新加坡衛生部長王乙康國會答複議員：這些措施将極大降低醫療成本

2024年3月6日，新加坡衛生部長王乙康在國會答複議員關于醫療成本上升的原因以及控制成本的措施等問題。

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以下内容為新加坡眼根據國會英文資料翻譯整理：

主席，現在讓我來解釋下一個關注點，即不斷上漲的醫療成本問題。林偉傑醫生、佳馥梅女士和黃玲玲女士問道，是什麼導緻醫療成本的上升？在這一部分，我将談論醫療成本上升的可能原因，解釋醫療資金的現實情況，以及我們正在采取哪些措施來努力降低成本。

導緻醫療成本上升的一個主要因素是我們的人口日益老齡化。随着年齡的增長，我們更有可能患上重病。在過去五年中，新加坡老年人口增加了近20%，從56萬增長到現在的69萬。我們即将成為一個超級老齡化社會。這些不僅僅是宏觀數字，它直接影響到個人和家庭。是以，當家庭中的一位成員年事已高并患上重病時，整個家庭都感受到了醫療費用的負擔和護理負擔。

第二個原因是醫療技術的進步。技術進步可以讓汽車或智能手機更便宜更好。但在醫療保健領域，情況并非如此。新療法可能效果更好，但花費也更高。例如，骨科手術的進步使膝關節置換術變得更加容易。在我的選區，我遇到了許多老年人做過膝關節置換術。有時，他們甚至兩個膝蓋都進行了手術，當我遇到他們時——我曾經也做過一次這個手術——我們還會比較我們的手術疤痕。

過去，由于年老導緻眼部血管退化，人們也會喪失中心視力。現在，這種情況可以通過反複的玻璃體內注射來治療和控制。這些進步使無法行走的人重新行走；讓失明的人重見光明。

這對患者的價值是無價的，而對患者的成本也是增加的。

第三，醫療費用上漲。即使是對于相同的治療，不談醫學進步；同樣的治療，費用也在上漲。近年來全球通貨膨脹都在上升，這也影響了醫療成本。醫療服務成本的一個關鍵組成部分是人力成本。

在新加坡，人力成本占醫療系統營運成本的一半以上。我們都同意，我們需要以公平和具有競争的方式地對醫護人員進行薪酬補償。随着許多國家的醫療需求增加，醫療人力的競争現在已經國際化，并變得更加激烈。這推高了人力成本，是以也推高了醫療成本。

最後，保險。保險讓我們高枕無憂。但是當保險覆寫範圍變得過于慷慨，甚至到最後一新元時，我們開始看到過度的處方和檢查，甚至是不必要的治療。這就是典型的“自助餐綜合症”，它推高了索賠金額。已經付費了，就可以放心大膽地過度消費。

這導緻索賠金額的增加，是以導緻了保險費的增加。然而，令人沮喪的是看到保險公司繼續提供不可持續的條款——可能是為了争奪市場佔有率。那麼，我們該如何解決醫療成本上漲的問題呢？我們首先需要認識到醫療費用中的兩個不争的事實。

第一個事實是，最終總是要由個人來買單。我用一個親身經曆的例子來解釋吧。1999年，當我和妻子搬到瑞士一年，我去那裡讀碩士學位，當時我們必須繳納社會保險。我記不得名字，但并不便宜。我們倆一起支付了幾千瑞士法郎。這是強制性的。如果我們不交，我們就不能在瑞士生活。然後，我妻子懷孕了。她找了一位很好的婦科醫生。每次去看她，我們都可以随時進出，不需要支付任何費用。這真的是免費的嗎？不是，其實我們已經為此支付了相當昂貴的保險費。

在英國，國民醫療服務體系的運作原則是提供免費醫療服務。英國政府從未觸動這一原則。

但它真的是免費的嗎？并不是。英國人必須支付高額稅款為國民醫療服務體系提供資金。因為在提供醫療服務是免費，國民醫療服務體系的等待時間就非常長。我指的是800萬人在等待。是以，英國患者也是用他們的時間和耐心付出代價。

支付醫療費用有不同的方式：通過稅收、強制性社會保障繳費、保險費用或個人儲蓄，甚至是個人的時間。最終，人們總是以某種方式付出代價。這就是第一個事實。

這引出了第二個事實，即我們支付的方式影響我們支付的金額。

如果政府種用稅收使醫療保健在提供時“免費”，那麼很可能會導緻我剛才提到的“自助餐綜合症”。會出現過度消費、浪費和高成本通貨膨脹。如果政府讓人們自行購買醫療保險，人們會非常謹慎，這可以減少醫療開支。但是，如果有人沒有購買保險且未投保，他們将得不到足夠的服務。

這就是為什麼在新加坡，我們建構了一個更為健全的支付醫療費用的方式。它包括由稅收資助的補貼；保健儲蓄（MediSave）；終身健保（MediShield Life）；以及保健基金計劃（MediFund）——我們所稱的“S+3Ms”。“S+3Ms”確定了普遍性，因為它讓所有新加坡人都能獲得優質醫療服務。這也是一個有針對性的系統，将重點援助放在最需要的人身上。

舉例來說明，公立醫院的C級病房可以享受高達80%的補貼，但A級病房和私立醫院則不享受。MediShield Life在補貼之後覆寫了剩餘賬單的相當部分，但我們確定患者通過MediSave進行一定程度的共付，以減少“自助餐綜合症”的發生。對于無法負擔共付款的最低收入者，MediFund可以提供援助。

這就是為什麼與一攬子援助計劃的司法管轄區相比，我們可以在國民醫療支出占GDP 5%的情況下實作良好健康結果的關鍵原因。牢記這兩個不言而喻的事實，我們可以做些什麼，又正在做些什麼來應對不斷上升的醫療費用呢？

首先，讓我從“S+3Ms”中的“S”開始。補貼将起到重要的作用。

我在2015年首次加入政府并進入國會時，我擔任了教育部的代理部長。教育部的預算是各部門中排名第二，約為120億新元，僅次于國防部。而衛生部的預算則排名第三，僅略超過90億新元。如今，9年過去了，我成為了衛生部長。衛生部的預算已遠遠超過了教育部，幾乎達到了190億新元，與國防部的預算相差無幾。

衛生部的預算是由稅收提供的。這些資金被用于資助醫療系統的許多方面：建設新的醫療基礎設施，營運醫院、綜合診所和養老院，采購藥品和裝置，開發新的資訊技術系統，聘請醫生、護士和所有醫療人員。衛生部的預算是由稅收資助的，并構成了醫療補貼，這些補貼在多年來一直在大幅增加。

接着，第二個“M”——MediShield Life——也需要加強。為此，我們将對MediShield Life進行全面審查。正如我所提到的，MediShield Life是一項全國性的健康保險計劃。它為所有人提供終身保障，甚至包括那些已有疾病的人。它是專門為絕大多數遭遇重大健康事件的受資助患者而設計的。

最後解讀一下。它包含了幾個重要的短語，我将會解釋。我說它覆寫了絕大多數受資助的患者，因為大多數的新加坡人尋求的是接受補貼的醫療護理，而“其中絕大多數人”需要财政援助來支付他們的醫療費用。

是以，對于C級病房的患者來說，在補貼後，他會發現MediShield Life的理賠應該會大幅支付其餘的醫院賬單。對于前往私立醫院的患者來說，他會發現MediShield Life隻覆寫了其醫院賬單的一小部分。這就是MediShield Life如何把重點入在受資助的患者，特别是那些使用C級病房的患者。

是以，“重大健康事件”之是以被提及，是因為這符合保險的精神，即保障我們在罕見情意下不會因患重病而産生巨額醫療費用。

有鑒于此，請允許我報告一下目前的MediShield Life目前的狀況。根據設計，10份補貼賬單中有9份都能得到充分保障。剩下的是相對較少且可以預期的共付額，可以從MediSave中支付。然而，這十分之九的基準正在被削弱，因為醫院賬單的金額正在變得越來越大。在過去幾年裡，公立醫院的賬單金額每年增長5%，私立醫院的賬單金額每年增長7%。

是以，由于賬單金額增長，MediShield Life充分覆寫的補貼賬單比例已降至十分之八左右，預計還會進一步下滑。

這有什麼實際的影響呢？接受補貼的患者發現醫院賬單出乎意料地高。即使經過補貼和MediShield Life，仍有很大一部分費用需要自付。這時，羅高的醫療費用才真正開始産生影響。

是以，衛生部已經責成MediShield Life理事會（由私營部門的上司人帶領的各方利益相關者組成）對該計劃進行全面審查，但我們已經給予理事會一些指導。

首先，加強MediShield Life，為新加坡人提供更大的保障，以應對高額賬單。這意味着提高患者可向MediShield Life計劃索賠的金額，也就是我們所說的理賠限額，無論是手術費用還是住院費用。

我們預計索賠限額會有相當大的提高。例如，如果需要介入手術，在心髒内植入支架以打通阻塞的動脈，再加上在重症監護室裡住幾個晚上，那麼理賠限額可能需要翻倍，乘以二。這将大大降低自付費用。

第二，加強其他門診病人的保險。我們還需要提高治療項目的理賠限額，例如腎透析，以減少患者的自付費用。理事會還将探讨将覆寫範圍擴大到更多類型的門診治療。

一些昂貴的門診治療是針對癌症的。林瑞蓮女士問道，我們是否可以提高患者的财務素養，以便他們更好地制定應對這類疾病的計劃。網上有可用的資源，我們将提高公衆對這些資源的認識。但我認為這個問題不僅僅是财務素養的問題。它實際上比這更嚴重。對于癌症來說，我們正面臨着特别嚴峻的挑戰，因為治療成本不受控制地上升。是以，我對你提到的調查結果一點也不感到意外。

我們最近對癌症藥物的融資進行了審查，并進行了一些變革，使我們能夠通過談判降低抗癌藥物的價格。是以，獲批的抗癌藥物的價格已經大幅下降，有些降幅高達60%。其影響仍在顯現，我們将繼續監控有關情況。

第三，理事會将考慮将MediShield Life計劃的承保範圍，使其涵蓋突破性的新療法，特别是細胞、組織和基因治療類産品（CTGTPs）。

醫學科學發展日新月異，CTGTPs 有可能徹底改變醫療保健，有效治療以前無法治愈的疾病。有人将其形容為醫療保健領域的 “登月計劃”。

從根本上說，這種治療方法是，我們從病人身上抽取血液，然後用這些血液教導并裝備血液中的細胞，使其能夠瞄準并殺死癌細胞，然後再把這些細胞重新注入病人體内，讓它們發揮作用。這是一種一次性治療方法。

然而，盡管這項技術前景廣闊、進展迅速，但它仍處于起步階段，而且非常昂貴。每次治療的費用從幾十萬美元到幾百萬美元不等。

我們希望開始将CTGTPs納入MediShield Life。但是，我們需要建立保障措施，以確定CTGTPs的融資是可持續的。例如，我們隻需要将MediShield Life的承保範圍擴充到經過評估為安全、臨床有效且具有成本效益的治療。換句話說，如果一種治療方法耗資數百萬新元，但隻有很小的希望能治愈一小部分人，那就不具有成本效益。這是幫助所有新加坡患者（無論其收水準如何）獲得具有成本效益、新穎、先進的治療方案的第一步。

這些提議的變化将更好地保護接受補貼的患者，使其免受重大醫療事故的影響。然而，MediShield Life的保費将不可避免地上漲。

上次我們審查該計劃時，平均保費上漲了25%。但請放心，我們将盡一切努力，盡可能確定MediSave計劃能全額支付保費。

例如，我們将考慮增加保費補貼，或為特定群體提供MediSave的補充款項。我們可能需要将更多的MediSave用于支付小額住院費用，這樣MediShield Life就能更好地使用于大額住院費用，進而緩和保費的增長。沒有人會因為無法負擔保費而失去MediShield Life保險。當理事會于今年下半年完成審查時，我們将分享更多詳細資訊。

以下是英文質詢内容：

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.

CF丨編輯

CF丨編審

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