ST: Parents' dilemma over mental patient

The usual u 'cannot downgrade' problem...


"Because of the urgency and seriousness of her condition two years ago, I took her to IMH for treatment without referral. Hence, at the moment she is still a full-paying, non-subsidised patient at IMH. Does it mean TTSH has stopped taking subsidised patients? She will be accepted as a full-paying patient."


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Nov 5, 2007
Parents' dilemma over mental patient
MY DAUGHTER has suffered from depression for a number of years. Two weeks ago, we went to see a polyclinic doctor to get a referral to see a psychiatrist at Tan Tock Seng Hospital (TTSH). We were told this was not possible. The reason given by TTSH - it has too many subsidised psychiatric patients - is unacceptable.
My daughter was asked to go back to the Institute of Mental Health (IMH) for treatment. She has been there for a number of years. Most of the time, as parent and caregiver, I have to ensure she follows up on her treatment. She intensely dislikes travelling the long distance because of lethargy arising from her illness. I have to spend many frustrating hours persuading her to go to IMH but she always resists. It is frustrating to take her there, even by taxi which is costly. Often, the parent has to go to IMH on her behalf. Besides the patient, the caregiver is also under tremendous stress. My daughter prefers to go to a nearer place. Because of the urgency and seriousness of her condition two years ago, I took her to IMH for treatment without referral. Hence, at the moment she is still a full-paying, non-subsidised patient at IMH.
Does it mean TTSH has stopped taking subsidised patients? She will be accepted as a full-paying patient. But she has not been in full employment since she graduated and came down with depression. Only her parents as caregivers can take care of her, but what if we are not around?
The healthy minds campaign is on, but it defeats the purpose as there are sufferers out there besides my daughter.
Catherine Tham Kuen (Mdm)
http://www.straitstimes.com/ST%2BForum/Story/STIStory_173608.html

Means testing put on hold and People will be consulted first: Minister Khaw

www.pap.org.sg : 2May06.
Means testing put on hold and People will be consulted first: Minister Khaw
Health Minister Khaw Boon Wan has announced that MEANS testing will not be implemented within the next two years as originally planned. He said that it will only be implemented after he has consulted the people.
Mr Khaw said he is not going to rush through without consulting people but will take his time discussing it with the community, and find practical ways to implement it.
Instead, Mr Khaw said he would focus on revamping the MediShield national health insurance system and on improving healthcare for the chronically-ill.

Said Mr Khaw: "I will do it only if it is practical, because the theory may be sound but if the implementation is more costly ... then it's not worth the effort. "So whether to do it or not, I don't know. It depends on whether we can come up with practical ideas."

He accused the WP of trying to score political points by proposing populist healthcare solutions that have proved disastrous in Britain, Europe and elsewhere. In Britain, he said, patients wait for months for even simple procedures.

And ideas such as reducing GST for medical bills, which is already being done for subsidised patients, would benefit the rich more than the poor. Private hospital bills are many times the size of Class C hospital bills. "Instead, our solution is to provide Class C with the greatest subsidy (at 80 per cent of cost)," he said.

Responding to the opposition’s idea to reduce GST for medical bills, Mr Khaw said that would benefit the rich more than the poor. Private hospital bills are many times the size of Class C hospital bills. “Instead, our solution is to provide Class C with the greatest subsidy (at 80% of cost),”


Source: Extracted from The Straits Times and TODAY 2 May 2006
WWW www.pap.org.sg Published by and at the directions of People's Action Party PAP HQ, Block 57B New Upper Changi Road, #01-1402 Singapore 463057. Copyright © 2006 People's Action Party. All Rights Reserved.
http://www.pap.org.sg/articleview.php?id=894&mode=&cid=23

What makes these two tick?

KBW stressed, looses his Karma powers... His wavering in the means testing issue is showing... Will he resign soon?

But who wouldn't with an unsolved $2.03B p.a. 'economic albatross' around the govt's neck; LHL's parliament's moral weaknesses, Ng EH's policy of weak subsidising the strong, the continually increasing rich poor divide, the pressure of such prejudices will surely make any dignified Health Minister jump to his grave!

May his Karma be strong.

• "In Mr Khaw's case, his spirituality is often cited as a key to his success."
  
• "last November, Mr Khaw dropped hints of retiring as he recalled how entering politics was never his wish. He had said this might be his last term in the Health Ministry, a "very meaningful portfolio" from which he would like to retire from politics. ..."
  
  
  What makes these two tick?
  Weekend • October 20, 2007
  Christie Lohchristie@mediacorp.com.sg
  EVEN in a centralised, collegiate and behind-the-scenes style of leadership like Singapore's, a few individuals do stand out.
  They may not be seen as possessing the giant stature of past ministers such as Dr Goh Keng Swee and Mr S Rajaratnam — yet. But the qualities of an agent of change, helping to shape a nation's future, are already surfacing in a couple of today's ministers.
  One does it with his Zen-like nature; the other, with his business-like mien.
  Beyond these qualities, what is it that makes ministers Khaw Boon Wan and Tharman Shanmugaratnam tick?
  The two career civil servants were among the so-called "Super Seven" to have risen rapidly within the ranks — joining the Cabinet in August 2003, just two years after making their political debut in the 2001 general elections.
  Since then, the two names have become synonymous with the national agendas for health and education.
  Mr Khaw, 54, is a man fighting to keep medical costs low. Hence the online posting of charges by private and public hospitals to make it easier for patients to compare prices and choose the kind of treatment that best suits their pockets.
  Then, there's the ongoing reform of the 3Ms (Medisave, MediShield, Medifund) — aimed at ensuring that Singaporeans will have sufficient enforced savings for medical contingencies — an issue which Prime Minister Lee Hsien Loong once said Mr Khaw "lives and sleeps with every day".
  In education, Mr Shanmugaratnam, 49, has tackled areas that have long troubled parents and their children. Among the lauded efforts to make education less rote and less based on academic results are the scrapping of the 29-year-old system of primary school streaming and the introduction of more fun ways to learn the Chinese language.
  In short, what the two men set in motion concerns everyone from the cradle to the grave.
  "It is the importance of the ministry that defines the importance of the man," said political scientist Ho Khai Leong from the Nanyang Technological University (NTU).
  While health and education are big issues in any country, they have become major preoccupations in Singapore, where concerns over affordable health care for the elderly have grown in tandem with the ever-growing number of senior citizens; and where education is seen as the key to keeping Singapore a step ahead of competitors who are catching up faster than ever.
  But while the portfolios in themselves are high profile, the leaders put in charge have also certainly excelled in their jobs, observers said.
  "They answered the call," Assoc Prof Ho said of Mr Khaw and Mr Shanmugaratnam, who became Senior Ministers of State immediately after the 2001 elections. "They are meticulous, knowing the details of the issues."
  Such understanding is seen as closely linked to two things: The individual's mental agility and his pre-politics experience in policy-making.
  During Mr Khaw's 23 years as a civil servant, he spent 14 years in the Ministry of Health (MOH). There, he had conceived the idea of Medisave in 1983 when he was an administrative service officer working for then-Health Minister Goh Chok Tong, said a former colleague.
  After that, the high-flier went on from 1985 to 1992 to head three hospitals: National University Hospital, Kandang Kerbau Hospital (now known as KK Women's and Children's Hospital) and Singapore General Hospital.
  While the engineer-trained Colombo Plan scholar had never expected such a healthcare-centred career, the experience has certainly revealed his flexibility and given him the "intimate knowledge" necessary for him to "make things happen" as Health Minister, said an industry insider.
  The experience probably also played a big part in imparting the necessary confidence to act firmly as minister.
  Looking at his track record in MOH, it wouldn't be too much of an exaggeration to say that Mr Khaw had impressed Mr Goh enough to be invited to join the 2001 campaigning team of Singapore's second Prime Minister.
  For Mr Shanmugaratnam, his career at the Monetary Authority of Singapore (MAS) provided him with a similar opportunity to prove his mettle to another future Prime Minister, Mr Lee Hsien Loong.
  The MAS was where Mr Shanmugaratnam, a London School of Economics graduate, spent nearly his entire professional life, working as an economist. It was only from 1995 to 1997 that he hopped over to the Education Ministry as its Deputy Secretary (Policy).
  So, although he had not spent much time in education circles, Mr Shanmugaratnam was, like Mr Khaw, an old hand at crafting big plans for the nation.
  The chance to shine before one of the country's top men came in 1997 when Mr Shanmugaratnam returned to MAS at a higher position than before: Deputy managing director. It was from then that he had ample opportunities to work with and impress Mr Lee, who was Deputy Prime Minister at the time and concurrently appointed head of MAS in 1998.
  Mr Shanmugaratnam was later promoted to managing director and then invited to join the People's Action Party.
  Prof Ho believes Mr Shanmugaratnam's "professorial" quality is one reason why he has been an effective Education Minister — he is able to break down complex issues and policies such that the public understands him. It is a trait that Mr Khaw shares, Prof Ho said.
  Another of Mr Shanmugaratnam's strong points is the "ability to empathise with the anxieties, concerns and aspirations of the people", noted Mr Viswa Sadasivan, chief executive of public relations firm Strategic Moves.
  Such empathy may have something to do with the fact that this is one minister who knows what it is like to be on the wrong side of the law.
  In 1992, Mr Shanmugaratnam, an MAS economist at the time, came under intense public scrutiny when he was charged for breaching the Official Secrets Act. Because he had brought a confidential report — containing an advance estimate of Singapore's quarterly economic growth — into a meeting with journalists who went on to publish the figure ahead of its official release, the courts fined him $1,500 in 1994.
  "All these experiences have made him a well-rounded person," said Mr Viswa.
  In Mr Khaw's case, his spirituality is often cited as a key to his success.
  Several commentators have said before that the Buddhist never appears ruffled. He is always calm and, like Senior Minister Goh, is able to connect with people on a grassroots level.
  Mr Viswa puts it down to the Zen belief that people on the ground should be treated with fairness and dignity, thus lending Mr Khaw a certain "moral courage" to act.
  Perhaps, Mr Khaw's readiness to act — in terms of pushing for far-reaching changes in Singapore's health landscape — may also be related to his desire to retire from politics sooner, rather than later.
  In a Today interview last November, Mr Khaw dropped hints of retiring as he recalled how entering politics was never his wish.
  He had said this might be his last term in the Health Ministry, a "very meaningful portfolio" from which he would like to retire from politics.
  And for a minister, what can be more meaningful than to put in place reforms that would benefit the whole nation long after he is gone?
  No matter when he makes his exit, there is little doubt that Mr Khaw has left his mark in the ministry. Ditto for Mr Shanmugaratnam.
  But for all their outstanding performances, one thing should not be forgotten: That no minister, or his ministry, is an island.
  As Prime Minister Lee once said, his Cabinet is "a collegiate team", where ministers jointly work on issues, such as dengue or labour, which touch their portfolios.
  At the same time, those who oversee ministries that deal with more sensitive information, such as Home Affairs and Defence, may be less in the public eye, but they too are making big contributions behind the scenes, said political commentator Zulkifli Baharudin.
  The businessman and former Nominated Member of Parliament added : "The Singapore system emphasises less on personality."
  Except that of the Prime Minister.
  Said Assoc Prof Ho: "PM is the first among equals. He's the one making policy and the rest are overshadowed by his presence." Copyright MediaCorp Press Ltd. All rights reserved http://www.todayonline.com/articles/217671.asp

Means testing a minefield

Means testing a minefield
ST: April 19, 2007 Thu

MEANS testing to allocate subsidy for using the public hospital system appears imminent. Health Minister Khaw Boon Wan has gone so far as to suggest that, for a start, a limited form of sorting to steer more aid towards low-income patients could be the five-day threshold.
Patients who have stayed longer than five days in B and C class wards will have their finances checked to determine how much or how little support they should receive, based on their means. It is important that the basis of evaluation is understood.
There is no quarrel with the thinking that rationing of state-funded health-care resources is necessary since these are limited by the Government's fiscal priorities. An unequal shareout among patients can be defended if done with fairness. It is unlike subsidised education, which is not means-tested as it is an inalienable right of citizens. There is a political dimension to the issue as well, in that the Government has to demonstrate its seriousness in minimising the bad effects of the wealth gap.
Implementation is the tricky part. Devising the yardsticks to make the means test least objectionable is going to challenge the most imaginative of ministry bureaucrats.
Should it be the income or assets test or something else? On income, the ministry can expect to run into a thicket of exceptions and objections. Patients of the middle-income bracket and upwards will reasonably expect undiscounted subsidised care, if they choose to, as they pay tax. Two-thirds of the workforce do not pay tax but receive the most state benefits.
The middle-income group will not begrudge non-taxpayers receiving the full subsidy, but will resent the means test as discriminatory of them. There are other inherent weaknesses. People of 'means' could be supporting aged or ailing parents. Assets test then? Assets can be hidden in trusts or are simply undeclared. Statutory declarations are intrusive, which will invite more resentment.
Retirees living in private housing but on limited savings would be most fearful of the cost of falling ill. They are a large group of health-care consumers. The assets test will probably penalise them.
In the end, the Government will come under pressure to increase its Budget allocation for health. Careful thought must go into the means exercise so that the system does not end up alienating one segment of the citizenry while helping another. The best neutral advice: Those who can afford it should consider taking out private medical insurance. It is the soundest bet against an inexorable trend of ever costlier treatment and husbanded resources.
http://www.straitstimes.com/portal/...e:1177019940000 http://forums.hardwarezone.com/showthread.php?t=1590174&page=2&pp=15
------

Have disease-specific time limits for means testing
I REFER to the editorial, 'Means testing a minefield' (ST, April 19). Most people would agree with the principle that the less well-off should receive more subsidies. However, follow-up questioning would likely reveal that none of them would consider themselves as 'well-off', and therefore they, too, should be deserving of subsidies.
Therein lies the difficulty of means testing - everyone agrees with the principle, but the devil is in the details of the implementation. I would like to make the following suggestions for the public and Health Ministry to consider.
Firstly, on the qualifying criteria for subsidy, no matter how the cut-off line is drawn, there will be unhappiness among those above the line. The use of a sliding scale, so that everyone enjoys at least some subsidy, is to be commended.
Furthermore, the criteria should keep pace with healthcare inflation. For example, the current maximum of $500 per capita family income for downgrading to C class was implemented in 2001. Data from Statistics Singapore shows that health-care costs have risen by almost 10 per cent since then, and only 238,000 households met this limit in 2005.
Secondly, the proposed limit of five days' stay in a public hospital is too simplistic. Certain conditions, by their very nature, necessitate a stay of more than five days, e.g., colon-cancer operation. It is also for these very conditions that we worry about chalking up large bills, rather than one-off admissions like childbirth, hernia surgery or knee replacement. With disease-specific data readily available from Casemix, the ministry should instead set disease-specific time limits.
Lastly, the public is apt to view this exercise as a cost-cutting measure. To assure us otherwise, the Government should channel the projected savings back to us, especially to those who will be affected adversely by means testing. This could be in the form of an upgrade of our MediShield packages, to assure us that although we may no longer qualify for C-class subsidies, we would still be able to afford the necessary health care when the need arises.
Gerald Tan Jit Shen
http://angrydr.blogspot.com/2007/04/subsidy-and-other-preoccupations-11.html

Means testing put on hold

• 2May06: "Means testing itself is not wrong, but how to do it properly is tricky and needs time. Originally, I was more ambitious when I returned to (the Health Ministry) three years ago. I thought we could do means testing."
• Nov2006: "Mr Khaw dropped hints of retiring as he recalled how entering politics was never his wish"
• 7April07: Means testing may kick in within next 12 months
  
  Oh... KBW has become ambitious again? Why the flip flop? ... oh, right, Kharma comes in waves...
  
  Means testing put on hold
  By : Tor Ching Li, TODAY
  Date : 02 May 2006 0657 hrs (SST)
  URL : http://www.channelnewsasia.com/stories/singaporelocalnews/view/206005/1/.html
  SINGAPORE: Means testing - which would see public healthcare patients being charged according to what they can afford - will not be implemented within the next two years as originally planned, said Health Minister Khaw Boon Wan on Monday morning.
  "Means testing itself is not wrong, but how to do it properly is tricky and needs time. Originally, I was more ambitious when I returned to (the Health Ministry) three years ago. I thought we could do means testing.
  "But after discussion with people, I think let us do other proposals first," Mr Khaw told reporters during a Sembawang walkabout.
  Instead, Mr Khaw said he would focus on revamping the MediShield national health insurance system and on improving healthcare for the chronically-ill.
  He was responding to Workers' Party (WP) chairman Sylvia Lim's questions on how means testing for healthcare would be carried out.
  She had raised the issue during a WP rally at Hougang on Sunday night, stating that present indicators such as house size and household income may not be accurate or appropriate benchmarks for how much a person could afford to pay.
  "If we make the same amount of money, it does not mean we have the same amount of money to spend," said Ms Lim.
  Mr Khaw stressed that nobody can fault the principle of means testing. This included WP chief Low Thia Khiang who, according to Mr Khaw, had raised in Parliament the idea of means testing for Government polyclinic patients because Mr Low felt that rich patients were "overcrowding" the heavily-subsidised polyclinics.
  However, whether means testing will eventually be carried out will depend on whether it is practical to do so.
  Said Mr Khaw: "I will do it only if it is practical, because the theory may be sound but if the implementation is more costly ... then it's not worth the effort.
  "So whether to do it or not, I don't know. It depends on whether we can come up with practical ideas."
  As for how long it would take to work this out, Mr Khaw replied: "I don't know. You know my attitude to work, I am single-minded about things and I focus my energy on a particular issue. Right now, my big issue - besides Sembawang - is the chronically-sick. I think they can get better healthcare than they are receiving now."
  When asked for his response to WP candidate Perry Tong's proposal for the Government to scrap the Goods and Services Tax (GST) on drugs - as well as to charge at cost medication for chronic illnesses such as high blood pressure and diabetes - Mr Khaw said the answer to rising healthcare costs was not so simple.
  "If it was so simple that just one or two simple ideas from Perry Tong and the whole healthcare issue disappears, we would not have healthcare problems around the world being such a major political issue, not just here," said Mr Khaw.
  He accused the WP of trying to score political points by proposing populist healthcare solutions that have proved disastrous in Britain, Europe and elsewhere. In Britain, he said, patients wait for months for even simple procedures.
  And ideas such as reducing GST for medical bills, which is already being done for subsidised patients, would benefit the rich more than the poor. Private hospital bills are many times the size of Class C hospital bills.
  "Instead, our solution is to provide Class C with the greatest subsidy (at 80 per cent of cost)," he said. - TODAY /dt
  Copyright © 2006 MCN International Pte Ltd

Means testing may kick in within next 12 months

Reducing subsidies to the middle class...
But:
"complexity of means testing"... ..." waiting time is already very long... ... We will end up doing only means testing and no treatment. So it's not practical unfortunately."

Means testing may kick in within next 12 months
Channel News Asia7 Apr 07
Means testing may kick in within the next 12 months, says Health Minister Khaw Boon Wan.
And the first to be affected will be patients in C-class wards who stay more than five days in hospital.
Patients in C-class wards now enjoy an 80 percent subsidy. But the Health Ministry realised that not all patients need such a subsidy, as there are some in the high income bracket who choose to be hospitalised in such wards.
To ensure that there is no abuse of the system, the Health Minister says means testing must be done on those who stay more than five days in hospital - the average length of stay. Means testing, which is a way to determine how much subsidy a patient should get, is already done in nursing homes and community hospitals.
Mr Khaw says: "We are in this business where all of us want to constantly improve our service level. But if your prices are wrong, if they are heavily subsidised or free or whatever, you are going to attract more and more patients to you, including those who can go to Gleneagles Hospital and Mount Elizabeth and so on. And we have very good doctors, very good specialists. So we know that at the end of the day, means testing are important.
"And until you introduce proper means testing, I'm afraid all these problems will remain, will simmer. I'm seriously thinking about all those who are long stay, who should now be discharged to community hospital, we should do means testing on them. Now they are saying that if they go to nursing homes they will be means tested but if they remain at SGH they are not means tested, therefore it's cheaper - then we will never solve this problem."
Mr Khaw says for those who can afford to pay more, their subsidy may be reduced to less than 80 percent but they will not be asked to move to a higher class ward.
However, he is not keen to extend means testing at the polyclinic level for practical reasons. Mr Khaw says: "It's not just looking at your personal income - we are talking about family income here. The whole family should be supporting the patient. So therefore I need to know how many children you have and how much are they earning. And we cannot have self-declaration because everybody will say they are poor, they earn $800 when actually it may not be so. So you begin to see the complexity of means testing.
"We know that at our polyclinics, waiting time is already very long. If at the counter we are going to start asking all these questions, you know, I think we cannot do business. We will end up doing only means testing and no treatment. So it's not practical unfortunately."
Mr Khaw was speaking at a dialogue session on on Saturday with unionists in the healthcare sector, where he answered several questions.
[Abridged]
http://www.geraldtan.com/medaffairs/meanstest.html#C16