Question

Please describe and compare the financing and organization of the healthcare delivery system in Singapore with that of the healthcare delivery system in the United States. Key points in this discussion includes: A thorough discussion of governments role, financing/funding, who/what is covered, how it is organized, how it is accessed, quality, disparities, cost, integrated, etc. (400-500 words respond)

compare the healthcare system of Singapore and America.

Answer 1

Greetings of the day!

Answer:

INTRODUCTION

Introduction

Singapore is an Asian country that has a population of approximately five million people. The country has one of the most efficient healthcare systems in the world. Since its independence in 1965, the country has taken several steps that have led to significant improvements in its healthcare system. In 1983, the government developed the National Healthcare Plan.

The aim of the plan was to provide a roadmap for the development of the healthcare system for the next 20 years (Meng-Kin 17). During this period, the government introduced several programs that targeted various groups of people. In 2002, the government introduced the ElderShield plan. The aim of this program was to improve the healthcare of the elderly and disabled. On the other hand, the US healthcare industry is more than two centuries old.

The US government spends vast sums of money on healthcare provision. Medicaid and Medicare account for the lion’s share of government expenditure on healthcare provision. This necessitates the US government to formulate strategies that would help in reducing the cost of healthcare provision.

Increase in the proportion of the elderly to the total population necessitates the US government to take urgent steps to prevent further escalation of the healthcare budget. The US government should formulate a strategy that would help in replicating the strengths of the healthcare system of Singapore in the US healthcare system.

Healthcare Regulation

Singapore’s healthcare system has three pillars. The healthcare system strives to improve the general health of the population through various preventive healthcare programs. In addition, the healthcare system puts great emphasis on the personal responsibility of individuals towards their healthcare. The government strives to reduce the cost of healthcare services by subsidising healthcare in public health institutions.

The Ministry of Health (MOH), Monetary Authority of Singapore (MAS) and the Central Provident Fund (CPF) are the main health regulators. CPF is a social security savings plan that enables Singapore nationals to support themselves in their old age (Ho 95).

On the other hand, the US has one of the most complex healthcare regulations in the world. Numerous agencies help in regulation of healthcare. Healthcare agencies may regulate healthcare at the state or federal level. In addition, the regulators may be private or public.

The United States Department of Health and Human Services and the National Institutes of Health (NIH) are the major bodies that cater for the healthcare needs of all American citizens. The American Medical Association (AMA) is one of the vital private organisations that help in the oversight of healthcare industry (Field 608). In the US, different states may have different agencies that help in regulation of healthcare.

Healthcare Delivery

Singapore’s healthcare system helps in the delivery of various types of healthcare to the population. Approximately 2000 private hospitals provide 80% of the primary healthcare needs of the population. This shows that the government’s efforts to provide primary healthcare services to the population have been unsuccessful. However, the government provides the bulk of hospital care services.

Government healthcare facilities provide approximately 80% of hospital care services. In 2010, there were 8,881 hospital beds in government healthcare facilities (Ministry of Health Singapore para 1). Public health facilities had slightly less than thirteen thousand nurses and approximately 1800 nurses. On the other hand, private healthcare facilities had 2,268 hospital beds.

The number of doctors and nurses in the private healthcare facilities was approximately 3,300 and 5,100 respectively (Ministry of Health Singapore para 2). These statistics show that the government is the dominant player in the provision of hospital care. However, a close analysis of the number of doctors and nurses shows that there are less hospital beds for every healthcare practitioner.

The number of hospital beds per healthcare practitioner has a significant effect on the quality of healthcare. This may imply that the quality of healthcare services in private healthcare facilities is higher than in government healthcare facilities.

Community hospitals play a key role in healthcare delivery in the US. Community hospitals may be state-owned or investor-owned. Community hospitals are the major healthcare facilities that provide primary and intermediate healthcare services. Most community hospitals tailor their services to meet the healthcare needs of the community (Purves 88).

This improves the efficiency of healthcare services of community hospitals. There are 4,973 community hospitals. The total capacity of these community hospitals is 797,403 beds. On the other hand, there are slightly more than 200 federal government hospitals.

Funding

Medisave, MediShield, Medifund, and ElderShield are the main medical schemes that help in financing public health in Singapore. Medisave is a social scheme that helps people to save for future healthcare expenses. Medisave caters for hospitalisation expenses and certain outpatient treatments of individuals and their immediate family members.

In addition, Medisave may help in paying the premiums of MediShield and Private Medical Insurance Scheme (PMIS). On the other hand, MediShield is primarily a medical insurance scheme that caters for severe health conditions. It caters for partial expenses of prolonged hospitalisation and outpatient treatment of various serious illnesses.

ElderShield is a health insurance scheme that caters for people who need long-term care. ElderShield mainly covers the elderly. Medifund is a government endowment fund that acts as a last resort source of funds if Medisave and MediShield are unable to cater for medical expenses.

The government replenishes the funds when there is a budget surplus. However, the government is not the only major player in the healthcare insurance industry. Several private health insurance companies provide health insurance to individuals and groups (Meng-Kin 19).

In the US, it is the duty of employers to ensure that their employees have medical cover. Medicare and Medicaid are the major medical schemes that help in financing public health. Medicare is a healthcare plan that covers the elderly and disabled. On the other hand, Medicaid covers people who have low incomes. Federal funds help in supporting Medicare while state and federal funds support Medicaid.

Patient Protection and Affordable Care Act (PPACA) is a healthcare regulation that ensures that all Americans have access to healthcare insurance. Access to healthcare insurance enables people to save huge sums of money that they would have used to cater for medical expenses (Pipes 107). People who would like to receive extended healthcare services may enrol in various private healthcare plans.

Healthcare Expenditure

Healthcare expenditure as a percentage of GDP is one of methods that help in determining the government’s commitment to improving the health status of the nation. In 2009, Singapore’s ratio of healthcare expenditure as a percentage of GDP was 3.9% (Ho 95). There is a gradual increase in the ratio of direct government expenditure on health through Medifund.

On the other, there is a gradual decrease in the social security expenditure on healthcare. In the private sector, out-of-pocket expenditure accounts for a sizeable percentage of healthcare payments (Ho 95). This necessitates the government and the private sector to formulate strategies that would improve access to healthcare insurance.

In 2008, the US had the highest healthcare expenditure as a percentage of GDP. The expenditure of the US on healthcare was 16% of its GDP. Medicare and Medicaid accounted for a sizeable percentage of the government spending on healthcare. In addition, out-of-pocket healthcare expenditure of the US was very high

financing and organization of the healthcare delivery system:

IN SINGAPORE

IN USA

Singapore has achieved universal health coverage through a mixed financing system. The country’s public statutory insurance system, MediShield Life, covers large bills arising from hospital care and certain outpatient treatments. Patients pay premiums, deductibles, co-insurance, and any costs above the claim limit. MediShield Life generally does not cover primary care or outpatient specialist care and prescription drugs. MediShield Life is complemented by government subsidies, as well as a compulsory medical savings account called MediSave, which can help residents pay for inpatient care and selected outpatient services. In addition, individuals can purchase supplemental private health insurance or get it through an employer. The national government is fully responsible for the health system. How does universal health coverage work? Singapore’s health care financing system is underpinned by the belief that all stakeholders share responsibility for attaining sustainable universal health coverage. Singapore has a multipayer health care financing framework, where a single treatment episode might be covered by multiple schemes and payers, often overlapping. The system, known as the 3Ms, comprises the following programs: MediShield Life, a universal basic health care insurance, is mandatory for citizens and permanent residents and provides lifelong protection against large hospital bills and select costly outpatient treatments. It was launched in 2015 to replace MediShield, an opt-out catastrophic illness insurance scheme. MediSave, a national medical savings scheme, helps cover out-of-pocket payments. Personal and employer salary contributions (8%–10.5%, depending on age) to MediSave accounts are mandatory for all working citizens and permanent residents. These tax-exempt, interest-bearing (currently 4% to 5%) accounts can be used to pay for family members’ health care expenses.1 MediFund is the government’s safety net for needy Singaporeans who cannot cover their out-of-pocket expenses, even with MediSave. Role of government: The Ministry of Health’s mission is to promote good health and reduce illness, ensure access to good and affordable health care, and pursue medical excellence. The Ministry of Health is responsible for regulating the public health system and the health care system overall.2 The government relies on competition and market forces to improve service and raise efficiency but intervenes directly when the market fails to keep health care costs down.3 For example, the Ministry of Health performs workforce planning to determine the number of health care professionals required, coordinates the training capacity, and dictates land availability for hospital and other health care facility development.4 The ministry also ensures that longer-term population needs are met through sustainable investment, especially in preventive and community-based care.5 The Ministry of Health has centralized certain functions to prevent fragmentation and to encourage economies of scale. National organizations with important functions include the following: MOH Holdings, the holding company for public health care institutions. It also handles infrastructure development and coordination of manpower and talent development for the national health system. Subsidiaries of MOH Holdings include: Integrated Health Information Services, which integrates, delivers, and manages information technology systems across all public health care institutions. The Agency for Integrated Care, which coordinates and facilitates placement of individuals with community providers, enables community providers through service development and capability-building, and administers some subsidy schemes.6 In 2018, the agency was also charged with coordinating the delivery of aged-care services across both the health and the social domain. The Agency for Care Effectiveness, Singapore’s national health technology assessment agency, which provides guidance on cost-effective drugs and treatments. The Health Sciences Authority, which regulates the manufacture, import, supply, storage, presentation, and advertisement of health products to meet appropriate safety, quality, and efficacy standards. The Health Promotion Board, responsible for promoting healthy living in Singapore. The board formulates health policies, implements health promotion and disease prevention programs (like those for school health and workplace health), and works with industry partners for healthier food products. The Central Provident Fund Board, which administers the MediSave and MediShield Life schemes on behalf of the Ministry of Health. Role of public health insurance: Singapore’s national health expenditures stood at 4.47 percent of GDP in 2016.7 Between 2009 and 2016, the government’s share of health expenditures increased from about 32 percent to 41 percent due to increased public subsidies, which are intended to help reduce out-of-pocket costs.8 Correspondingly, the out-of-pocket share of health expenditures fell from 43 percent to 31 percent. Singapore’s average annual health care inflation was 2.6 percent, compared to 2.3 percent for all goods and services, between 2007 and 2017.9 MediShield Life premiums are subsidized by the government on the basis of income. In addition, working-age persons pay higher premiums so that older residents can have lower premium increases. These features have helped to keep annual premiums affordable, ranging from SGD 98 (USD 72)10 for low-income Singaporeans under age 20 to SGD 1,530 (USD 1,117) for high-income residents over age 90.11 To ease the transition from the old MediShield scheme’s lower premiums (with its age cut-off and exclusion of those with preexisting illnesses) to the higher premiums of MediShield Life, which provides lifelong coverage, beneficiaries with serious preexisting conditions pay 30 percent higher premiums for the first 10 years, after which they pay the same standard premium as their low-risk counterparts.12 During the first five years of MediShield Life, the government cushioned the impact of bringing beneficiaries with preexisting conditions into the scheme by absorbing about 75 percent of the costs, which was approximately SGD 850 million (USD 621 million).13 The government provides various other subsidies to help make care more affordable: At public hospitals, patients can obtain a subsidy by choosing a ward with fewer amenities. For example, patients admitted to C-class wards, which are rooms with eight beds, receive a subsidy of up to 80 percent of their hospital bill for that admission. In contrast, A-class single occupancy rooms are not subsidized. Clinical care is not affected by ward class. Primary care visits at public clinics, known as polyclinics, are subsidized up to 75 percent, with different charges based on residency status. Specialist outpatient care visits can be subsidized up to 75 percent, depending on the patient’s income level and residency status. Emergency services at public hospitals are subsidized equally for all. Subsidies are also provided to patients requiring intermediate and long-term care after hospital discharge, as well as to community-dwelling elderly individuals needing assistance with daily living. Subsidies are means-tested on the basis of household income or the value of a patient’s residence (for those without income). Patients can receive up to a 75 percent subsidy for residential services and up to an 80 percent subsidy for nonresidential services if they are receiving care from providers approved by the Ministry of Health.14 Additional government cash grants and subsidies for consumables and transportation services are available for patients who need assistance with daily living. In addition, the Community Health Assist Scheme, for lower- to middle-income citizens, provides subsidies that can be used at private general practitioner (GP) and dental clinics. About 1.2 million Singaporeans are in the scheme, and they receive subsidized care at more than 1,000 GPs and 700 dental clinics.15 In 2018, the government disbursed about SGD 152 million (USD 111 million) in subsidies under the Community Health Assist Scheme to about 630,000 Singaporeans.16 Government health care subsidies are funded from general taxation and are based on the principles of fiscal balance and affordability. The government has also introduced measures to supplement Singaporeans’ MediSave accounts. For example, lower-income workers receive top-ups to help them save for their retirement health care needs.17 The government also provides annual top-ups to the MediSave accounts of eligible elderly people and gives newborns a MediSave grant of SGD 4,000 (USD 2,940) to defray part of their parents’ infant care expenses. Role of private health insurance: Patients who wish to obtain additional coverage for private hospitals or care in private wards in public hospitals can purchase private insurance. The most common coverage is through Integrated Shield Plans, which ride on MediShield Life and are available only to citizens and permanents residents with MediShield Life. As of 2017, 68 percent of citizens and permanent residents had one of these plans.18 In contrast to the standard benefits of MediShield Life, different Integrated Shield Plans offer different benefits. Premiums for these plans can be paid for using MediSave, subject to various limits and regulations.19 Integrated Shield Plan holders can also purchase insurance riders that provide additional complementary coverage; these riders usually provide first-dollar coverage with either a yearly deductible or zero copayment. Premiums for riders cannot be paid with MediSave. In recent years, there have been sharper increases in Integrated Shield premiums, especially for riders with no copayment, a trend largely reflective of increases in private hospital insurance claims.20 To address concerns about the overuse of services and about overcharging, the Ministry of Health has required that new Integrated Shield Plan riders have a minimum 5 percent copayment with an annual cap on copayments.21 There are also private insurance options, offered by for-profit insurers, that are not integrated with MediShield Life. Premiums for these other insurance options cannot be paid from MediSave. Many employers also extend medical benefits to their employees. Because of the many insurance options available, there may be varying degrees of coverage duplication by MediShield Life, employer benefits, and personal health insurance. Services covered: Services covered under MediShield Life are22: inpatient treatments and care, including surgery, radiosurgery, and bone marrow transplants day surgeries psychiatric hospital stays selected outpatient treatments, including kidney dialysis and chemotherapy and radiotherapy for cancer some costly long-term medications, such as immunosuppressants after an organ transplant. MediShield Life does not cover cosmetic surgery or maternity charges (including cesarean sections), with the exception of treatments for serious complications related to pregnancy and childbirth. The maximum amount that can be claimed from MediShield Life depends on the claim limit, which varies by type of treatment and length of hospital stay. The maximum claim limit per policy year is set at SGD 100,000 (USD 73,000); there is no lifetime limit. Singaporeans are expected to pay for the rest of their health care costs (after government subsidies and MediShield Life payments) from their MediSave accounts or out-of-pocket. MediSave can be used to pay for many services, including chronic care, maternity care, fertility treatments, hospice and palliative care, and day rehabilitation services. Limits on withdrawals from MediSave accounts ensure that Singaporeans have enough in those accounts for basic health care needs in old age. Withdrawal limits are adequate to ensure that most charges incurred for outpatient treatments and treatments at subsidized inpatient wards are covered. Withdrawal limits have been raised to keep pace with rising costs. Cost-sharing and out-of-pocket spending: Under MediShield Life, residents have an annual deductible of SGD 1,500 to SGD 3,000 (USD 1,095–2,190) and coinsurance of 3 percent to 10 percent (with the coinsurance percentage decreasing as the claimable amount increases).23 For current outpatient treatments, there is 10 percent coinsurance. Copayments (see table below) have been an integral feature of Singapore’s health care system as a way to retain individual responsibility for one’s health, as well as provider and system discipline pertaining to health care costs. Patients pay directly for part of the cost of services, and pay more when they demand a higher level of services.24 Safety nets: The combination of government subsidies, MediShield Life, and MediSave has enabled seven in 10 subsidized bills to be fully paid without any cash outlay by the patient. Of the remaining 30 percent of bills, one-third require a patient payment of SGD 100 (USD 73) or less in cash, and another third cost patients SGD 100 to SGD 500 (USD 73–365).25 MediFund is an endowment fund set up by the government in 1993 that serves as a safety net for Singaporeans who need further help with the remaining cash component of their health care bills at public health care institutions, after insurance and MediSave. MediFund coverage has been enhanced over the years to cover more outpatient and community-based care as well as to provide more targeted assistance to disadvantaged children and elderly people. During years of budget surpluses, the government tops up the principal sum, redistributing the benefits of economic growth to Singaporeans in need. This measure has enabled an increase in enrollment in MediFund, which provided about SGD 150 million (USD 110 million) in assistance in 2017, up from SGD 4.7 million (USD 3.4 million) in 1993.26 How is the delivery system organized and how are providers paid? Physician education and workforce:Singapore has three medical schools, all of which are part of public universities. Clinical teaching is carried out almost exclusively in public health care institutions. The government regulates the number of doctors by varying the number of admissions to medical schools according to projected needs. The pipeline of doctors is supplemented by foreign-trained doctors. The government regulates the entry of these doctors by adjusting a list of approved overseas medical schools.28 Between 2012 and 2018, the total annual admissions of medical students to the three local universities increased by about 40 percent. Tuition fees are heavily subsidized: net annual fees for Singapore nationals are about SGD 29,000 to 33,000 (USD 21,000 to 24,000) for five-year undergraduate medical programs, or SGD 47,000 (USD 34,000) for four-year graduate programs.29 Upon graduation, all medical students are required to work in the public health care system for four to five years.30 As of 2018, Singapore had 13,766 registered medical practitioners, with nearly two-thirds in the public sector. This translates to about 2.4 doctors per 1,000 people, a significant increase from 1.9 in 2012. Around 41 percent of doctors are specialists.31 Primary care: Primary care is provided through public polyclinics and private GPs. There are currently 20 polyclinics and more than 2,200 GP clinics.32 Polyclinics usually have more than 10 doctors and some also provide dental, psychiatric, and allied health services. Polyclinics provide 20 percent of primary care, with a strong focus on chronic-disease management.33 The majority of GP clinics operate as solo practices (including those run by clinic chains), and primarily operate on a fee-for-service payment model; the clinics have flexibility to set their own fees. Patients can choose a primary care doctor at a polyclinic or at a GP clinic, and they can usually walk in and be seen the same day without needing a prior appointment. Patients are free to change providers or to be seen by two or more providers over a given period. The Ministry of Health has launched several initiatives over the years to tap into the capability and capacity of GPs, including the Chronic Disease Management Program, which covers 20 chronic diseases. Another initiative, the Primary Care Networks (PCN) scheme, aims to anchor effective chronic-disease management in primary care through the organization of like-minded GPs in a network. As of 2019, there are 10 primary care networks and more than 350 participating GP clinics. The ministry provides resources to these PCNs for managing patients with complex needs, including nurse counsellors and care coordinators, chronic-disease registries, and administrative support. In return, GPs in PCNs are expected to adhere to stipulated clinical quality requirements.34 In terms of manpower, 59 percent of registered doctors are nonspecialists, including primary care doctors and those still undergoing specialist training in public institutions. The gross median monthly income for GPs is SGD 13,707 (USD 10,006), while the gross median monthly income for specialists is SGD 20,078–23,705 (USD 14,657–17,305).35 Outpatient specialist care: Specialist outpatient services are provided by both the public and the private sector on a fee-for-service basis. Public-sector specialists are salaried and see both private and subsidized patients in the specialist outpatient clinics of public hospitals and national specialty care centers.36 Fees for private and subsidized patients at these clinics are determined by and paid to the hospital. Polyclinic referrals are considered subsidized patients at specialist outpatient clinics, while referrals from GPs are treated as private patients unless they are referred by clinics accredited by the Community Health Assist Scheme. Patients who refer themselves to specialist outpatient clinics are considered private patients. Private patients can choose their specialist, while subsidized patients have a specialist assigned to them. Private specialist clinics receive referrals from GPs as well as self-referrals, and have flexibility to set their fees. Administrative mechanisms for direct patient payments to providers: Singaporeans prepay for care through MediSave (via payroll deductions) and MediShield Life (mandatory premiums). After-hours care: Polyclinics are not open at night or on Sundays and public holidays. However, a significant number of GP clinics are open at night and on weekends and public holidays. Thirty GP clinics are open 24 hours, as are emergency departments in public hospitals and some emergency clinics in private hospitals. There are also telehealth providers that are available any time of day. Hospitals: As of 2017, Singapore had 18 acute care hospitals: nine public hospitals, eight for-profit hospitals, and one not-for-profit Catholic hospital. In total, Singapore has 2.4 beds per 1,000 population.37 The majority of public-hospital patients are admitted through emergency departments, making up more than 70 percent of admissions. Admissions to private hospitals tend to be elective. Legally speaking, public hospitals are corporatized companies wholly owned by the government.38 As owner, the government can shape hospitals’ behavior without having to resort to onerous regulations or purchase negotiations.39 This has enabled the Ministry of Health to reorganize the public health care system to ensure better-coordinated and seamless care (for example, by creating integrated clusters of public hospitals and polyclinics). The government funds public hospitals on the basis of diagnosis-related groups (DRGs) for inpatient and day surgery services and per piece rates for outpatient visits subject to an overall block.40 Public hospitals are required to meet expenses from government payments and patient fees. Public hospitals are allowed to keep surpluses but need to meet shortfalls from their reserves, unless there are exceptional circumstances. The government introduced community hospitals to provide rehabilitation and subacute care, including to patients who have dementia or need palliative care. Community hospitals also provide outpatient services, such as day rehabilitation. There were seven community hospitals in 2018, with nearly 1,700 beds.41 The Ministry of Health pays community hospitals on a per-diem basis. Patients admitted to community hospitals may be eligible for subsidized care, ranging from 20 percent to 75 percent based on their per-capita household income and residency status. Mental health care: The Institute of Mental Health, a public hospital, is Singapore’s only psychiatric hospital, and provides acute tertiary psychiatric, rehabilitative, and counselling services for children, adolescents, adults, and the elderly. It has both inpatient wards, with more than 2,000 beds, and Specialist Outpatient Clinics at various community locations. The Community Mental Health Team, which comprises doctors, community psychiatric nurses, and allied health professionals, provides community-based treatment and psychosocial rehabilitation for patients after discharge so they may continue to live in the community while working toward recovery. Other public and private hospitals also have psychological medicine departments or specialists that offer psychiatric services. The Ministry of Health is working with health care institutions and professionals to implement the Community Mental Health Plan, which was launched in 2017. By early 2019, mental health or dementia services were available at 12 polyclinics. The ministry has also expanded the Mental Health General Practitioner (GP) Partnership program to encourage patients with emotional health issues to seek early treatment. GPs in the program can prescribe psychiatric drugs at a lower cost and have a liaison coordinator to facilitate referrals between services. Patients can also get subsidies for mental health conditions. The number of GPs trained to diagnose and support persons with mental health conditions grew from 70 in 2012 to 190 by the end of 2018. These GPs are supported by 20 community intervention teams led by allied health professionals.42 Long-term care and social supports: There are three main groups of long-term care services. Center-based services. These cater to seniors who require care services during the day on a regular basis while their family members are at work. As of 2017, there were 102 day care centers, dementia day care centers, day rehabilitation centers, and senior care centers. Home-based services. As of 2017, there were 21 home medical and home nursing providers, and nine home palliative care providers.43 In addition, three inpatient hospices are run by charitable organizations. Long-term residential facilities. Nursing homes provide a range of services, including medical care, nursing care, and rehabilitative services to residents who are unable to be cared for at home. Respite care is also available at some of the nursing homes. As of 2017, there were 73 nursing homes, including private, nonprofit, and public facilities, contributing a total of approximately 14,900 beds.44 The Ministry of Health contributes to the growth and development of eldercare services in Singapore, as well as the development of nursing homes, under its Build Own Lease framework. MediSave cannot currently be used for nursing home services or home-/center-based services, but residents can use ElderShield, a basic long-term care insurance scheme designed to cover severe disability, especially during old age, on top of government subsidies of up to 80 percent for various services.45 Coverage is automatically extended to all citizens and permanent residents with a MediSave account when they reach age 40. Residents can opt out, and the opt-out rate is 5 percent in recent years.46 ElderShield is a prefunded insurance scheme within which premiums are collected during policyholders’ working years and risk-pooled within each generation. Premiums do not rise with age, and policyholders are covered for life. The scheme provides monthly cash payouts of $400 for 72 months or $300 for 60 months, depending on the plan.47 Policyholders can also purchase supplements that provide higher coverage — for example, higher payouts or a longer duration of payouts — and pay for premiums using their MediSave coverage (up to a limit). See How Other Countries Compare What are the major strategies to ensure quality of care? The Ministry of Health’s key legislative tool for regulating health care providers is the Private Hospitals and Medical Clinics Act. Health care facilities, such as hospitals, nursing homes, clinics, and clinical laboratories, are required to obtain a license before they can commence operations. They are also subject to regular compliance audits and relicensing. Health care professionals are regulated by their respective professional boards, which are set up as statutory bodies under the Ministry of Health. In addition, hospitals are required to put in place a clinical privileging system that grants doctors the appropriate scope of practice commensurate with their areas of competence. There are also additional requirements for specific high-risk specialized procedures or services; doctors are required to apply for authorization before providing these procedures or services. Hospitals must establish quality assurance committees to monitor and evaluate the safety and quality of their practices, procedures, and services. The ministry benchmarks the performance of Singapore’s system against international counterparts, and conducts annual patient experience surveys of public health care institutions. Some health care institutions have voluntarily undertaken external accreditations, such as those provided by the Joint Commission International. Under the Chronic Disease Management Program, participating primary care clinics and medical institutions are expected to provide care in line with the latest clinical practice guidelines or best available evidence-based practice, as well as to track clinical data to monitor outcomes.48 Participation is a prerequisite for joining the Community Health Assist Scheme.49 See How Other Countries Compare What is being done to reduce disparities? In public hospitals, care is provided based on patients’ clinical condition, rather than on their subsidy status. When nonsubsidized drugs or treatments are deemed clinically required and cannot be replaced by subsidized alternatives, needy patients receive assistance (such as through MediFund) in accessing these drugs or treatments. Singapore has also adopted a system of differentiated charges, based on a patient’s and his or her family’s ability to pay. Means-testing is used, but even higher-income patients receive subsidies when they access subsidized services (although they pay more than lower-income patients). For example, higher-income patients who choose to stay in subsidized C-class hospital wards will receive up to a 65 percent subsidy while lower-income patients in these wards receive up to an 80 percent subsidy. Nearly all government-funded services, from acute to long-term care, have differentiated charges, except for polyclinic services and accident and emergency services. The government has also introduced schemes to assist specific cohorts of Singaporeans: The Pioneer Generation package, honoring older residents50 who contributed to Singapore’s nation-building but are unlikely to have accumulated sufficient money in their MediSave accounts to support retirement health needs, as MediSave was introduced late in their working lives. Pioneers receive additional outpatient care subsidies, annual MediSave top-ups (up to $800), and MediShield Life premium subsidies (up to 60%).51 The Merdeka Generation package, which recognizes Singaporeans who laid the groundwork for an independent Singapore.52 The benefits include MediSave top-ups of $200 per year for five years beginning in 2018. Merdeka Generation seniors also receive additional subsidies for outpatient care at certain clinics, as well as an additional subsidy of 5 percent for their annual MediShield Life premiums that increases to 10 percent at age 75.53 What is being done to promote delivery system integration and care coordination? In 2018, the Ministry of Health established three integrated clusters organized by geographic regions and made up of public-sector institutions ranging from acute hospitals to polyclinics. Each cluster is expected to develop and strengthen partnerships with GPs and other community partners across care settings to enable seamless care transitions and also to anchor care more firmly in primary and community settings. The clusters have embarked on several programs, ranging from preventive health and chronic disease to caring for frail patients. The clusters also work with social and other related agencies to support residents who have varying combinations of health and social needs as well as to address social determinants of health. While the elderly remain a key area of focus, the clusters have adopted a life-course approach and are progressively addressing other age groups as well. In addition to ensuring better system integration, the reorganization of providers seeks to derive greater economies of scale, to facilitate scaling up of programs and services, and to tap into a larger pool of manpower resources and talents. What is the status of electronic health records? Since 2011, Singapore’s national electronic health record (EHR) has been progressively deployed to both public and private health care institutions to support the goal of “One Patient, One Health Record.” The national EHR is owned by the Ministry of Health and managed by Integrated Health Information Services. The secure system collects summary patient health records from different health care providers, and authorized health care professionals can access the EHR to have a holistic and longitudinal view of a patient’s health care history.54 As of 2019, more than 1,300 health care institutions participate in the national EHR.55 Singaporeans and permanent residents can access some of their health records via HealthHub, a national one-stop health portal. They can also track and manage their medical appointments, request medication refills or renewals, and view bills and make payments at select public hospitals, national centers, and polyclinics.56 How are costs contained? The hallmark of Singapore’s health care market has been strong government control and oversight. Demand- and supply-side controls encourage patients and providers to be judicious and cost-conscious in their use of health care services.58 In addition, the public sector’s role as the dominant health care provider sets the benchmark for the private sector, as well as the entire health system’s ethos of deemphasizing profit maximization.59,60 Private providers need to ensure that they do not price themselves out of a market where public-sector care is available, and therefore offer reasonable prices and quality. The corporatization of public hospitals has introduced commercial accounting systems, which provide a more accurate picture of operating costs and instill greater financial discipline and accountability. In the costing and funding of hospitals, the depreciation of equipment and other fixed asset costs are registered and factored into annual budgets and, in turn, patient charges and government funding. The Ministry of Health also closely monitors cost-recovery ratios for different types of services to ensure that public hospitals’ overall revenue is not excessive. Costs and funding rates are set through a detailed costing exercise. Funding amounts are then incremented annually, taking into consideration volume and cost growth, but set deliberately lower than actual trends. This process compels hospitals to be disciplined with their spending, as they have limited ability to charge patients more to recover any shortfalls.61 The Ministry of Health encourages the appropriate use of drugs through the provision of subsidies for essential drugs. Patients pay only a small amount for clinically relevant and cost-effective drugs on the standard drug list. Subsidies are also available for a list of more expensive, nonstandard drugs under the Medication Assistance Fund. Patients receiving these drugs must meet predefined clinical criteria. The Medication Assistance Fund scheme was expanded in 2012 to allow each institution to determine, through a specific set of guidelines and a peer-review mechanism, whether a nonstandard drug should be subsidized by the fund. The Ministry of Health publishes public and private hospitals’ history of transacted hospital bill amounts and operation fees to encourage consumers to be price-conscious and to stimulate price competition among providers. In late 2018, the ministry also began setting fee benchmarks for private-sector health professionals, with input from an independent committee that includes representatives from the medical community, providers, patients, and payers. Intended to help the public assess the reasonableness of provider charges, the benchmarks will be reviewed and updated regularly, with reference to historical data. Doctors are not prohibited from charging lower or higher fees.63 Other cost-control initiatives include using technology to improve productivity, and the use of group purchasing procurement to obtain better prices. Supply chain professionals from the three public health care clusters harness their synergies in meeting procurement and supply chain needs. Public hospitals are also evolving their model of care to help Singaporeans receive care in the most appropriate setting. What major innovations and reforms have recently been introduced? In late 2017, the Ministry of Health launched its Beyond Healthcare 2020 strategy to move more care to the community, encourage health promotion, and ensure value.64 In 2018, the ministry launched the Licensing Experimentation and Adaptation Program, a regulatory “sandbox” for identifying and understanding new health care innovations, such as telemedicine and mobile medicine, through industry partnerships. The program seeks to develop an appropriate regulatory approach to facilitate such innovations while prioritizing patient safety and welfare.65 To provide better protection against long-term care costs, the ministry will launch CareShield Life in 2020 to replace ElderShield. The new scheme will have higher cash payouts, starting at SGD 600 (USD 438) and increasing over time. There is no cap on payout for as long as the policyholder remains severely disabled.66 CareShield Life will be mandatory for citizens and permanent residents born in or after 1980. In addition, people with severe disabilities can withdraw up to SGD 2,400 (USD 1,752) per year, or SGD 200 (USD 146) per month, from their own and their spouse’s MediSave account for their long-term care needs, after setting aside a minimum amount for other health care needs. The Ministry of Health will also be launching ElderFund in 2020, to provide discretionary assistance, up to SGD 250 (USD 183) per month, for severely disabled and needy citizens who require further help with their long-term care costs. In addition, the ministry and public hospitals are working on value-driven outcomes with inter- and intra-hospital benchmarking to minimize unnecessary variation and to encourage the adoption of best practices. The ministry has also started to bundle payments to facilitate care transformation and reward efficiency. And it has implemented a pay-for-performance framework to reward the three public health care clusters that do well on key priorities, such as reducing hospital-acquired infections, managing length of stay, and minimizing waiting time for specialist appointments.

The United States is unique in that it is the only industrialized nation that does not have a government sponsored universal health insurance program. In America, only persons covered by insurance are entitled to receive routine and basic health care which is a right to all persons in most other countries. The Patient Protection and Affordable Care Act of 2010 (ACA) expanded access to health care to over 22 million Americans, though it’s future remains uncertain. The American health care system is made up of delivery providers and settings, the public health domain, and the myriad private insurance companies involved in the financing of health care services. Over 16 million health professionals make up the largest workforce in America. There are nearly 6000 hospitals, 16,000 nursing homes, 11,000 home health agencies and hospices, and nearly 3,000 inpatient mental health facilities. As of 2015, there were 321,420,000 people in the United States. As of 2013, 195 million Americans had private health insurance, 105 had either of the public health insurance coverages (Medicare and Medicaid), The types of provider organizations generally fall into Managed Care Organizations (MCO). There are over 1000 health insurance companies, 70 Blue Cross/Blue Shield plans, 452 licensed health maintenance organizations (HMO), 925 preferred provider organizations (PPO).The government agencies involved in health care research, delivery and finance range from local health departments to state health departments and laboratories to the National Centers for Disease Control, National Institutes of Health and the Centers for Medicare and Medicaid Services, among many. Systems of the US Health Care System MANAGED CARE ORGANIZATIONS (MCOs) Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan’s network. How much of your care the plan will pay for depends on the network’s rules. Plans that restrict your choices usually cost you less. If you want a flexible plan, it will probably cost more. There are three types of managed care plans: Health Maintenance Organizations (HMO) usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care. Preferred Provider Organizations (PPO) usually pay more if you get care within the network. They still pay part of the cost if you go outside the network. Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care. Managed care integrates health care to improve efficiency. manages the use of medical services and sets pricing of services/ Managed care is financed by employer or government, less premium and deductible costs to patient (enrollee). MCO contracts with HMO or PPO, depending on plan selected by employer or state plans. An MCO is like an insurance company, managing contracts (health plan) and payments. MILITARY The United States military health care system is free of charge to active duty military personnel, member of Public Health Service and NOAA (National Oceanographic and Atmospheric Association). The system combines public health and medical care to provide preventive and treatment services. Family members of active duty or retired career military are covered by Tricare, through Department of Defense financing. The Veterans Administration (VA) health care system is available to retirees and disabled veterans. It is the largest and oldest health care organization in America with 5.5 million participants SPECIAL POPULATIONS In the United States vulnerable populations such as the elderly, the poor and disabled are covered for health care under “safety net’ programs such as Medicare and Medicaid. The Bureau of Primary Health Care (BPHC) in the Department of Health and Human Services (DHHS) provides support to migrant and seasonal farm workers, homeless persons, public housing residents and school age children. Medicare covers all citizens age 65 and older regardless of income, disabled and persons with end-stage renal disease. Medicaid covers low-income individuals and persons with disabilities. CHIP – the 1997 Children’s Health Insurance Program, preceded the ACA coverage for children in uninsured families. ***In 2017, the U.S. Congress, Senate and President are continuing to debate the viability of these health care programs. INTEGRATED DELIVERY SYSTEMS (IDS) Integrated delivery systems refer to health networks linking hospitals, physicians and insurers. Their focus is on quality improvement and cost controls. Integrated delivery systems typically include one or more hospitals; outpatient clinics and ambulatory surgical centers; physician group practices; long-term care facilities; home health and hospice services; and, one or more MCOs. Specialized services often participate in local IDS, including rural mobile delivery systems, women’s health care, cancer centers and rehabilitation clinics. The sharing of resources can help to avoid duplication of services and fill in gaps of services in rural communities. LONG TERM CARE DELIVERY Long term care are the services and supports necessary to meet health or personal care needs over an extended period of time. Long term care involves medical and nonmedical care provided to chronically ill and persons with disabilities including a range of services and supports needed for custodial care. Non-skilled service or care, such as help with bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. needs. Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life, sometimes called Activities of Daily Living (ADLs). Basic actions that independently functioning individuals perform on a daily basis:, such as: Housework Managing money Taking medication Preparing and cleaning up after meals Shopping for groceries or clothes Using the telephone or other communication devices Caring for pets Responding to emergency alerts such as fire alarms Long-term care can be provided in a patient’s home, assisted living facilities, and nursing homes. Medicare does not cover long term care; Medicaid covers limited LTC services to an eligible patient PUBLIC HEALTH SYSTEM The United States Public Health System (PHS) monitors health status in the community. Public health departments provide diagnostic and investigative services targeting health problems and hazards in the community. The PHS provides health information and education to the community, policy to support community and its residents and works to enforce and regulate health and safety laws. In concert with local integrated delivery systems, the PHS helps to provide access to health care. The PHS is the state system responsible for quality standards in health care and regulate licensure and competence of health care professionals and monitor quality of care of health services. At the national and state level, the public health system helps to control the spread of illness and death by conducting epidemiologic research in the study of disease. US HEALTH CARE SYSTEM IN CRISIS Unlike all other health care systems in the developed world, the US health care system is complex in that there is little integration and no centralized agency to oversee care in financing. America is the only nation without a national health care system. Rising costs In the past few decades have been technology driven due the high cost of diagnostic testing and treatments, and sometimes, unnecessary interventions. Unlike nations with lower cost national health services, the U.S. system is focused on acute care rather than prevention. The inequality of access to care and extremely high costs in comparison to other systems has resulted in mediocre outcomes. The U.S. trails behind other countries in quality of care, as well as patient outcomes. While lawmakers argue for a free-market system, the current quasi-market system affords very little options available. Government subsidies are available to health providers in the private sector, but the private sector causes gaps in health care such as environmental protection, research and training, and care of vulnerable populations. The concept of market justice (profit motivated, based on ability to pay) vs social justice (well being of the community) is the crux of the controversy, leading lawmakers to a stalemate in the “repeal and replace” platform of the 2017 presidential campaign. The balance of power (special interest groups and lobbyists representing for profit medical product, health services and pharmaceutical companies) presents the greatest challenge to cost containment. America’s health care system will be covered with particular attention to quality of care, which depends on accountability, access based on insurance coverage rather than medical need, and medical practice based on legal risk (malpractice insurance). Health Financing: The Macroeconomic Level Financing health care has evolved from personal payment at the time of service delivery to financing through health insurance (prepayment) by the employer and employee at the workplace. This has progressed in most industrialized countries towards governmental financing through social security or general taxation, supplemented by private and non-governmental organizations (NGOs) (Table 11.3), and personal out-of-pocket expenditures. Ultimately, every country faces the need for governmental funding of health care either for the total population or at least for vulnerable groups such as the elderly and the poor, as in the USA, where governmental funding comes to nearly 50 percent of total health expenditures. Government funding is necessary also for services that insurance plans avoid or are inefficient in reaching, including as community-oriented services and groups at special risk, such as infants and women . Health-care financing is one of the core components of health systems. Most health sector reform measures attempt to address health financing issues such as mobilization of funds, distribution of financial risks, allocation and utilization of services, and provider payment incentives. However, comprehensive information on health financing such as costs, prices, and expenditure is not readily available. This limitation affects appropriate health policy analysis to strengthen health financing governance at all levels. Ultimately, the priorities for good governance are to determine the proper roles and functions of financing within health systems that are well integrated with the provision and regulation of quality health services; to provide a level playing field for the balanced share of the public, private, and voluntary sectors; to develop universal health coverage for all within an affordable and sustainable financing framework; and to strengthen health financing methods with improved financial management systems. Specific emphasis is placed on devising rules and norms, and the enforcement of regulations to implement more equitable and fair financing policies with integrity, that are based on accurate and reliable financial data and information. Therefore the focus on governance should be on financing functions in detail—collection of funds, pooling of resources, and purchasing or payment for health services. These financing and related payment mechanisms to providers must be regulated more effectively with a system of checks and balances without incurring high administrative and transaction acts, to attain the policy goals of effective and efficient allocation and proper utilization of scarce societal resources toward Health for All. As WHO expresses it metaphorically, failure of stewardship can be identified with three kinds of visual limitations. Turning a blind eye to corruption is a clear example of bad governance, whereas myopia and tunnel vision, the other two failings, are not. Good governance requires oversight, clear standards, and the ability to hold providers and payers accountable. Where these do not exist, it is unlikely that health systems will work, services will be delivered, and health status will improve. Poor governance undermines the quality of services and the acquisition and spending of public funds. Corruption eats away at the foundation of health-care finance, diverting funds during collection of premiums, undermining procurement rules in the purchase of inputs, and allowing funds to disappear between the point of collection and points of delivery. Absent physicians effectively steal from the public sector; petty theft of drugs, light bulbs, or food is just as much robbery. Even absent such corruption, underperformance by health-care providers leads to spending that has no impact. Addressing these problems entails clear rules, oversight, and enforceable discipline for those who violate public trust. As healthcare financing moves away from a fee-for-service model toward innovative payment models, including capitation, a healthcare system’s success will rest on its ability to proactively manage the health of its patient population. Coordinating with other local stakeholders by creating a pediatric care network is an effective way to address population health. In the example provided above from Denver, there were several keys to success. These include having (1) an organized asthma team with clear goals and defined program leadership roles; (2) regular and accurate data reports to review processes and health outcomes; (3) well-defined initiatives and goals; and (4) continuous funding from multiple sources. An active NOAC will enable care teams in multiple settings to provide coordinated, high-quality asthma care to their pediatric patients. Health care expenditure involves money spent from all sources for the entire health sector, regardless of who operates or provides the services. The methods of financing health care include tax supported, social security supported, employer–employee financed, charitable organizations, or consumer payment at the time of service. The total of expenditures for health care and how those funds are spent are the most fundamental issues in health economics and planning. Allocation of resources requires a skillful planning process to balance spending on different subsectors of the system and to ensure equity between regions and various socioeconomic groups in society. What is the “right” amount of health care financing? This is a political decision which reflects the social and economic value placed on health by a nation. These attitudes affect such issues as how well medical and other health care staff are paid in comparison to other professions, and the supply of physical and human resources for health care in a given society. Virtually all developed countries have recognized the importance of national health and the role of financing systems to make health care universally available. Some basic principles and recommendations for successful health care financing policies are: Incentives for improving health performance measures, including: preventive health measures health promotion Universal coverage through social security or tax-based system Financing within national means for social benefits Adequate overall financing (> 6 percent GNP) Shift from supply-side planning to costs per capita Performance or output measures Categorical grants to promote national objectives and specific health target programs Increase financing at national, state, and local government levels (7–10 percent GNP) Health insurance as a supplement Define “basket of services” and consumer rights Reduce acute care beds to < 3 per 1000 population District health authorities with capitation funding Disincentives for excess hospitalization, surgery Incentives for integration of services

Lessons the U.S. Can Learn