ALKHOBAR, 6 October 2006— The Kingdom is in the process of implementing new laws in regards to health insurance. While more and more medical insurance cards are being handed out every day, the value of those cards is questionable. Employers view health insurance as a cost to be contained. Insurance companies are profit-based and want to control costs, as well. Clinics and hospitals are not charities either, so their revenue must at least cover their expenses.
And where does all this talk of profit leave the employee and his insurance card? The answer to that question is making a lot of people sick.
Many employees only discover the serious limitations in their insurance coverage once they actually need health care. If you haven’t read the “General Exclusions” section of your health insurance policy, do so immediately. It will probably be a revelation. Note that most health insurance policies do not cover injuries or sickness arising out of the employee’s work. A whole host of chronic conditions, such as allergies, multiple sclerosis and acne, aren’t covered either. Suffer from depression? Become obese? Need a new kidney? Sorry. Probably not covered.
Even worse, many medical insurance policies do not assist policyholders in maintaining good health. Preventive care and routine testing is generally excluded. For example, insurance won’t pay for a flu shot but it will pay for a doctor’s visit and medication if you do catch influenza. Cigarette smokers aren’t covered for routine chest X-rays, but treatment for lung cancer is usually authorized — unless of course the insurance company decides that the cancer was actually self-inflicted harm. Women are frequently denied insurance coverage for annual mammograms — until they discover a big lump. Then, at that time, the insurance company quickly grants payment approval to have the breast cut off.
Insurance companies claim that they are following the laws of the land and that employers clearly understand the level of health care provided by the medical insurance purchased. Profit is definitely the motive behind all these policies but perhaps it is time to change the equation and recalculate the bottom line.
“If you have a major insurance provider who comes to a client and says, ‘Hospital A will charge you a premium of SR1,000 per month and Hospital B will charge you a premium of SR700 per month,’ and it is left up to the employer alone to make the decision, the employer is thrifty and will definitely go for the SR700. That is if he considers health insurance to be a cost,” said Dr. Osamah Al-Sanea, executive director for Allied Health Services, Saad Specialist Hospital. “If the employer considers health insurance as a benefit that will attract more people to join him, then he will stop and investigate what exactly is covered by each insurance premium and the quality of the care that will be provided. Unfortunately, at Saad Specialist Hospital we have not found that the Saudi market is ready yet to put a value on quality health care and appreciate it.”
There is an urgent need to raise awareness at the consumer level concerning exactly what is required to provide quality service. For instance, how does a hospital’s management price the services provided at the facility? According to Dr. Al-Sanea, the hospital either calculates its cost and adds a small profit margin or the hospital accepts whatever will be paid and then tailors the service accordingly. He explained that Saad Specialist Hospital follows the first pricing strategy. The hospital administration adds up all skills, equipment and consumables that are required to deliver a medical service using established best practices and then a small margin is added to that figure. This is what Saad Specialist Hospital then charges for the procedure. Dr. Al-Sanea emphasized that any profit that Saad makes is reinvested in its medical services.
“The insurance companies don’t support that model,” said Dr. Al-Sanea. “They come to us and say, ‘That other hospital only charges SR800 for this procedure and you want SR1,200. We will only give you SR900.’ We reply to such remarks by showing itemized charges for every requirement of the procedure, but it is futile. I vividly remember that for an anterior resection of the colon, a complex surgery, we charged a fee of SR25,000, which was unacceptable to the insurance company involved. They told us that another hospital only charged SR12,000 for the same surgery. We went back and added up the cost of just the disposable equipment to be used in that surgery. The disposable equipment alone cost SR18,000. So what does that mean? Either the other hospital that is charging SR12,000 is doing the surgery in an unsafe manner or they aren’t actually doing the procedure that they claim to be doing.”
It is important to point out that Saad Specialist Hospital has been accredited by medical certification organizations in Saudi Arabia, the US, Canada and Australia. Maintaining that certification requires that the hospital’s medical team adhere to standards for best practices in patient care at all times. Saad can’t cut corners to lower costs. But lurking in the insurance offices at some other local hospitals can lead one to wonder about the many ways in which patient care could be compromised by less scrupulous medical organizations. In the insurance office of an Alkhobar hospital last week, Arab News heard that one large insurance company was being charged SR3,000 for a nasal surgery package that was normally billed at SR6,000 to individuals paying cash. It was described as a “volume discount.”
The Council of Cooperative Health Insurance (http://www.cchi.gov.sa/english/en_home.htm) is supposed to regulate the Kingdom’s insurance industry and ensure that adequate health care is being provided, but the job is huge and requires many professionals with high-level medical, administrative and financial skill sets. The Ministry of Health is also facing many challenges in deciding which physicians are adequately certified to perform specialist procedures.
“In Saudi Arabia when it comes to certifying both hospitals and physicians, these certifications are basically in the hands of clerks who look at papers,” Dr. Al-Sanea said. “It is very confusing right now trying to determine the true qualifications of physicians, especially for surgeons. Some form of evaluation is required but who has the high-level skills to do these evaluations?”
In this climate of confusion it is the insurance companies that are benefiting and the health care consumers who have the potential to be hurt. If hospitals object to the low fees paid by certain insurance companies, they have no recourse but to either lower their standards or reject individuals holding those insurance policies. The hospitals that do accept the low fees offered by certain insurance companies have every incentive to continue using outdated equipment, hire less qualified staff and even compromise on basics such as sanitation.
It was an excellent step for employees of the Kingdom’s companies to be eligible for health insurance. But that should be just the first step in improving the welfare of those whose continued good health furthers this economy. As long as health insurance companies are the ones actually setting the standards for medical care in Saudi Arabia, the Kingdom’s health care consumers will suffer never ending pain.