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29 March 2024

New insurance structure to reduce misuse: official

Patients need to become more aware, says an official. (EB FILE)

Published
By Dina Ibrahim

Changes to the payment structure of government-run health insurance schemes have been introduced to encourage the participation of patients in decision-making and prevent the misuse of insurance cards, according to a senior official.

Patients insured under the Abu Dhabi Government's Daman scheme originally paid no charges but following a change of policy, must now pay 50 per cent of the cost of both treatment and medicines.

Members of the Dubai Government's Enaya scheme previously paid between Dh25 and Dh50 for treatment and medicines but must now pay 20 per cent of the costs, with the remaining 80 per cent being covered by the insurance provider.

In comparison, private insurers such as AXA and Oman Insurance charge patients only Dh50 for both treatment and medicines every time they visit a doctor.

"This is an insurance card and not an open pass," said Dr Haidar Saeed Al Yousuf, Director of Health Funding at Dubai Health Authority.

"Unfortunately some people use it as an open pass and try to get medicines they do not need. If the process is unregulated you will always find some level of misuse.

"Patients need to become more aware and to get involved in decision-making with regard to their health. For instance, why should unnecessary procedures that are more on the luxury-side be carried out?" he asked.

"The Government of Dubai is making these changes in its capacity as an employer. This type of change in health policy is something employers do all the time, mainly to make the utilisation of these services more efficient."

He said: "One of the major challenges physicians face is to get patients to be more involved in decision-making regarding their health and the choice of procedures, providers and how much of a particular treatment they need."

Dr Al Yousuf said whenever health services were used in an inefficient way someone had to bear the cost.

"Say, I need an elective procedure that can be performed by the same surgeon in either hospital A or hospital B, and I can choose which one I go to. Hospital A has nicer lighting, better sofas, more luxury, but the price per night is Dh1,000.

"Hospital B may be slightly less luxurious and the sofas are not leather-bound, but it costs Dh600 per night. However, the surgeon is the same. So, if I am paying for part of this treatment, do I go to hospital A or hospital B?"

Dr Al Yousuf said the changes had not been made in response to rising costs in hospitals and medical inflation. "It's a planned process aimed at optimising utilisation and maximising resources," he added. "Enaya is concerned with the well-being of the employees of the Government of Dubai and with giving them access to both public and private facilities at an affordable cost.

"In order for us to be able to do that, we need to ensure that both providers and employees are responsible in the way they handle these privileges when this card is given to them.

"Moreover, Enaya has many preventative benefits unlike standard insurance and does not discriminate against people with chronic diseases and pre-existing conditions," he said. He said that misuse of the service was not limited to insurance cardholders.

"Unfortunately, we have seen some providers abuse this as well and we want the public to be aware of this and to question decisions.

"On the other hand, there are some providers who are really good and do only what is necessary, and if there is something unnecessary they won't do it. We want to encourage the good providers and discourage those who think this is free money from the government," Dr Al Yousuf said.

"Providers always do this everywhere and we try to negotiate with them. We looked at our network and considered removing some providers who had increased their prices and somehow they came back and reviewed the prices.

"Price increases that are coupled with new services or tangible upgrades can be justified and this is being looked at, case by case. We want to be fair to the providers," he added.

The premia charged by Daman have increased slightly, said company CEO Dr Michael Bitzer.

"New business makes up about 10 per cent of Daman's 300,000 enhanced members and this category has witnessed an eight to nine per cent price increase in their premia. As for current clients who are renewing their policies, we have two groups – small and large.

"The small group cluster is assessed every three months and the premia adjustment is based on this review. The increase for this segment was also in the range of eight to nine per cent, with exceptions in some cases.

"Large groups are renewed based on the basis of their claims records and in some cases there are discounts.

"However, the majority of clients faced increases of between five and 20 per cent, depending on their claims records. The total average increase of larger groups was around seven per cent."

Dr Bitzer said talks with a number of hospitals in Dubai and Sharjah that were seeking significant fee increases had resulted in compromises being reached. He said 2010 would be a challenging year in terms of competition.

"Competition is stiff – more than 30 companies are licensed for health insurance in Abu Dhabi alone," he said.

"And we have many companies focusing more on health insurance due to the fact that it is a growing business and everyone is attracted by such growth," said Bitzer. The company's premiere scheme, one of its most expensive plans with worldwide coverage, is its fastest growing product, followed by its regional plan.

"Quality is the most important factor, a good health insurance product has its price and clients are willing to invest in health care.

"Daman is also investing in new enhanced IT solutions.

"Soon we will launch online connectivity between the company and the hospitals. Also, to curb long-term costs, Daman is investing in a disease management programme that will teach patients how to control their conditions," said Bitzer.