IT is surely not a surprising development that an unpleasantly confrontational situation has evolved here, where specialist medical practitioners are up in arms against what seems to be discriminatory practices instituted by Integrated Shield Plan (ISP) insurers, excluding them from their recognised panel of doctors for policyholders ("Trade-offs in widening insurers' panel of doctors, warns Life Insurance Association",The Business Times, March 30). Against this salvo from the LIA, the Singapore Medical Association has laid charges that increases in ISP premiums have less to do with unreasonable doctors' charges and come mainly from ever-increasing service fees imposed by the ISPs - in practice, just a kickback in guise.

Just what is so special about the 21 per cent of doctors who get onto their ISP panels as compared to the 79 per cent who don't get access:

1) Are they especially good as indicated by clinical outcomes? If so, LIA should provide substantiative data.

2) Are they especially cheap as the final medical bills have proven - but have corners been cut in tailoring the bill to suit the insurers' demands?

3) Or are panel doctors those willing to pay deductions from their bills back to the insurers as a form of service charge - the prevalent practice.

Kickbacks are of course illegal and unethical among medical professionals, frowned on by the Singapore Medical Council. What is the Council's stand on this?

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Whatever it is, it is a murky and unacceptable practice till clarified otherwise. Yes, there are doctors who charge many multiples of prevailing rates but these tend to have extremely saleable unique skills, use the most advanced equipment, can command a hefty premium to the market, and really do not need any business from ISPs, appealing to patients willing to forego insurance in their absolute trust of them. We don't need to give due consideration to these uber specialists and they have excluded themselves of their own volition from the shared insurance pie which others wish to partake from.

Apart from these with distinctive special marketable skills who can unilaterally dictate their fees, almost all other specialists charge according to the recommended guidelines as set out by the Ministry of Health (MOH), for fear of pricing themselves out of the market. The market for private health care is more cut-throat than the laity imagines and yes, patients do shop around.

Even as the LIA remonstrates that Ministry of Health benchmarks come with a range of five times between the upper and lower limit, there is nothing to stop them changing the calibration to between 1 and 1.1 times. It is way within their jurisdiction. There is already ample meat for doctors at this compressed range of charge, reflecting what full-paying A-class patients in restructured hospitals pay - worry not for them that they will suffer from remuneration deprivation for their endeavours.

The default setting by ISPs should be for all doctors to be on their panels as long as their professional charges do not exceed the ministry guidelines by more than 10 per cent, then leave the insured their choice to select a specialist who may even charge below recommended rates just to secure a deal. This is not unheard-of, even for specialists with senior standing newly venturing into private practice.

Specialist fees often take up only a small proportion of the final total medical bill. To keep private hospitals honest, on their feet and to rein in costs for the whole insurance pool, ISPs should focus as much on auditing private hospitals that charge exorbitantly. Sure, they must turn a profit, but private hospital bills which are several times what unsubsidised A-class patients pay in restructured hospitals should be subject to disqualification or arbitration - small bolls of cotton wool or name tags at tens of dollars are way above cost and simply egregious practices, just to illustrate two glaring examples.

Without insurance audit, different chains of private hospitals simply eye one another's charges and push them up to the highest common denomination, which is not unlike the case now.

A look at Parkway Reits (which I must confess I own) easily confirms how recession- or pandemic-proof private hospital are, profits rising almost incessantly - this without a squeak of protest from LIA.

The present system is awash with inefficiencies, abuse and wanton profiteering. If we want a revamp of how, who and what private health insurance is to remunerate, don't just hit on medical professionals, the low-hanging fruit, who singly till now have no recourse. Bring everyone collectively to the discussion table if we don't want further accusatory finger-pointing, premium escalations and healthcare degradation. I suspect a just and even-handed solution will not be possible without governmental intervention. Some hard answers just can't be left to the whims of market forces.

Dr Yik Keng Yeong