新加坡卫生部长王乙康国会答复议员：这些措施将极大降低医疗成本

主席，现在让我来解释下一个关注点，即不断上涨的医疗成本问题。林伟杰医生、佳馥梅女士和黄玲玲女士问道，是什么导致医疗成本的上升？在这一部分，我将谈论医疗成本上升的可能原因，解释医疗资金的现实情况，以及我们正在采取哪些措施来努力降低成本。

导致医疗成本上升的一个主要因素是我们的人口日益老龄化。随着年龄的增长，我们更有可能患上重病。在过去五年中，新加坡老年人口增加了近20%，从56万增长到现在的69万。我们即将成为一个超级老龄化社会。这些不仅仅是宏观数字，它直接影响到个人和家庭。因此，当家庭中的一位成员年事已高并患上重病时，整个家庭都感受到了医疗费用的负担和护理负担。

第二个原因是医疗技术的进步。技术进步可以让汽车或智能手机更便宜更好。但在医疗保健领域，情况并非如此。新疗法可能效果更好，但花费也更高。例如，骨科手术的进步使膝关节置换术变得更加容易。在我的选区，我遇到了许多老年人做过膝关节置换术。有时，他们甚至两个膝盖都进行了手术，当我遇到他们时——我曾经也做过一次这个手术——我们还会比较我们的手术疤痕。

过去，由于年老导致眼部血管退化，人们也会丧失中心视力。现在，这种情况可以通过反复的玻璃体內注射来治疗和控制。这些进步使无法行走的人重新行走；让失明的人重见光明。

这对患者的价值是无价的，而对患者的成本也是增加的。

第三，医疗费用上涨。即使是对于相同的治疗，不谈医学进步；同样的治疗，费用也在上涨。近年来全球通货膨胀都在上升，这也影响了医疗成本。医疗服务成本的一个关键组成部分是人力成本。

在新加坡，人力成本占医疗系统运营成本的一半以上。我们都同意，我们需要以公平和具有竞争的方式地对医护人员进行薪酬补偿。随着许多国家的医疗需求增加，医疗人力的竞争现在已经国际化，并变得更加激烈。这推高了人力成本，因此也推高了医疗成本。

最后，保险。保险让我们高枕无忧。但是当保险覆盖范围变得过于慷慨，甚至到最后一新元时，我们开始看到过度的处方和检查，甚至是不必要的治疗。这就是典型的“自助餐综合症”，它推高了索赔金额。已经付费了，就可以放心大胆地过度消费。

这导致索赔金额的增加，因此导致了保险费的增加。然而，令人沮丧的是看到保险公司继续提供不可持续的条款——可能是为了争夺市场份额。那么，我们该如何解决医疗成本上涨的问题呢？我们首先需要认识到医疗费用中的两个不争的事实。

第一个事实是，最终总是要由个人来买单。我用一个亲身经历的例子来解释吧。1999年，当我和妻子搬到瑞士一年，我去那里读硕士学位，当时我们必须缴纳社会保险。我记不得名字，但并不便宜。我们俩一起支付了几千瑞士法郎。这是强制性的。如果我们不交，我们就不能在瑞士生活。然后，我妻子怀孕了。她找了一位很好的妇科医生。每次去看她，我们都可以随时进出，不需要支付任何费用。这真的是免费的吗？不是，其实我们已经为此支付了相当昂贵的保险费。

在英国，国民医疗服务体系的运作原则是提供免费医疗服务。英国政府从未触动这一原则。

但它真的是免费的吗？并不是。英国人必须支付高额税款为国民医疗服务体系提供资金。因为在提供医疗服务是免费，国民医疗服务体系的等待时间就非常长。我指的是800万人在等待。因此，英国患者也是用他们的时间和耐心付出代价。

支付医疗费用有不同的方式：通过税收、强制性社会保障缴费、保险费用或个人储蓄，甚至是个人的时间。最终，人们总是以某种方式付出代价。这就是第一个事实。

这引出了第二个事实，即我们支付的方式影响我们支付的金额。

如果政府种用税收使医疗保健在提供时“免费”，那么很可能会导致我刚才提到的“自助餐综合症”。会出现过度消费、浪费和高成本通货膨胀。如果政府让人们自行购买医疗保险，人们会非常谨慎，这可以减少医疗开支。但是，如果有人没有购买保险且未投保，他们将得不到足够的服务。

这就是为什么在新加坡，我们构建了一个更为健全的支付医疗费用的方式。它包括由税收资助的补贴；保健储蓄（MediSave）；终身健保（MediShield Life）；以及保健基金计划（MediFund）——我们所称的“S+3Ms”。“S+3Ms”确保了普遍性，因为它让所有新加坡人都能获得优质医疗服务。这也是一个有针对性的系统，将重点援助放在最需要的人身上。

举例来说明，公立医院的C级病房可以享受高达80%的补贴，但A级病房和私立医院则不享受。MediShield Life在补贴之后覆盖了剩余账单的相当部分，但我们确保患者通过MediSave进行一定程度的共付，以减少“自助餐综合症”的发生。对于无法负担共付款的最低收入者，MediFund可以提供援助。

这就是为什么与一揽子援助计划的司法管辖区相比，我们可以在国民医疗支出占GDP 5%的情况下实现良好健康结果的关键原因。牢记这两个不言而喻的事实，我们可以做些什么，又正在做些什么来应对不断上升的医疗费用呢？

首先，让我从“S+3Ms”中的“S”开始。补贴将起到重要的作用。

我在2015年首次加入政府并进入国会时，我担任了教育部的代理部长。教育部的预算是各部门中排名第二，约为120亿新元，仅次于国防部。而卫生部的预算则排名第三，仅略超过90亿新元。如今，9年过去了，我成为了卫生部长。卫生部的预算已远远超过了教育部，几乎达到了190亿新元，与国防部的预算相差无几。

卫生部的预算是由税收提供的。这些资金被用于资助医疗系统的许多方面：建设新的医疗基础设施，运营医院、综合诊所和养老院，采购药品和设备，开发新的信息技术系统，聘请医生、护士和所有医疗人员。卫生部的预算是由税收资助的，并构成了医疗补贴，这些补贴在多年来一直在大幅增加。

接着，第二个“M”——MediShield Life——也需要加强。为此，我们将对MediShield Life进行全面审查。正如我所提到的，MediShield Life是一项全国性的健康保险计划。它为所有人提供终身保障，甚至包括那些已有疾病的人。它是专门为绝大多数遭遇重大健康事件的受资助患者而设计的。

最后解读一下。它包含了几个重要的短语，我将会解释。我说它覆盖了绝大多数受资助的患者，因为大多数的新加坡人寻求的是接受补贴的医疗护理，而“其中绝大多数人”需要财政援助来支付他们的医疗费用。

因此，对于C级病房的患者来说，在补贴后，他会发现MediShield Life的理赔应该会大幅支付其余的医院账单。对于前往私立医院的患者来说，他会发现MediShield Life只覆盖了其医院账单的一小部分。这就是MediShield Life如何把重点入在受资助的患者，特别是那些使用C级病房的患者。

因此，“重大健康事件”之所以被提及，是因为这符合保险的精神，即保障我们在罕见情意下不会因患重病而产生巨额医疗费用。

有鉴于此，请允许我报告一下目前的MediShield Life目前的状况。根据设计，10份补贴账单中有9份都能得到充分保障。剩下的是相对较少且可以预期的共付额，可以从MediSave中支付。然而，这十分之九的基准正在被削弱，因为医院账单的金额正在变得越来越大。在过去几年里，公立医院的账单金额每年增长5%，私立医院的账单金额每年增长7%。

因此，由于账单金额增长，MediShield Life充分覆盖的补贴账单比例已降至十分之八左右，预计还会进一步下滑。

这有什么实际的影响呢？接受补贴的患者发现医院账单出乎意料地高。即使经过补贴和MediShield Life，仍有很大一部分费用需要自付。这时，罗高的医疗费用才真正开始产生影响。

因此，卫生部已经责成MediShield Life理事会（由私营部门的领导人带领的各方利益相关者组成）对该计划进行全面审查，但我们已经给予理事会一些指导。

首先，加强MediShield Life，为新加坡人提供更大的保障，以应对高额账单。这意味着提高患者可向MediShield Life计划索赔的金额，也就是我们所说的理赔限额，无论是手术费用还是住院费用。

我们预计索赔限额会有相当大的提高。例如，如果需要介入手术，在心脏内植入支架以打通阻塞的动脉，再加上在重症监护室里住几个晚上，那么理赔限额可能需要翻倍，乘以二。这将大大降低自付费用。

第二，加强其他门诊病人的保险。我们还需要提高治疗项目的理赔限额，例如肾透析，以减少患者的自付费用。理事会还将探讨将覆盖范围扩大到更多类型的门诊治疗。

一些昂贵的门诊治疗是针对癌症的。林瑞莲女士问道，我们是否可以提高患者的财务素养，以便他们更好地制定应对这类疾病的计划。网上有可用的资源，我们将提高公众对这些资源的认识。但我认为这个问题不仅仅是财务素养的问题。它实际上比这更严重。对于癌症来说，我们正面临着特别严峻的挑战，因为治疗成本不受控制地上升。因此，我对你提到的调查结果一点也不感到意外。

我们最近对癌症药物的融资进行了审查，并进行了一些变革，使我们能够通过谈判降低抗癌药物的价格。因此，获批的抗癌药物的价格已经大幅下降，有些降幅高达60%。其影响仍在显现，我们将继续监控有关情况。

第三，理事会将考虑将MediShield Life计划的承保范围，使其涵盖突破性的新疗法，特别是细胞、组织和基因治疗类产品（CTGTPs）。

医学科学发展日新月异，CTGTPs 有可能彻底改变医疗保健，有效治疗以前无法治愈的疾病。有人将其形容为医疗保健领域的 "登月计划"。

从根本上说，这种治疗方法是，我们从病人身上抽取血液，然后用这些血液教导并装备血液中的细胞，使其能够瞄准并杀死癌细胞，然后再把这些细胞重新注入病人体内，让它们发挥作用。这是一种一次性治疗方法。

然而，尽管这项技术前景广阔、进展迅速，但它仍处于起步阶段，而且非常昂贵。每次治疗的费用从几十万美元到几百万美元不等。

我们希望开始将CTGTPs纳入MediShield Life。但是，我们需要建立保障措施，以确保CTGTPs的融资是可持续的。例如，我们只需要将MediShield Life的承保范围扩展到经过评估为安全、临床有效且具有成本效益的治疗。换句话说，如果一种治疗方法耗资数百万新元，但只有很小的希望能治愈一小部分人，那就不具有成本效益。这是帮助所有新加坡患者（无论其收水平如何）获得具有成本效益、新颖、先进的治疗方案的第一步。

这些提议的变化将更好地保护接受补贴的患者，使其免受重大医疗事故的影响。然而，MediShield Life的保费将不可避免地上涨。

上次我们审查该计划时，平均保费上涨了25%。但请放心，我们将尽一切努力，尽可能确保MediSave计划能全额支付保费。

例如，我们将考虑增加保费补贴，或为特定群体提供MediSave的补充款项。我们可能需要将更多的MediSave用于支付小额住院费用，这样MediShield Life就能更好地使用于大额住院费用，从而缓和保费的增长。没有人会因为无法负担保费而失去MediShield Life保险。当理事会于今年下半年完成审查时，我们将分享更多详细信息。

Chairman, let me now address the next concern, which is rising healthcare costs. Dr Lim Wee Kiak, Ms Mariam Jaafar and Ms Ng Ling Ling asked, what is driving up healthcare costs? In this section, I will talk about the likely reasons for rising healthcare costs, explain the realities of healthcare financing and then what we are doing to try to moderate costs.

A major factor for rising healthcare costs is that we are getting older, and as we get older, we are more likely to fall seriously ill. Over the last five years, the number of Singaporean seniors increased by almost 20%, from 560,000 to 690,000 now. We are on the verge of becoming a super-aged society. These are not macro numbers, it directly affects individuals and families. So, when in a family, one member grows older and falls seriously ill, the entire family feels the burden of healthcare costs and also the caregiving burden.

The second reason, advancement in medical technology. Technological advancement can make a car or a smartphone cheaper and better. But in healthcare, it is often not the case. New treatments may work better, but always cost more. For example, advancement in orthopaedic surgeries have made knee replacements much easier to do. In my constituencies, I met many seniors who have gone through knee replacements. Sometimes, they have gone through both and when I meet them – I have gone through one – we end up comparing our battle scars.

In the past, people with degenerating blood vessels in their eyes due to old age, they will lose their central vision. Now, the condition can be treated and controlled through repeated intravitral injections. These advancements allow a person who cannot walk, to walk again; allow a person who would have been blind, to see again.

The value to the patients is priceless. The cost to the patients has also gone up.

Third, healthcare costs inflation. Even for the same treatment, not talking about medical advancement; the same treatment, the cost has gone up. Inflation all around the world has gone up in recent years and that has also affected healthcare costs. A key component of healthcare delivery cost is manpower.

In Singapore, manpower is more than half of the cost to run the healthcare system. We all agree we need to compensate our healthcare workers fairly and competitively. As healthcare demands have gone up in many countries, the competition for medical manpower is now international and has become more intense. And this pushed up manpower costs and, therefore, healthcare costs.

Finally, insurance. Insurance gives us peace of mind. But when the coverage becomes too generous down to the last dollar, we start to see excessive prescriptions and tests and even unnecessary treatments. This is the classic buffet syndrome, which has driven up claims. Already paid for, might as well overeat.

It has driven up claims and, therefore, it has driven up insurance premiums. Yet, it is frustrating to see insurance companies continue to offer unsustainable terms – presumably they are competing for market share. So, how do we address rising healthcare costs? We need to first recognise two truisms in healthcare financing.

The first truism is that, ultimately, the people always pay. Let me explain with a personal example. When my wife and I moved to Switzerland for a year for me to do my Master's programme, that was in 1999, we had to make a social security payment. I cannot remember the name, but it was not cheap. A few thousand Swiss francs for the both of us. It was compulsory. If we do not pay, we could not live in Switzerland. Then, we got pregnant. My wife found a good gynaecologist. Each time we visited her, we can just go in and go out. We did not have to pay anything. Was it really free? Not really. We paid for it already, through the rather expensive social security fee.

In Britain, the National Health Service (NHS) operates by the principle of free healthcare at the point of delivery. No UK government has ever touched that principle. It continues to be free at the point of delivery. 

But is it really free? Not really. The British have to pay high taxes to finance the NHS, because there is no cost at the point of healthcare delivery, the waiting times at the NHS are very long. I talked about eight million people waiting. So, British patients are also paying with their time and their patience.

There are different ways to pay for healthcare: by taxes, by compulsory social security payments, through insurance premiums or personal savings or your personal time. Ultimately, the people always pay one way or another. That is truism number one.

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This leads to the second truism, which is how we pay affects how much we pay.

If a government uses taxes to make healthcare "free" at the point of delivery, then it will likely lead to the buffet syndrome that I just mentioned. There will be over-consumption, wastage and high-cost inflation. If a government leaves the people to buy their own health insurance, people will tend to be very careful, which can moderate healthcare expenditure. But if someone did not buy insurance and is uninsured, they will be underserved.  

That is why in Singapore, we weaved together a more robust way to pay for healthcare. It comprises subsidy funded by taxation; MediSave which is own personal savings; MediShield Life which is a national insurance scheme; and MediFund which is the final social safety net – what we termed S+3Ms. S+3Ms ensures universality because it provides all Singaporeans access to quality healthcare. It is also a targeted system, focusing assistance on those who need it the most.

To illustrate, subsidies of up to 80% are extended to C Class wards in public hospitals, but not A Class wards, not private hospitals. MediShield Life covers a significant part of the remaining bill after subsidy, but we ensure some co-payment by patients, mostly through MediSave, so that there is less of a buffet syndrome. MediFund comes in for the lowest income who cannot afford the co-payment. 

This is a key reason why we can achieve good health outcomes with national healthcare spending of 5% of GDP, compared to jurisdictions with blanket assistance schemes. With these two truisms in mind, what can we do and what are we doing about rising healthcare costs?  

First, let me start with the S, of S+3Ms. Subsidies will have a big role to play.

When I first joined the Government in 2015 and entered this House, I was the Acting Minister for Education (MOE). MOE's budget was the second largest amongst Ministries, at about S$12 billion, and only behind the Ministry of Defence's (MINDEF's). MOH's was the distant third, just over S$9 billion. Today, nine years later, I become Minister for Health. MOH's budget has far surpassed MOE's, to almost S$19 billion and not very far behind MINDEF's.  

MOH's budget is tax funded. It is channeled to fund many aspects of the healthcare system: build new healthcare infrastructure, operate hospitals, polyclinics and nursing homes, procure medicines and equipment, developing new IT systems, hiring doctors, nurses and all our medical personnel. MOH's budget is tax funded and constitutes healthcare subsidies, which have been rising significantly over the years.

Then, the second M – MediShield Life – will also need to work harder. To this end, we will be conducting a comprehensive review of MediShield Life. MediShield Life, as I mentioned, is a national health insurance scheme. It covers everyone for life, even those with pre-existing illnesses. It is specifically designed for the great majority of subsidised patients who are encountering a major health episode.

 The last sentence needs some deciphering. It contains a couple of important phrases, which I will explain. I said it covers great majority of subsidised patients, because most Singaporeans seek subsidised care and the "great majority of them" need financial assistance to foot their healthcare bills.   

Hence, for a C Class Ward patient, he will find that after subsidy, MediShield Life claims should substantially pay for the rest of his hospital bill. For a patient that goes to a private hospital, he will find that MediShield Life covers only a modest part of his hospital bill. That is how MediShield Life is focused on the subsidised patients, especially those that uses C Class wards.

Then "a major health episode", because this upholds the spirit of insurance, which is to protect us against rare occasions when we incur a big hospital bill because we fall seriously ill.  

With that context, let me report the state of MediShield Life today. It was designed such that nine out of 10 subsidised bills are adequately covered. Nine out of 10. What remains are relatively small and expected co-payments, which can be paid from MediSave. However, this nine in 10 benchmark is being eroded, because the size of hospital bills is getting even bigger. Bill sizes have grown by 5% annually in public hospitals and by 7% annually in private hospitals over the last few years.  

As a result, the proportion of subsidised bills adequately covered by MediShield Life has come down to around eight out of 10, and is expected to slip further.  

What is the practical impact? Subsidised patients are seeing hospital bills that are unexpectedly large. And after subsidy and MediShield Life, there is still a substantial out-of-pocket component left. This is when higher healthcare costs really start to bite. 

MOH has, therefore, tasked our MediShield Life Council – which is from various stakeholders led by a private sector person – to comprehensively review the scheme, but we have given the Council some direction.  

First, enhance MediShield Life to give Singaporeans greater assurance against large bills. This means increasing how much a patient can claim from MediShield Life – this is what we call claim limits – for both surgeries and hospital stays.

We envisage a fairly significant increase in the claim limits. For example, for an episode involving angioplasty where a stent is placed into your heart to open up a blocked artery, plus, say, a few nights in ICU, the claim limits may need to double, times two. This will reduce out-of-pocket costs significantly. 

Second, enhance other outpatient coverage. We also need to raise the claim limits for treatments, such as kidney dialysis, to reduce out of pocket expenses for patients. The Council will also explore extending coverage to more types of outpatient care.  

Some of the most costly outpatient treatments are for cancer. Ms Sylvia Lim asked if we could improve financial literacy for patients to better plan against such a disease. There are resources available online and we will raise the public's awareness to them. But I think the issue goes beyond financial literacy. It is actually more serious than that. We are facing an especially difficult challenge for cancer, as treatment costs were rising uncontrollably. So, I am not surprised at the survey results that you cited at all.  

Hence, we recently reviewed cancer drug financing and introduced changes that will allow us to negotiate for lower prices for cancer drugs. As a result, prices for approved cancer drugs have since dropped significantly, some by up to 60%. The impact is still playing out and we will continue to monitor the situation. 

Third, the Council will consider expanding MediShield Life coverage to new groundbreaking treatments, specifically Cell, Tissue and Gene Therapy Products (CTGTPs). 

Medical science is advancing rapidly, and CTGTPs have the potential to revolutionise healthcare and deliver effective treatment of previously incurable diseases. Some describe these as the equivalent of a moonshot for healthcare.  

Essentially, the treatment involved is, we extract blood from a patient, then with the blood, you teach and equip the cells in the blood to target and kill, say, cancer cells, then you put the cells back into the patient's body to do its work. It is a one-time treatment. 

However, while the technology is promising and advancing fast, it is nascent and very expensive. It could cost anything from a few hundred thousand dollars to a few million dollars, per treatment. 

We want to start including CTGTPs under MediShield Life. But, we need to put in place safeguards to ensure that financing of CTGTPs is sustainable. For instance, we will need to extend MediShield Life coverage only to treatments that are assessed to be safe, clinically effective and cost effective. In other words, if a treatment costs a few million dollars with a small hope of curing a small group of people, it is not cost effective. This is a significant step to help all Singaporean patients, regardless of their income levels, have access to cost effective, novel, state-of-the-art therapies.

These proposed changes will better protect subsidised patients against major health episodes. MediShield Life premiums, however, will inevitably go up.  

The last time we reviewed the scheme, premiums went up by 25% on average. But, rest assured that we will do the necessary to ensure that, as far as possible, premiums can be paid fully by MediSave.  

For example, we will consider enhancing premium subsidies, or have MediSave top-ups for specific groups. We may have to use more MediSave for small hospital bills, so that MediShield Life can better focus on big hospital bills, and in that way, we moderate premium increases. No one will lose MediShield Life coverage due to a genuine inability to afford the premiums. We will share more details when the Council completes its review in the second half of this year.

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