Patients deserve greater disclosure by healthcare players

Earlier this month, I had to see a doctor for a dog bite (it was my fault for being careless). I had my wounds cleaned thoroughly and received a tetanus shot and some antibiotic cream.

I coughed up S$5 as co-payment, and S$25 for the tetanus shot as it was not covered under my company’s insurance plan. Curious about the total cost of my visit to the doctor, I asked for a receipt. The clinic assistant said the portion of fees covered by insurance could not be disclosed.

I found after a check with two general practitioners that contracts with the managed care companies, also known as third-party administrators (TPAs), prevent them from disclosing the full cost of medical treatment to the patients whose claims the TPAs process.

When a healthcare consumer is unable to find out the actual cost of medical care, it is surely a sign that the system must demand more transparency of its stakeholders.

TPAs have been around for many years, but have lately been cast into the spotlight again. Current players include Alliance Healthcare Group, Fullerton Health, MHC Asia Group and Parkway Shenton.

They administer medical claims for companies, employees and insurers, and charge doctors who join their scheme an administrative fee.

There is lingering dissatisfaction among doctors with TPAs, as shown in the latest managed care survey conducted last year by the Singapore Medical Association and College of Family Physicians Singapore, where 56 per cent of 218 respondents said they were dissatisfied or very dissatisfied overall with managed care companies. More than nine in 10 respondents felt fees reimbursed by TPAs for seeing patients on various managed care schemes had not increased over the past 10 years.

The foray by TPAs into the Integrated Shield space in the past year has further upset the medical fraternity and raised troubling questions on whether policyholders are aware of arrangements that come with the TPAs’ involvement.

The SMA, which represents the bulk of doctors here and dedicated the August issue of its monthly newsletter to managed care, recently flagged potential conflicts of interest in current processes.

Some TPAs restrict fees that doctors are allowed to charge patients to levels that are too low, and that ultimately compromise the quality of care, some doctors told TODAY.

Some general practitioners are paid S$7 in consultation fees for each patient — barely enough for a McDonald’s set meal, one doctor noted — and a surgeon in private practice has encountered problems trying to engage an anaesthetist at the rates set by TPAs.

TPAs are also making doctors pay administrative fees computed as a percentage of what doctors charge their patients, which raises the question of whether doctors are at risk of “fee sharing” with TPAs. Other complaints include unfair contract clauses and late reimbursements by TPAs to doctors for services rendered.

However, doctors say not all TPAs have the same practices and that some are quite fair.

‘OPAQUE TRANSACTIONS OBSCURE TRUST’

The SMA wants TPAs to be regulated as healthcare entities.

In a Parliamentary reply to Tampines Member of Parliament Desmond Choo this month, Health Minister Gan Kim Yong said the Health Ministry is working with the medical professional bodies and associations to raise doctors’ awareness of appropriate arrangements with TPAs. It will work with the Life Insurance Association to remind the Integrated Shield Plan (IP) insurers to ensure appointed TPAs disclose to policyholders any financial arrangements they have with the doctor, he said.

In the absence of any regulation of TPAs, greater transparency and the mandatory disclosure of fee arrangements between doctors, TPAs and insurers, cannot happen soon enough.

Yes, TPAs that provide services such as an IT platform and the manning of hotlines should be compensated for their efforts, but exactly how much of a cut of healthcare fees are they taking?

And as noted by SMA president Wong Tien Hua in his column in the August issue of SMA News, “TPAs render the transactions between the doctor and his patient opaque, thereby obscuring the trust that is needed in the relationship”.

Integrated Shield policyholders whose insurers engage TPAs should be informed of the fact. I would argue that information on administrative and other fees that TPAs charge the doctor should be disclosed and, if patients are referred to a specialist because of the specialist’s arrangement with the TPA, it should also be declared.

For corporate healthcare insurance, TPAs should disclose to companies and employees how much of what they receive from companies is retained, and how much goes towards patient care. Patients should always have the right to know the full cost of their visit to the doctor.

This raises the question: Do most patients care about fees incurred that are paid for by insurance? Perhaps not. A doctor working with multiple TPAs told me that not once in 15 years has a patient on a corporate healthcare scheme asked about the full cost of treatment. But an equally crucial point is that, in any case, the general practitioner would not have been able to disclose the information due to contractual agreements with the TPAs.

The greatest advantages of a system that mandates more transparency would be the protection of patients’ interests in the longer term, greater impetus for doctors to be fairly reimbursed, and a higher chance of a fair deal for stakeholders all around.

According to explanatory notes that came with the Singapore Medical Council’s new ethical code and ethical guidelines, doctors on TPA schemes must not allow financial constraints or pressures inherent in such schemes to influence the objectivity of their clinical judgment in managing patients, such that the required standard of care is not provided.

Healthcare authorities and other stakeholders should provide doctors with more support in this endeavour. The system should deter parties seeking to take advantage of opaque processes to profit unfairly, and make it easier for parties to seek out, and to provide, a fair deal.

ABOUT THE AUTHOR:

Neo Chai Chin is a correspondent with TODAY’s Local News Desk.