By Lee Puay Ling and Dr Jeremy Lim

The elderly Singaporean is increasingly hard pressed when it comes to healthcare. Our Singapore healthcare financing model emphasizes, in addition to government subsidies, employment, 3Ms and family. The latter three may no longer be sturdy pillars…

Singapore prides herself as a traditional society, where there is a strong sense of filial piety and the young takes good care of the old. Our elderly are enjoying greater life expectancy – Singapore’s life expectancy of 81.7 years is higher than the average of OECD countries’ 79.7 years in 2010, but a closer inspection reveals troubling news amidst this happy statistic- the years of healthy life lost due to disability has increased by roughly two years from two decades ago. The average man spends 10.7 years while the average woman spends 13.3 years of their lives suffering from poor health.

Poor health aside, the elderly are financially vulnerable as a group. 35% of elderly above the age of 75 years are not enrolled in the MediShield scheme. Neither do they enjoy employer benefits since most of them are not working or are working without benefits. The ‘traditional’ model of family support may also be under strain: smaller families, single Singaporeans and children of elderly Singaporeans struggling with high housing prices, inflation and paying for their own children’s expenses all stress the long-assumed family safety net. The occasional Medisave top-up, while helpful, is not definitive; Medisave only commenced in 1983 and Singaporeans in their 70s and 80s would have built the Medisave nest egg for only a decade or two and hence would not have sufficient monies to provide for a lifetime of healthcare needs.

With many years of disability and a financing system not designed for them, many elderly may lack the monetary means to pay for their hefty medical bills. This may lead to foregoing of necessary medical and preventive healthcare, further exacerbating the risks of ill health and disability. Do we need reform? Any revamps of the system needs to address two critical objectives: ‘compression of morbidity’ and ‘financial peace of mind’. What are the options?

Compression of Morbidity

‘Compression of morbidity’ is the shortening of the number of years lived with disability before death by delaying the first onset of chronic diseases and mitigating the lifestyle impact of these chronic conditions. This means two things: remaining healthy as long as possible and timely disease detection and treatment to enable continued functionality. Singapore does reasonably well in the former. In fact, Bloomberg has declared Singapore the world’s healthiest country! In the latter, we may fall short. The 2010 National Health Survey revealed that amongst our elderly aged 60 to 69 years, half of those with diabetes and a quarter of those with hypertension did not know they had the diseases. Of those who were previously diagnosed, only 68% maintained good blood sugar control and 67.4% had good blood pressure control. It is noteworthy that of the 1,264 new cases of kidney failure in 2009, 62% arise from poorly controlled diabetes. By encouraging more Singaporeans to go for early screenings and keeping track of their health status, their number of healthy years lived can be maximised.

Peace of Mind

15.5% of elderly in Singapore are single and 7.9% live alone; these numbers are slowly rising . In general, the elderly and their families absorb most of the healthcare burden on their own (sans government subsidies which account for approximately 30% of total healthcare spending) as only 12.3% of them receive financial support through their employers and businesses. We agree co-payments are needed to mitigate moral hazard, but the elderly who are already largely unemployed, with modest Medisave and are excluded from MediShield, do not have the same financing options that younger Singaporeans have and hence have to bear a larger share of medical expenses. Does it make good financial sense to provide greater financial support? Can we prevent expensive downstream hospitalisations with modest investments upfront? What about the caregiver costs when their children need to take time off work or even drop out of the workforce? Are these factored into cost-benefit analysis? Healthier elderly Singaporeans can also contribute significantly, not just in jobs where their experience counts but also as grandparental caregivers and child-minders. There is a moral dimension too: today’s elderly have contributed tremendously to Singapore, can society do more for them? Pragmatically, how we care for the elderly today sends a clear signal to the young and may affect decisions around migration and the sense of commitment to Singapore.

Some policy options

Healthier Singaporeans: If we agree that ‘prevention is better than cure’, then policy interventions to promote health and detect diseases early would be worthwhile. Much work has been done in this respect in recent years, and more and more with a holistic, whole-of-person and community-centric perspective. The Health Promotion Board has been working together with food manufacturers with some success in engineering healthier food, such as brown rice enriched rice noodles. Further downstream, parks with exercise equipment are commonplace and urban planners are increasingly designing housing estates to provide amenities that encourage exercise (cycling paths, sheltered walkways etc). Can more be done? Certainly, building on the decades of fine work at population level, Singapore could consider adding on targeted interventions, focusing on higher risk population segments, such as the Malay community which has higher rates of obesity at 24% and Malay men between 30 to 39 years old who have higher rates of smoking at 49%, families of patients with diseases with strong genetic predispositions, e.g. females who inherited the mutated BRCA1 and BRCA2 genes are at higher risks of breast cancer, etc. For those known to have diseases, could healthcare providers be more proactive in ensuring adherence to treatment regimes and supporting patients better? Yes, simple measures such as daily reminders, organizing patients into groups for mutual support, regular contact with nurses or health coaches could improve our national health. Are the numbers well worth it? Yes, 23.5% of the population have high blood pressure and 11.2% have diabetes. Collectively, the Ministry of Health estimates more than a million Singaporeans with at least one chronic condition.

Earlier Disease Detection: Kaiser Permanente, a well-known health provider in America, exploits every care encounter to identify and fill ‘care gaps’. When patients consult, whether for diarrhoea or for arthritis follow-up, Kaiser doctors through the IT system, are prompted on what preventive health measures are needed, e.g. mammography, colon cancer screening etc. Dr Tan Wu Meng has written eloquently in the Straits Times about the under-valued time of consultation. In our productivity-driven system (where productivity is often wrongly defined for healthcare), doctors are urged to be more ‘productive’ and see more patients per clinic session. With this mindset, only the presenting symptoms will be addressed and a valuable preventive health opportunity lost.

Should health screening be free?: Financial considerations while not the only factor influencing decisions to seek health screening is certainly an important one. Health screening with earlier detection and hence treatment can save lives and improve quality of life. The humanitarian perspective aside, there is a compelling economic argument in the Singapore model since expensive tertiary services are heavily subsidized by the government. A dollar spent today may save thousands tomorrow. What about the fear of ‘moral hazard’? Wouldn’t citizens undergo unnecessary screenings? ‘Unnecessary’ has two elements- tests which are not necessary and necessary tests repeated unnecessarily frequently. To address both of these, it is useful to look at the profession for guidance. The Academy of Medicine, Singapore has issued guidelines on what constitutes appropriate health screening and these could be used as a starting point for discussions on what to fund through the public purse.

‘Peace of Mind’: Minister Gan said earlier this month, “There is a strong desire among Singaporeans for greater peace of mind – the assurance that I will be able to afford healthcare when my family and I need it, whether now or when I grow old. We take these concerns to heart. We want Singaporeans to be confident that they can always afford the care they need.” How can Singaporeans have this ‘peace of mind’?

Let’s examine the nature of this lack of ‘peace of mind’. Singaporeans are likely most concerned about two issues – the uncertainty of illness affliction and hence the burden of healthcare costs and their share of the bill. On the former, Minister Gan has correctly identified that expanding risk pooling is fundamental. It does not make sense for every Singaporean to try and save for an eventuality that may never materialize; besides, most Singaporeans will never be able to save enough to pay fully for a complex and long-drawn illness. This would need substantial revamp of health insurance and MediShield would be the correct starting point. MediShield is the bedrock insurance program for Singaporeans intended to protect against the financial consequences of medical catastrophies. However, MediShield eligibility falls off the cliff upon reaching 90 years of age and premiums increase sharply with age. We need to assure that MediShield is truly inclusive and covers every Singaporean. We recommend three changes:

Firstly, expand MediShield to include all Singaporeans regardless of age or pre-existing illnesses. This is a monumental decision as it reframes MediShield from being a scheme run on commercial principles (albeit as a non-profit) to one that is founded on social principles.

Secondly, ensure all Singaporeans can afford to pay the premiums and avoid drop-outs. Premiums may be higher for the extreme elderly or those with substantial pre-existing illnesses and government funding for those who cannot afford to pay their own premiums should be considered.

Thirdly, limit the individual’s risk of medical bankruptcy by imposing a cap on what patients have to pay as their share of the total bill. The derivation of the quantum needs to be transparent though. The cap will have to be means-tested in keeping with the government’s philosophy of targeting subsidies, but patients need to know before the fact how the cap is determined and what they are expected to pay. One final point, setting caps on what patients pay does not remove the financial risks in and of themselves. It just means someone else, in this case, the government, has to bear the risk. This will need to have downstream effects on tax rates, and social activists advocating for financial risk protection for society’s vulnerable are really asking for the government to do more AND for taxpayers to fund these measures.

Our system has served Singaporeans well in the early heady years of nation building when the population was young and diseases were acute and episodic. Today, we are much older and disease patterns have shifted to long-term conditions needing mainly outpatient based care. It is timely that the government has announced its decision to conduct a comprehensive review of the health system. A plea for the vulnerable elderly: as we plan for tomorrow, remember that many of our elderly Singaporeans need the changes today.

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Lee Puay Ling is an intern with Insights Health Associates. Dr Jeremy Lim is the Principal Consultant at Insights Health Associates.