Health practitioners in the UAE — doctors, insurance companies and hospitals — say that patient education is the only answer to combat overprescription, readmittance and inappropriate use of specialised care, leading to inflated costs. The prevalence of these has caused professionals across the board to focus on awareness programmes.
While the UAE is recognised for excellent specialist care, many of the problems that bring patients to surgeons and specialists can be cured by a visit to the spa.
“At least 30 per cent of my patients are just stressed,” says Dr Sanjay Madan of uniCare Medical Centre in Dubai. “They need good advice and some physiotherapy.” An orthopaedic surgeon, he is an expert in treating congenital and acquired bone deformities, arthritis and metabolic bone diseases, among other conditions. But often, he says, he ends up prescribing some sunshine to his patients.
“It’s probably stress and some deficiency, such as Vitamin D, which can cause back problems,” he tells GN Focus. “But a patient can come to any doctor, it is free.”
Straight to specialists
Direct settlement of outpatient treatment, service providers say, is partially responsible for a specialist being the first port of call in the UAE, when the global norm is to visit a specialist only after a referral from a general practitioner.
“Members need to be educated on how to use their health insurance cards responsibly,” Dr Sven Rohte, Chief Commercial Officer at National Health Insurance Company — Daman, tells GN Focus. “Unfortunately, medical inflation is on the rise in the UAE and that’s due to the lack of public information on proper use of insurance, resulting in high utilisation and increased chances for hospitals to abuse the insurance cards.”
Daman has been one of the leaders in health education, focusing on preventive care. “It is not a usual strategy for insurance companies, but we see it as an important part of our work,” says Dr Rohte. This strategy sees insurance companies join hands with hospitals to ensure that the patient is an informed consumer. Education programmes focus on lifestyle and preventive care.
Daman’s programmes on this include the walk organised at Yas Marina to commemorate World Diabetes Day. During Ramadan, it organises an interactive seminar to support and educate patients suffering from type II diabetes. Its health reflection campaign draws public attention to healthy eating and physical activity.
In Abu Dhabi, Mafraq Hospital has launched several awareness initiatives. Ana Rosa for women, launched in October last year, is expected to reach about 6,000 female patients within the year. The hospital is organising a school sports day to raise awareness of healthy lifestyle changes and to educate patients and visitors about diabetes. It has a campaign to keep children safe from burns during Ramadan. It also runs a men’s health campaign and is the first prostate-focused health campaign in the UAE.
“An informed customer can see the correlation between treatment and premium costs,” Stuart Leatherby, Managing Director, Middle East and Africa Aetna Global Benefits, tells GN Focus. Insurance companies warn that one of the direct results of an overburdened health-care system is increased premium or reduced services.
“The premium is proportionate to the utilisation of health-care services by patients and the market prices for health-care services,” says Dr Rohte. “Higher utilisation will result in higher premiums for members when renewing their policies. They might be in a situation where if they wouldn’t want to pay the higher premium, they will have to settle for fewer benefits.
“This can be countered by introducing copayments where the member pays a percentage of the cost, which will make them more involved in the payment process and will make them more aware of the costs,” adds Dr Rohte.
Use primary care
While education about medical conditions is the obvious topic of discussion, some programmes deliver other messages. Some designed by Aetna Global Benefits, partnered with RSA insurance in the UAE, drive home the fact of primary care being available, in an effort to create process-driven medical care.
“Some of the initiatives we are looking at — rather than restrict coverage, make it easier to use primary health care,” says Leatherby. “If a process is followed, the medical condition can be established before following the pathway to where the patient needs to go next. Over the past two or three months we have put together initiatives around mammograms and flu vaccination at particular facilities, which demonstrate that there are facilities outside that you can use.”
Hospitals identify with this goal, encouraging people to visit their friendly neighbourhood general practitioner. “The public still lacks knowledge about services offered at the primary level of health care,” says Dr Anwar Sallam, Consultant Paediatric Pulmonologist, Chief of General Paediatrics and Deputy Chief Medical Officer, Mafraq Hospital. “Abu Dhabi Health Services Company Seha’s vision is to bridge that gap between the primary health-care level and specialist services. Ultimately, this problem is going to be alleviated and I can see that happening soon. When our clients become aware of the real meaning of primary health care and the services offered there, then both the physicians and the patients will work together in achieving the best for the patients.”
Experts agree that the problem is multifold. Lack of a central system of medical records contributes to the issue. “In the best systems, there is consistency in the way medical records are maintained,” says Leatherby. “When patients visit a doctor, they may not be holding any medical records. There is no central system that keeps these. A doctor may see a patient three or four times. The patient can decide to go to the specialist who won’t have access to the medical records.”
While Dubai is in the process of implementing its health insurance law, Health Authority Abu Dhabi and Seha have created online reporting systems to make a database.
In the absence of records, diagnosis, in some cases, is almost like pinning a tail on a donkey. “You have to start from scratch,” Leatherby says. “There is a big expat community, which doesn’t stay on for a long time and its medical history does not travel with it. There are some conditions that may not lead to symptoms. When a doctor is well informed about a person’s medical history, it helps in diagnosis.”
Over-diagnosis and overprescription of tests is one of the fallouts. Despite a fully paid insurance system, the patient is the one set to lose the most.
“We certainly feel that the trend [of overprescribing diagnostic trends] is prevalent here,” says Leatherby. “Before termination of care when we review information we realise that tests do make up a significant portion of overall costs. There is a lot of diagnosis taking place.
“Over-medication can be a box of tablets as opposed to a strip,” says Leatherby. “That can occur anywhere in the world. In a number of cases the actual patient can drive the over medication. They need to get something out of the visit.”
Stress is the underlying cause for ailments, says Dr Madan, but it’s not something that forms the list of symptoms. Unnecessary tests, he says, “are done because the patient is coming again, the second or the third time. He is not getting relief. If I prescribe tests for a patient with neck pain, I may find a genetic problem. But that is not causing the pain. The problem is stress or inflammation. Those findings will always be there in the X-ray or other tests. But they are incidental.”
Along with repeated outpatient visits, Leatherby says readmittance rates are high in the UAE. It’s not the goal of any patient to not be treated fully. “We are trying to ensure that the customer has the best possible chance of not being readmitted into the hospital,” says Leatherby.
One of the most recent programmes launched by Aetna Global Benefits across the GCC is a discharge-planning process. Leatherby says, “When our members are discharged they will get a call welcoming them home. There will be conversation to make sure that the patient understands the treatment plans. They may need to visit the hospital as outpatients and may need to interface with different doctors. We are operating as another health resource to help them understand what they need to do to get healthy. The preliminary response has been fantastic. Members who have been contacted have appreciated having the resource from the health insurer.”