insurance schemes, where the maximum amount claimable ranges from $1,500 to $3,500, in addition to other claims such as room and board and surgery procedures. Together, Medisave and MediShield can cover more than 80% of the average B2 patient bill for a coronary angioplasty procedure involving stent implants.

The Ministry of Health, however, recognises that the costs of implants vary considerably, depending on the type of medical condition treated. Therefore, the current Medisave withdrawal limits and MediShield claimable limits may not fully cater for the wide range in costs between treatments for different medical conditions.

To address this, the Ministry will reset the Medisave withdrawal limits and MediShield Claimable limits for inpatient and day surgery cases to be based on Diagnosis-Related-Groups (DRGs) next year. This will better reflect the resources needed to treat the different medical conditions, and will allow patients to withdraw or claim more from Medisave or MediShield, for medical conditions that are on the average more expensive to treat. Under this new structure, Medisave and MediShield would be able to fully cover the bills for most subsidised patients undergoing coronary angioplasty procedures with stent implants. The price of medical technology like stents can vary greatly and equally effective stents can be priced differently by manufacturers. If a patient wants a more expensive stent, Medisave and MediShield will not fully cover the patient's bill.

Dr Lily Neo (Jalan Besar): Mr Speaker, Sir, may I ask the Minister whether the stent insertion procedure that can be done in a day surgery be applicable for Medisave application as well?

Mr Lim Hng Kiang: The answer is yes.

Mdm Halimah Yacob (Jurong): I would like to ask the Minister whether the review, where the payment will be based on diagnosis-related illnesses, will still be subject to a maximum claim amount. The Minister did mention that the costs of the stents vary. To my knowledge, very often, the patient does not have enough understanding to know what the cost of the best kind of stent that is necessary for an angioplasty procedure is and, therefore, would take advice from the doctors. So, the cost of the procedure and the stent is something that is very much not within the control of the patient. Could the Minister therefore consider that point as well?

Mr Lim Hng Kiang: Mr Speaker, Sir, the hon. Member has raised three related issues.

The first issue, as I explained, is the way we structure the withdrawal limits of the claims. Today, it is a very blunt instrument where we have a table of operations with seven categories. When we change over to the DRGs next year, this will be a more responsive system, with over 600 categories. So, the claims will be more related to the type of medical treatment undertaken. But that alone will not solve the problem.

The second issue is what is the withdrawal limit that we allow. As long as we have Medisave, which is a compulsory savings scheme, it cannot be a free-for-all. So, the Ministry will continue to set some kind of a maximum, because the whole idea of Medisave is to be able to provide savings for the future medical needs, especially when one grows old. So, we cannot allow free use of the Medisave. There will continue to be some limits. Of course, we will review these limits regularly to make sure they keep up with the medical technology and changes in medical procedures.

The third issue is how do we address very expensive medical devices and medical technology. What we have in the Ministry of Health is a procedure by which we review what are considered standard treatment, standard devices and standard drugs. These will be subsidised and these are the kinds of things for which we will allow Medisave to be withdrawn.

Medical technology changes very rapidly, and there will be non-standard procedures, non-standard devices and non-standard drugs. So, how do we address this? We could take a very strict approach and say, "If they are non-standard, they will not be allowed in our hospitals. If you want, you will have to go to the private hospitals." Or we could take a more liberal approach and offer the patient some choice, eg, "This is the standard that we will subsidise and will allow Medisave withdrawals, but if you want a non-standard drug or non- standard device, then you will have to pay the full cost of that", in which case, we must make sure that there is proper financial counselling and that the patient understands what he is in for. On the ground, with thousands of such operations, there could be lapses, and there will be the kind of cases that the hon. Member raised, ie, where the patient may not understand that by selecting a particular stent, he is selecting a very expensive one that costs $6,000 and, later on, when he has to pay for it in cash, he then finds that he cannot afford it. This is the kind of issue we have to address. We are reviewing this and we will lay out the parameters sometime next year.

Dr Lily Neo: May I ask the Minister whether it is correct to say that the stent insertion procedure is used to treat ischemic heart disease and myocardial infarction, and these two conditions caused 3,243 Singaporeans to die last year, and the second highest incidents of deaths in Singapore? In view of this fact, will his Ministry prioritise and allow patients to have full claim from Medisave or even subsidised for such life-saving procedures?

Mr Lim Hng Kiang: Stent is almost used as a standard device nowadays, and if you are admitted as a B2 patient and the average stay perhaps is four days, the average B2 patient bill for such a procedure is $4,600. The total amount that can be withdrawn from Medisave and MediShield is about $4,000 or 86%. So, you pay the balance in cash. If you go for a standard procedure involving standard stents, our current rules allow the withdrawal which is about 86%.

The problem arises when the patient chooses a top-of-the-market stent which costs $6,000, as is the case which I understood from Mdm Halimah. In that case, he had two stents, which cost $12,000. This is obviously way beyond the Medisave limit. This is a non-standard procedure and, therefore, he was asked to pay cash. How do we address this?

As I have said in my answer, we could say that such things are not allowed in the restructured hospitals. If somebody wants to go for these top-of-the-range stents, then please go to the private hospitals. We will then not have such problems in the restructured hospitals. Or we can take a more liberal approach and say, "These are non-standard. If you want them, please be sure you know the financial repercussions", and we make sure we have financial counselling. But I can assure Members that out of the 1,000 cases, there will be lapses or claims of lapses, and we will face these problems.

So, this is something that we will have to review and we will decide next year whether or not we take a more stringent approach or we still allow this choice in our restructured hospitals.

Dr Lily Neo: Am I correct to say that the stent insertion procedure can be done as a day surgery, therefore, saving patients hospitalisation costs and is also a good way of reducing hospitals' operating costs? Will the Minister prioritise or encourage patients to have the stent procedure done as a day surgery?

Mr Lim Hng Kiang: Mr Speaker, Sir, I am no doctor. I leave this to the professionals. If the professionals feel that in a particular condition stents can be done in a day surgery, we encourage them to do so in a day surgery. If the professionals say that this is safer done in an in-patient setting, then we will do it in an in-patient setting.

Mdm Halimah Yacob: Mr Speaker, Sir, I understand what the Minister is saying. I hope that in the review the Minister would also take into consideration this point that while the Government wants to try and persuade people to be prudent in the management of their hospital bills ---

Mr Speaker: What is your question, Mdm Halimah?

Mdm Halimah Yacob: My question is: would the Minister also take into account in the review the point that when someone has enough Medisave savings and he wants to use it for a stent and angioplasty procedure which is expensive and he thinks that it is useful for him, then he should be given some flexibility to take care of his own interests, although I understand the basic premise of some of the principles there?

Mr Lim Hng Kiang: On the use of Medisave, we have to be very clear. There has to be some restraint and discipline and, therefore, there will be some maximum withdrawal limits imposed. I am not prepared to say that everybody is allowed to use his Medisave in whatever way he likes. We can use our cash in whatever way we like but, for Medisave, its purpose is forced savings intended to last us a lifetime and, therefore, it cannot be a free-for-all. Whether or not we allow you to spend your cash freely in the restructured hospitals, that is something that we want to consider. Even if it is your cash, we may not allow you to spend freely in the hospital. We may say, "If you want to spend your cash freely in the hospital, please go to the private hospitals." This is something that we are considering.

Mdm Halimah Yacob: Mr Speaker, Sir, I think the Minister has missed my point. My point really is not that we should encourage people to use the Medisave flexibly and freely, but that for life-threatening procedures, such as angioplasty, there should be some flexibility to let the individual decide, if he has enough Medisave savings that he wants to use for that purpose, without too much restriction on the use, ie, for life-saving procedures, not just any frivolous kind of procedures.

Mr Lim Hng Kiang: As I have explained in my answer, we have a team of cardiac surgeons and cardiologists who regularly reviews these procedures and makes sure that our list of standard procedures covers all the cost-effective procedures that we want to subvent and that we allow Medisave to be used for. The problem arises because there are claims by manufacturers that if you use this latest stent, it will give you additional benefits. But this is not assessed by our team of experts to be a cost-effective procedure that we want to include under our Medisave list based on proper evidence, but it is available on the market. So, do we allow this choice, or do we say, "If you go to a restructured hospital, we will only do those cases which are recommended and assessed by our team of experts"?