Medical Savings Accounts: The Singapore Experience
Monday, April 01, 1996
by Thomas A. Massaro, M.D., Ph.D. and Yu-Ning Wong
Table of Contents
- Executive Summary
- Singapore?s Economic and Social Welfare Systems
- The Central Provident Fund
- Financing Medical Care in Singapore
- Government Subsidies for Health Care
- Physician Services
- The Hospital Sector
- Evaluation of the Singapore System
- Can Medisave Work in the United States?
- About the Authors
In 1993 half of the approximately 4,000 physicians were in private practice. By the year 2000, the total number of physicians will rise to 5,200, with most of the growth expected in the private sector. The population per physician will drop from 800 to 650, with specialists remaining at the current 40 percent of total.
"By the year 2000, the population per physician will drop from 800 to 650, with specialists continuing to make up 40 percent of the total."
Physician training. The government strictly monitors the licensing and specialization of doctors. To manage physician supply, the medical school class at the National University of Singapore is limited to 150, and the number of foreign medical schools whose degrees are recognized has recently been reduced from 176 to 28.19 Training is not dissimilar to that in the U.S. The five-year undergraduate medical school experience is followed by one year as a house doctor and two or three additional years of basic training. Those who choose and are able to find slots must train for an additional two to three years to practice a specialty.
Physician compensation. Doctors appear to be reasonably well-compensated. Physicians in government-owned facilities receive a civil service pay scale plus a "clinical faculty supplement" of 25 percent of their base wage. Those with very heavy clinical loads, especially in procedure-based specialties, may opt for an incentive based on their total billings in place of the fixed 25 percent supplement. Table II shows average salaries for clinical personnel. A senior registrar (roughly equivalent to a post-residency fellowship in the U.S.) receives a salary equal to three times the country's average annual wage. A junior staff physician receives five times the average wage, and a senior physician earns about six times the average wage. These income levels are comparable to the U.S., where five to six times the average wage is normal.20
Private physicians are probably better compensated than their public sector counterparts. They are generally paid on a fee-for-service basis. Office visits cost S$12 to S$120, depending on duration, complexity and qualifications of the physician. Surcharges apply for first visits, after-hours service and emergency care. Hospital consultations bring S$50 to S$200 per day. Maternity care, including prenatal and postnatal visits, costs S$1,500 to S$4,000.21 Table III shows excerpts from the Singapore Medical Association Guideline on Fees for billing in the private sector.22
Paperwork. How do Singapore doctors generate their high personal incomes while being compensated at the low reimbursement rates shown in Table III? The answer uniformly given by those who have practiced in both the U.S. and Singapore is: relative freedom from administrative encumbrances. Singapore restricts practice options by limiting the number of physicians, the ratio of specialists and the amount and location of high-technology services, but it imposes little regulation on the interaction between patient and physician. As a result, physicians see more patients and their practice costs are lower because billing is simple. Thus a greater fraction of the professional fee goes to the clinician's salary.