Advisers are warning that the severity of medical inflation in the United Arab Emirates (UAE) is making international private medical insurance (IPMI) unsustainable in the region.
The panel at Health & Protection’s Middle East IPMI roundtable in Dubai heard that medical inflation is “the biggest critical factor after adviser knowledge” affecting the sector in the UAE, with members seen as revenue not patients.
And they agreed that issues needed to be tackled across the industry by advisers and insurers to affect behaviour change from patients, employers and doctors to bring soaring costs under control.
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Medical inflation has been running at around 10% per year for several years in the region and this is expected to continue for several more.
The issue is such a significant one that Damien Walsh, director of health and protection at AES International, called it “the biggest critical factor after adviser knowledge”.
He primarily laid the blame at the door of healthcare providers, hospitals, clinics, doctors and other practitioners, questioning the integrity of all those who participate and allow it to happen.
“We have to tackle them. As advisers we have to name and shame the facilities because the system is broken and the bonus system that doctors get for running a CT, MRI or an ultrasound is wrong,” he said.
“And that’s where the rules have to come in for having codes and regulating the amounts that you can actually charge at those particular facilities.
“That will mean insurers can actually make money, we can make money and satisfy our clients. Then it can become sustainable, but this model at this point in time is not going to work.”
Walsh added that while the introduction of terminology rules to improve consistency on costs was welcome, he believed hospitals and doctors would still look to get around it or hide costs in other ways.
“You can have your colonoscopy at whatever price it may be, but it’s the ancillaries that they’re going to throw into it,” he continued.
“But our members are not patients in the UAE. They are revenue. The first question the doctor will ask you is what is your insurance? It’s not, how sick are you?
“Why can’t we as leaders around the table name and shame the people doing CTs, MRIs and follow-up MRIs all in the space of 10 days?”
‘STAND SHOULDER TO SHOULDER’
The panel also highlighted other tactics often used by providers to encourage patients to agree to unnecessary diagnostics or treatments themselves.
However, Lifecare International group commercial director for MEA Amber Mussen-Thorp noted there was hope for the situation as many people in the industry, including several on the panel, had experience in locations where cost containment had been successful.
And she urged insurers to work together to help restrict the bad practices suffocating the market.
“We’ve got the ability to see into the future and know how we’ve mastered it in the UK so we can bring that to this market,” she said.
“It has to start from somewhere. You have to as insurers stand shoulder to shoulder.
“Procedure pricing would be a fantastic thing here with all the overtreatment – everything’s collected in that one code.
“Insurers can audit their cost from the administrator because it will say one consultation, one set of diagnostic tests, the operation and follow up physio, and that procedure will cost X amount.
“That’s how you can monitor it and track it from an audit perspective.”
Along with insurers working more closely together, the quality of service from healthcare providers was also raised, with the panel noting many facilities were compromising the quality of their work.
This produced a call for additional oversight from regulators to further look at hospital practices.
“It just has to be greater regulatory control over the facilities themselves,” said Beneple director of corporate insurance services Boyd Edmondson.
“We talk about medical inflation, we talk about price points in terms of companies going out and buying cheap and nasty, the origin of that is driven by pricing at the medical facilities.
“And if we address the pricing at the medical facilities, we’re clearing up a lot of issues along the way.
“Whether we ever get that right is a difficult one to answer, but that’s where the inflationary increases and the cheap and nasty type of products come from – it’s a result of what the medical facilities are dealing with.”
As an example of the costs in the system, repeat prescriptions are often only issued after another $200 consultation, rather than as the routine service it is in many parts of the world.
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‘IT WAS THE PATIENT’S FAULT’
However, it appears that healthcare providers are unlikely to accept this torrent of criticism lightly and have come up with unusual arguments to defend some of their practices when they feel threatened or called out.
Cigna Insurance chief distribution officer for Middle East and Africa Leah Cotterill detailed one experience at a conference a few weeks earlier where she had been speaking about using technology to combat medical fraud, waste and abuse.
“One of the healthcare providers in the room decided he had a point of view on this and that I was the insurer pointing the finger at the healthcare providers,” she recounted.
“He said it wasn’t the healthcare provider’s fault, it was the patient’s fault because the patient comes into the room and says: ‘I’ve been on Google and my friend told me, I need this, this, this, this and this’.
“And he felt, therefore, that they were compelled to do that. I did politely in front of the room suggest to him that wasn’t the point.”
Despite this, Cotterill was keen to stress that she did not want to tar all providers, facilities and clinicians with the same brush.
But she noted that to avoid these practices, common processes such as pre-authorisation and other checks and balances needed to be done which can have an unwanted knock-on effect to the customer experience.
Cotterill emphasised that insurers do not want to delay care, but explained investing in data and behavioural analysis was helping inform insurers about potentially problematic doctors.
“We’ve been looking at how we can use historical data to inform the patterns of behaviour not of clinics but of actual doctors to look at cost per encounter,” she continued.
“We did a lot of this analysis for the Smartcare product launch and the network for that product is based on cost per episode rather than just on unit cost.
“We’re a fair way down the line with this, looking at how we engage differently with providers that behave well and do the right thing and we’re actually quite happy to pay them more, because if they get better outcomes quicker for patients, that’s a really positive result.
“You end up potentially with this scenario, with investment and the industry coming together, where you say these are the good guys and I don’t need to worry about pre-authorisation or my preauthorisation limit is higher or it’s for a much smaller number of conditions.
“And in contrast with others, they’ve demonstrated that they’re not good actors and therefore, I’m going to start them off from zero pre-authorisation, and then you allow market forces to engage.”
TARGETING BAD BEHVIOURS
This insight moved the discussion onto how technology could influence behaviours and act as a further break on surging costs, while not impacting care or the patient experience.
One suggestion was that the rapid growth of and familiarity with remote and virtual consultations during the pandemic meant it was feasible to use these facilities more proactively.
These could help gatekeep the treatment journey, keep patients out of overused facilities and prevent potential overcharging, while giving more practical benefits such as removing travel time.
Or the option of replicating a model used in other major cities where a doctor makes personal visits within a certain radius was cited as potentially being cheaper than visiting a private consultant.
However, there was recognition that many residents actively enjoyed visits to doctors and made an event out of it.
This was just one of the behavioural trends among employers and end users that the industry would need to work hard to shift wherever possible.
Mayar Jaroudi, general manager – GCC at Now Health International, recognised that market behaviour has to be changed in many ways.
“Control has to be from the patient side,” he explained.
“In Europe, in the U.K. and everywhere else, when you’re given medication, you’re given a certain number of pills. Here, you walk in and you get the whole bottle and it gets thrown in a big mixed bag of other medication.
“I’ve seen several occasions where patients have pushed back and asked why do we need all this? So the behaviour itself and the ease of access needs to be changed.
“But the legislation to prevent this is on its way, the coding is there and more and more will be coming in.”
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KEY ROLE FOR ADVISERS
This reforming of patient behaviours was also recognised as a key role for advisers who are able to use their influence to warn clients about bad behaviours at certain facilities.
“Here comes our role as advisers in the patient education and the cost containment concept, we have a lot to say here,” said Nasco regional customer development director Diana Haydar.
“We have the patient education part because they trust us. We can orient them on things such as ‘beware of this hospital as they abuse the system, go there instead’.
Haydar also urged her intermediary colleagues to only deal with insurers who believe in using teleconsultations, noting not all have them embedded in their policies or services.
“And whenever we are negotiating renewals we see overutilisation or we see where the numbers are being inflated, we know that these are not the real numbers,” she continued.
“So we have a lot to do here as advisers but again, only if we are really qualified for this, not if we are only transactional brokers.”
And that responsibility for advisers is also passed on to working with employers and helping to guide their behaviours, informing them about the impact on premiums and their bills by carrying on as normal.
Indeed, some employers can be very stubborn in their desire to include certain facilities and educating them can be a challenge and a lot of hard work.
“I have seen with a lot of my clients they specify certain providers on the insurance contract,” explained Health Beyond Borders CEO and founder Laila Al Jassmi.
“They do not understand when insurers tell them a provider is a high cost to their budget and the quality of outcome might not be to the level they expect.
“But they still say their employees come from a certain country or part of the world, and they just want a certain provider to be within the network.
“This is something I have seen with a lot of my clients where we reach a point that we cannot do anything and if we don’t get this provider on board, we lose the project.”
DEMAND FOR DATA
Other panellists highlighted the options of negotiating with hospitals separately where possible or by adding a significant co-pay up to a certain value when including high-cost facilities in treatment networks.
This then pushes some of the onus onto the scheme sponsor to meet that commitment.
However, the lack of clear, transparent, independent and authoritative data about the performance of hospitals was another area advisers would like to see action on.
Without these independent figures they accepted it was hard to persuade some employers that providers were not offering good quality service.
There was a desire for either insurers, third party administrators or regulators to take on the situation and begin publishing authentic figures to help illustrate the situation and allow advisers to let the evidence make its mark.
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