The landscape of private specialist practice in Singapore has changed dramatically since the Integrated Shield Plans (IP) insurers' decision to implement preferred panels of specialists.
The SMA has voiced specialists' concerns about these panels through the press and expressed its views in a position paper in 2021 (https://bit.ly/3uVgpKr). This culminated in the Ministry of Health (MOH) establishing the Multilateral Health Insurance Committee (MHIC), in which SMA actively participates. It is thus timely to assess whether SMA's concerns have been adequately addressed and how the situation can be improved moving forward.
I will give a brief background of the problems that arose due to the implementation of IP panels, as well as my views for areas of improvement. Do also refer to the findings of the second SMA Integrated Shield Plan Providers' Ranking Survey, published in this issue of SMA News on page 14.
Exclusivity, standardisation and fee restriction
Three major concerns stood out to me. Firstly, when the IP panels were initiated, they were highly exclusive, with between 200 to 300 private specialists on each panel, and with each panel including only about 20% of all private specialists. Many doctors were unable to join the panels, and some patients were unable to continue receiving care from their usual specialists who were not on their respective IP insurers' panels.
Secondly, panel specialists were imposed with an increased administrative burden as they have to submit patients' information for pre-authorisation. The pre-authorisation form was not standardised across the IP panels, and the information requested included information not relevant to the case on hand. Sometimes, it would take several email exchanges between the specialist and the IP insurer before the approval was granted.
Lastly, panel specialists were restricted in the fees that they could charge. For some IP insurers, the charges were pegged at the lower bound of the MOH Fee Benchmarks.
With regard to the first issue of exclusive panels, the Life Insurance Association (LIA) announced in 2022 that the IP insurers would commit to having at least 500 specialists on each panel. Specialists on at least one insurer's panel can also be enrolled in the extended panels (EPs) of other IP providers, allowing patients access to more specialists. Furthermore, the LIA announced that all IP insurers had agreed to streamline and adopt a standardised pre-authorisation form.
Survey findings
Has there been objective improvement since these measures were implemented? We have conducted two surveys to rank the IP insurers (based on 2021 and 2022 experiences), and they would be representative of the time periods before and after the IP providers' measures for panel expansion were implemented.
The recent survey showed an improvement in the inclusiveness of panels, with four out of seven insurers scoring above the midpoint. The ease of the pre-authorisation process remained unchanged, with only three out of seven IP insurers scoring above the midpoint. There was a slight improvement in the appropriateness of fee scales. However, only two out of seven IP insurers scored above the midpoint.
While there has been some improvement in the inclusiveness of panels, my concern is that it may have reached a plateau. The word on the ground is that some IP insurers have already stopped accepting new specialists onto their panels.
What can be done?
I believe that all specialists should be able to join IP panels without restriction. It would be even better if we could remove the need for these panels, since the MOH Fee Benchmarks are already in place.
Some steps, which can be implemented immediately, can help in achieving this ideal. One such step could be to open the EPs for all specialists to enrol in – this would be helpful to the newer generation of specialists who are just starting out and are unable to get onto the main IP panels. Specialists on EPs could also be allowed to join the main panel after being on the EP for six to 12 months. Another step would be to improve the website visibility of EP specialists; at present, four out of seven IP providers do not even mention the EPs on their websites. Lastly, any additional deductible payments imposed on policyholders who undergo treatment from EP specialists should be removed.
With regard to the concern of administrative hurdles, there is a lack of improvement in the ease of the pre – authorisation process, despite all insurers having implemented the standardised pre-authorisation form. This could be due to further claims scrutiny and questioning by some insurers after the form is submitted. There is no easy solution to this problem. Some degree of claims scrutiny is to be expected; however, insurers should be ready to take on liability and responsibility if they disagree with the doctors' decision for a procedure or propose treatments different from the doctors' recommendations.
Lastly, while there has been a slight improvement in the appropriateness of fee scales, insurers should take reference from the full range of the MOH Fee Benchmarks and renumerate fairly – in my view, at least at the midpoint of the benchmarks.