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Means testing has been in place since 2000, with major changes to the rules being made in October last year. Here's how it works for step-down care: Medical social workers ascertain the incomes of a patient, his or her spouse and their children, whether or not they are living with their parents. This total income is then divided by the number of 'dependants' in the family to get the per capita family income. If the children are married and have kids of their own, both children and grandchildren are classed as dependants if the patient's child is working. But they are not included in the count if the patient's child has no income. Income from the patient's children-in-law is not taken into account. Said Ms Jenny Wong, a medical social worker with Dover Park Hospice: 'Means testing is a time-consuming affair, whether family members are cooperative or not.' Things can get complicated, especially if the patient has had multiple marriages. Some older patients have more than one spouse and about a dozen children. All their incomes would need to be computed. What is worse is having to deal with family members who are not on talking terms. Some fear that other family members may find out how much they earn, in spite of reassurances that such information is confidential. Taking all possible dependants into account is important, as it could change the amount of subsidy the patient gets. Patients with a per capita family income of $300 or less get a 75 per cent subsidy. If it is between $301 and $700, a 50 per cent subsidy is given; and those who fall within the $701 to $1000 band get a 25 per cent subsidy. The difference among the bands could involve a few thousand dollars a year. That is why medical social workers try to get patient's children, who might do odd jobs or part-time work, to declare their incomes, so that they and their children would be included as dependants. This could increase the amount of subsidy the patients receive. Even when everyone cooperates, it takes time to get all the information. Take, for example, something that might appear straightforward - a printed payslip. Usually, this would require the patient to make a special request to his employer, explaining why he requires a payslip. A ministry spokesman said about 10 per cent of patients who apply for a subsidy do not receive it. Lack of cooperation from the family is a major reason. Nevertheless, the total subsidy given out has increased over the years, from about $80 million in financial year 2004/5 to more than $100 million last year. Most of the 4,000 subsidised patients get the maximum 75 per cent, the spokesman said. The nursing homes' experience with means testing, based on family income, led to several changes to ease administration last October. The ministry now accepts self-declaration of income by odd-job workers, instead of requiring a statutory declaration which costs $20 to $25 and requires a trip to the Supreme Court or a lawyer's office. The ministry has also become less stringent: Patients who live in private properties used to be ineligible for subsidies. Now, those living in 'lower-end' private properties with annual values of less than $10,000 are treated the same way as HDB dwellers. Some leeway has also been given to the nursing homes to vary subsidies - so long as this involves less than 10 per cent of their subsidised patients. Dr Noreen Chan, chief executive officer of Dover Park Hospice, gave this example: A patient from a family that qualifies for a 50 per cent subsidy might be given 75 per cent instead, because he or she is the second in the family requiring step-down care. But at Ang Mo Kio Community Hospital, this rule is rarely relaxed, with only 13 cases in the past three years needing - and getting - more than they qualified for. Mr S. Vivakanandan, chief executive officer of Ang Mo Kio-Thye Hua Kwan Hospital, said that since the changes to the system last year, no patient had needed a bigger subsidy. This was due to the robust nature of means testing, he said, which ensures that deserving needy patients do not 'fall through the administrative cracks'. Using family income works in the step-down facilities because of the longer duration of stay - weeks, sometimes even months or years - that makes the extra effort worthwhile, to achieve a fair subsidy system. Even then, it requires much paperwork to assess the 4,000 patients who are subsidised each year. It is not something that can be duplicated easily in public hospitals, which see more than 200,000 subsidised patients each year, mostly for just a few days at a time. Furthermore, how many families would be prepared to turn up with documents showing the entire extended family's income, at a time when they have a critically ill patient to worry over? Here, a quick and simple system might well work better than a fairer but more complicated one.
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