ARE WE MISUSING OUR MEDICAL INSURANCE COVERS?

Savannah* and Summer* are five year old twins in kindergarten who are spending their Sunday afternoon at the outpatient department of a private hospital. Last night, Savannah coughed so much, nobody got to sleep much. But by this morning, she had settled down to just a runny nose and she was able to attend the church service with her family. Thankfully she has no fever and her appetite is fine.

After the service, the family headed out to a restaurant for lunch and decided to make a quick stop by the hospital to see a doctor and make sure the cough is taken care of. At the hospital, the mother fills out two insurance claim forms so that both twins can have a doctor’s review. This is despite the fact that Summer has no symptoms.

During the review, Savannah is found to have a viral upper respiratory tract infection and is put on antihistamines to alleviate her symptoms as the infection clears. Summer is found to be well and does not warrant a prescription. Her mother insists that she should have an antihistamine to go just in case she develops symptoms in the course of the school week. The doctor politely declines but the twins’ mother is not happy.

Majority of private medical insurance holders in this country are covered primarily by their employers. Only a small minority hold an individual cover. To this end, many private medical insurance providers, for many years, did not provide the product to individuals. As the employers will cover the principle and his family, the spouse and children are able to access medical care with ease, much to the relief of the family breadwinner.

However, many medical insurance providers will confess that medical insurance as a product, is likely to generate losses as a bottom line, than any other insurance product offered. Many insurance providers are battling with fraudulent claims as a source of their losses. Yet in retrospect, maybe the focus should be geared more towards managing wastage and misuse of the medical cover.

For many doctors who work in the outpatient setting, it is easy to observe when the family outpatient cover has been exhausted before the end of the year. The visits to the doctor get fewer as the patient has to dig into their pocket to pay for the service and the medication. Once the new year starts, the visits increase yet again and all non-emergency problems are now addressed.

Access to healthcare is a basic right enshrined in the constitution. Private medical insurance goes a long way in easing the financial burden for many families in Kenya. However, if we are going to run the medical insurance industry into losses, out options are only going to get limited. The only way for them to stay afloat is to either raise the premiums or to lower the benefits package.

To this end, how then can we work together to ensure this resource is not misused? The wastage must be curbed. Health management information systems (HMIS) interoperability may be of great help. Quite frequently, a patient may seek care in three different places for the same medical condition because they are not getting better fast enough. Each visit warrants a new consultation, a new battery of medical tests and a new prescription. All these are billed separately.

A mother who comes home to find her baby coughing with fever and vomiting, will rush to hospital in the evening and get a prescription of Augmentin and Panadol for tonsillitis. If the fever has not broken by morning, she seeks a second opinion at a different facility and gets a prescription of Zinnat and Calpol for the same diagnosis. After 48 hours of unremitting fevers, she seeks a referral to a paediatrician who prescribes a three-day course of Ceftriaxone and Adol as the baby is vomiting and unable to keep the medication down. She has no problem complying with all these orders since she does not have to worry about the cost. Her medical insurance is covering for it.

By the third day, the baby is getting better, the fever has settled and he is sent home to complete treatment on Cifex for another five days. By the end of treatment, the baby has two bottles of unused antibiotics at home that have to be discarded and two bottles of paracetamol formulations that are opened and due to expire before they are needed again. In the meantime, the insurance company has settled the bills for all these wasted medicines.

Unfortunately, it is difficult to prove whether the change of antibiotics is what resulted in resolution of symptoms or was it simply a result of time. At initiation of treatment, even with the most powerful antibiotics, different infections take different time periods to respond to treatment adequately enough for symptoms to settle.

Therefore, every one of those antibiotics taken even for a day, contributed to fighting the infection. Given sufficient time, the first prescription could quite possibly have taken care of the infection and the symptoms but it was stopped prematurely.

In the event the baby’s records were accessible to all the care givers handling him irrespective of the hospital or clinic where care was sought, it would be possible to use what the baby already has at home efficiently and safely to prevent wastage.

The same scenario applies in diagnostic investigations which may be repetitive just because the patient goes home without a copy of their test results, which could be used by the next doctor. A patient undergoes CT Scan of the head but since the results are confined to the hospital HMIS, change of doctor or medical institution means that they have nothing to show from their previous caregiver. The new care team is forced to start all over again, at an unnecessary cost.

The technology available in this country should make it possible for everyone to have a form of centralized medical record database, accessible to their care providers as needed, irrespective of location. This will promote prudent prescription practices and help fight antibiotic resistance.

It is time the medicine cabinets at home stopped looking like mini-pharmacies!