Policyholders must come first in insurer-vs-doctor Shield debate

Singapore

STRIKING a balance between the interests of doctors and insurers requires focusing on the best outcome for the insured. Stakeholders will need to work together to plug the gaps of Integrated Shield Plans (IPs) medical panels by raising transparency and efficiency for the benefit of consumers, industry observers said.

Insurers and doctors have been at odds in recent weeks over the use of IP panels. Insurers say panels keep the fees of healthcare practitioners in check, but doctors say this limits patient options.

The dust has temporarily settled after the Ministry of Health stepped in to appoint a committee to look into IP-related issues.

But, as a reader pointed out in a letter to The Business Times, "everyone - insurers, doctors, government - is invited to the table except the most important people: the insured".

The consumer's voice and autonomy is further stifled by inadequate understanding of pricing mechanisms in the healthcare sector, and poor access to information.

Greater transparency from both the insurers and doctors will therefore help policyholders.

For instance, with the data that insurers claim to have on the quality and track record of doctors here, insurers could do more to help policyholders ensure they can find the right doctors.

Jeremy Lim, associate professor at the National University of Singapore's Saw Swee Hock School of Public Health, suggested an app that provides patients with a comprehensive list of doctors, filtered by their needs and preferences, and include reviews by others.

Dr Lim, who is also director of the Leadership Institute for Global Health Transformation, said this would help patients feel confident they have the right doctor.

Information on prices, costs consumers need to bear, amounts claimable and time taken for claims to be processed should also be accessible.

All this would require investment into data and analytics, said Dr Lim. But the technology is available.

In the United States, for instance, online medical appointment booking service Zocdoc allows patients to search for healthcare providers that are within their insurers' networks as well as verify their plan details before making an appointment. Users are also able to review the provider's ratings and patient feedback.

Zubin Daruwalla, health industries leader at PwC Singapore, said the use of quality data could help organisations and stakeholders ensure transparency throughout the decision-making and care delivery process.

But he added that full transparency would require the cooperation of all parties within the healthcare ecosystem. This includes pharmaceuticals, medtech developers, regulators, advocacy groups and patients.

Doctors, too, should be held accountable for their fees and conduct.

Dr Lim pointed out that the costs insurers bear extend beyond a doctor's professional fees. A hospital bill could comprise a doctor's professional fee, medication, lab and diagnostic test costs, and facility bills.

"When doctors say they charge within the fee benchmark, that might only cover one of four pricing drivers. And insurers, I guess, are reasonably concerned about the other price drivers," said Dr Lim.

The use of IP panels was recommended by the Health Insurance Task Force (HITF) in 2016 and is among the measures the industry is implementing to address over-charging, over-servicing, and over-consumption of healthcare services.

But for the panel to serve its purpose, transparency is crucial.

"The level of lower costs and better services depends on how integrated (panels) are and how much they are able to overcome information asymmetry in their operations across parties involved," said Lee Chew Chiat, government and public services industry leader at Deloitte South-east Asia.

From a consumer and patient standpoint, he added, most would prefer to have a larger network of providers to choose from.

But insurers might prefer to keep panels small so they can negotiate preferential rates from healthcare providers in exchange for promising them higher patient volumes.

"There is probably a narrow middle ground where there is sufficient price volume bargaining power and a wide enough panel," said Dr Lim. "Until someone does all these heavy lifting to actually count the numbers, it's hard to determine whether the panels are indeed adequate."

Panels are an inevitability given that they help to lower premiums.

Insurers in the US and the UK also adopt similar approaches to keep costs under control. A study published on healthcare journal Health Affairs found that in the US, a plan with narrow physician and hospital networks was 16 per cent cheaper than a plan with broad networks for both. Narrowing just one type of network was also associated with a 6 to 9 per cent decrease in premium. In the UK, insurers negotiate discounts with providers and pass these on in the form of reduced premiums.

That said, keeping health insurance costs low requires a multi-pronged approach.

Deloitte's Mr Lee said Singapore has done a good job in keeping healthcare costs and insurance premiums within a manageable level compared with other advanced countries.

Other measures to address IP sustainability include co-payments to encourage prudent use of healthcare, fee benchmarks, and pre-authorisation of treatments.

Efforts have also been poured into driving efficiency through new digital offerings, which could lead to eventual cost savings.

The General Insurance Association Singapore; Life Insurance Association, Singapore; and Integrated Health Information Systems had in March jointly called for proposals to develop an end-to-end health insurance claims platform.

The integrated platform aims to speed up claims by allowing healthcare providers to retrieve details of patients' relevant policy coverage information for IPs and Group Hospital and Surgical Insurance, submit claims digitally and provide timely bill information and updates of the patients' status.