Great Eastern’s decision to suspend pre-authorization certificates for Mount Elizabeth and Mount Elizabeth Novena hospitals represents a significant shift in Singapore’s private healthcare landscape, highlighting escalating tensions between insurers and premium private hospitals over cost control and pricing transparency.

Background Context

The Pre-Authorisation System

Pre-authorization serves as a critical financial safeguard in Singapore’s healthcare system:

Risk Mitigation: Confirms insurer approval before treatment begins
Cost Certainty: Provides patients with guaranteed coverage confirmation
Administrative Efficiency: Streamlines billing between hospitals and insurers
Cash Flow Protection: Reduces patient out-of-pocket exposure

Mount Elizabeth Hospital’s Market Position

Premium Positioning: Among Singapore’s most expensive private hospitals
International Reputation: Popular with medical tourists and expatriates
Advanced Facilities: State-of-the-art equipment and specialist services
Corporate Backing: Part of IHH Healthcare, Malaysia’s largest private healthcare group

Financial Impact Analysis

Cost Differential Evidence

Great Eastern’s claims of 20-30% higher costs (sometimes more) suggest:

Significant Premium: For a $50,000 procedure, this translates to $10,000-$15,000 additional cost
Compound Effect: Higher baseline costs amplified by length of stay and ancillary services
Procedural Variations: Even routine procedures carry substantial premiums

Impact on Hospital Bills

Immediate Financial Consequences

Patient Cash Flow Risk
- Patients must pay upfront without a pre-authorization guarantee
- Potential delays in treatment while arranging payment
- Increased financial stress during medical emergencies
Administrative Burden Shift
- Hospitals must issue an eLOG (electronic Letter of Guarantee) instead
- Claims processing becomes retrospective rather than prospective
- Increased documentation and verification requirements
Payment Uncertainty
- Claims are subject to post-treatment assessment
- Potential for partial claim rejections
- Disputes over “reasonable and customary” charges

Long-term Financial Implications

Pricing Pressure: Hospitals may need to moderate pricing to maintain insurer relationships
Market Positioning: May affect Mount Elizabeth’s premium positioning strategy
Revenue Impact: Potential reduction in Great Eastern policyholder admissions

Insurance Market Dynamics

Great Eastern’s Strategic Rationale

Cost Control Imperative
- Rising medical inflation threatens profitability
- Actuarial pressure to manage claim costs
- Need to maintain competitive premium pricing
Negotiating Leverage
- Using suspension as a bargaining tool for better rates
- Demonstrating commitment to cost management to regulators
- Setting precedent for other high-cost providers
Market Discipline
- Encouraging price transparency across the private hospital sector
- Promoting value-based healthcare delivery
- Reducing cross-subsidization between hospitals

Broader Insurance Industry Impact

Precedent Setting: Other insurers may follow similar strategies
Provider Relations: Shift from partnership to adversarial relationships
Market Segmentation: Potential creation of tiered hospital networks

Stakeholder Impact Assessment

Patients (Great Eastern Policyholders)

Immediate Impacts:

Financial Exposure: Increased upfront payment requirements
Treatment Delays: Potential postponement while arranging payment
Anxiety: Uncertainty about coverage and costs
Choice Limitation: Pressure to choose alternative hospitals

Long-term Consequences:

Premium Implications: Potential for lower premium increases if cost control succeeds
Network Changes: Possible expansion of preferred provider networks
Coverage Evolution: Potential for more restrictive policy terms

Mount Elizabeth Hospitals

Operational Impacts:

Cash Flow: Immediate reduction in guaranteed payment stream
Patient Volume: Potential decline in Great Eastern policyholder admissions
Pricing Pressure: Need to justify premium positioning
Administrative Costs: Increased billing and collection efforts

Strategic Considerations:

Market Position: Challenge to premium brand positioning
Competitive Response: Need to demonstrate value proposition
Negotiation Stance: Balancing revenue protection with market access

Healthcare Ecosystem

Medical Professionals

Income Impact: Potential reduction in procedures at affected hospitals
Practice Patterns: May influence referral decisions
Professional Relationships: Strain between insurers and specialist doctors

Regulatory Environment

MOH Involvement: Government oversight of insurance-hospital relationships
Policy Implications: Potential for regulatory intervention in pricing
Market Monitoring: Increased scrutiny of private healthcare costs

Systemic Implications

Market Structure Changes

Power Dynamics: Shift from hospital-dominated to insurer-influenced pricing
Consolidation Pressure: Smaller hospitals may struggle with insurer demands
Innovation Incentives: Focus on cost-effective rather than premium services

Healthcare Affordability

Access Concerns: Risk of creating a two-tier system based on insurance coverage
Cost Transparency: Pressure for more transparent pricing across the healthcare sector
Value-Based Care: Emphasis on outcomes rather than amenities

Risk Assessment

Short-term Risks

Patient Disruption: Immediate impact on planned procedures and treatments
Legal Challenges: Potential disputes over policy interpretation
Regulatory Intervention: Government action to protect patient interests

Long-term Risks

Market Fragmentation: Creation of incompatible insurer-hospital networks
Quality Concerns: Potential compromise in care quality due to cost pressure
Access Inequality: Differential treatment based on insurance coverage

Strategic Recommendations

For Great Eastern

Communication Strategy: Clear explanation of alternative processes to policyholders
Negotiation Approach: Seek structured pricing agreements rather than blanket suspension
Network Development: Strengthen relationships with cost-effective providers

For Mount Elizabeth Hospitals

Value Demonstration: Provide clear justification for premium pricing
Cost Structure Review: Identify areas for efficiency improvements
Alternative Partnerships: Diversify insurer relationships

For Policyholders

Treatment Planning: Consider alternative hospitals for non-emergency procedures
Policy Review: Understand coverage implications and alternatives
Financial Planning: Prepare for potential upfront payment requirements

Conclusion

Great Eastern’s pre-authorization suspension marks a significant milestone in Singapore’s private healthcare market, signalling a shift toward more stringent cost management by insurers. While this may help control healthcare inflation and premium increases, it also introduces new risks and uncertainties for patients and healthcare providers.

The ultimate resolution will likely require a balanced approach that addresses legitimate cost concerns while maintaining patient access to quality healthcare. The outcome will have a significant impact on the future structure and dynamics of Singapore’s private healthcare market.

This situation exemplifies the broader global challenge of balancing healthcare quality, accessibility, and affordability in mixed public-private healthcare systems. The resolution of this dispute will serve as an essential precedent for healthcare policy and market dynamics in Singapore and potentially other similar healthcare systems.

Great Eastern’s Pre-Authorisation Suspension: Implications for Hospital Bills and Insurance in Singapore

Executive Summary

Great Eastern’s decision to suspend pre-authorization certificates for Mount Elizabeth hospitals represents a pivotal moment in Singapore’s healthcare landscape, with far-reaching implications for hospital billing practices, insurance coverage models, and patient access to care. This comprehensive analysis examines the immediate and long-term consequences across Singapore’s healthcare ecosystem.

Background: The Singapore Healthcare Context

Healthcare System Structure

Singapore operates a unique mixed healthcare system combining:

Public Healthcare: Subsidized care through government hospitals and polyclinics
Private Healthcare: Premium facilities serving locals and medical tourists
Insurance Framework: MediShield Life (basic coverage) + Integrated Shield Plans (enhanced coverage)
Medical Tourism: Significant revenue from regional patients seeking advanced care

The Role of Integrated Shield Plans (IPs)

IPs serve as the bridge between basic MediShield Life coverage and full private healthcare access:

Coverage Enhancement: Higher claim limits and private hospital access
Premium Positioning: Allow access to premium facilities like Mount Elizabeth
Market Penetration: High adoption rates among the middle and upper-middle class

Immediate Implications for Hospital Bills

Impact on Patient Financial Exposure

Cash Flow Disruption

Before the Suspension:

Patients received pre-authorization confirming coverage
Hospitals billed insurers directly for approved amounts
Patient out-of-pocket limited to deductibles and co-insurance

After the Suspension:

Patients must pay the entire bill upfront (potentially $50,000-$300,000+)
Reimbursement becomes uncertain and delayed
Financial planning for medical care becomes nearly impossible

Specific Cost Categories Affected

Surgical Procedures: Complex surgeries requiring specialized equipment
- Cardiac procedures: $150,000-$400,000
- Orthopaedic surgeries: $80,000-$250,000
- Cancer treatments: $100,000-$500,000+
Emergency Treatments: Unplanned admissions with no time for financial planning
- ICU stays: $5,000-$15,000 per day
- Emergency surgeries: $50,000-$200,000
- Specialised interventions Variable, often exceeding $100,000
Ongoing Treatments: Chronic conditions requiring regular, expensive care
- Dialysis: $150,000+ annually
- Cancer chemotherapy: $200,000+ per treatment cycle
- Rehabilitation: $50,000-$150,000 for comprehensive programs

Hospital Billing System Changes

Administrative Burden ShiftPre-AuthorisatioPre-Authorisation

Pre-Authorisation: Streamlined billing with insurer guarantees
Post-Suspension: Complex eLOG processes and uncertain collections
Documentation Requirements: Enhanced record-keeping for claim justification
Collection Processes: Increased focus on patient payment arrangements

Revenue Cycle Impact

Cash Flow Timing: Shift from guaranteed payments to collection-dependent revenue
Bad Debt Risk: Increased exposure to unpaid bills from financially stressed patients
Administrative Costs: Higher overhead for billing and collection activities

Insurance Industry Implications

Market Dynamics Transformation

Insurer-Hospital Power Balance

Historical Relationship:

Hospitals set prices, and insurers largely accepted them
Limited negotiation leverage for insurers
Patient demand drove hospital selection

New Dynamic:

Insurers asserting cost control authority
Hospitals facing pricing pressure and reduced patient flow
Patients caught between competing interests

Competitive Responses

Other Insurers: Likely to adopt similar cost-control measures
Hospital Groups: May need to adjust pricing strategies across the board
New Market Entrants: Opportunity for value-focused insurance products

Product Evolution and Pricing

Policy Design Changes

Network Restrictions: More selective hospital partnerships
Tiered Coverage: Different benefits based on hospital choice
Cost-Sharing Adjustments: Higher patient contributions for premium facilities
Pre-Authorisation Expansion: Broader requirements across treatments

Premium Impact Scenarios

Scenario 1: Cost Control Success

Reduced claim costs lead to lower premium increases
Enhanced affordability for middle-income segments
Improved insurer profitability and sustainability

Scenario 2: Market Fragmentation

Premium products for high-end hospitals
Basic products for cost-effective facilities
Widening coverage gaps between products

Systemic Healthcare Implications

Access and Equity Concerns

Socioeconomic Stratification

High-Income Patients: Can afford upfront payments, maintain access to premium care
Middle-Income Patients: Face difficult choices between financial security and optimal care
Lower-Income Patients: May be priced out of private healthcare entirely

Geographic and Demographic Impact

Expatriate Community: May seek alternative insurance arrangements
Medical Tourists: Could impact Singapore’s medical tourism competitiveness
Ageing Population: Increased financial stress for the elderly requiring complex care

Quality and Innovation Effects

Hospital Response Strategies

Cost OpOptimizationEfficiency improvements without compromising quality
Value Demonstration: Enhanced outcome reporting and patient satisfaction metrics
Service Differentiation: Focus on unique capabilities and specialised services
Alternative Partnerships: Direct-pay arrangements and employer contracts

Innovation Incentives

Technology Investment: ROI calculations now include insurer acceptance
Treatment Protocols: Pressure to demonstrate cost-effectiveness
Research and Development: Focus on value-based rather than premium solutions

Regulatory and Policy Implications

Government Response Considerations

MOH Regulatory Authority

Market Monitoring: Enhanced oversight of insurer-hospital relationships
Consumer Protection: Ensuring policy contract compliance
Market Stability: Preventing systemic disruptions to healthcare access

Potential Policy Interventions

Price Transparency Requirements: Mandatory publication of treatment costs
Standardizedilling: Common procedures and pricing methodologies
Dispute Resolution: Formal mechanisms for insurer-hospital conflicts
Access Guarantees: Emergency care protections regardless of insurance status

Long-term Structural Reforms

Universal Coverage Expansion: Potential enhancement of MediShield Life
Price Regulation: Government intervention in private healthcare pricing
Insurance Market Reform: Standardisation of coverage and exclusions

Economic Implications

Healthcare Spending Patterns

Immediate Effects

Reduced Utilisation of Patients deferring or avoiding care due to cost concerns.
Facility Shifting: Migration from premium to mid-tier hospitals
Treatment Modifications: Choosing less expensive but potentially less optimal treatments

Long-term Trends

Cost Consciousness: Increased patient price sensitivity across all healthcare decisions
Value-Based Selection: Hospital choice based on cost-effectiveness rather than prestige
Insurance Shopping: More careful evaluation of coverage options and limitations

Medical Tourism Impact

Competitive Position: Potential erosion of Singapore’s premium healthcare brand
Regional Competition: Other countries may capitalise on onricing concerns
Economic Contribution: Reduced foreign patient revenue affects hospital finances

Future Scenarios and Outcomes

Best Case Scenario: Negotiated Resolution

Structured Pricing Agreements: Hospitals and insurers reach a compromise on rates
Enhanced Transparency: Clear pricing and coverage guidelines for patients
Improved Value: Better cost-effectiveness without compromising quality

Worst Case Scenario: Market Fragmentation

Access Inequality: A Clear two-tier system based on ability to pay
Insurance Complexity: Multiple products with confusing coverage variations
Quality Compromise: Cost pressure leading to reduced care standards

Most Likely Scenario: Gradual Adaptation

Selective Partnerships: Some hospitals accepting lower rates, others maintaining premium positioning
Product Differentiation: Range of insurance products for different market segments
Regulatory Intervention: Government action to address the most egregious access issues

Strategic Recommendations

For Policyholders

Review Coverage: Understand current policy limitations and alternatives
Financial Planning: Build healthcare emergency funds for potential gaps
Provider Research: Compare hospital options for planned procedures
Insurance Shopping: Evaluate alternatives during renewal periods

For Healthcare Providers

Value Proposition: Clearly demonstrate superior outcomes and specialised capabilities
Cost Structure Review: Identify efficiency opportunities without compromising quality
Diversification: Reduce dependence on any single insurer
Innovation Focus: Invest in cost-effective technologies and protocols

For Insurers

Communication: Transparent explanation of changes and alternatives to policyholders
Network Development: Strengthen relationships with cost-effective providers
Product Innovation: Develop tiered coverage options for different market segments
Data Analytics: Sophisticated outcome and cost-effectiveness analysis

For Policymakers

Market Monitoring: Close oversight of access and affordability impacts
Consumer Protection: Ensure insurance contracts are honoured appropriately
Stakeholder Engagement: Facilitate dialogue between insurers and providers
Long-term Planning: Consider structural reforms to enhance system sustainability

Conclusion

Great Eastern’s pre-authorisation suspension represents more than a billing dispute – it’s a fundamental challenge to Singapore’s healthcare financing model. The implications extend far beyond the immediate parties involved, affecting:

Patient Access: Creating financial barriers to previously covered care
Market Dynamics: Shifting power from providers to insurers
Healthcare Quality: Potential tension between cost control and clinical excellence
System Equity: Risk of increasing healthcare inequality based on financial capacity

The resolution of this crisis will have a significant impact on Singapore’s healthcare landscape for years to come. Success will require striking a balance between legitimate cost control concerns and patient access needs, while maintaining Singapore’s reputation for healthcare excellence.

The ultimate test will be whether Singapore can maintain its position as a regional healthcare leader while addressing affordability concerns that affect both local residents and international patients. The stakes extend beyond healthcare to Singapore’s broader economic competitiveness and social cohesion.

This situation serves as a microcosm of global healthcare challenges: balancing quality, accessibility, and affordability in an era of rising medical costs and increasing health complexity. Singapore’s response will provide valuable lessons for healthcare systems worldwide grappling with similar tensions between market forces and public health objectives.

The Pre-Auth Crisis

Dr. Sarah Lim adjusted her reading glasses and stared at the email that had arrived at 7:23 AM, her coffee growing cold as the implications sank in. The subject line was deceptively simple: “Temporary Suspension of Pre-Authorisation – Mount Elizabeth Hospitals.” But the ramifications were anything but simple.

“Great Eastern has temporarily stopped issuing pre-authorisation certificates…” she read aloud in her consultation room, her voice trailing off as she calculated the immediate impact on her patient roster.

Mrs. Chen’s cardiac bypass surgery, scheduled for Thursday. Mr. Rajesh’s kidney stone removal, planned for next week. The elderly Madam Wong, whose family had been saving for months for her hip replacement. All Great Eastern policyholders. All now face an impossible choice between financial ruin and postponed treatment.

Dr. Lim had built her cardiothoracic surgery practice at Mount Elizabeth over the course of fifteen years, drawn by the hospital’s reputation for excellence and its state-of-the-art facilities. The hybrid operating theatres, the advanced imaging systems, and the specialised cardiac team – these weren’t luxuries, they were necessities for the complex procedures she performed. But try explaining that to an insurance company focused on spreadsheets rather than surgical outcomes.

Her phone buzzed. Mrs. Chen’s daughter, Linda.

“Doctor, we just got a call from the hospital’s billing department. They’re saying we need to pay $180,000 upfront for my mother’s surgery? We don’t have that kind of money lying around. What’s happening?”

Dr. Lim closed her eyes. She’d had this conversation four times already this morning, and it wasn’t even 9 AM yet.

“Linda, there’s been a temporary change in Great Eastern’s policies. But listen to me carefully – your mother’s surgery cannot wait. We’ll figure out the payment arrangements. The hospital can issue something called an eLOG…”

“An e-what? Doctor, you’re not making sense. We purchased this insurance precisely so we wouldn’t have to worry about financial burdens related to our health. My mother worked her whole life, paid her premiums religiously. How can they just… refuse?”

How indeed, Dr. Lim thought. She’d seen the internal memos about Mount Elizabeth’s pricing. Yes, they charged more than other hospitals. But they also achieved surgical outcomes that other hospitals couldn’t match. The success rates, the reduced complications, the shortened recovery times – didn’t that count for something?

Her next patient arrived early. Mr. Syed, a 58-year-old executive scheduled for a complex valve repair. He looked haggard, stress lines etched deeper than when she’d last seen him.

“Doctor, I’ve been on the phone with Great Eastern all morning. They’re telling me I need to go to another hospital if I want pre-authorisation. You’ve been planning my surgery for weeks. You know my case. Can’t you just… operate somewhere else?”

Dr. Lim felt the familiar weight of responsibility settle on her shoulders. “Mr. Syed, your mitral valve repair requires particular expertise and equipment. I could theoretically perform it elsewhere, but the specialised heart-lung machine we need, as well as the particular surgical team I work with, are all here. Moving you to another facility would mean starting from scratch, new consultations, new planning, and honestly, I’m not sure they have the specific capabilities for your particular case.”

“So what are you saying? That I’m stuck?”

That’s precisely what she was saying, though she couldn’t put it so bluntly. Mr. Syed needed surgery within the next two weeks. His condition was deteriorating. But Great Eastern’s hardball tactics meant he’d have to pay $200,000 upfront and hope for reimbursement later.

Dr. Lim’s morning clinic was a parade of similar conversations. Worried families, confused patients, and financial coordinators frantically calling Great Eastern’s customer service, only to be told the same thing: no pre-authorisation for Mounfort Elizabeth hospitals, effective immediately.

By lunch, she’d rescheduled three surgeries, referred two patients to other hospitals against her better judgment, and spent forty-five minutes on the phone with a Great Eastern case manager who seemed more interested in reading from a script than understanding the medical urgency of her cases.

“Doctor, you have to understand, Mount Elizabeth charges 30% more than other hospitals,” the case manager had explained with the patience of someone who’d had this conversation dozens of times already. “We’re just trying to control costs for everyone’s benefit.”

“And you have to understand,” Dr. Lim had replied, her professional composure cracking slightly, “that my patients don’t care about your actuarial tables when they’re facing life-threatening conditions. That 30% pays for equipment and expertise that can mean the difference between a successful surgery and a catastrophic outcome.”

The afternoon brought a new complication. Dr. James Tan, her colleague in the orthopaedicc department, knocked on her office doo,r, looking defeated.

“Sarah, I just had to tell the Ng family that their daughter’s scoliosis surgery might need to be postponed indefinitely. The girl is sixteen, the curve is progressing rapidly, but they can’t come up with $150,000 on short notice. The father actually broke down crying in my office.”

They sat in contemplative silence. Both had entered medicine to help people, not to navigate insurance politics.

“You know what bothers me most?” Dr. Tan continued. “Great Eastern is spinning this as being about cost control and patient benefit. But they’re not offering their policyholders any real alternatives. They’re just creating a barrier and hoping people will either pay up or go away.”

Dr. Lim nodded, thinking about the email from hospital administration that had arrived an hour earlier. The chief medical officer wanted to meet with all department heads tomorrow to discuss “strategies for managing the current insurance situation.” Translation: figure out how to keep the hospital operating while one of Singapore’s largest insurers played hardball.

Her last patient of the day was different. Mrs. Kumar, a Great Eastern policyholder scheduled for a relatively routine gallbladder removal, had come prepared.

“Doctor, I’ve been reading about the tpre-authorisationtion issue online. I’ve already called three other hospitals for quotes. Singapore General quoted me $45,000 all-in for the same procedure. You’re quoting $65,000. I like you, I trust you, but I can’t justify paying that much more for what seems like the same operation.”

Dr. Lim appreciated Mrs. Kumar’s directness. “You’re absolutely right to ask these questions. Let me explain what that extra cost covers…”

She pulled up Mrs. Kumar’s scans on her computer screen. “Your gallbladder has some unusual adhesions from your previous surgery. At Singapore General, they’ll likely need to convert to an open procedure, which means a larger incision, a longer recovery, and a higher risk of complications. Here, we utilise the latest 4K laparoscopic equipment and specialised instruments, enabling us to maintain a minimally invasive approach even in complex cases like yours. Yes, it costs more upfront, but your recovery time will be half as long, and your risk of complications is significantly lower.”

Mrs. Kumar studied the images, then looked up at Dr. Lim. “But if something goes wrong, if Great Eastern doesn’t reimburse the full amount, my family will be financially devastated.”

And there it was – the impossible position that Great Eastern’s policy had created. Patients are forced to choose between potentially superior care and financial security, doctors are compelled to justify their expertise in purely economic terms, and hospitals are caught between maintaining standards and remaining accessible.

That evening, Dr. Lim sat in her car in the Mount Elizabeth parking garage, too exhausted to drive home immediately. Her phone showed seventeen missed calls from patients and their families, all with variations of the same question: What now?

She thought about her medical school oath, about the promise to “first, do no harm.” But what constituted harm in this situation? Recommending patients go to less equipped hospitals to save money? Asking families to mortgage their homes for medical care? Continuing to practice at a hospital that many of her patients could no longer afford?

Her phone rang. Linda Chen again.

“Doctor, we’ve decided to go ahead with my mother’s surgery. We’re borrowing against our flat, and my brother is flying in from Australia with his savings. But we trust you, and we can’t risk waiting any longer.”

Dr. Lim felt a mixture of gratitude and guilt. Gratitude that Mrs. Chen would receive the care she needed, guilt that it required such financial sacrifice.

“Linda, I promise you, we’ll do everything possible to ensure your mother has the best possible outcome. And I’ll personally follow up with Great Eastern about your reimbursement.”

“Thank you, DoDoctorYou know, this whole situation has made me realise something. Insurance is supposed to give you peace of mind, but right now, it feels like we’re fighting our own insurance company just to get the care we’ve already paid for.”

After hanging up, Dr. Lim finally started her car. Tomorrow would bring more difficult conversations, more impossible choices, more families caught between their health and their financial stability.

As she drove through the Singapore night, she wondered if Great Eastern’s executives, sitting in their air-conditioned offices making actuarial calculations, understood the human cost of their cost-control measures. Did they see the faces of the patients caught in the middle of their dispute with Mount Elizabeth? Did they lose sleep over the surgeries postponed, the treatments delayed, the families forced into financial hardship?

She suspected they slept well, confident in their spreadsheets and fiscal responsibility to shareholders. But Dr. Lim knew she’d be awake for hours, thinking about Mrs. Chen’s upcoming surgery, about Mr. Syed’s deteriorating condition, about the sixteen-year-old girl whose spinal curve was progressing while adults argued about money.

The pre-authorisation crisis had created more than administrative headaches – it had exposed the fundamental tension between healthcare as a business and healthcare as a human right. And caught in the middle were doctors like her, trying to heal people while navigating an increasingly complex web of financial gatekeepers and corporate policies.

As she pulled into her driveway, Dr. Lim’s phone buzzed with another message from a patient. The crisis wasn’t just changing how Mount Elizabeth operated – it was changing the very nature of the doctor-patient relationship, introducing financial stress into what should be purely medical decisions.

Tomorrow, she’d be back in the operating room, focused on the precision of her surgical technique and the well-being of her patients. But tonight, she’d go to the doctor, wondering if Singapore’s healthcare system was heading toward a future where your insurance company’s negotiation tactics mattered more than your doctor’s medical judgment.

The pre-authorisation suspension was supposed to be temporary. But Dr. Lim suspected its effects on patients, doctors, and the healthcare system would be anything but temporary. Some changes, once made, are impossible to undo.

And in the morning, there would be more phone calls, more difficult conversations, and more families forced to choose between the care they needed and the financial security they’d worked their whole lives to build.

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