Health-care group Parkway lists prices of 30 procedures

Doctor's fee to be separated from rest of bill; details on 4 hospitals' websites

By Poon Chian Hui, The Straits Times, 3 Oct 2013

PRIVATE health-care group Parkway Pantai has released a price list of 30 common procedures at its hospitals based on patients' medical bills in the past year, in a move that could guard against overcharging and help patients make more informed decisions.

Taking a step further than the Health Ministry's posting online of price information for mainly public hospitals, Parkway will also list the doctor's fee separately from the rest of the bill.

For instance, the median bill for cataract surgery at Mount Elizabeth Hospital is $4,610, of which $3,210 goes to the doctor. The remaining $1,400 goes to items such as the hospital stay, operating theatre fees and medical supplies used.

The list of 30 includes surgical procedures such as breast lump removal and tonsillectomy, and diagnostic or screening tests like colonoscopy and angiograms.

Parkway Pantai is Singapore's largest private health-care operator with four hospitals - Mount Elizabeth, Mount Elizabeth Novena, Gleneagles and Parkway East.

Currently, no other private hospital in Singapore publishes a breakdown of fees voluntarily, said Dr Lim Suet Wun, executive vice-president of Parkway Hospitals.

"Patients want peace of mind when they seek medical attention. We are addressing this by being more transparent with the estimated total costs, including doctor's fees," he told The Straits Times.

The move comes three years after surgeon Susan Lim, from Mount Elizabeth Medical Centre, first faced disciplinary action for overcharging a Bruneian patient, who was billed about $25 million for seven months of treatment.

All four hospitals will carry the information on their websites.

Figures will be reviewed and updated from time to time, and also gradually expanded to include more procedures, said Parkway.

It also said the data is not intended to be price recommendations, which would contravene fair competition laws here.

The chairman of the Government Parliamentary Committee (GPC) for Health, Dr Lam Pin Min, welcomed the move as an "encouraging start". The GPC had earlier recommended that better information on professional and hospital fees be made public as a check on medical costs.

Accurate financial information can also help patients make more informed decisions, said Dr Jeremy Lim, principal consultant of Insights Health Associates.

"The figures will be useful reference points for doctors in setting fees, as well as for various regulatory bodies in handling complaints of overcharging," he noted.

Agreeing, urologist Ho Siew Hong from Gleneagles Hospital said patients need not "shop around" at different clinics now to compare prices.

But doctors said the list could exert an unintended influence on what they consider a fair price.

Said cardiologist Kenneth Ng at Mount Elizabeth Novena: "If it is too costly, the doctor may run into problems with the patient."

A doctor's fee comprises many variables, including skill level and experience, techniques used and the quality of medical devices, even for something as common as cataract surgery, noted ophthalmologist Au Eong Kah Guan of Mount Elizabeth Medical Centre.

"In health care, it is difficult to compare bill sizes side by side," he said.

But patients welcomed the move, as the fear of high costs can delay treatment, said restaurant owner Kang Seok Lan, 48, who has gone to both public and private centres for eye problems.

"Some people dare not go to a private doctor because they are afraid it will be too expensive," she said. "Instead, they join the long queue at public centres."

Dr Lam, however, said that ultimately, choosing a doctor is not just about price. "Patients need to be comfortable with their health-care provider, and the doctor-patient relationship is critical in building the trust that no financial element can determine."

Parkway set good example by listing charges

By Tan Chi Chiu, Published The Straits Times, 4 Oct 2013

EARLIER this week, private health-care group Parkway Pantai released a price list of 30 common procedures at its hospitals. Going a step further than the Health Ministry's posting of prices in public and private hospitals online, Parkway said it would also list doctors' fees separately from the rest of the bill.

More hospitals - both public and private - should follow Parkway's example. Such transparency of fees is crucial. Neither doctors nor patients are helped by aggregated data comprising many different hidden components. Since the Competition Commission of Singapore (CCS) has banned medical fee guidelines, published data on actually charged fees seems to be all that is left. This data should be as accurate and detailed as possible.

Such disclosures will help guard against overcharging, and assist patients in making more informed decisions, thus upholding the right of patient autonomy. More importantly, they give patients a significant role in determining acceptable price ranges in the imperfect marketplace of medical services.

Parkway's announcement comes in the wake of the Court of Appeal's verdict in the highly publicised case of Dr Susan Lim v Singapore Medical Council (SMC), delivered on June 28, 2013.

The SMC had suspended Dr Lim, a well-known surgeon, for professional misconduct after it concluded that she overcharged a member of the Brunei royal family.

But the ruling in favour of the SMC has left the medical profession in a quandary as to how to define "ethical limits" in real-life situations.

The court's written judgment, while helpful, still left doctors without clear guidance on how to set fees. However it did lay down several important principles.

The first was that doctors must uphold the honour, honesty and integrity of the profession. This includes the principle that they must not overcharge.

The court also agreed with the SMC Disciplinary Committee (DC) that "there are objective criteria that can be drawn from all the circumstances of the case". These include the complexity of care, the experience of the doctor and the cost of the service rendered.

But while the judgment was helpful, it left much room for interpretation. For example, the court affirmed the DC's opinion that "we do not… accept that the affluence of the patient is an objective criterion… in setting or assessing what is a fair and reasonable fee".

Since means-testing is already routine in public health care, and "A Class" and private sector patients sometimes pay higher prices, the court's view of overcharging presumably refers to fees that are beyond a fair and reasonable range rather than a specific point.

The court also agreed with the Competition Commission of Singapore that giving patients more information would help them make good health-care decisions and deter overcharging by doctors.

But what is "overcharging"? The court stated that: "It is a matter for peer review by members of the medical profession… to opine on the possible range of fees which would be considered fair and reasonable."

Despite attempting to abide by "objective criteria", this still leaves the possibility that doctors may inadvertently overreach and get into trouble. But the court also noted that "not every case of overcharging will constitute grossly improper conduct… The extent to which a client is overcharged is a very strong factor".

The court also emphasised that given the severe consequences of being convicted of professional misconduct through overcharging, "the ethical rule that a doctor must charge a fair and reasonable fee… is also one that will not be enforced unreasonably". It also affirmed the DC's view that peers would be "slow to find a breach or to find professional misconduct in marginal cases".

From this it is possible to conclude that there are two main factors to consider before a doctor can be regarded as having engaged in professional misconduct by overcharging.

The first is that his or her peers must decide that a fee is excessive.

The second is when a fee already regarded as excessive crosses a further threshold into the absurd or unconscionable.

When would such a threshold be crossed? The court's judgment provides a breathtaking list of criteria. These include deliberate departures from peer practice and prices that are grossly disproportionate to the services rendered. Other criteria include charges that are opportunistic or take advantage of patients' ignorance or vulnerabilities, as well as charges that are opaque or arise from the false representation of third party fees. This is not territory that a doctor is likely to accidentally stumble into.

When it comes to fees, professional misconduct is not a specific point along a continuous range of possible fees. Indeed, such a point should never be specified. If it were, nothing would prevent doctors from clustering their charges right up to that limit, which could be quite high. The result would be a de facto cartel, which would be against the public interest. The "ethical limit" is perhaps better seen as a "tolerance limit" on a wide spectrum. Although somewhat subjective, a panel of professional peers would have little difficulty in deciding when an outside limit has been breached in extreme cases.

It is helpful to quote the late United States Supreme Court Justice Potter Stewart who famously said, in delivering judgment on Jacobellis v Ohio (1964): "I shall not today attempt further to define… 'hardcore pornography'; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it." This is arguably applicable to deciding whether doctors' fees appear so "obscene" that they represent professional misconduct.

The "Susan Lim case" was exceptional. Doctors have always been aware of the perils of overcharging. And they have (mostly) done the right thing, way before this landmark case picked the issue apart and brought it to sharper focus.

That said, Parkway's recent initiative is worth emulating. More transparency is a better safeguard for patients when it comes to protection from overcharging than relying on the recent court judgment.

Dr Tan Chi Chiu is a gastroenterologist and an elected Member and Chairman of Medical Ethics of the Singapore Medical Council. This article draws on material first published in the September issue of the Singapore Medical Association's SMA News.

Parkway medical price list welcome

Not illegal as historical fee data used; SMA, competition watchdog support move

By Poon Chian Hui, The Straits Times, 26 Oct 2013

PUTTING up medical fee guidelines may be illegal, but not if the information is compiled from actual bills of patients.

The Competition Commission of Singapore (CCS) made this clear in the light of a price list published by private health-care group Parkway Pantai earlier this month.

The list, which includes fees for 30 common procedures offered at its four hospitals here, is based on patients' bills for the past year.

Going a step further than the Health Ministry's online posting of prices in public and private hospitals, which is based on historical data, Parkway listed doctors' fees separately from the rest of the bill.

The list, for instance, shows that the median cost of an operation to remove tonsils at Gleneagles Hospital is $8,156. Of this, $4,681 goes to the doctor. The remaining covers items such as the hospital stay and operating theatre charges.

While the move drew praise, questions were also raised on whether the list contravened anti-competition laws here.

In 2007, the Singapore Medical Association (SMA) scrapped its medical fee guidelines due to concerns that they might infringe the Competition Act, which came into effect the previous year.

The guidelines, first issued in 1987, had recommended prices for some 1,500 medical services.

Following a three-year tussle to restore the guidelines, the CCS ruled in 2010 that they could not be allowed.

But the competition watchdog told The Straits Times that it welcomes Parkway's version.

It promotes price transparency in the market, allowing consumers to make more informed choices, said a spokesman.

"In Parkway's case, its price data is historical and aggregated from several sources, and do not seek to affect the individual pricing decisions of the specialists,"she explained.

In contrast, fee guidelines or recommendations "provide a focal point for future price convergence".

Such deliberate attempts to seek consensus on prices may be treated as price-fixing - a practice that is illegal under the Competition Act.

Added the CCS spokesman: "Pricing transparency, which does not infringe the Competition Act, can be achieved through the publishing of historical and current price information."

The Straits Times understands that the SMA's guidelines were based on specialists giving their opinion on what prices should be, based on their experience of fees that had been charged before.

Dr Wong Tien Hua, SMA's first vice-president, said the association, having been "a strong advocate of fee and price transparency in the medical profession to serve and safeguard the interest of patients", supports Parkway's move.

Many of Parkway's own specialists have also welcomed the new list, including the disclosure of doctors' fees, said Dr Kelvin Loh, chief executive of Mount Elizabeth Novena Hospital, one of the group's four hospitals.

He said: "Our specialists want patients to have peace of mind when they come to us for care."