The Doctors’ Dilemma: Sacrifice the Bottom Line, or Fall Foul of Singapore Medical Council?

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Some doctors remain in a dilemma following new medical ethical guidelines which came into force this month. And this could mean patients’ medical benefits may no longer be accepted at certain clinics
SINGAPORE: Covered by a medical benefits scheme? You may have to fork out your medical fees in cash, if your doctor was among those who recently suspended or terminated their contracts with third-party administrators (TPA) who provide medical benefits such as co-payment for a visit to a GP.

This is in response to the Singapore Medical Council’s (SMC) new ethical guidelines which came into effect this month. The new guidelines prohibit doctors from paying TPA fees that are calculated as a percentage of the patient’s total bill.

Doctors have been left scrambling to work out whether they should continue to accept patients who are on benefit schemes – and potentially fall foul of the new guidelines – or withdraw from the process altogether, leaving some patients either paying full fees or looking for treatment elsewhere.

“We're stuck between a rock and a hard place,” said Dr Tan Tze Lee, a general practitioner at the Edinburgh Clinic in Choa Chu Kang who has dropped out.

“The professional bodies have given us their advisories ... but at the end of the day I am the one who has to make the decision whether or not to sign,” he said. “I am risk-averse, and because everything is due to interpretation, I decided, better not.”

SMC’s new ethical code came into effect on Jan 1, but it gave doctors six months – until Jul 1 – to ensure their contracts with TPAs meet the new guidelines. Since the guidelines came into effect, a number of doctors have terminated or temporarily suspended their contracts with TPAs.

Paying TPA percentage fees may be construed as a form of “fee splitting” between doctors and TPAs, said SMC in an advisory to doctors issued in December 2016. It pointed out that the work done by third parties in handling claims does not vary depending on the fees doctors charge patients. Hence, the fees paid to TPAs must likewise reflect the “fair work done” in processing the claims.

In a second advisory to doctors dated Jun 23, SMC said that should it receive any complaint or information that a doctor has breached the guidelines, “it will refer such complaint or information to the chairman of the Complaint Panel, and a Complaints Committee will inquire into the complaint or information.”

It added that the onus is on doctors, rather than third parties, to ensure that the fees they pay are in compliance with the new guidelines.

CHANGES BY THIRD-PARTY ADMINISTRATORS MAY NOT BE IN COMPLIANCE WITH NEW GUIDELINES

Since the guidelines were first announced last year, TPAs have made changes to their fee structures to ensure that they comply with the SMC guidelines.

However, in its Jun 23 advisory, SMC noted that some revised fee structures it has seen based on information provided by the TPAs still do not comply with the new guidelines. It said some of the revised fee structures appear to be tiered and primarily based on “the fee payable to the doctor, the amount claimable by the patient (which is in turn based on the fee payable to the doctor), and/or for surgical procedures, the Ministry of Health Table of Surgical Procedures”.

It clarified that while the new guidelines do not prohibit tiered fixed fee structures as such, the payment of a fee to third parties “cannot be based primarily on the services the doctors provide or the fees that doctors collect”.

In response to queries from Channel NewsAsia, the SMC said it is aware that following its Jun 23 advisory, some third parties have amended their fee structures or explained and elaborated further on the basis for their fees. “However, in general, if two cases that a doctor is seeing are within the same tier of complexity of work done by the third party but are charged different fees, such a fee structure may not be adequately justified as reflecting the work of the third party,” it said.

Benefits administrator MHC said it used to charge doctors a percentage fee of 10 to 15 per cent. Its CEO Low Lee Yong told Channel NewsAsia that it has revised its payment structure to a fixed fee model, and stressed that its new model does not breach the revised ethical guidelines.

As for Parkway Shenton, it said that its “flat fee model” remained unchanged for the past eight years before the review of the SMC guideline. “Prior to 1 July, we have had numerous discussions with both MOH and SMC to understand their viewpoints and concerns,” said Parkway Shenton’s CEO Adrian Lee. “With SMC’s clarifications and legal counsel, we made iterations to our fee schedule to ensure that it is in strict adherence to SMC guidelines.”

Parkway Shenton declined to give more details to the changes it made, but said it does not intend to make further changes. MHC, on the other hand, “may review the fee structure to ensure our changes are fair, transparent and reflective of the work done.”

DISRUPTION TO PATIENTS “NEGLIGIBLE”: THIRD-PARTY ADMINISTRATORS

Both TPAs said the majority of their doctors have chosen to stay on with them, with MHC’s Dr Low noting that the drop out rate is “negligible”.

“The handful of doctors who have dropped out have since requested to be put back in the panel,” he said. The disruption to patients, he added, is also negligible.

“We continue to be in conversation with doctors who have opted out of the panel and those who have taken a wait-and-see approach, and will accept them back into the scheme when they are more comfortable with the programme,” said Parkway Shenton’s Mr Lee.

“Since Jul 1, we have been working with our corporate partners and clients to keep everyone apprised of the daily change of panel doctors,” he added. “To date, we have not received any adverse feedback from our clients or their members.”

But one patient was left reeling from an S$80 medical bill when his regular family doctor abruptly terminated its contract with the TPAs. The final-year university student, who wished to be known only as Casper, said he got a "rude shock" when he visited the clinic on Jul 1. His school's student insurance coverage allows for cashless payment at the school's clinic or at about 200 GPs around the island.

"When I gave them my student card, the lady at the counter pointed to a notice which said the clinic no longer accepted patients under TPA schemes," he added. "It was frustrating because I knew I needed antibiotics and that would cost me a lot.

"But because it was already so late (in the evening) and I was travelling soon, I just decided to pay in full."

"I've been seeing this doctor for close to seven years and it was so convenient that my school was partnering with this clinic," he said. "Besides being close to my house, the doctor also has my past records."

THE DOCTORS' DILEMMA

But as the onus is on doctors, rather than TPAs, to make the call, some doctors Channel NewsAsia spoke to remain in a dilemma: falling foul of the SMC if they stayed on with the TPAs, or losing business from patients on the TPA schemes.

"There are GPs where more than 70 per cent of their patient load comes from TPAs," said one GP who runs a clinic in the east. "How are they going to survive if they terminate their agreement with TPAs?"

He explained that TPAs provide doctors with a ready pool of patients to tap on, particularly when they are new. “When I first started out, I was in a mature estate with many established GP clinics. It was hard starting out then, and why would patients with regular GPs come to see me instead?"

“Yet, we're not allowed to market ourselves,” he said. "So the TPAs offer the potential for new patients."

But as patients on the TPA scheme made up only 5 to 6 per cent of his clinic’s collections, the GP, who declined to be named, decided it was not worth it to stay on. His last remaining contract with a TPA ended on Jun 30.

“Even on the modified terms, it’s still considered fee splitting to me,” he said. “My wife and I talked it over and decided that it was not worth it to continue.

“I lost a few long-term patients because of this, and of course it’s a bit sad,” he added. “But I don’t blame them since they have to pay out of their own pockets if they wanted to see me henceforth.”

Medical director of the Central 24-hour clinic chain Lye Tong Fong said they have chosen to stay on with the “five or six” TPAs they have contracts with. About 50 per cent of their patients are on the TPA schemes.

“Some of them are our long-term chronic patients, and I don’t think it’s fair to leave patients’ interests out and leave them in the lurch regarding their payment,” he said. “It’s also not easy to jump from one doctor to another, especially if you have a chronic disease.”

“Of course, I would expect certain changes and rectifications to come along the way if any need should arise, and on our end, we will make sure the charging is based on one fixed fee,” he added. “If any contention arises, we will reject to work with the TPA from then onwards.”

Dr Lye said it is good that the SMC “put out such guidelines so everyone can fall in line”. But he noted that TPAs should also be regulated. “Millions of dollars flow to them, and patients’ interests are at stake here, because whether their problems can be clearly sorted out depends on the payers themselves,” he said.

But in the meantime, rather than collecting administrative fees from doctors, TPAs should collect them from companies instead, according to the GP who runs a clinic in the east. “Why should the TPA take a cut of the GP's fees and affect his earnings when rightfully it's the employers that should be shouldering the administrative costs? Maybe when this is the case I would reconsider re-joining.”

“If the companies want their medical expenditure to be controlled, the company can subscribe to a co-payment or cap scheme,” he added.

“At the end of the day I just want to focus on doing the best I can for my patients. Leave the money out of it.”

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