MediShield cover for birth defects

Birth defects: Views sought on MediShield coverage
Govt proposal will help affected families with hospital bills, but may push up premiums for all
By Salma Khalik, The Straits Times, 14 Mar 2012

Singaporeans are to be asked to decide whether babies with serious birth defects should be covered by the national health insurance scheme.

About two infants a day are born with conditions such as heart problems or damaged nervous systems.

Health Minister Gan Kim Yong suggested last week that babies with congenital illnesses should be included under MediShield. But he warned that this could push up premiums for everyone.

The issue is now due to be put up for public consultation.

Ms Rae Kok is one parent who might have benefited from the proposed move. 'My child had multiple conditions,' said the 35-year-old. 'She was tube-fed throughout, and stayed at the hospital for three weeks in all.'

The girl had a genetic condition called chromosome disorder, a cleft palate and heart problems. Neither her parents nor the doctors had an inkling of her problems before she was delivered at KK Women's and Children's Hospital (KKH) seven years ago.

Although Ms Kok's daughter was receiving the maximum government subsidy in a Class C ward, the family spent more than $20,000 on her treatment in the first three years.

Had she been a private patient, her family would have paid considerably more. Neonatal intensive care for private patients amounts to about $1,000 a day, and six-figure bills are not unusual.

At the moment, MediShield - which provides medical cover for more than 90 per cent of the population - excludes congenital problems. These are medical issues that exist at birth.

Of the 40,000 babies born every year in Singapore, about 860 - an average of more than two of the 110 births a day - have a serious birth defect.

More than half of the ill infants have a heart problem, almost a quarter have musculoskeletal problems such as scoliosis and about one in 10 has defects involving the urinary tract, chromosomes or central nervous system.

Many of them end up at KKH - either before birth if such a problem was discovered early, or they are transferred from private hospitals to benefit from subsidised care.

Dr Joseph Gomez, who heads KKH's Neonatal Intensive Care Unit, said: 'Significant numbers are accepted from the private sector with congenital anomalies of the nervous system, heart, intestines, lungs, et cetera.'

He added that the hospital admits about 500 babies a year to the Neonatal Intensive Care Unit. These are the 'most ill babies', he said, adding that the vast majority are premature.

Not all congenital conditions require lifelong treatment. For some, treatment in their infancy is enough to correct the defect.

These would include problems like a cleft palate, which Ms Kok's daughter had.

On the other hand, Dr Angeline Lai, who heads the hospital's Genetics Service, said babies with Down syndrome, caused by an extra chromosome that interferes with the way their bodies and brains develop, might require long-term care.

Some children with Down syndrome might have mild impairment, while in others, it can be fairly severe. Older mothers are at higher risk of giving birth to such children, who usually have lower levels of intelligence.

Dr Lai said such children 'do better in a special education environment where they can learn at their own pace'.

'With home and good educational support, they are expected to have a good and happy quality of life.'

Ms Kok does not have that problem. For her daughter, the first three years were the most traumatic. Recalling their ordeal, Ms Kok said: 'We were in and out of the hospital for the three years after my child was born.

'She developed thyroid problems and a brain tumour. We even did an MRI but it was not operable. Miraculously, the brain tumour disappeared.'

A senior executive in a voluntary welfare organisation, Ms Kok would have been happy to have had insurance coverage for her daughter before she was born.

She has bought MediShield coverage for her child, 'but everything which is congenital is excluded', she said.

If the rules for MediShield are changed, her daughter might get full coverage - like any other child her age.

MediShield cover for birth defects: Seeking feedback not futile exercise

MR TAN Kin Lian's call for MediShield to cover birth defects assumes that the feedback process is likely to be a futile exercise, as those who do not face birth-defect risks will be against any change that will add to their cost of living ('Why MediShield should cover birth defects'; Monday).

There is no human being who does not worry over having children or grandchildren with birth defects.

Contrary to Mr Tan's view, no one is risk-free. I have also never met people who are so insensitive and uncaring that they exhibit no compassion or sympathy whatsoever for those born with birth defects.

Mr Tan also believes that having a child with birth defects is an uncontrollable risk. Passively believing in karma will bear us no fruit, whereas actively avoiding alcohol, drugs, smoking and unhealthy foods, as well as having children when we are younger, measurably cuts the risks of birth defects.

Medical insurance for birth defects, while noble, is fraught with legal complications.

We may perhaps be able to deal with the physical aspects of birth defects. But the neurological aspects, such as slow learning, mental retardation and pathological human development, which manifest long after birth, offer a big basket of potential litigation between claimants and insurance companies, with no one benefiting but the lawyers.

Dr Yik Keng Yeong
ST Forum, 24 Mar 2012

Five ways to counter MediShield premium hikes

MEDICAL insurance coverage should be primarily predicated on personal responsibility ('Why MediShield should cover birth defects' by Mr Tan Kin Lian; Monday).

Relying on others to provide coverage should be secondary.

Employers do not guarantee that medical policies will be renewed upon their expiration, and do not guarantee permanent employment to anyone.

So employees will lose their sole source of medical coverage once they are no longer employed, if they do not take it upon themselves to seek coverage.

I agree that MediShield should be extended to cover congenital anomalies for newborn babies, as well as seniors who do not have such cover.

To counter impending rate increases, I suggest the following measures for such cases:

- Impose higher deductibles and co-insurance amounts;

- Require seeking treatment in government or restructured hospitals, in lower class wards;

- Impose a pro-rated factor for those who choose to receive treatment in private hospitals;

- Set an overall limit of claim, per year and per lifetime; and

- Impose perpetual loading, with opportunities for reviews to reduce or remove the loading.

Su Kim Teck
ST Forum, 24 Mar 2012

Why MediShield should cover birth defects

THE Government is seeking public feedback on the proposal to extend MediShield to cover birth defects ('Birth defects: Views sought on MediShield coverage'; last Wednesday). Health Minister Gan Kim Yong has warned that extending coverage to such cases could push up premiums for everyone.

The feedback process is likely to be a futile exercise, as those who do not face birth-defect risks will be against any change that will add to their cost of living.

MediShield should be extended to cover most conditions that are outside the control of individuals. Having a child with birth defects is clearly an uncontrollable risk that should be covered.

The Government should also look at other flaws in MediShield, such as the large number of people who did not join the scheme for various reasons at the time of its implementation and who now wish to be insured.

Most of these people are older and may have some chronic illnesses that prevent them from being accepted under the Central Provident Fund's current underwriting rules. But they do pay higher premiums based on their age, and may be willing to pay a loading or surcharge.

It is better to allow them to join MediShield and enjoy the benefits from risk pooling, rather than let them remain outside the system.

Those who are provided with medical benefits by their employers should be allowed to stay outside of MediShield if they wish to, and join it at a later date when they are no longer employed or covered. This will avoid double coverage, which adds to the cost of living.

As a national insurance scheme, MediShield should have an underwriting approach that is different from those of profit-making private insurers. The aim should be to provide coverage for nearly everyone, rather than to select only the healthy to make a profit.

There are other ways of dealing with the challenge of higher premiums than to restrict coverage. Some of the costs can be borne by the Government and, more importantly, medical charges should be regulated and not allowed to escalate due to market failures.

Tan Kin Lian
ST Forum, 19 Mar 2012

BabyShield health insurance long overdue
Dedicated plan to cover birth risks, congenital problems lacking here
By Salma Khalik, The Straits Times, 9 Feb 2011

EVERY year, about 860 babies – or more than two a day – are born with some serious birth defect. Among them, more than half have a heart problem, almost a quarter have musculoskeletal problems such as scoliosis and about one in 10 has defects involving the urinary tract, chromosomes or central nervous system. On top of that, thousands of babies are born prematurely every year, some of whom require special treatment in the first days of their life.

In 2009, 13.5 per cent of babies born at KK Women’s and Children’s Hospital (KKH) were premature. Of these, someneeded no special care. But 8.5 per cent of all babies born at KKH – or more than 1,000 babies – needed either intensive or special care following their delivery. For parents with such babies, the cost of hospital care is not cheap. According to Ministry of Health (MOH) figures, the median bill for neonatal care for babies below the age of one year was $450 for a subsidised patient in 2009. For a private patient, the median was $900. Even among subsidised patients, 5 per cent had bills that totalled more than $5,000. For some, especially those with babies with serious congenital defects, the financial woes do not end there, as the child may need continuing medical care for some years, or even for the rest of his life. There is currently little parents can do to protect themselves against such heavyfinancial liability, unlike in Malaysia, where parents are able to insure against treatment for congenital problems andother medical conditions following birth.

Despite the emphasis the MOH places on medical insurance, with Health Minister Khaw Boon Wan frequently urgingeveryone to have such insurance, Singapore does not have one that covers babies at birth, with one exception. Babies conceived through in-vitro fertilization (IVF) are insured. Parents trying to conceive through IVF methods must buy insurance for their babies. Under the existing coverage, the cheapest premium is a one-time payment of $60, when only one embryo is involved. The baby is protected for the first six months of life, with payouts of $100 or $300 a day, depending on the level of hospital care needed. Payment ceases 180 days from birth. It is compulsory because of the higher risks of complications from such assisted conceptions. At the upper limit, parents who are using four embryos in one attempt have to pay an insurance premium of $2,330. The irony is that babies conceived naturally, who might also encounter medical problems, do not have that protection.

Commercial insurers have been chary of offering such coverage here for two main reasons. First, they argue that it is difficult to assess the potential health risks an unborn child might face. The only insurance that provides some cover – PRUfirst gift from Prudential – covers a child for only up to $2,500 for hospital fees and $5,000 for congenital defects. This is far less coverage than its Malaysian equivalent, which pays up to RM50,000 (S$21,000).

This brings up the insurance companies’ other reason for not offering good coverage for unborn babies – the lack of a“critical mass”, given Singapore’s falling birth rate coupled with its small population. In other words, they do not thinkthere will be enough people insuring to make it a profitable operation. To be sure, private insurers have no socialobligations, but are responsible to their shareholders for their bottom line. As a result, normally conceived babies are the only group in Singapore who cannot get comprehensive health insurance.

This is something that should be rectified. Mr Khaw recently suggested that babies born with congenital problems could be covered under MediShield when it is next reviewed. This would bring babies under the national health insurance plan, and is an improvement on the current situation. But bringing these babies within the mainstream MediShield fold is unfair to others who are healthy, and whose premiums

will have to go up to cover those with known medical problems, who will draw on the insurance from day one. It would be more equitable to have a dedicated national pre-birth insurance plan. This BabyShield plan would cover all babies before birth, before it is known if a child is healthy or is born with a congenital problem. Premiums should be payablewith Medisave.

Babies insured under this plan to cover the risks of birth should be allowed to move to the normal MediShield insurance once they are born – regardless of whether they suffer from any congenital problem or not. In order not to overburden other subscribers, BabyShield should deposit a lump sum into MediShield should the infant have congenital problems that will require years of treatments. Despite being a national health insurance plan, MediShield turns down applicants.

In 2009, 500 applicants for MediShield coverage were rejected. It is not known how many were babies. Sometimes, it extends coverage with exclusions. Exclusions means no coverage for any hospitalisation that is linked to the disease excluded. But that is the very disease the person needs help for. Once BabyShield is introduced, all expectant parents should be persuaded to sign their babies up before birth. Ideally, they should do so within the first trimester of pregnancy, not wait till a possible problem has been diagnosed. With about 40,000 babies born a year here, there issome critical mass to help keep premiums affordable and payouts meaningful.

Today, many parents already start their children on MediShield when they register their births. They would probably require little persuasion to insure their babies a few months earlier. Having a dedicated BabyShield insurance plan will bring the insurance umbrella to cover all, especially babies with difficult births, or those born with congenital medical problems, who are now left out in the cold.

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