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TAN SU-KYM: Financing for Healthcare (Financing Mechanisms (Medifund (MAF,…
TAN SU-KYM: Financing for Healthcare
Healthcare landscape
2000-2010
Competition and centralisation
Centralisation through clustering
Group Purchasing Office
:
bulk buying of medical consumables and materials. Increases leverage of hospitals to demand lower prices. In addition, the cost price would be standardised
Finance Shared Services
:
outsourced accounts payable, account receivable and payroll service provider to various institutions. Accounting functions are consolidated/shared (reduce manpower and operating cost
Integrated Health Information System:
MOH to be the central employer for all public healthcare IT professionals
To keep cost of providing medical services low: careful evaluation of new medical technologies for adoption to ensure cost-effectiveness
Competition
Creates price diversity
Reasons: Cost structure differs
Prices marked up to cover cost of institution/department
Within same organisation: cost and price differ (inpatient and outpatient)
Solution to reduce cost: consolidating common services for healthcare institutions
Transfer stable patients from hospitals to step-down care institutions to save resources like medical equipment and manpower
Various permutations per item per week regulated by MOH
Post 2010
Regional Groups or Clusters were created to enable integrated care
Hospitals, polyclinics, community hospital, education centre and specialty centers under each group
Partner with general practitioners, polyclinics and other healthcare providers in the area
"build partnerships and seek synergies beyond the public sector
Future Healthcare Landscape
3 clusters: West (NUHS), Central (NHG) and East (SingHealth)
Challenges faced in healthcare industry
Ageing population
Leads to silver tsunami
Number of bed occupancy increase
Longer waiting time for admission
Increasing incidence of chronic diseases
Increasing demand for more healthcare services
Increasing demand for more affordable healthcare
Have various levels of subsidy, availability of subsidy for various healthcare services and settings
Inform patients the choice of ward class, choices of treatment options, for patients to select the most affordable options provided
Refine Medifund criteria to prevent it from being too strict
Updates to Healthcare 2020 Masterplan
Ultimate goal: promote healthy living and active ageing
Easier access
Increase capacity: one new hospital on average, in each year; more nursing homes, community and home care services in the community
Better quality
Appropriate and quality care
Improve primary care services by introducing more community health centres and family medicine clinics
More affordable
Cheaper outpatient and drugs at public hospitals with more government subsidies
Lower cash payment with more uses for Medisave
More peace of mind with Medishield Life
Lifetime coverage for all
Enhanced benefits
Premium subsidies for lower- to middle-income
Pioneer Generation gets more help
Financing Mechanisms
Government subsidies
CHAS Card
Provides Singaporean lower and middle income households with better access to primary healthcare, bring affordable healthcare services closer to patients
GPs and private dentists have been engaged by MOH to provide common outpatient medical and dental treatment to the needy at subsidised rates
Covers
Common illnesses such as cold, cough and fever
19 chronic conditions under the Chronic Disease Management Programme
Selected dental services
Recommended health screening
Blue
Household monthly income: $1,100 and below
AV (those with no income): $13,000 and below
Common illness: up to $18.50 subsidy/visit
Simple chronic: up to $80 subsidy/visit; capped at $320 per year
Complex chronic: up to $120 subsidy/visit; capped at $480 per year
Selected dental services: $11-$26.50 subsidy/procedure (dependent on procedure)
Subsidy at SOCs: 70%
Orange
Household monthly income: $1,101-$1,800
AV (those with no income): $13,001-$21,000
Common illness: not applicable
Simple chronic: up to $50 subsidy/visit; capped at $200 per year
Complex chronic: up to $75 subsidy/visit; capped at $300 per year
Selected dental services: $50-$170.50 subsidy/procedure (crown, denture and root canal only)
Subsidy at SOCS: 60%
Subsidy at SOCs
Monthly household income per person: more than $1,800 (or did not apply)
AV of home (those without income): more than $21,000 (or did not apply)
Subsidy: 50%
Pioneer Generation Package
Recognise and honour Pioneer Generation
Criteria: Singaporeans aged 65 or older in 2014; became Singaporean by 31 Dec 1986
Subsidy
Common illness: up to $28.50 subsidy/visit
Simple chronic: up to $90 subsidy/visit; capped at $360 per year
Complex chronic: up to $135 subsidy/visit; capped at $540 per year
Selected dental services: $21-$266.50 subsidy/procedure (dependent on procedure)
SOCs: and drug subsidy additional 50%
Drug subsidy
CHAS (blue + orange): 75%
None: 50%
Pioneer Generation: Additional 50%
various subsidies
Specialist clinics
Singapore citizen: 50% (w/o means test); 60-70% (after means test)
Permanent residents: 25%
Foreign resident: 0%
Non-resident: -30%
Day Surgery
Singapore citizen: 65%
Permanent resident: 40%
Foreign resident: 0%
Non-resident: -30%
Inpatient (re-structured hospitals)
Singapore citizen: (C: 80-65%; B2: 65-50%)
Permanent resident: (C: 55-32.5%; B2: 40-25%)
Inpatient (public hospitals)
Singapore citizen: (A: none; B1: 20%; B2: 65%; C: 80%)
Permanent residents: (A: none; B1: 10%; B2: 40%; C: 55%)
Foreign resident: pay full rate
Non-resident: pay surcharge
Subvention
Amount of money given to provide subsidised rates for patients using subsidised services (staying in B2 and C class wards)
Types
Lump sum subvention
:
funds given based on budgetary forecast
Piece rate subvention
:
funds awarded based on number of patient days and volume of outpatient consult episodes consumed. Funding: based on usage
Casemix subvention
:
funds allocated based on DRG (Diagnostic-related group). Every DRG depends on complexity of treatment will command a different amount
Global budget subvention
:
funds allocated based on lump sum, piece rate and casemix funding principles
Medisave
What?
Portion of CPF savings used to pay for personal or immediate family members medical bills
Immediate family members: parents, spouse and children
Can use to pay for insurance premiums for Medishield Life and Integrated Shield Plans
Nursing homes CANNOT use (long-term treatment cannot, only short-term can)
Covers?
Staying healthy (GPs, polyclinics and SOCs)
: $400 per year per account under Medisave400 limit (stay healthy with outpatient preventive care and chronic disease treatment)
Protect yourself against diseases
: various vaccinations for high-risk groups (very young, elderly and persons with chronic medical conditions or poor immune function)
Recommended screening
: mammograms every 2 years (women aged 50 and above); colonoscopies every 10 years (persons aged 50 and above)
Chronic disease
: outpatient treatment (19 approved conditions under Chronic Disease Management Programme (CDMP)); 15% co-payment needed but no deductible
Starting your family
(public, private hospitals, including SOCs)
Couples need help conceiving
: $6k, $5k and $4k for first, second and third (and subsequent) treatment cycles respectively for Assisted Conception Procedures (ACP)
Welcome little baby
: $450 per day hospital charges; $750 for normal delivery and $2,150 for caesarean delivery; additional $450 for pre-delivery expenses
Repeated treatment
(conditions requiring prolonged, regular treatment and may be costly over time)
Cancer
: at SOCs
Renal dialysis
: $450 per month per patient
Selected drugs, services or devices
Outpatient intravenous antibiotic treatment
: $600 per weekly cycle, up to $2,400 a year
Get medical scan
(SOCs and polyclinics)
$300 per year per patients (various scans needed for diagnosis/treat medical condition)
medical scans like CT/MRI scans
not for plain X-rays/scans covered under other Medisave uses (cancer-related scans), scans for conditions under CDMP, screening mammograms, pre-delivery scans)
Treatment in old age[Flexi-Medisave]
(polyclinics, public hospital SOCs and participating CHAS GPs)
$200 per year per patient for outpatient treatments (aged 65 and above)
use your own/spouse's Medisave (if spouse also 65 years and above)
covers consultation fees, medical services, drugs and tests necessary for diagnosis or treatment of a medical condition, as ordered by doctor (not applied to dental treatment)
Pay medical and long-term care insurance
(pay Medishield Life and/or Eldershield premiums to have peace of mind for large medical expenses)
Medishield Life and Integrated Shield Plans
: basic insurance scheme helping Singaporeans pay for large hospital bills and expensive outpatient treatment
Eldershield and Eldershield Supplements
: an insurance scheme protecting elderly against long-term care expenses needed in case of several disability
Hospitalisation and Surgery
Hospitalisation:
$450 per day/$300 per day surgery) covers hospital charges, including daily ward charges, daily treatment fees, investigations and medicines
Surgery
: claims based on fixed limit from TSOP (range from $250-$7550, depending on complexity of surgery)
Rehabilitation and Palliative care
Rehabilitation
Inpatient: $250 per day, up to $5,000 per year
Outpatient: $25 per day, up to $1,500 per year
Palliative care
Inpatient: $200 per day
Home palliative care: $2,500 per lifetime (terminal cancer/end-stage organ failure: no limit and can use full Medisave balance)
Medishield Life
What?
Basic health insurance plan help cope large hospital bills and selected costly outpatient treatments
Covers medical expenses for stay in B2 or C wards in public hospitals
Protects all Singapore citizens and PR, including very old and those with pre-existing conditions
Benefits: higher claim limit; lower co-insurance rates; Medishield Life pay more with patients paying less
Integrated Shield Plans
2 components: Medishield Life and Private medical insurance coverage
Private medical coverage: more coverage for A and B1 wards; managed by private insurer
Eldershield
Those who are ill or those who are not able to work because of illness
Helps to reduce burden of long term care
Only applicable if insured under Eldershield and meet requirements to receive payout
Medifund
Key principles
Personal responsibility: co-pay according to your ability
Medical necessity: exclude non-essential choice like A class, and cosmetic surgery
Family responsibility: make use of family's medisave when can
Many helping hands: charitable organisations to help
What?
Must be unable to pay for healthcare bills despite receiving government subsidies and drawing on other means of payments including Medishield Life/Integrated Plans, Medisave and Cash
Staying in B2 or C ward for inpatient/subsidised outpatient
Medifund Sliver
Singaporeans aged 65 and above: deliver assistance to needy elderly patients in a more targeted manner
Medifund Junior
Needy children below 18 years old (those diagnosed with congenital/neonatal conditions)
Target more needy financial assistance for sick children from needy families
Household income
Medifund (general)
Less than or equal to $A: 100% eligible
$A-$B: 0-100% eligible
Medifund Sliver
Less than or equal to $B: 100% eligible
$B-$C: 0-100% eligible
Approval levels
Level1: Pre-qualified cases
Level2: straight forward applications (less than recommended)
Level3: non-straight forward applications (more than recommended)
MAF
Separate funding from Medifund
Coverage for non-standard drugs
Maximum subsidy: 75% (upon assessment by Medical Social Service)
Per capita household income: $1,500 or less
Only HSA-approved indications allowed
MAF Plus
Expanded version of MAF to cover non-standard and non-formulatory drugs
Increase maximum subsidy level from 50 to 75% (upon assessment by Medical Social Service)
Deducted first before making use of Medishield/Medisave
Provide information application
Financial assistance of immediate family members
Bankbook/bank statement
Full name and NRIC of self and family members
Employer Medical Benefit Scheme
Employed Singaporeans: medical insurance coverage by employers
They think sufficient, not inclined to purchase further medical coverage
Issue: employee hospitalisation and surgical insurance: not long-term coverage
Disadvantages
Pre-existing illness/medical conditions: employees change job
Retirement/unemployment: does not insure, exposed to financial risk when need most after retirement
Civil Service Medical Benefits
Comprehensive Co-payment Scheme (CCS)
Medisave-cum-Subsidised Outpatient Scheme (MSO)
Co-payment on Ward Charges Scheme (CPW)
CPW: most generous; followed by CSC then MSO
Common types of health insurance
Catastrophic medical insurance
Cover major illnesses where medical cost is high
Covers in-patient and outpatient benefits, and certain expensive and prolonged treatments (kidney dialysis and cancer treatment)
Example: Medishield Life
Long-term care insurance
Pays a fixed monthly amount for long-term nursing treatment if insured cannot perform a number of "activities of daily living" (ADLs)
ADLs: bathing, dressing, feeding, going to the toilet and moving around
Insurance concepts
Deductibles
initial amount to pay for claims made in a policy year before payout from insurance company/Medishield Life
Avoid first-dollar coverage and help Medishield Life target only large bills
Co-insurance
percentage insured member pays on the portion of the claim above the deductible
Guard against over-consumption
Claim limits
maximum amount claimable from insurance policy for each type of expense
Financial Counselling
What?
Counsel patients on financial impact of medical treatment
Let them know estimated bill size of treatment
Let them be able to decide:
Choice of ward (Private/subsidised)
Proceed or don't proceed with treatment
Seek alternative options at other institutions
Standard or non-standard options
Intent: save patients and families from financial burden
When to conduct?
Have subsequent changes to the estimated hospitalisation bill size (complications, longer length of stay, more drugs or treatment required, etc)
Patients admitted through A&E (conducted within 48 hours of admission -> diagnosis and/or treatment patients need at the point of admission may still be uncertain)
Key steps
Introduced to different class of wards and charges (there may be a possibility of ward switch)
Subsidised charges on chart based on 100% subsidies (information given is before means test is being performed)
Subsidies vary (due to being qualified for MT)
Allow them time to decide (a lot of information and complex decision making)
Previous valid MT available (valid for 1 yr)
Authorisation form obtained before MT (privacy of patient's income and confidential information)
Paper MT declaration form (capture signature; serial number for MOH's record and tracking)
Conduct on-line MT (MT determine amt of gov subsidies patient entitled to)
Patient sign eFinancial Counselling form (obtain acknowledge that FC is done)
Means Testing
What?
Targeted at preventing undeserving "rich" from abusing subsidies
Those with chronic conditions needing long-term care are afraid that they might not be able to cope with the financial burden if the existing subsidies is lowered
Individual MT
Use for: inpatient admission
Employed: average monthly income received for the last available 12-month period (bonuses, but not the last salary, included for calculation). CPF contributions will not affect income information
Self-employed: monthly income derived from last available net trade income assessed by IRAS within last 2 yrs
OR
income declared to CPF within last 2 yrs
Unemployed/no income: full subsidy (65% for Class B and 80% for Class C);
OR
property with AV of more than $11k (50% for Class B2 and 65% for Class C)
Household MT
Use for: inpatient downgrading; SOC enhanced subsidy; ILTC subsidy; Medifund application; CHAS application
Norm to determine eligibility for subsidy and assistance
Takes into consideration: Gross income of person needing care, spouse and all immediate family members living in the same household;
AND
total number of family members living in same household
OR
AV of place for households with no income
Per capita household income: total monthly gross earnings of family in same household / number of family members living in same household
Steps of MT
Consent form: subsidy for B2 and C wards
Payslips and bank statements
Consent to release Medisave/Medishield Life information
Means-test declaration form (income, residential value, per capita income)
Means-test declaration form (particulars of applicant, family members in same address, consent/declaration)
Bill
Acknowledge that FC was performed
Medisave authorisation form (withdrawal/claim of Medisave and Medishield Life)