How much is TOO MUCH?
A REASONABLE DAILY FEE, ONE DOCTOR SAYS, IS $1,000-$2,000 BUT ANOTHER SAYS: $450,000
By Salma Khalik, Health Correspondent
Just how much can a doctor charge a patient?
As little as one to two thousand dollars a day, and as much as $450,000 a day - these are the two extremes that doctors themselves considered reasonable fees for Dr Susan Lim to have charged for round-the-clock service to a royal patient from Brunei. The figures were quoted by expert witnesses during the first disciplinary hearing against the private surgeon for overcharging Pengiran Anak Hajah Damit, who was the Brunei queen's sister and Sultan Hassanal Bolkiah's cousin.
A summary of the first disciplinary hearing - which ended without a verdict - was submitted to the High Court last week. The court will decide whether the Singapore Medical Council (SMC) can proceed with a second hearing against the surgeon. Dr Lim's lawyer, senior counsel Lee Eng Beng from Rajan & Tann, argued in the High Court that as far as such fees go, there is no industry standard. This is because Singapore's Competition Commission had already ruled against such fee guidelines, saying they were uncompetitive. Fees vary, therefore, from case to case. And in the case of this particular patient, Dr Lim had an agreement with her that the fees would come to $100,000 to $200,000 a day for the 24/7 service requested, said Mr Lee.
However, lawyers for the SMC dispute that there was ever such an agreement, based on correspondence from the Health Ministry in Brunei. They said that what Dr Lim had was a 'standard letter' that patients at all hospitals sign, adding: 'We do not believe that this is licence for doctors to render exorbitant bills and insist on payment of these bills which are not justified by the treatment given.'
The Ministry of Health (MOH) has levelled 94 charges against Dr Lim, of which about 10 relate to services provided by other specialists. Those 10 charges claim that Dr Lim had marked up the bills significantly, in one case, by as many as 526 times. The first disciplinary hearing convened by the SMC to look into the MOH charges was curtailed without a verdict. Dr Lim is now fighting the SMC's attempt to convene a fresh hearing and has taken the case to the High Court. In the first hearing, lawyers from both sides had called expert witnesses to try and establish what would be considered a reliable benchmark for fees.
The total Dr Lim charged the patient in 2004 was $2.8 million; for 2005, it was $3.8 million; and for 2006 it came to $7.5 million. Dr Hong Ga Sze, a surgeon in private practice who said he had assumed routine work, pegged the daily rate at $1,000 to $2,000. Dr Tan Yew Oo, an oncologist at the Gleneagles Cancer Centre, gave a rate of $10,000 to $20,000 a day. Professor Soo Khee Chee, head of the , said $100,000 a day was fine and agreed that on a day such as June 14, 2007 - when the patient, who was very sick, was air-lifted to Brunei - Dr Lim could have charged as much as $450,000 as the service provided was 'unique'. This includes all other expenses, such as the cost of the plane.
Just for Dr Lim's service, without the extras, he said, she could have charged up to $300,000 that day. His conclusions, he said, were based on his own experience and sense of morality. The three doctors were all witnesses for the SMC.
In their written submission to Justice Philip Pillai, who is presiding over the judicial review of the legality of SMC setting up a second disciplinary committee, Dr Lim's lawyers concluded: 'SMC's expert witness have failed to testify as to an established benchmark for what fees are acceptable.' They added: 'Top surgeons and doctors can earn millions of dollars in income if their services are highly sought after by patients and are priced accordingly.
'It is public knowledge that top surgeons such as Dr , prior to joining government service, earned an income of $4.5 million in 2001.'
They also cited examples of high charges levied by other doctors. Professor Ian Smith of the Royal Marsden Hospital in England, who treated the Brunei patient for two days, in January and April 2007, sent a bill for $135,000.
Dr Lim's lawyers said Prof Smith was an employee of Britain's National Health Service and did not have to worry about business costs. Unlike Dr Lim, he did not have accompanying staff and spent only 15 minutes with the patient each time. Among Singapore doctors, Dr Khoo Kei Siong, deputy director of Parkway Cancer Centre, quoted a fee of $300,000 - excluding expenses like a first-class air ticket and accommodation - for a 30-minute consultation overseas that took less than three days in all, including travel time.
Dr Goh Seng Heng, a general practitioner who does aesthetic treatments, charged $55,000 for 21/2 hours of treatment spread over 15 days. He also charged an Indonesian client $3,000 an hour for the 17 hours of travel and treatment time he undertook. The total bill was $51,000. On another occasion, Dr Goh charged $25,000 for a 15-minute session when equipment was used.
Dr Lim's lawyers also argued that the fees, as initially proposed, properly reflected the commercial costs of devoting a large part of the resources of the Susan Lim Holding group almost exclusively to the patient. This included clearing the entire clinic of other patients before the arrival of the royal entourage.
In 2007, Dr Lim's original bill was $24.8 million, before goods and services tax (GST). If this had been paid in full, it would have made up the lion's share of the group's revenue for the year of about $31 million. And this revenue figure is less than the $32.5 million projected revenue based on past growth. Profit before tax also fell. If the Brunei palace had paid the discounted $12 million bill in 2007, profit before tax would have been $5.7 million. This would still have been lower than that of the three preceding years, when Susan Lim Holding's annual pre-tax profit averaged $7.6 million.