Affordable Excellence: The Singapore Healthcare Story Affordable Excellence: The Singapore Healthcare Story How to Create and Manage Sustainable Healthcare Systems William A. Haselne SINGAPORE © 2013 William A. Haseltine Published by: Ridge Books an imprint of NUS Press National University of Singapore AS3-01-02, 3 Arts Link Singapore 117569 Fax: (65) 6774-0652 E-mail: [email protected] Website: http://www.nus.edu.sg/nuspress ISBN 978-9971-69-664-1 (Paper) All rights reserved. !is book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher. National Library Board, Singapore Cataloguing-in-Publication Data Haseltine, William A. Affordable excellence : the Singapore healthcare story : how to create and manage sustainable healthcare systems / William A. Haseltine. – Singapore : Ridge Books, c2013. p. cm. ISBN : 978-9971-69-664-1 (pbk.) 1. Medical policy – Singapore. 2. Medical care – Singapore. 3. Medical care, Cost of – Singapore. I. Title. RA410 338.433621 -- dc23 OCN825696488 Cover image by Tay Kay Chin Typeset by Forum, Kuala Lumpur, Malaysia Printed by Mainland Press Pte Ltd Contents List of Illustrations vi Acknowledgements ix Introduction xii Chapter 1 !e Singapore Healthcare System: An Overview 1 Chapter 2 High Quality, Low Cost 16 Chapter 3 Helping Patients Pay 38 Chapter 4 Controlling Costs 64 Chapter 5 Financing 83 Chapter 6 Design and Infrastructure 93 Chapter 7 Investing in the Future through Medical Education 106 and Research Chapter 8 Facing the Future 128 Appendix 143 Notes 148 Bibliography 162 Index 174 List of Illustraons Tables Chapter 2 Table 2.1 Health Indicators, Singapore 17 Table 2.2 Life Expectancy at Birth (years) 19 Table 2.3 Infant Mortality Rate (probability of dying by 20 age 1 per 1,000 live births) Table 2.4 Under-Five Mortality Rate (probability of dying by 22 age 5 per 1,000 live births) Table 2.5 Adult Mortality Rate (probability of dying between 23 15 and 60 years per 1,000 population) Table 2.6 Physician Density 2000–2010 (per 10,000 population) 25 and Hospital Beds 2000–2009 (per 10,000 population) Table 2.6a Cost Comparisons of Some Major Procedures between 32 the United States and 3 Medical Travel Destination Countries Table 2.7 Healthcare Costs, Singapore 34 Table 2.8 Expenditures, 2000 and 2008 35 Table 2.8a Expenditures, 2000 and 2008 36 Chapter 3 Table 3.1 CPF Contribution and Allocation Rates for the 40 Various Types of Employees Table 3.1a CPF Contribution and Allocation Rates for the 41 Various Types of Employees Table 3.2 Medisave Withdrawal Limits 46 Table 3.3 Top Up for CPF Medisave Account 49 i List of Illustraons ii Table 3.4 Tax Benefits for Voluntary Contributions by 50 Companies to Self-Employed Persons’ Medisave Account Table 3.5 MediShield Yearly Premiums 54 Table 3.6 Deductible and Co-Insurance 55 Table 3.7 Premiums for ElderShield400 60 Chapter 4 Table 4.1 Annual Premiums for Basic Health Insurance 66 around the World Table 4.2 Appendix Surgery (Appendicectomy) 72 Table 4.3 Public Hospitals: Medical Specialties 73 Chapter 5 Table 5.1 Subsidies at Public Hospitals 85 Chapter 6 Table 6.1 Fee Scheme at Ang Mo Kio Polyclinic 95 Table 6.2 Intermediate and Long-Term Care (ILTC) 102 Services Chapter 7 Table 7.1 Statistics, Biomedical Industry 123 Figures Chapter 2 Figure 2.1 In-Hospital Case-Fatality Rates within 30 Days 27 after Admission for Acute Myocardial Infarction, 2007 Figure 2.2 In-Hospital Case-Fatality Rates within 30 Days 28 after Admission for Ischemic Stroke, 2007 Figure 2.3 In-Hospital Case-Fatality Rates within 30 Days 29 after Admission for Hemorrhagic Stroke, 2007 viii List of Illustraons Chapter 3 Figure 3.1 How MediShield is Utilized to Pay for 56 One’s Healthcare Bill: Case 1 Figure 3.1a How MediShield is Utilized to Pay for 57 One’s Healthcare Bill: Case 2 Chapter 7 Figure 7.1 NUS Yong Loo Lin School of Medicine, 109 NUS Faculty of Dentistry, and NUS Alice Lee Centre for Nursing Studies Charts Chapter 2 Chart 2.1 Overall Satisfaction of Public Healthcare Institutions 31 and Willingness to Recommend Public Healthcare Institutions Chapter 3 Chart 3.1 Distribution of Medisave Withdrawal 48 !e author has resolved all copyright issues related to material in this publication. Acknowledgments !is book was inspired by a speech given in 2010 by then Minister for Health of Singapore, Khaw Boon Wan, to an international group of health specialists. I had the good fortune to attend the meeting of NIHA (the Initiative to Improve Health in Asia), a Pan-Asian Policy Program sponsored by the National University of Singapore and the Global Asia Institute. !e Minister’s speech outlined the history and more importantly, the thinking, behind the creation of the Singapore healthcare system. !e system he described is both effective and unique. I asked if a book existed describing the Singapore approach to healthcare and was surprised to learn that none did. A few weeks later, I had a follow-up conversation over dinner with the NUS President, Tan Chorh Chuan, Director of the Global Asia Institute, Seetharam Kallidaikurichi Easwaran, and Paul Kratoska, then Director of NUS Press who encouraged me to write this volume. Seetharam Kallidaikurichi kindly provided support for a researcher for a year and the book was on its way. I mentioned that I was writing a volume on the Singapore healthcare system that might provide lessons in the creation of sustainable healthcare system to others in both developing and developed countries to Strobe Talbott of the Brookings Institution, and he and his colleagues kindly offered to jointly publish the book with NUS Press. I am grateful to Robert Faherty, Director of the Brookings Press for his encouragement. I thank Peter Schoppert, now Director of NUS Press, for his enthusiasm and assistance. I owe special thanks to Claudia Olsson, Managing Director of ACCESS Health International, Singapore for her valuable assistance throughout. She organized interviews for me, conducted others herself, did much of the research for the final chapter of the book and worked closely with our researcher, Eti Bhaskar. Eti was tireless in preparing ix x Acknowledgments background material for each chapter and tracking down the necessary information. I owe her a deep debt of gratitude. Both the Ministry of Health and the Singapore Economic Develop- ment Board were very helpful. The current Minister Gan Kim Yong graciously allowed us to interview him and his colleagues at the Ministry. Both helped to arrange the numerous interviews with key players in the healthcare system, both public and private, as well as past and present. Special thanks go to Lee Chien Earn, former Head of the Department of Public Health and Deputy Chief Medical Officer of the Ministry of Health and Lim Eng Kok, Deputy Director (Service Management) of the Ministry of Health, for their continued assistance and help in identifying people and documents important for this story. Representatives from the Ministry of Health graciously responded to my long series of written questions. I have cited this material and reproduced some of these answers in the Appendix of this volume. I list here many of the people who were kind enough to grant us interviews, without which we would not have been able to assemble the remarkable story of the Singapore healthcare system past and present. !ey were to a person helpful in all ways and patient in answering our questions. !ese include: Tan See Leng, Group CEO and Managing Director of Parkway Pantai Limited; Tan Ser Kiat, Chairman of SingHealth Foundation; Chee Yam Cheng, Group CEO of National Healthcare Group; Yong Ying-I, Previous Permanent Secretary for Health; Yee Ping Yi, CEO of the CPF Board; Sarah Muttitt, former CIO, Information Systems Division, MOH Holdings; K. Ranga Rama Krishnan, Dean, Duke-NUS Graduate Medical School; Edward Holmes, A*STAR Executive Deputy Chairman, Biomedical Research Council; Phua Kai Hong, Associate Professor of Health Policy and Management, Lee Kuan Yew School of Public Policy; Chia Kee Seng, Dean, NUS Saw Swee Hock School of Public Health; Jason Cheah, CEO, Agency for Integrated Care; Wong Loong Mun, Chief Care Integration Officer, Agency for Integrated Care (AIC); C. Frank Starmer, Associate Dean for Learning Technologies, Duke-NUS Graduate Medical School; Lim Chuan Poh, A*STAR Chairman; John Lim, CEO, Health Sciences Authority; Chua Song Khim, Group CEO of China Healthcare Ltd; Anthony Tan, former Director of the Healthcare Finance and Corporate Services of the Ministry of Health; Ang Hak Seng, CEO of the Health Promotion Board; John Wong, former Dean of the NUS Yong Loo Lin School of Medicine; Benjamin Ong, Chief Executive of the National University Health System; Elizabeth Koh, former Group Director (People Matters) and Senior Director (Healthcare Leadership Acknowledgments xi Development), Ministry of Health; Elizabeth Quah, Group Director (Planning), Ministry of Health; Peter Lee, former Deputy Director of the Learning Systems Standards & Quality Improvement Division, and the Organizational Excellence Corporate Human Resource Division, Ministry of Health; David Matchar, Professor and Director, Program in Health Services and Systems Research, Duke-NUS Graduate Medical School; Tan Yong Seng, Chairman, People’s Association Active Ageing Council; Mary Ann Tsao, President, Tsao Foundation; Susana Concordo Harding, Director, International Longevity Centre Singapore, Tsao Foundation; Phua Puay Li, Director, Manpower Planning & Strategy Division, Ministry of Health; Martyn R. Partridge, Senior Vice Dean, Lee Kong Chian School of Medicine; Lim Siong Guan, Group President, Government of Singapore Investment Corporation; Denise Lee, Manager (Clinical Benchmarking), Performance and Technology Assessment Division (PTA), Ministry of Health; Kishore Mahbubani, Dean and Professor in the Practice of Public Policy of the Lee Kuan Yew School of Public Policy at NUS.