Health Insurance

Insurers and healthcare professionals:
Partnering for the patient



When I was a child in the UK in the 1970s, healthcare was simple: If you were ill you went to the doctor and he gave you whatever treatment you needed, whether it was minor or major, cheap or expensive. Of course in the UK, the National Health Service, an envy of the world at that time, meant this was delivered free of charge to all. Today, things have changed somewhat and although a wonderful NHS still exists, it is run much more as a business rather than a service.

Here in the Middle East the same is true. Governments have come to realise that rising costs of health treatment mean that free treatment for any condition for all is a luxury of the past. Today alternatives are sought and applied. In recent years various governments around the region have encouraged the private sector and health insurers to take much of the cost. In some cases governments in the region have even introduced compulsory insurance, though with varying degrees of success. Although these developments all help governments in their fiscal planning they have meant that healthcare has become more and more a business which is run for profits, rather than a service which is run for the good of the people. As healthcare professionals I am sure many of you have seen this trend, and you undoubtedly have your strong views on this.

The business of healthcare

So how do healthcare professionals cope in this changing world? Why should a doctor be instructed by a business manager how to treat his patients? These are difficult questions. However, these are changes which all healthcare professionals now have to contend with on a day-to-day basis. Our hospital managers want the machines in constant use – almost like a car rental company wants its cars on the road to generate income. He wants the beds full – much like a hotel manager would. He wants to create the greatest fee income for the services provided – like any other business in the world.

Since costs of healthcare are rising and government subsidies falling, many individuals are taking out insurance to help manage their costs.

I have been involved in the insurance industry all of my working life, specialising in life and health insurance in the Middle East region. Regrettably, insurance is generally quite poorly understood in this part of the world, be it due to cultural, religious or educational reasons. This is true in the population as a whole, the healthcare provision sector, and indeed in the insurance industry itself! Hence those taking the insurance solution are often unaware what is covered and what is not covered (and indeed why that is so), until they actually need the cover. To compound this, doctors are expected to know what is covered, what is not, split the costs of bills accordingly so the insurer pays part and the patient pays part, and even change treatments to fit a policy wording. All this when you have a sick patient in front of you, who you want to help recover, and possibly with relatives demanding this and demanding that at the same time. The role of the doctor is very different from my 1970s UK memories.

But the simple fact is the world has changed. Doctors will need to understand insurance. Not just what is and is not covered, but actually why insurers apply exclusions. And insurers need to understand doctors and the trends in medical treatment. The world of healthcare in the early 21st century is a different one. It has become a business not a service. It will work best when each party in the business transaction understands the other’s business and needs. In this way the parties become part of a service delivery chain which is working together and not in opposition. And in this way all parties will achieve the business profits which are now demanded, healthcare professionals will be able to provide best treatments and the patients will become healthy again for a fair and affordable cost.

The next issue

Over coming issues of Middle East Health I will address some of the key areas of insurance. These will include:

- understanding policy terms, conditions, exclusions and why they exist
- underwriting processes and standardisation of forms
- insurance and healthcare statistics
- avoidance of fraud claims
- disease management practices

Through these I will demonstrate how insurers and healthcare professionals can work most effectively together to make profits whilst actually improving efficiencies, patient health and treatment practices.

 Date of upload: 15th Aug 2011


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