When his father needed treatment for his prostate gland in 2008, property developer Yudi Rahmat Raharja found someone who could arrange for it to be done at a public hospital in Singapore.
The Jakarta-based agent organised everything, from an ambulance pickup at Changi Airport to doctors' appointments.
"I don't remember being charged any agent's fee, and had no issue with how much we were charged by the hospital," Mr Yudi, 50, said.
"We understood the agent's work was reflected in the total bill."
Instead of Mr Yudi footing the agent's commission, the hospital paid for it.
This practice of paying foreign agents to refer patients had been going on for years at some public healthcare institutions, with agents potentially earning thousands of dollars in referral fees.
But the institutions have now terminated such contracts.
The Ministry of Health (MOH) issued the order after The Sunday Times published a report about the connection between hospitals such as National University (NUH), Singapore General (SGH) and Changi General (CGH) and these agents.
MOH told The Sunday Times following the report in September last year that the priority of public healthcare institutions was to serve Singaporeans' healthcare needs.
While foreign agents were not tasked with marketing hospital services and served mainly to facilitate visits by foreign patients, the ministry said it wanted hospitals to cease such contracts, "to avoid potential misinterpretation and misrepresentation".
Foreign patients did not get subsidies and could be charged a premium for procedures performed by senior doctors, so agents' fees, as a percentage of the total bill, could be very lucrative.
In one case, an Indonesian agent contracted to provide NUH "administrative services" was paid 8 per cent of the hospital bill, excluding doctors' fees, for every foreign patient accepted by NUH.
BEHIND THE STORY
Senior correspondent Joyce Lim first got wind of the dealings between foreign agents and public health institutions when The Sunday Times obtained a contract signed by NUH with an Indonesian agent to provide "administrative services".
She spent a month staking out public hospitals and eventually tracked down foreign agents, who confirmed arrangements with NUH and SGH. The investigation crossed borders, with Indonesia correspondent Wahyudi Soeriaatmadja convincing Jakarta-based hospital agent HCM Medika to open up about the trade.
The expose led to public outcry over public health institutions paying such incentives when their priority should be to treat the sick in Singapore. Questions on such arrangements with foreign agents were also raised in Parliament, which led to disclosures by the Health Ministry on the numbers of foreign patients being treated at public hospitals.
The agent would get an additional percentage if the patient bill exceeded $500,000, and even more if it exceeded $1 million.
Jakarta-based hospital agent HCM Medika said that since it was established in 2007, it had facilitated medical visits for 15,000 patients to Singapore and Malaysia.
"For Singapore public hospitals, an appointment could take one to two weeks. For private hospitals, patients can get a confirmation and meet a doctor as quickly as the next day," said Ms Lena, a relationship officer at HCM Medika.
"We don't charge patients. We are getting fees from the hospitals."
She declined to disclose what a hospital would pay her company.
Other agents in Indonesia and Vietnam told The Sunday Times that they, too, had arrangements with SGH and CGH.
Among other hospitals, Tan Tock Seng said it did not engage such agents, while other public hospitals did not reply to queries.
SingHealth, which runs SGH and CGH, and NUH told The Sunday Times they would cease the agreements.
"NUH's foremost priority is to provide care for Singaporeans," an NUH spokesman added. "NUH reviews all referrals to ensure that it has the capacity, capability and resources to provide treatment that will be beneficial to the patient. Singaporeans are given priority for appointments and hospital beds."
SingHealth said the primary role of agents, which it termed "medical associates", was to help overseas patients navigate the healthcare system, including advising them on relevant health records needed and assisting with administrative paperwork and travel.
"Medical associates are non-exclusive to SingHealth and they charge an administrative fee (per patient) for their services," said SingHealth.
Doctors interviewed by The Sunday Times expressed concern about such fees.
"This practice of giving a 'referral fee' to 'medical agents' is unethical," said Dr Keith Goh, consultant neurosurgeon at International Neuro Associates. The 8 per cent commission on a hospital bill of $500,000 would be $40,000 - "which is more than the annual salary of a staff nurse", he noted.
Dr Tan Chi Chiu, chairman of the Singapore Medical Council's Medical Ethics Committee, said there is nothing wrong with public doctors treating foreigners. But foreign patients may pay more, and "doctors need to ensure that this does not set up a financial incentive" to favour such patients over subsidised ones, he said.
The concern about foreigners crowding out Singaporeans in restructured hospitals is not new and was raised in Parliament in 2010.
After The Sunday Times published its report, social media was flooded with queries about how many overseas patients were being treated at public hospitals and if they had contributed to the long waiting time for appointments.
As a result, two MPs raised the issue in Parliament last November.
Responding, Senior Minister of State for Health Lam Pin Min said public hospitals treated 10,900 foreign patients in 2017. Those referred by contracted service providers made up about 0.4 per cent of attendances in public health institutions.
Following the MOH's instruction to end contracts, public healthcare institutions also removed or blocked webpages containing information for overseas patients.
• This story is a compilation of articles published from Sept 30 to Nov 21 last year.