DEATHS FROM CARDIAC ARREST (Measures to reduce incidence)

DEATHS FROM CARDIAC ARREST:

(Measures to reduce incidence): 5.

Dr Lily Neo asked the Minister for Health, in view of the recent survey by the National Heart Centre that shows one to two Singaporeans below 60 die from cardiac arrest every day, what actions is his Ministry taking to reduce this incidence and save lives.

The Senior Minister of State for Health (Dr Balaji Sadasivan) (for the Minister for Health): Mr Speaker, Sir, the National Heart Centre recently conducted a study of post mortem cases to review the causes of sudden death among Singapore residents. This revealed that 220 persons between the ages of 18 and 60 years of age who died suddenly in 2003 had a cardiac cause of death. This means that the average number of persons under the age of sixty who die from sudden cardiac arrest each day is 0.6 and not one to two. Of course, this does not mean that there is a 0.6 death each day. What the numbers mean is that on some days there are no sudden cardiac deaths, on some days there is one death and occasionally there may be two deaths in a day.

What may be of more concern to Members of the House is the trend. Are things getting worse and are more young people dying from cardiac disease or is the trend showing improvement? I am happy to report that the statistics show that trend is one of improvement.

A review of the current trends of heart attacks and survival rates has shown that the overall rate of heart attacks in Singapore for those aged between 20 and 64 years has gradually declined over the past decade, at 2.3% per year. Additionally, with modern therapy, the death rate from a heart attack has also fallen, from 27.8% to 22.0%, giving an average decline of 2.6% per year.

Therefore, although coronary heart disease is the main cause of sudden death in this relatively young age group, taken in the context of the above statistics, it is clear that our investments made in our healthcare infrastructure and our healthcare system are saving lives.

At the hospital level, patients with heart attacks receive treatment in modern coronary care units, under the care of cardiologists. Clot busting drugs, angioplasty and stents open up the blocked arteries. Recent developments in drug treatment, including statins, result in improved survival outcomes. For the small numbers who still have life threatening heart rhythm problems after a heart attack, there are sophisticated implants called defibrillators that can save lives. My Ministry, through the recently introduced Medical Service Package (MSP), provides subsidies for all these cardiac implants.

Our ambulances are also equipped with automatic defibrillators, and our ambulance staff are trained in CPR (cardiopulmonary resuscitation). They ensure that patients seen with cardiac arrests are provided with prompt and effective therapy.

However, above all, the greatest benefit is achieved by taking preventive measures to reduce the incidence of coronary heart disease. Hence, the need to promote a healthy lifestyle. Singaporeans can avoid heart diseases with regular exercise, by stopping smoking and by having a healthy diet.

Dr Lily Neo (Jalan Besar): Mr Speaker, Sir, may I ask the Senior Minister of State, in view of the fact that measurable cardiovascular risk factors indices appear to have deteriorated in Singapore, whereas theepidemic of heart disease in England is heading downwards and the deaths from heart disease have fallen by a third, is there a need for us to re-examine and re-strategise our current practices in combatting cardiovascular diseases? Are we learning the experiences and best practices of other countries? Do we need to emphasise further on work health promotion and health screening to improve the health status of adult Singaporeans? Should there be more emphasison targeting high-risk groups? And, lastly, instead of just disseminating health messages, should we not now try to reinforce the benefits of healthy choices and better equip people with such choices?

Dr Balaji Sadasivan: Mr Speaker, Sir, I agree with the Member that we must constantly try to improve our healthcare services andreduce mortality rates from heart diseases, and we should constantly review all measures and see if improvements can be made. But if you look at it globally, in terms of health care, our life expectancy is now reaching into one of the top 10 in the world and our mortality rate from cardiac disease is also going downcompared tothe developed countries. So the Heart Centre and all the cardiology units in Singapore are making progress. And, of course, we will urge them to continue to improve their services.

MEDICAL INSURANCE: 6.

Dr Lily Neo asked the Minister for Health (a) how will he address the concerns of Singaporeans on the affordability of healthcare costs, especially hospitalisation costs; (b) does he agree that "risk-pooling insurance" is a good consideration compared to "save and pay as we go" in financing healthcare; (c) if so, what are his action plans; and (d) will he ensure that any insurance plans implemented will be adequate for hospital needs of the majority and one that can also cater for the long term future medical needs.

7.

Mr Zainudin Nordin asked the Minister for Health (a) what is the maximum limit for any person to buy a medical insurance policy under MediShield for protection in his old age; and (b) if a person can afford to invest in an additional insurance policy, will he be allowed to buy it under MediShield.

The Minister for Health (Mr Khaw Boon Wan): Sir, with your permission, I would like to take Question Nos.6 and 7together, as both are about medical insurance.

Currently, Medisave can be used to buy a catastrophic medical insurance policy. There are 15 approved medical insurance policies for Singaporeans to choose from. Withdrawal from Medisave to pay for the insurance premium is limited to $660 per year per policyholder. This withdrawal limit is more thanenough for the basic insurance product such as MediShield.

All the 15 insurance policies are competing insurance products; they are not complementary products. So buying one policy is enough. Paying for duplicated coverage brings no additional benefits.

That said, my Ministry is reviewing our policy governing catastrophic medical insurance. The objective of our review is partly to address the concern raised by Dr Lily Neo on the affordability of hospitalisation costs. Although our work is not yet finished, we have drawn the following six conclusions.

First, catastrophic medical insurance can play a useful role in helping to spread the financial risk of falling very sick and incurring a very large hospital bill.

Very few Singaporeans get hospitalised; at any point in time, only 1 in 800 Singaporeans does. Moreover, not every hospitalisation results in a very large bill. Because of heavy Government subsidy, only a minority with a catastrophic illness will end up with a very large bill. If the vast majority of Singaporeans subscribe to a catastrophic medical insurance policy, then the insurance premiums needed to pay for these very large hospital bills can be quite affordable. The premiums will certainly be very much less than if the patient is to self-insure and pay through his personal savings. This is of course the benefit of "risk-pooling", noted by Dr Lily Neo.

Second, national medical insurance plans are however not without problems. Experience elsewhere shows huge problems of over-consumption by patients and over-servicing by providers. And this is what we have referred to as the "buffet syndrome" of medical insurance. With the premiums being paid for, the financial burden has shifted to the insurer, resulting in both patients and hospitals losing any incentive to be prudent.

Third, the challenge is to maximise the benefits of risk-pooling while minimising the buffet syndrome. And one effective way is to exclude small payments from insurance coverage. Hence, outpatient treatment should be self-insured, paid out-of-pocket. Hospitalisation for most illnesses should also be self-insured and paid largely out of Medisave. We have had 20 years now of Medisave and most Medisave accounts are sufficient to cover such common hospitalisations, especially in class B2 and C where my Ministry will continue to subsidise heavily, up to 80% of the cost.

Fourth, the benefits of risk-pooling are greatest for coverage against catastrophic illnesses, like cancer, organ failure, which require prolonged hospitalisation and intensive treatment. These hospital bills, despite heavy B2/C subsidy, would be unaffordable to many families. Fortunately, the probability of falling very sick is low. And this is where a catastrophic medical insurance plan like MediShield comes in very useful. That is why we allow Medisave to be used to buy catastrophic medical insurance plans.

Fifth, MediShield has, however, been losing its effectiveness as a catastrophic insurance plan. All medical insurance plans have to be periodically reviewed and their parameters like premiums and benefits adjusted. Since its introduction 14 years ago, MediShield has largely remained unchanged. As a result, when a patient has a catastrophic illness and, let us say, incursa class C hospitalisation cost of $100,000, his bill, after subsidy, is about $20,000. As a policyholder of MediShield, he expectsMediShieldto foot the bulk of this bill. But MediShield today only covers about 40%, or $8,000. Many such class C patients do not have $12,000 in Medisave to settle their share of the bill.Hence, there is this public anxiety about large hospital bills. Part of the reason for this reduced effectiveness of MediShield is that its deductible level has not been adjusted. So instead of covering only the very large bills and covering them adequately, MediShield today covers too many bills, big and small, and covers them poorly. That is why we must return MediShield to its original purpose of only looking after very large hospital billsbut cover themadequately. To fund the additional benefits, premiums would have to be raised, especially since they have not been adjusted for over 12 years.

Sixth, while maximising the effectiveness of MediShield, we must also try to keep its premiums as low as possible. Ideally, MediShield should be compulsory for all Singaporeans. This will then ensure maximum participation with minimum distribution cost. Unfortunately, we have inadvertently compromised this principle by having private medical insurers compete with MediShield and, in so doing,fragment the risk-pool. Instead of one large MediShield risk-pool, we have today 15 smaller risk-pools, with correspondingly higher premiums than necessary. Not surprisingly, instead of competing to render better benefits at lower premiums, private insurers find it more profitable to pick and choose and draw away the healthy lives from the MediShield pool into their smaller pools. This is a phenomenon known as "cherry-picking" in the insurance industry. This must ultimately lead to the demise of MediShield, as its risk-pool becomes progressively older and sicker. MediShield has not yet reached this critical stage. But we must remove this cherry-picking and reverse the fragmentation of the MediShield risk-pool as soon as possible.

Over the next few months, my Ministry will conduct extensive discussions with the public, the insurers, the unions, the employers and all interested parties, to see how best to reform MediShield for the benefit of the majority.

Dr Lily Neo: May I ask the Minister whether any insurance element introduced by his Ministry should have the three essential tenets of a viable insurance scheme: firstly, national coverage with no one being left out; secondly, long-term sustainability to give Singaporeans assurance on their long-term medical needs; and, thirdly, ensuring that this scheme will givepeace of mind to all Singaporeans on their medical needs in public hospitals, regardless of medical conditions, albeit with deductibles and co-payment in place. May I ask the Minister whether MediShield in fact has failed in these three tenets? May I ask the Minister whether it is correct that, firstly, MediShield isan opt-out scheme with many most vulnerable being left out? Secondly, it has an age limit which does not serve us well in view of our ageing population and longer life span of Singaporeans. And, thirdly, it also has low annual and lifetime limit which defeats the purpose of assurance on health cost affordablilty. The Minister earlier said that he will keep MediShield to cover catastrophic illnesses. But that only constitutes 5%-10% of the hospital bills. How does the Minister expect Singaporeans to pay the rest of the 90%-95% of the hospital bills? Did he notagree that risk-pooling is a better method ---

Mr Speaker: Please keep your questions short, Dr Neo.

Dr Lily Neo: --- than save and pay as equal financing? Lastly, how does he reassure some Singaporeans who think that this MediShield revamping is another way of the Government taxing the people?

Mr Speaker: May I remind Members to keeptheir questions short, please? We have quite a few other Questions to deal with before the end of Question Time.

Mr Khaw Boon Wan: Mr Speaker,let me simplify the argument this way. What are we trying to do? Insurance is to really protect against financial disaster. Most of us buy life insurance because we worry that we may have a premature death. Ifyou buy insurance,at leastthe family will be taken care of, and likewise with medical insurance. So we buy medical insurance, not hoping to fall sick, but just in casewe are very sick, the bill is very large, at least financiallywe do not have this burden to worry about.Therefore, medical insurance can take various forms.We can look after all and sundry - large bills, small bills, outpatient, inpatient - and this is what we call in our tradecomprehensive medical insurance. And many countries do that. America is a typical example. Or we decide that, no,just focus on what we are most worried about. And if you ask me, I thinkwhatwe are most worried aboutare very large bills.With Medisave, in fact, for most bills, Medisave can cover. So if your bill is a few hundred dollars, or a couple of thousanddollars, do not worry,so long as you regularly contribute to Medisave. The fact is thatyou do not fall sickevery year and need to be hospitalised every year.

In fact, statistically, every year, only 10% of Singaporeans need to be hospitalised. So, on average, most ofus, over 10 years, we are hospitalised once. I am 52. I was hospitalised twice. So I am belowthe average, meaning that I am healthier, and I am sure most of you are like me too. But yes, there are people who are more sickly for various reasons,and therefore hospitalisation frequency may be higher. So the value of risk-pooling, which I totally agree with Dr Lily Neo. But itshouldbe appliedproperly.Because if you misapply it and try to cover all and sundry, you willface great difficulties like in the UnitedStates, and I am not making all these up. It is true.

There are abusesin the American insurance system likeover-consumption, in other words, frivolous claims. Having boughtan insurance, the insurer will pay and youdo not care. Any slightest sickness,you walk into the hospital, demand a bed, or whatever, because it does not costyou anything. Insurance will pay for it. Moreover,you get a medical certificate, andyou do not have to work. So this is one aspect of abuse. The other abuse is at the other end - over-servicing by the hospitals. It is what I call the "motor repair shop syndrome". You all know this. When you seea cargoing intoa repair shop, the first thinghe asks you is, "Are you insured?" If you are insured, you will likely see therepair shop put in anew bumper, repaint the whole car, and so on, because somebody is paying for it, and the consumer is not complaining. He gets thecar back almost brand new andrepainted. So this problem of over-consumption and over-servicing is real. Let usnot brush this aside. So, yes, I agree with Dr Lily Neo that we should begin to expand the role of MediShield, but let us do it with our eyes open and try to see how best to do it.

My prescription for Singaporeans about high healthcare costsis this: take a five-step approach. Step No. 1, avoid falling sick. How? Healthy lifestyle. So this Sunday, Prime Minister Lee is going to launch our National Healthy Lifestyle in a big way in Sentosa.This year, we are scaling it up, going extensively beyond the Ministry of Health to all public and private sectors, all Ministries, and I am glad the GPC, led by Dr Lily Neo, will also be there to be role models of healthy lifestyle.

Step No. 2, yes, sometimes we do fall sick,make sure you have a good family physician who will adviseyou on how best to look after your sickness. As primary healthcare in Singapore ismodest and inexpensive,pay for it out-of-pocket.

Step No. 3,bad luck, you are a little bit sicker, and you need to be hospitalised. Again, your family physician will be able to advise youtogo to thisor that hospital, see that particular doctor orspecialist.Most of the time, with heavy subsidy in Class B2/C, the hospital bills are very modest, a few hundred dollars, or couple of thousand dollars. With Medisave, there is no problem paying for it. If you are young

and have not started building up your Medisave yet, Medisave gives you an overdraft. You can pay for it later when you work. So, Medisave is enough to cover most hospitalisation bills.

Step No. 4, bad luck cases,when your bills are very large, that is when MediShieldought to come in, and that is why I have been focusing my mind on today's lack of effectiveness of MediShield, not by design, but because of lack of adjustments over the last 14 years. But better late than never.Let us reform MediShield and make sure it serves its original purpose well.

Step No. 5,really bad luck cases, ie, despite Medisave, MediShield, the bill is still too huge to cope. Do not worry, Medifund is thereto take care of this very small number of very unfortunate Singaporeans who are very sick. Medisave is completely wiped out, but Medifund is there to protect them.

With these five steps, Singaporeans can have peace of mind. But I need Singaporeans to do three things:

Step 1: Healthy lifestyle.

Step 2: Contribute regularly to Medisave. Employees have no problem. Self-employed,taxi drivers, hawkers, etc, please contribute regularly while you are young and healthy.

Step 3: Support me in my MediShield reform.

Dr Lily Neo: Sir, I just want to register my point to say that I agree with the Minister. We must definitely avoid over-consumption. I will elaborate later in my speech in the adjournment motion, but I would just like to urge the Minister tointroduce an insurance scheme that will solve the affordability concerns of Singaporeans.

Mr Yeo Guat Kwang (Aljunied): May I ask the Minister: when the review is completed and we have a revamped and more effective MediShield scheme, would we accept those who have already opted out to opt into the scheme again, because I understand that there are more than 270,000 Singaporeans who have already opted out of the scheme?

Mr Khaw Boon Wan: I think a lot depends on whatyou mean by "opting out". If you have opted out of MediShield but into one of the 15 MediShield-like insurance, eg, IncomeShield, etc, I do not consider you as having opted out. You are still in the system. My worry is the small percentage of Singaporeans who completely opt out, who are not in any kind of scheme, then it is a bit troublesome, because I need to know what is your motivation for opting out. Again, using an analogy, it is like house fire insurance policies. All of us with properties buy some form of fire insurance. Insurers are most happy to insure you, but not while your house is actually burning. It cannot be that onlywhen you are sick and down thatyou start opting in. Then it is not fair to those who have not opted out,becauseyou suddenlydiscover you have cancer andthen onlystart subscribing to MediShield. We can take him but, surely, the premiums will need to be adjusted, to be fair to the majority who have stayed loyal to the scheme.

Mr Speaker: Miss Penny Low. Last question.

Miss Penny Low (Pasir Ris-Punggol): Sir, the Minister rightly said that insurance is for the purpose of covering financial disaster. But I think there are two components to the disaster. One is the new and increased medical bill, the other is the loss of income. It appears that the revamped MediShield scheme would remain largely an indemnity plan. Would the Minister consider adding an optional - and I emphasise "optional" - componentto provide a lump-sum or periodic payment to cover the loss of income, because some of these people who have catastrophic illnesses may be breadwinners to the family?

Mr Khaw Boon Wan: Mr Speaker, Sir, I always keep my options open. So, I consider all options. But let me just be candid upfront. "羊 毛 出 在 羊 身 上 ( Yang mao chu zai yang shen shang )" - the English translation is "there is no free lunch". If you want more benefits, your premiums will also be larger. If you want less benefits, your premiums will be less. So, if you want to load your insurance policy with unemployment benefits because you are out of job so you need income support, then you are talking about a differentkettle of fish now. Should we have unemployment benefits nation-wide available? That is something I am sure my colleague, Dr Ng Eng Hen, would be most happy to engage with you. I stay focused on healthcare.