Tiêu đề Case - Singapore Healthcare.pdf ✅

Singapore Healthcare Introduction Dr. Lim Cheok Peng had reason to be pleased. As Managing Director of Parkway Group Healthcare, Asia’s second-largest listed hospital operator, he and his new Chairman, Richard Seow, had just concluded a highly successful shareholders’ meeting. Results for 2005 showed revenues growing (35%) to over half a billion Singapore dollars1 and profits growing (23%) to almost S$62 million. Following years of languishing in the doldrums, Parkway’s share price, too, had risen to a healthy S$2.30, one of the highest levels the share had seen in several years. On the governance side, after many years of strategic, if genteel, tussles with the erstwhile principal shareholder, Symphony Asia Capital Partners Limited, Parkway had a new principal shareholder. Newbridge Capital, a US-based private equity group, had purchased the shares of the founding families of the Parkway Group, giving them 26% of the shares of the group. Newbridge had several global investments in the healthcare sector including investments in Quintiles Transnational, Matrix Laboratories, and Oxford Health Plans, among others. This gave Cheok Peng greater confidence that his perspectives on growth would be understood and supported by his principal shareholder. It was now time for Parkway to look toward the future. Parkway’s Singapore hospitals contributed 87% of the revenues of the Parkway Group in 2005. Parkway’s fortunes, therefore, would be closely linked to the fortunes of the healthcare industry in Singapore for the immediate future. Given the relatively small size of Singapore’s economy, significant growth would have to come from further afield. Moreover, what could Parkway expect from its large Singapore investments? Was there anything that they could do now to improve the quality of their returns from this industry? Healthcare in Singapore – An Overview Good Health at Low Cost In slightly over a generation, Singapore had developed a reputation for world-class healthcare. The World Health Organisation ranked Singapore’s health system the best in Asia, ahead of Japan and, globally, ahead of the United States. The Joint Commission International, the overseas arm of the United States’ main medical accreditation agency, rated many Singapore hospitals on a par with international standards in 2003.2 Expatriates in Asia, an important internationally mobile user group, rated health care in Singapore third in the world behind the United States and Australia. The country’s health indicators justified its reputation: within the space of a generation, Singapore jumped from third-world to first-world standards in health outcomes. In 2004, its 3.5 million residents enjoyed an average life expectancy of 79.3 years,3 one of the highest in the world, up from 63 years in 1960.4 The country also has the world’s lowest infant mortalityrate at 2.2 per 1,000 live births.5 Singapore achieved these excellent outcomes in public health despite spending relatively less on health care compared to other developed countries. Singapore spent around 4% of its GDP
on healthcare,6 with an aggregate expenditure of S$5 billion in 2001.7 Figure 1: Health Outcomes and Cost (Source: WHO) A Public/Private Healthcare System Singapore has a two-tier healthcare system; the private sector provides most primary services and the public sector dominates tertiary care.8 Private practitioners provide 80% of all primary care, delivered through almost 1,900 clinics spread across the island.9 While a few branded chains of clinics have emerged – the Raffles Group, Parkway Shenton, etc., – the vast majority are independent clinics run mostly by one (sometimes more than one) doctor. The public sector provides about 20% of the volume of care through 18 subsidized outpatientpolyclinics that provide a wide range of primary and secondary care. These polyclinics are divided equally between the two large Integrated Delivery Networks or IDNs that offer publiccare in Singapore. These two IDNs – Singhealth and the National Healthcare Group (NHG) –are each a collection of tertiary hospitals, community hospitals, specialty care centers, and polyclinics (multi-purpose primary care centers with some diagnostics). Secondary care in Singapore comprises hospices and long-stay nursing homes that are run predominantly by voluntary organizations and some private entities, supplemented by government funding. The implicit presumption has been that families will look after patients needing chronic or long-term care. Those disadvantaged few who cannot rely on their families in these circumstances, must rely on charitable institutions to look after them. Eighty percent of tertiary care in Singapore is provided by the public sector, whose 13 hospitals and specialty centers account for 74% of the 11,795 hospital beds in Singapore. 10 However, these hospitals are divided into the two IDNs mentioned above. Singhealth has the largest hospital in Singapore, the Singapore General Hospital (SGH), along with Changi General and KK Women’s and Children’s Hospitals, several specialist clinics such as the National Cancer Centre, Singapore National Eye Centre and others. NHG has Singapore’s first and largest teaching hospital, the National University Hospital (NUH), along with Alexandra, Tan Tock Seng and Woodbridge Hospitals and the National Skin Centre. There are several players in the private tertiary hospital space in Singapore, including Raffles
Medical Group and HMI, but the only true contender with the public general hospitals is the Parkway Group with its Gleneagles and Mount Elizabeth hospitals. Along with SGH and NUH, Gleneagles and Mount Elizabeth are the serious tertiary healthcare offering to Singapore and the region. As can be seen from Figures 2 and 3 below, the private sector’s share of tertiary healthcare has been falling steadily since 1999. In volume terms, public sector hospitals handled nearly 84% of all inpatient discharges and day surgeries performed in Singapore. However, their share of revenue is lower, at 64%, indicating the lower average revenue received by the public sector.11 Figure 2: Inpatient Revenue per 1,000 Population (Source: Singapore Ministry of Health) Figure 3: Day Surgery Revenue per 1,000 Population (Source: Singapore Ministry of Health) Subsidies Influence Location of Care Delivery Health expenditures in Singapore are financed by a combination of taxes, employee medical benefits, compulsory medical savings, insurance, and out-of-pocket payments. Primary health care in Singapore is mostly funded by private expenditures, but the state pays a greater proportion of tertiary care. According to the WHO, the Singapore government pays approximately 35% of the total healthcare bill.12 Patients, consequently, expect to pay some part of all medical expenses. Singapore citizens and residents maintain compulsory medical savings (Medisave) accounts, which they can use to pay for eligible outpatient or hospital expenses. Over 90% of the
population is covered under a catastrophic health insurance scheme called “Medishield” that covers key major and prolonged illnesses.13 Finally, an increasing number of people are purchasing either hospitalization cover or other forms of medical insurance. The government subsidises both primary and tertiary healthcare, principally through public polyclinics and hospitals. Rates at private clinics and hospitals are unregulated, although the Ministry of Health does provide guidelines for visitation fees. In public hospitals, patients can opt for varying service levels with correspondingly different amounts of subsidy as outlined in Table 1.14 C-class wards are non-air conditioned wards with a relatively large number of beds in each ward. A-class wards are single-bedded air conditioned rooms, and the B class wards are air conditioned wards with varying numbers of beds in each room. The subsidy percentage applies not just to room costs but all costs including those of associated surgeries and medication. The appropriate level of subsidy is applied depending on the class of ward a patient applies for at the outset of a medical episode. There is, at this moment, no other means by which an individual’s eligibility for a particular ward is evaluated. The choice of subsidy level is made entirely based on patient selection. Table 1: Subsidies in Public Hospitals Class of Ward Government Subsidy C 80% B2 65% B2+ 50% B1 20% A 0% A subsidy system driven entirely by patient choice has meant that demand for public services rose during bad times. Singaporeans wanting to save money during tough economic circumstances needed only to opt for more subsidized levels of care, forgoing the benefits of added facilities in the less subsidized wards. A recent study by Singapore’s Ministry of Health confirmed that during, and immediately after, the Asian financial crisis of 1997, the public sector’s workload rose sharply while demand for private sector services fell.15 In primary care, subsidized public polyclinics limit private GPs’ competitive options. For instance, when patients need chronic care, GPs have advised them to go to polyclinics to save money. This prompted one government body to propose that government subsidies also be extended to GPs who offer chronic care.16 Demand for polyclinic services is limited by fixing the total number of polyclinics. Initially, polyclinics attempted to innovate by offering more customer-focused services such as 24-hour care. However, GPs protested, saying that this ate into the already meagre pickings available to independent practitioners whose only hope of survival lay in offering services that the polyclinics would not. Players and Conditions at Different Levels of Care The school of medicine at the National University of Singapore is currently the only medical school in the country, producing about 230 doctors a year.17 From 2007, the Duke-NUS Graduate Medical School will train 25 students.18 Beyond this annual addition to the pool of physicians, the Singapore Medical Council and Ministry of Health allow graduates of 71