Dr. Charles A. Berko
Indeed, we have all come a long way as a country, from the “cash and carry” system to the National Health Insurance Scheme; we need to pat ourselves on the back for a job well done.
This is a novel unprecedented achievement in the history of this country, and taking pride in it, as a people, is in order. The look of relief on the faces of those eking out a living when they are attended to, with no issue of cost being raised, is a sight to see.
Previously, you’ll see distress and all manner of facial expressions associated with communications with unseen creatures on mobile phones, others also pleading, as if the power of waiving the fee lies in the hands of the care provider.
With the introduction of the National Health Insurance Scheme (NHIS), these problems, and the perennial situation of people presenting to the health facilities late with easily salvageable and preventable conditions had they reported earlier, have been reduced, though not completely effaced.
All these being said, there are still teething problems that need to be considered, and addressed, to manage this program efficiently and smoothly, without unduly burdening the healthcare providers, or shortchanging the clients.
We live in a country where facilities are easily abused, due to the absence of checks and balances, and even where they exist, are only in the statute books, with no effective method of enforcement.
There are those who will visit the hospital on countless occasions within a short period, some for good reason, and others, simply because it is “free”.
Whole families come reporting to the hospital, only for the practitioner to discover that only one of them is really sick, and that the others have come along for the ride, taking the opportunity to abuse the system, thus increasing the patient load unnecessarily, and stretching the limited resources of the facilities involved.
There is the matter of costing, where the health insurance scheme, basically pays the facility a fixed amount, irrespective of the services rendered, the idea of fixing it is agreeable, because some facilities may take the liberty to inflate the bill, but it should also be noted that for some chronic conditions like hypertension, diabetes etc., you routinely, will have to do extensive laboratory investigations, and that more may be spent on them, and much more, when they are admitted – as is often the case – and these have not been considered, and a flat fee is being charged in most instances.
The clinician needs to be able to make decisions in the patient’s utmost interest, and not have his hands tied, due to cost. Should the patient, who has complications of surgery, be denied a “second look” because insurance may not pay? Should the client whose random blood glucose be done often, because of an intractable hyperglycemia, be denied that, because insurance will pay for a fixed number of glucose drips?
Late payment of the health claims is also something that should be dealt with, so inflation does not erode any gains and cause more difficulties for the hospitals when the bills are paid several months down the line, especially so, when about half of the insurance claims will be rejected for one reason or the other, though service has already been rendered. This deficit is shoved down the throat of the hospitals.
For these and other reasons, some hospitals don’t have certain drugs in stock because they provide at a loss, considering that they are supposed to run as an entity with little or no government support. In some instances, consumables like gloves and intravenous cannulae are unavailable, as petty cash has to be redirected elsewhere, to enable other sections of the hospitals to run.
A case in point is when a patient presented an acute left ventricular failure, and there was no lasix available in the hospital, as well as no oxygen (in a big referral centre), and the patient eventually died, who should be blamed? Could this have been prevented if the amenities were available? The patient may have died anyway, but more could have been done, had resources been available, prolonging the life.
We certainly are not the only country practicing this health insurance scheme, others have done it, and we can easily import this knowledge. A couple of solutions are outlined as follows;
Co-payment, where an individual pays a fixed amount per visit – mostly those who will often visit the facilities due to their chronic medical condition, a little for your medication refill is not too much to ask. It will be better to probably pay a bit more and live, than to clutch a card in your cold lifeless hands, whilst having money in the bank.
Right to refuse care should be employed in cases where the clients have been assessed, and the providers convinced that these individuals are just out to abuse the system, rather than having a genuine medical concern, their insurance numbers could be tagged, so that they can be looked out for, but they should also be assessed first, so that they are not turned away, even when they have a case.
A case by case cost assessment and evaluation should be used in chronic medical conditions and also other critical medical conditions where the individual will require more resources than is averagely provided, except in cases where the scheme explicitly does not cover.
Others should also be allowed the option of opting for higher premiums which will qualify them for comprehensive packages, whatever condition they may have, as is done with auto insurance and others, after all, different strokes are needed for different folks.
All size fits all is untenable and unacceptable, especially, since there is social stratification, whether we like it or not.
Insurance tariffs, as well as claims paid to the hospitals, should be reviewed often, cognizant of the fact that prices of goods and services keep changing.
The hospitals need to be upgraded, expanded, and resourced to meet the increasing patient load, and be able to offer more specialised care. It is very disheartening when an 80-year-old diabetic has to be referred at night from a place like Tema to Korle-Bu, due to the hospital’s inability to accommodate her. And this is something that happens in most places constantly. The facilities are bursting at the seams, and this should be of concern to all.
These are some of the methods that could be employed to ensure that the hospitals can, at least, break even and continue to provide the much needed quality care, than just exist in name.
The Health Insurance Scheme is God-sent, but more needs to be done. Let us take the necessary actions and overhaul this scheme and the health service in general, and make it work better.
You may be the one who is rushed to a facility where no bed will be available to lie on, or be told a particular drug that you need is not available, and also that a referral center for which you could be sent to, is full and cannot accept anymore clients.