AFFORDABILITY OF MEDICINES AND MEDICAL SERVICE PACKAGE

Column: 211

AFFORDABILITY OF MEDICINES AND MEDICAL SERVICE PACKAGE: 17.

Mdm Halimah Yacob asked the Acting Minister for Health when will the

Column: 212

Medical Service Package which was recently introduced for treatment of cardiac cases at the restructured hospitals be extended to other medical procedures such as renal, stroke or neurology cases.

18.

Mdm Halimah Yacob asked the Acting Minister for Health in view of the rising cost of medicines (a) what measures are being taken to ensure that the cost of medicines dispensed at public hospitals and outpatient clinics remains affordable; (b) what are the criteria for determining whether a particular medicine is standard where there is a subsidy or non-standard where there is no subsidy; and (c) will the hospitals consider charging patients attending outpatient clinics for follow-up treatment the same rate for medicines as when they were treated as subsidised patients in the hospital.

The Minister of State for Health (Dr Balaji Sadasivan) (for the Acting Minister for Health): Sir, with your permission, may I take Question Nos. 17 and 18 together?

Mr Deputy Speaker: Yes.

Dr Balaji Sadasivan: Sir, healthcare is an expensive service to provide because it involves resources such as trained professionals, high technology equipment, and medical implants and pharmaceuticals. Of these, pharmaceuticals form 10-15% of healthcare cost. We do not control the price of these resources. Nevertheless, the Ministry is working to keep healthcare affordable.

In 1979, the Ministry developed a list of standard and non-standard drugs with the help of expert physicians. The Standard Drug List (SDL) was modelled after the WHO Essential Drug List, with modifications to suit local disease profiles and practice. It consists of drugs assessed by the MOH Drug Advisory Committee to be cost-effective and essential to the

Column: 213

provision of medical care to all Singaporeans. The SDL is further categorised into lists 1 and 2. SDL 1 consists of mainly first-line drugs required for the treatment of common diseases of mild to moderate severity. SDL 2 was established in 1992 to allow essential but more expensive drugs (eg, cancer drugs) to be included.

MOH reviews the SDL regularly to take into account changes in clinical practice and advances in medical science. Revisions to the SDL are made with the input of the MOH Drug Advisory Committee and the respective national specialty committees. Evidence from the medical literature and comments from medical practitioners of the respective specialties are also taken into consideration. Where necessary, new drugs are added to the SDL.

To ensure that the cost of medicines remains affordable, our hospitals and polyclinics have taken the following measures. They include:

(a) Ensuring that drugs are prescribed appropriately: MOH has been working with the relevant specialists to develop clinical practice guidelines for various common diseases to help doctors provide the appropriate treatments that are evidence based.

(b) Using cheaper alternatives where available: With the introduction of electronic prescription systems, doctors are now kept informed about the costs of drugs and available alternatives. Doctors are encouraged, where possible, to use generic instead of patented drugs.

(c) Central procurement through the Group Purchasing Office: The Group Purchasing Office (GPO) was set up in the year 2000 to support the institutions under the two clusters to perform central procurement. The GPO obtains competitive prices through purchasing tools

Column: 214

such as open tenders for bulk purchases. Savings obtained by this economy of scale are passed directly to patients.

To succeed in our efforts to keep healthcare costs affordable, we need the support of both the doctors and the public. Medical care in Singapore can remain affordable if we ensure that we spend our healthcare dollars in a sensible manner. Many older medicines, which are generic, are effective and have a well proven track record of curing or controlling a disease. It does not always mean that a newer patented drug is better than an older generic drug. Often, the latest medical treatments only provide a theoretical benefit but at a significantly higher cost. The long-term benefits and risks of these new treatments are often unknown. Doctors therefore need to look at medical treatments objectively and not be swayed by the subjective influences of advertising and marketing efforts. The public should also not think that expensive or newer medicine is always better.

MOH has recently reviewed the inpatient subsidy system and introduced the Medical Service Package (MSP) for heart diseases on 5th July 2004. The main objective of the MSP is to ensure that patients receive the appropriate subsidies for all cardiac services according to their ward class. The need for services is strictly based on medical indication. Under the MSP, medical services are classified into basic and extended. Basic medical services refer to treatments where the treatment indications are standard. These services will not be subject to peer review. Extended medical services refer to treatments where treatment indications are still evolving or controversial. Doctors will conduct peer reviews on the use of extended medical services to ensure that the most appropriate treatment is provided to their patients. This will serve as a form of

Column: 215

quality control where the cardiology profession monitors the work of the individual cardiologist. This is to ensure that neither under-treatment of patients nor over-provision of services occurs. Experimental treatments like placement of an artificial heart or stem cell therapy will be considered as excluded services and will require MOH's approval before doctors can proceed with such treatments.

Previously, there was minimal subsidy for implants like stents, pace-makers and defibrillators. Stents can cost between $1,800 and $5,000. Defibrillators can cost about $25,000. With the introduction of the MSP, patients who need these implants will receive a subsidy of 65% for the implants if they are in B2 class and 80% if they are in C class. The MSP has also added nine new cardiac drugs to the list of drugs on the standard list and these drugs will be subsidised at 65% for B2 patients and 80% for C class patients. We will monitor closely the utilisation of cardiac services and the quality of care provided.

The development of the MSP for the other specialties will involve defining the list of services and evaluating the benefits to patients. It will also involve making the necessary changes to the hospitals' billing and IT systems. MOH will be monitoring closely the impact of the MSP on cardiac services over the next three to six months. Based on the results of this pilot, MOH will take a phased approach in extending the MSP to other specialties. With the subsidies under the MSP, healthcare services for heart diseases, which are expensive services to provide, will remain affordable for Singaporeans.

Mdm Halimah Yacob: < Sir, I would like to thank the Minister of State for the explanation. The Medical Service Package

Column: 216

is really a welcome move, and also the subsidy for stents and other procedures.

Sir, I would like to thank the Minister of State for the explanation. The Medical Service Package is really a welcome move, and also the subsidy for stents and other procedures.

Mr Deputy Speaker: What is your question?

Mdm Halimah Yacob: The concern of some patients is that when they are in hospital receiving treatment for the procedures for cardiac treatment, for instance, their medicines will also be subsidised up to the level of 65% or 80%. But the minute they are discharged, then the level of subsidy for the medicine goes down. I would like to ask the Minister of State whether the same level of subsidy could be extended once patients are discharged and have to go for follow-up treatment at outpatient clinics.

Dr Balaji Sadasivan: Sir, our systems for subsidies for inpatient and outpatient are different. What we have done for inpatient is to take all parts of the treatment - medicines, implants, surgery, ward care - together, and we provide a 65% subsidy. For outpatient, our subsidy is up to 50%. At this point in time, I think we will continue with these subsidy levels.

In the past, we tried to differentiate - 65% subsidy for different parts of the inpatient treatment - and patients suffered. Because when they needed an implant, they did not get any subsidy and they had to pay for these implants out of their own pockets. With the MSP, what we are doing is that we are rationalising the treatment for inpatient care and ensuring that they get this overall 65% subsidy.

Dr Lily Neo: Sir, in view of the fact that stroke is the fourth leading cause of death in Singapore and stroke incidents have been on the increase with 7,500 cases of hospitalisation each year and about 33% of these cases end up with disability, will the Minister of State

Column: 217

prioritise subsidising stroke patients further and soonest in our public hospitals?

Mr Deputy Speaker: Dr Neo, we have one minute left.

Dr Lily Neo: Will he also extend subsidy to early and sustained rehabilitation of stroke patients in order to reduce disability? Am I correct to say that early brain scanning is essential for the outcome of stroke patients? Therefore, will he also extend subsidy to brain scanning at outpatient clinics in order for doctors to administer action soonest?

Mr Deputy Speaker: Dr Neo, you are not giving the Minister time to respond.

Dr Balaji Sadasivan: Sir, in short, we give a 65% subsidy for all diseases, whether it is stroke, heart disease or cancer. We do not discriminate between sick patients based on their diseases.

3.00 pm

Mr Deputy Speaker: Order. End of Question Time.

[Pursuant to Standing Order No. 21(3), Written Answers to Question Nos. 21, 22, 25-31 and 34 on the Order Paper are reproduced in the Appendix*. Question Nos. 19, 20, 23, 24, 32 and 33 have been postponed to the next available sitting of Parliament.]

*Cols. 255-274