Find out more about our Academic Medical Centre and efforts in Academic Medicine
Find out more about what JOAM do to support AM initiatives
Academic Medicine Executive Committee (AM EXCO)
Our appointed ACP leaders within the respective 15 ACPs
Guidelines, forms, and templates for Academic Medicine.
A major change in the insurance coverage of subsidised cancer patients took effect on Sept 1, 2022. The same change will apply to private patients on Integrated Shield Plans (IPs) from April 1, 2023.
MediShield Life and IPs can no longer cover all cancer treatments, only those proven to work. This, too, on the condition that the drug provides value for money.
While these changes are meant to keep the rising costs of cancer treatment in check, there are other aspects deserving further scrutiny.
Specifically, apart from drugs, is there sufficient insurance cover for other costs related to treating cancer – including those for consultation and tests?
First, some background. The cost of cancer treatment has been rising at the rate of about 20 per cent a year. The Ministry of Health (MOH) said this could eventually push up insurance premiums beyond the means of most people.
Since the announcement in August 2021 of the impending changes, the prices of drugs procured by the public sector have fallen by around 30 per cent across the board, as only drugs whose prices can be justified by the value provided are included in the Cancer Drug List. Only drugs and treatments on this list are allowed to be covered by insurance and MediSave.
Unfortunately, this price drop is not reflected in the private sector, for which the same rules will apply from April.
To help subsidised patients needing more expensive cancer drugs, MOH has also raised insurance cover – resulting in about 90 per cent of these cancer patients having their bills fully covered, up from 70 per cent before the change, said the ministry. This is meant to give peace of mind to subsidised cancer patients with big bills.
Prior to September 2022, MediShield Life provided a blanket cover of up to $3,000 a month for cancer treatment, to pay for everything, including the drug, the doctor’s fees, all tests and supportive medication.
Since then, the insurance coverage for cancer has been split into two segments: drugs (the main driver of spiralling costs) and other cancer services.
MediShield Life cover for drugs now ranges between $200 and $9,600 a month. MediShield Life also pays up to $1,200 a year for services such as doctor’s fee, various tests and other medication patients might need, such as antibiotics and anti-nausea drugs.
But the insurance cover for cancer services since September 2022 has been far too low, at about $100 a month. On March 4, MOH announced that the amount will be tripled to $3,600 a year from April.
The ministry must be lauded for heeding feedback from public hospitals that the insurance coverage was insufficient for significant numbers of cancer patients.
Health Minister Ong Ye Kung posted on social media following the latest announcement: “Like many policy changes, the recent moves on cancer drugs serve to make treatment affordable. But it requires the support of stakeholders, and feedback like this that can help us improve and fine-tune the policy.”
While the issue of drug prices has been addressed head-on, the matter of payment for cancer services may still need tweaking. Raising the cap seven months after the new scheme was launched has created new hardships for some patients.
Several have contacted The Sunday Times, shocked that they had to pay cash for their treatment, which had been fully covered previously. They are patients whose drugs cost less than $1,000 a month. They were previously able to draw on what’s left of the monthly cap of $3,000 to pay for the rest of their treatment costs. In the months since September, they had maxed out the annual $1,200 from MediShield and $600 allowed from MediSave.
Not everyone on cheap cancer drugs are facing this cash crisis, as some have lower treatment costs, either because they are no longer in the intense phase of the treatment, or do not need as much supportive care. These are dependent on factors such as the type of cancer, or even the individual patient profile.
Nevertheless, even with the higher annual cap, the issue may still not have been resolved for everyone. This is something for the authorities to ponder – as this affects both subsidised patients in the public healthcare sector today, and private cancer patients from April, as the IP insurers will base their coverage on what MediShield Life offers.
Help cancer patients afford needed services
The question now is whether the new cap of $3,600 a year is enough cover for the majority of subsidised cancer patients.
Some of these services can be very expensive, even though not all patients may need them. The National Cancer Centre Singapore (NCCS) says the minimum cost for MRI scans that some patients need starts at a subsidised price of $400. CT scan prices are at least $233, depending on which part of the body is scanned.
Apart from scans, the $3,600 a year (or $300 a month) for cancer services is also meant to pay for consultations, lab investigations, chemotherapy preparation and administration, blood transfusions and supportive care drugs such as antibiotics, anti-nausea medicine and white cell boosters.
The price for anti-nausea drugs for one treatment cycle, for example, ranges from 45 cents to $86.67, while consultation fees for a repeat visit range from $21.60 to $75.
A spokesman for the National University Cancer Institute, Singapore (NCIS) said: “The frequency of doctor visits, lab tests and scans for cancer patients depends on several factors, such as cancer type, stage, treatment plan and the patient’s overall health condition, and may vary throughout the year.
“During active treatment, such as chemotherapy or radiation therapy, patients may require more frequent medical attention, including regular blood tests and scans, to monitor their progress and manage any side effects of treatment.”
The spokesman did not say how frequent such monitoring is, but ST understands that it can be as often as once every couple of weeks.
If the aim of the policy changes is to provide full coverage for 90 per cent of subsidised cancer patients, then the amount patients can claim for services should reflect this.
A deeper dive into available data should help the authorities arrive at a payout more reflective of real conditions on the ground. Cancer patients have been paying for such services for many years, so healthcare policymakers should have breakdowns and details of how much their bills came to.
Insurance should provide assurance
Insurance is meant to cover big medical bills. For Singapore’s national healthcare insurance to not fully cover excessively large, outlier bills makes sense, since that could easily push up premiums significantly for all.
Furthermore, since all IPs sit atop MediShield Life, claims from patients with IPs are far more likely to be higher than claims from subsidised patients the scheme is targeted at. So a high cap could work against the national good.
Having said that, it also does not quite serve the purpose of insurance if cancer-related services that patients need are not fully covered, especially since these are not components causing costs to spiral in the first place.
Nevertheless, certain, less necessary treatments, such as anti-fungal treatment, can be very expensive. Perhaps, there should be a separate category to allow for such coverage, over and above the overall limit for cancer services.
Alternatively, the prices for cancer services need to be lowered, or even capped for subsidised patients, so they fall within insurable amounts. Or at the very least, patients should be permitted to tap their MediSave accounts for more than the current $600 a year.
Here, too, one wonders how the $600 a year cap was arrived at.
Patients with cancer are already worried about their health and future. Insurance is supposed to give them peace of mind. But that won’t happen if they are not poor enough to qualify for additional government funding, but have difficulty finding the cash to pay for their very necessary treatment.
Some oncologists are already talking about whether they should ward patients facing high cancer services bills – because inpatient treatments are calculated separately and do not come with the $3,600 a year insurance cap.
This is not only an inefficient way to deal with the problem, but it will also put more pressure on already tight bed space and add to total cost. It may help some patients, but not the nation.
It would be good for MediShield Life to be further fine-tuned to ensure it remains robust over the years. There is a certain urgency for this, as similar changes will affect private patients with IPs from April. About 70 per cent of the population is covered by IPs.
Otherwise, patients and doctors will try to game the system, which helps nobody.