Last month (21 Dec), a member of the public Ian Lee Chi Meng wrote to ST Forum relating that his mother was charged with high bill by National University Hospital (NUH), despite being referred through a polyclinic (‘Forum: Stuck with high bill for cataract operation and follow-up visits‘).
His mother, Madam Song Yuen Han, had earlier obtained referrals from Queenstown Polyclinic to benefit from subsidised treatment at NUH for her cataract. Mr Lee said, “My father has been very upset over what he says is overcharging by NUH. When I looked into the issue, I was shocked to learn that they had incurred more than $23,000 for my mother’s cataract operation and subsequent clinical follow-up.”
“NUH told us that my mother had lost her subsidised patient status when she selected a higher-grade lens – which she was advised to, to avoid the need for reading glasses after the operation – and when she elected to choose her own doctor,” he said.
Mr Lee wondered since his mother was referred by a polyclinic for her first visit to NUH, how she would know which doctor to choose? NUH told Mr Lee that financial counselling was adequately conducted, with all consent forms duly signed by his mother.
“We thought the forms signed were routine indemnity forms for the operation. My mother would not have knowingly signed forms to exclude herself as a subsidised patient and be treated as a full-paying private patient instead,” Mr Lee explained.
“What was not addressed was how much every subsequent follow-up visit to NUH would cost, and at private patient rates too.”
As it turns out, Mdm Song was overcharged due to a “simple miscommunication” as reported in the media last Thursday (‘More clarity needed on polyclinic referrals and accessing subsidised care‘, 16 Jan).
When Mdm Song went to NUH for treatment, she was asked at the point of admission if she wanted to stick with the same doctor who had seen her before, even though she had a referral letter from polyclinic in her hand. The 72-year-old replied that she did. However, she did not know this would mean that the hospital would treat her as a private patient and not as a subsidised one from then on. That is because subsidised patients are not allowed to choose their doctor.
According to the media, a reply from Dr Loon Seng Chee, acting head of NUH’s Department of Ophthalmology, explained that Mdm Song had chosen her doctor and had been given financial counseling and knew she would not be subsidised.
“Did she knowingly agree to forgo her subsidised status, or did she not fully understand what her response about sticking with the same doctor would mean for her eventual bills?” asked health journalist Salma Khalik.
Ms Salma opined that it’s important that elderly be given clear, unambiguous information about the medical treatments they opt for, and the difference in cost between opting for private versus subsidised care, so that they would not be surprised by the bills later.
Even though Mdm Song did go through financial counseling and sign papers, Mdm Song admitted she was quite “blur” about the whole process. Ms Salma further argued that since Mdm Song had a referral letter from a polyclinic, it should have been implicit that she wanted subsidised treatment.
Ms Salma said, “In fact, the first thing its (NUH) staff should have checked was if Madam Song wanted subsidised care. If the answer was yes, then she should not even have been asked about her choice of doctor.”
“Staff need to have clear standard operating procedures on their interactions with patients, especially when doing financial counseling or admissions. This should include clearly asking patients if they want to be treated as subsidised patients; and shown how much they would likely pay as a private patient as opposed to being a subsidised one,” she added.
In the case of Mdm Song, her bill for cataract surgery was triple what it would have been as a subsidised patient. She also had to pay private rates for follow-up checks at NUH, which is about double the subsidised rate.
Quality of financial counseling sessions at public hospitals
In her job as a healthcare journalist, Ms Salma revealed that she would sometimes listen in at a number of financial counseling sessions at different public hospitals.
“Some are exemplary in the advice they give,” she said. “But I have also heard patients being advised by staff that there was no bed available in C class, but if they were willing to choose B2, they could be taken to the ward immediately. The staff tell the patients that both ward classes are subsidised and payment can be covered by MediShield Life and Medisave.”
“What they omit mentioning is the difference in subsidy between C and B2 wards. The subsidy is 65 to 80 per cent in C class, and 50 to 65 per cent in B2. The patient’s share of a B2 bill would likely be much higher,” she pointed out.
“Another point to note is that a patient choosing C class would be placed in a B2 ward if there is no C class bed available, but charged C class rates. So there is no need to upgrade to get an available bed.”
Ms Salma also recalled that patients were sometimes told that if they want a good doctor, they need to choose their doctor. Otherwise they could be treated by a “trainee”. Fearing poorer treatment, or wanting a bed immediately, patients thus advised may then opt for private care.
Ms Salma opined, “This kind of behaviour to nudge patients into choosing a more expensive option would amount to a kind of upselling by hospital staff, which is not ethical for a public sector hospital.”
NUH overlooks polyclinic referral
Yesterday, Group Director Chan Beng Seng from the Ministry of Health (MOH) replied in response to Ms Salma’s ST article (‘Forum: Woman treated as private patient in error‘, 21 Jan).
Defending the public hospitals, Mr Chan sais that guidelines are in place on how financial counselling should be performed at public hospitals.
“All hospitals are required by law to provide financial counseling to all patients who are admitted for inpatient treatment or day surgery,” he said. “Subsidised patients referred from a subsidised provider are eligible for subsidised care.”
During financial counseling, Mr Chan said that patients are provided with a bill estimate and shown how much of the bill will be covered by subsidies and MediShield Life, and the amount that can be paid through Medisave.
In Mdm Song’s case, Mr Chan explained that NUH had treated her as a private patient for a first condition, as she had requested to be treated by a specific doctor.
“She subsequently had a second unrelated condition for which she had a polyclinic referral. As the second referral was to a specialist in the same department, NUH had overlooked the polyclinic referral and treated her as a private patient in error,” Mr Chan acknowledged.
“This was an oversight which NUH subsequently rectified.”
“The Ministry of Health will continue to work with the public hospitals to review how we can further improve the financial counseling process. Patients who face financial difficulties with their bills can approach the medical social workers at the PHIs for assistance,” he added.