MOH didn’t know about medical referral fees until now?


MOH didn’t know about referral fees that has been going on for years?

I refer to the articles “MOH puts a stop to foreign patient referral contracts“, “Helping Indonesians get treatment in Singapore” and “Singhealth, NUH to stp using agents by end of Oct” (Sunday Times, Sep 30).

The former states that “The Health Ministry (MOH) has told public hospitals to terminate all contracts with foreign agents who refer patients from overseas, after The Sunday Times highlighted the existence of such a practice.”

This has been going on for decades. So, arguably, aren’t you surprised by “(MOH) has told public hospitals to terminate all contracts with foreign agents who refer patients from overseas, after The Sunday Times highlighted the existence of such a practice”?

This is arguably even more ludicrous, given that the payment of referral fees to third parties has been barred since December 2016 (“Doctors barred from paying percentage of fees to 3rd-party agents”, Today, Dec 14, 2016).

The above mentioned article said that “Some major TPAs here charge percentage fees and have done so for years, but what had doctors crying foul in recent months was a few players charging fees of up to 25 per cent of doctors’ professional fees — in some cases, for merely the “referral” of patients on a particular insurance scheme or panel.”

As to “The Sunday Times learnt that the National University Hospital (NUH), Singapore General Hospital (SGH) and Changi General Hospital (CGH) have such contracts with third-party agents.

In one case, an Indonesian agent was contracted to provide NUH “administrative services”. For every foreign patient accepted by NUH, the agent is paid 8 per cent of the patient’s hospital bill, excluding doctors’ fees.

If patients brought in by the agent spend more than $500,000, the agent gets an additional 2 per cent cut for every dollar above the cap. If the fees go past $1 million, the agent gets an additional 4 per cent for every dollar above that.

The agent must ensure the patient pays the hospital first before getting the fee. The agent’s duties include assisting potential patients with information they require before making “the most suitable recommendation”, as well as helping patients arrange specialist appointments, according to the NUH contract” – I understand that even agents in Singapore have been getting referral fees for years.

In respect of “Other agents from Indonesia and Vietnam told The Sunday Times that they also had arrangements with SGH and CGH, both run by SingHealth. The hospitals declined to say how long such practices have been going on.

Asked about such contracts, MOH said the priority of public healthcare institutions is to serve Singaporeans’ healthcare needs. They “are not allowed to actively market themselves to foreign patients”.

Some public healthcare institutions (PHIs) have contracts with agents who facilitate and assist foreign patients seeking medical treatment in Singapore. While these agents have not been tasked to market their services, we have asked the PHIs to discontinue such practices and terminate existing contracts with the agents, to avoid potential misinterpretation and misrepresentation,” it said.

SingHealth and NUH told The Sunday Times they will cease the agreements by the end of next month.

“NUH’s foremost priority is to provide care for Singaporeans,” the NUH spokesman added. “NUH reviews all referrals to ensure that it has the capacity, capability and resources to provide treatment that will be beneficial to the patient. Singaporeans are given priority, for appointments and hospital beds.”

SingHealth said the primary role of medical associates is to help overseas patients navigate the healthcare system, including advising patients on relevant health records needed, and assisting with the administrative processes, paperwork and travel arrangements.

“Medical associates are non-exclusive to SingHealth and they charge an administrative fee (per patient) for their services,” said SingHealth.

Doctors whom The Sunday Times spoke too were surprised that public hospitals engaged such agents.

“This practice of giving a ‘referral fee’ to ‘medical agents’ is unethical,” said Dr Keith Goh, consultant neurosurgeon of International Neuro Associates. The 8 per cent commission on a hospital bill of $500,000 would be $40,000 – “which is more than the annual salary of a staff nurse”, he added.

Some doctors pointed out how under the Singapore Medical Council’s (SMC) ethical code and guidelines, they are not allowed to offer a percentage of a bill as a referral fee” – in this connection, in a reply to my letter “Give breakdown in medical bills” (Business Times, Apr 13, 2005) – the Singapore Medical Association (SMA) said “Mr Leong further claims that doctors may make excessive profits by marking up the cost of medicines and investigations, and receiving a typical referral fee.

The Singapore Medical Council’s (SMC) Ethical Code strictly prohibits fee-sharingand obtaining commissions from referrals, and the SMC has previously disciplined doctors for doing so.

This is a serious allegation and SMA would like to invite Mr Leong to inform us if he has any concrete examples of this happening. SMA will investigate and take the necessary action. Alternatively, Mr Leong can inform SMC directly.”

So, it is good now (13 years after my above letter to the newspaper forum!) for the practice of giving or taking of referral fees or sharing of fees, to be finally and totally outlawed, as it is a big step towards reining in rising medical costs..

In respect of “Dr Tan Chi Chiu, chairman of SMC’s Medical Ethics Committee, said that there are no issues with public doctors treating foreigners. But foreign patients may pay more, and “doctors need to ensure that this does not set up a financial incentive” to favour such patients over subsidised ones” – some issues similar to the outlawing of fees sharing may still exist:

Free benefits?

Several years ago – medical groups started to give free accident insurance for a few months to newborn babies.

Initially, the medical groups paid for the premiums, but subsequently third parties paid the premiums.

Mutual benefits?

Over the years – we understand that this has evolved into third parties paying upfront cash benefits to medical groups.

Tender to highest bidder?

We understand that one medical group had even put out a closed tender, and about 10 third parties made proposals to bid for an automatic free medical expenses cover for one year for newborn babies.

Similar issues to fees sharing?

We understand that the proposals may include cash benefits, referring patients, etc.
How different are such arrangements to the fee sharing that is now forbidden under the ethical code?

Implications for consumers?

At the end of the day – what are the implications for consumers?
Wouldn’t possible allotment to the highest bidders be ultimately detrimental to consumers?Wouldn’t it push up the cost to consumers ultimately? Wouldn’t there be a risk that referrals will be made on the basis of who gives the best mutual benefits to the companies or in a sense – fee sharing directly or indirectly – instead of on the basis of the best medical practitioner or provider that can give the best treatment and care or cost value to the patient?

Leong Sze Hian



About the Author

Leong Sze Hian has served as the president of 4 professional bodies, honorary consul of 2 countries, an alumnus of Harvard University, authored 4 books, quoted over 1500 times in the media , has been a radio talkshow host, a newspaper daily columnist, Wharton Fellow, SEACeM Fellow, columnist for theonlinecitizen and Malaysiakini, executive producer of Ilo Ilo (40 international awards), Hotel Mumbai (associate producer), invited to speak more than 200 times in about 40 countries, CIFA advisory board member, founding advisor to the Financial Planning Associations of 2 countries. He has 3 Masters, 2 Bachelors degrees and 13 professional  qualifications.