Lower-income patients to get higher subsidies for cost-effective surgical implants
From Dec 1, 2023, patients who need surgical implants such as high-cost replacement heart valves, hearing devices, intraocular lens for cataracts or knee replacement implants can get higher means-tested subsidies than today, and not be subjected to a dollar cap.
These are among the bulk of commonly used implants in public healthcare institutions that will be included in a new Implant Subsidy List, which will kick in on the same day, said Ministry of Health (MOH) officials at a media briefing on Nov 29.
They have been assessed by MOH’s Agency for Care Effectiveness (ACE) to be clinically effective and cost-effective. MOH said that lower-income patients who need high-cost implants will benefit most from the changes.
Currently, patients in B2 to C wards and day surgery settings receive subsidies for all implants, with Singapore citizens getting up to 50 per cent subsidy, capped at $1,000 and Singapore permanent residents (PRs) getting up to 25 per cent subsidy, with a cap of $500.
Because of this, implant manufacturers have little incentive to reduce their prices as all their implants are eligible for subsidy, MOH said. ACE has found that there can be a big variation in the prices offered here and overseas, and prices of implants can even vary across hospitals here.
This new Implant Subsidy List is similar in part to the Cancer Drug List, which was introduced in September 2022, and includes only treatments that are deemed to be clinically proven and cost-effective. That has helped to lower the costs of cancer drugs used in public healthcare institutions.
With the new list, implants are no longer automatically eligible for subsidy, which facilitates negotiations with their manufacturers for more competitive prices, MOH said.
An earlier pilot implant subsidy list for three types of implants for heart patients and hearing implants resulted in price reductions of up to 25 per cent and savings of around $8.3 million over 2017 to 2022, MOH said.
The changes, made to ensure that healthcare cost growth remains sustainable, come as the use of implants, which has increased over the years, is expected to rise further with a rapidly ageing population. MOH also expects newer and higher-cost implants to come on the market quickly.
From 2013 to 2021, implant spending in the public healthcare institutions grew from $93 million to $163 million, according to MOH data. This is contributed by increasing implant charges and increasing volume of implant procedures, said an MOH spokesperson.
There is a wide range of implants used here, including pacemakers for those with abnormally slow heart rate, treatment implants to help reduce eye pressure in those with glaucoma, and hip replacement implants for those with osteoarthritis of the hip joint, for instance.
Having a list means that Singaporeans who meet the criteria for the items on the list will receive between 50 and 80 per cent subsidy in class B2 and C wards and day surgery settings, depending on their means-test level, with no dollar cap. And Singapore PRs will get 25 to 50 per cent subsidy in these settings, also with no dollar cap, MOH said.
There are no changes to MediShield Life, MediSave and Integrated Shield Plan coverage for implants, so patients can continue to tap on these schemes, whether or not the implant they want to use is on the new list. MOH said it will review the financing coverage of these schemes at a later juncture.
MOH said that about 8 per cent of the volume of implants used at public healthcare institutions have been found to not be clinically effective and cost-effective. They will thus not be included in the list. MOH declined to name them but said these are specific products across the implant categories that are already on the new list.
Generally, the majority of the unlisted implants will have a suitable subsidised alternative on the new list. If not, patients may consider non-implant treatment options, MOH said.
The 15 categories in the new Implant Subsidy List include cardiac implantable electronic devices such as pacemakers, cochlear implants, which are hearing devices that bypass the damaged parts of the inner ear to stimulate the remaining auditory nerve fibres, and hip, knee and sports medicine implants.
Another 10 categories, including spine implants, mammary implants and brachytherapy, are currently under assessment and will progressively move to the list by the end of 2025. In the meantime, the implants in the 10 categories will be eligible for current capped subsidies, MOH said.
At the National Heart Centre Singapore (NHCS), its chief executive, Associate Professor Yeo Khung Keong, said the new subsidy framework will ensure that the right patients get the subsidies, and encourage implant manufacturers to lower their prices because only competitively priced products will be included in the list. These savings can then be passed on to patients.
“In the public sector, we already have a high level of support. Cardiology has a special medical service package that helps address the needs of patients who need life-saving, high-cost implants such as pacemakers or defibrillators,” said Prof Yeo.
“I think this is an attempt to do even more, to cover more costly items that are not already covered, such as replacement heart valves costing $30,000 to $40,000 that a group of patients may need.”
The Implant Subsidy List will supersede the special medical service package, which has been around for about two decades and offers up to 65 per cent to 80 per cent subsidies for implants for B2 to C class patients.
Prof Yeo said that some of the newer technology that has surfaced in the past few years are not included in the package, but the new list will cover them, benefiting needy patients.
Overall, the list will result in better prices for patients as implants that are uncompetitively priced will be excluded from the list, if similarly effective technology exists, he said.
“They may be a bit more fancy or branded, but there are alternatives that can do the job as well.” said Prof Yeo.