It’s a S$24.8 million ($20 million) medical bill that shocked oil-rich Brunei and may hinder Singapore’s bid to become a top medical-tourist destination.
Susan Lim, Asia’s first liver-transplant surgeon, sought as much as S$200,000 a day over seven months in 2007 to treat a member of Brunei’s royal family who later succumbed to cancer. The bill, which included third-party disbursements, sparked a complaint from Brunei, a Singapore investigation and an inquiry into her fees.
“Reputations are tarnished at all levels” with such scandals, said Josef Woodman, who spent more than five years researching medical tourism and is the author of Patients Beyond Borders, a guide to finding offshore medical treatment. “This underscores the need for improved oversight and regulations that would help to prevent abuses.”
The Brunei case and another complaint from the United Arab Emirates accusing a group of Singapore doctors, including Lim, of overbilling may hamper the state’s ambition to attract more foreign patients in Asia’s $5.5 billion medical-tourism market. Heart-bypass surgery in Singapore costs about a sixth of that charged in the U.S.
Lim denied any wrongdoing and in e-mailed responses said the Bruneian patient had agreed to the charges.
“The patient was never held to ransom,” Lim said. “She was willing to pay the price we had agreed to.”
India, Malaysia, Thailand and South Korea are among countries competing with Singapore for a slice of the industry, said Pawel Suwinski, a health care analyst at Frost & Sullivan Ltd.
“Singapore is losing ground to cheaper countries and is evolving into a hub for complex surgeries,” said Wei Siang Yu, who owns Fly Free For Health, a Singapore-based medical concierge service.
Brunei is ruled by Sultan Haji Hassanal Bolkiah, the second-richest royal in the world, according to Forbes. The country’s health ministry sought a discount through its counterpart in Singapore on Lim’s S$24.8 million bill for treatment of Pangiran Anak Hajah Damit, the Sultan’s sister-in-law, claiming in a letter made public in court documents that the “extremely high” charges weren’t justified.
The Singapore Health Ministry said in a letter of complaint made public in court documents that “overcharging on such a magnitude could also bring disrepute to the medical profession in Singapore.”
Lim had voluntarily cut Damit’s original bill to S$12.1 million including S$3.3 million for a team of doctors and nurses, according to court papers. The amount covered “extraordinary” services including setting up medical facilities in hotel suites and “round the clock devotion,” to the patient, her lawyers from Rajah & Tann LLP said in the court papers.
Lim, 56, married to Citigroup Inc. private bank Chairman Deepak Sharma, said in the e-mail she reduced the bill “as a gesture of friendship.” She said the perception she cut the cost to avoid professional misconduct charges is untrue.
Singapore’s health ministry began a probe in 2007 to determine whether Lim’s bills showed a pattern of overcharging, improper billing and whether some fees were inappropriate for services done by other doctors. A panel appointed by the medical council to hold the inquiry stepped down after Lim complained the members had prejudged her case. A second panel is now pursuing the investigation.
Lim failed to block the second hearing when the city’s high court ruled on May 26 that it could proceed. Lim has until June 27 to appeal.
Officials from the medical council declined to comment for this story, referring to a May 26 statement that said the council will continue to take all steps to ensure “a full, fair and timely hearing of the matter.”
Singapore Health Ministry officials referred inquiries to the city-state’s tourism board, which said Lim’s case had “minimal impact” on the island’s medical tourism industry.
Lim’s case has renewed calls for medical fee guidelines in Singapore to be reinstated. The Competition Commission of Singapore had rejected the proposal last year.
“People who are coming in for medical tourism would like to ensure that the clinics and doctors are credible and have some certainty of their expenses before even making the trip,” said Janson Yap, the Southeast Asia head of life sciences and health care at Deloitte LLP. “Having guidelines would be helpful.”
The antitrust regulator said more effective measures include the health ministry’s requirement for itemized medical bills and hospitals providing financial counseling for patients.
The controversy over the Brunei bills resulted in a loss of new patients and other businesses being put on hold, Lim said. Her medical practice is now “technically bankrupt” and if not for a loan she and her family provided would have shut down, she said.
The value of her medical practice plunged to S$11.6 million, based on 2008 financial statements, from S$103 million two years earlier, she said.
Singapore earned S$940 million from medical tourism last year, according to the tourism board, which has a goal of 1 million medical tourists by 2012. A group of doctors and investors is building an S$800 million integrated private hospital, medical center and hotel to attract more foreign patients.
Other Asian nations have their own initiatives.
Thailand, whose King Bhumibol Adulyadej is the world’s richest royal, has a five-year plan to double revenue from foreign patients by 2014. Malaysia has eased health-care advertising guidelines and offers tax breaks to hospitals serving foreign patients.
India, home to the Taj Mahal, says it’s a “perfect destination” for medical tourism, combining health treatments using the latest technology and visits to “some of the most alluring and awe-inspiring places of the world.”
A heart bypass costs $10,000 in India, $20,000 in Thailand and $23,000 in Singapore, according to data from Deloitte. The same surgery costs $44,000 in Dubai and $130,000 in the U.S.
“While list prices appear higher in Singapore than in other Asian countries, final bills are often comparable due to shorter hospital stays,” said Tan Yen Nee, deputy director of enrichment at the Singapore tourism board.
“We’ve only had two or three patients seek care in Singapore over the last three or four years,” said David Boucher, president of Companion Global Healthcare Inc., a Columbia, South Carolina-based medical tourism facilitator that sends about 25 employees of U.S. companies to Asia each year.
Most go to Bumrungrad Hospital Public Co. in Thailand, Boucher said.
Bangkok’s Bumrungrad treated 30 percent more patients from Singapore between January and April compared with a year earlier, triple the hospital’s overall growth rate, said Kenneth Mays, the marketing director at the hospital.
The United Arab Emirates’ Health Ministry settled a billing dispute with Singapore in 2008 after the fees to about 100 UAE patients were halved to S$17.2 million, according to court papers.
Lim had said Damit agreed to her charges of S$100,000 to as much as S$200,000 a day, according to court papers. The Brunei Health Ministry said it wasn’t aware of such an arrangement.
Singapore’s medical fees still are significantly lower than charges patients face in London or Dubai, said Moza Juma Mattr, a Dubai citizen who visits Lim twice a year for treatment. The allegations against Lim haven’t dissuaded Mattr, who spoke in Lim’s clinic where one wall is lined with pictures of the surgeon posing with past U.S. presidents including Jimmy Carter and Bill Clinton.
“I’m shocked by the complaints against Susan,” said Mattr, wife of Mohammed al-Gergawi, United Arab Emirates’ Minister for Cabinet Affairs. “I don’t believe that a smart woman like Susan will destroy her reputation and Singapore’s.”