Transforming Healthcare Delivery – Healthier SG and the Family Physician

Roy Teow

"Health is not just being disease-free. Health is when every cell in your body is bouncing with life." – Sadhguru

Healthier SG (HSG) is a transformation of the patient's journey from the cradle to the grave. It endeavours to encourage better health and prevent foreseeable health events to reduce the odds of a black swan outcome.

For this to happen, we need a caring, competent companion and healer. This heavy responsibility is bestowed on none other than the family physician. For many years, our humble family physician community has dreamt of a better world, where the medical landscape is more accessible, equal and encouraging, and where we can more effectively fulfil our life's calling and vocation. This landscape is now transforming, given a political "booster vaccination" by the Ministry of Health (MOH) with the doctor co-investing both income and time. Through HSG, solo clinics will work as part of a team within each Primary Care Network (PCN) and will also be better integrated into the geographic healthcare cluster.

Our dear Hobbit has highlighted many challenges, which we will leave our readers to explore. Members of our SingHealth Delivering on Target (DOT) PCN increased the sample size of the data used for the calculation of the margin loss for drug utilisation. This helped to improve the compensation to doctors in the form of a Chronic Enrolment Grant.

Below, I share my thoughts on the intricate relationship between family physicians and the various aspects of the HSG scheme, and the impact one has on the other.

Transition to HSG – Administrative considerations

The next few months leading to the launch of HSG will test and tax the administrative readiness of individual HSG clinics. In addition to existing patients, new enrolees – whether healthy or with chronic ailments – may register with the HSG clinics. The increased volume of free health screenings with no co-payment will once again stress test the workflow adequacy of the Screen for Life health screening programme. Free vaccinations with no co-payment for approved medical conditions and select criteria may demand more administrative intervention and justification. Preparing a health plan for every healthy enrolee may indeed be challenging, especially if an active problem list is brought up during this encounter.

The real challenge of HSG starts in January 2024. Patients with ailments that qualify for Chronic Disease Management Programme have two Community Health Assist Scheme (CHAS) frameworks to select from – the existing CHAS Chronic Tier and the new HSG Chronic Tier (HSGCT).

Patients with high medication needs may tap on HSGCT. Clinics have the option of prescribing whitelisted medication for home delivery by ALPS (a public healthcare supply chain agency) or holding double inventory in the clinic, based upon the relative merits in their practical application. As the medications are subsidised based on CHAS status, there is always a payment, albeit small, for the unsubsidised portion. The HSGCT is thus an area of concern for the immediate medication margin loss when existing patients request its use.

Furthermore, from February 2024, exemption of Medisave co-payment will be implemented, subject to the prevailing criteria. One may begin to appreciate the immense volume of administrative work involved for the still incomplete list above, as well as the amount of monitoring needed.

Additional administrative staff may be needed in this challenging climate of recruitment. Administrative fees (aka practice cost) may need to be included and properly itemised. Though charging a practice cost has been endorsed by MOH, its implementation is patchy, with low public awareness amid no publicity from MOH.

A lot hinges on an excellent and nimble HSG-enabled clinic management system to form an effective backbone for family physicians. The need for immediate access to data and crosschecking of databases across the entire island may introduce new variables to the equation.

Healthcare cluster/PCN

All HSG clinics sign their Letters of Agreement with their geographic cluster partner, which empowers the Agency for Integrated Care to audit and manage the financing of HSG at the clinic. At the same time, HSG clinics work primarily with their selected PCN to monitor and improve their best practice standards. Best practices are observed and shared to incentivise patients and providers alike.

PCNs may be independent or linked to a restructured hospital system (RHS) of a healthcare cluster. The clinic may be in a different geographic location from the RHS PCN or in a solo PCN which spans across all three healthcare clusters. Having a formal structured framework of operation, and the support of their clusters for RHS PCNs, enables faster and better introduction of quality indicators to improve medical care and preventive surveillance of our patients. However, as regional shared care and right-sited programmes may be rolled out based on geographic location or PCN, some clinics may be bypassed.

Another challenge for PCNs is that their funding will be based on the number of HSG clinics registered with them. This is despite the same amount of work to be done by each PCN headquarter regardless of the clinic's HSG status. This may be even more challenging for independent PCNs with no direct RHS support.

The pharmaceutical industry

With whitelisted drugs in HSG, the volume of medication purchases by family physicians will decrease, further compromising the higher incentive volume-based tiered purchases. Pharmaceutical companies are still evaluating the potential impact that HSG may have on their business. Possible measures considered include focusing on medications from the non-whitelisted range, extending the same whitelisted medication price directly to all HSG clinics, and/or allowing clinics to purchase the better priced products at a lower tier (moving their metrics towards total annual purchases across all product range).

The challenges ahead

Once the ease of online prescription through ALPS is better appreciated, family practice may well be on the way towards relegating away prescribing rights. Healthcare costs are anticipated to increase correspondingly. Administrative efforts by the clinics need to be factored in and remunerated. This can be viewed as an investment in the future with returns in health dollars.

There is also fear and concern for our next generation of primary care doctors. Once all patients have selected and enrolled in their HSG clinic, it may be more difficult to start a new family practice.

Pre-emptive diagnosis of chronic medical conditions may be a double-edged sword. We hope every citizen has at least bought their first health insurance.

Even a booming solo practice under the auspices of HSG may eventually meet its demise when the family physician retires. The medical business may continue, but the practice location, particularly in a HDB rental setting, will definitely face challenges with the property cooling measures enforced on 15 October 2019 where the assignment of new commercial tenancies is no longer allowed.1

If the HDB unit is returned, repercussions may involve the unnecessary loss of goodwill built up over the years as well as the loss of valuable medical records. Other options include special provisions for clinics, fixed assignment fees, MOH taking over clinics to use as training grounds for family physicians, or HDB tweaking the rule to allow changes in tenant composition.

The current rule on HDB transfer of rental tenancy may not affect those family physicians with children taking up family medicine as a vocation, as existing HDB rules allow property transfer within the family.2

Aspirations of HSG

"A physician is judged by the three A's: Ability, Availability and Affability." – Dr Paul Reznikoff

We are now moving toward the launch of HSG. In the spirit of togetherness, I hope that all family physicians enrol into HSG to better look after our patients, with the programme's attendant list of patient benefits. At the same time, we hope that MOH understands the real concerns of all family physicians and enables all the necessary considerations, as well as removes all perceived barriers. We trust that MOH appreciates, respects and reciprocates our faith in signing up with HSG.

We look forward to a healthy nation where everyone, both well or with chronic ailments, takes personal responsibility for maintaining our individual good health through compliance and adherence to the prescribed health plans.

  1. Housing & Development Board. Heartland BiZ! October 2016. Available at: Accessed 10 April 2023.
  2. Housing & Development Board. Change of Partners, Shareholders, or Mode of Business. In: Managing Your Unit. Available at: Accessed 28 March 2023.

Roy Teow runs a solo family practice at Khatib. He enjoys inducing the smoker to stop smoking, among other behavioural changes. He hopes to improve cohesiveness among doctors through the social platforms of connectivity. Previously snapping lecture slides, he now collects webinars and looks forward to a copyright-exempt zone where he may freely share his library.