NAIROBI, Kenya, Jan 28 – A cold, one of the common respiratory diseases, is often responsible for most outpatient visits to hospitals.
Ranking second and third after respiratory diseases, malaria and diarrhoea account for a significant proportion of outpatient hospital visits.
High medical costs coupled with multiple tests could, however, deplete your outpatient medical cover after a few visits to a hospital long before the year ends.
Ashok Shah, the Chief Executive Officer Apollo Group which provides health covers through its subsidiary APA Insurance, says seeking essential medical services, especially for common ailments, from clinics as opposed to major hospitals saves up to 50 per cent in medical costs.
Shah says general practitioners in clinics charge significantly lower rates compared to larger hospitals.
“Health clinics are better at keeping standard rates for a longer period. The problem is though that a lot of people insured always go to the large hospitals. The difference can be as much as 50 per cent in terms of cost,” Shah explains.
He says general practitioners in clinics, due to the wealth of experience, often keep medical costs low by authorising fewer diagnostic tests.
“The people who might be giving you outpatient care in large hospitals might not have practised for as long as a doctor in a clinic who might be able to give a correct diagnosis without taking too many tests,” Shah goes on to explain.
According to him, hospitals have a tendency of recommending more tests to utilize the equipment they have, in some cases recommending CT scans where an X-ray machine would do. This tendency, he says, explains why an outpatient may be billed a significant amount for a common ailment.
“In most cases, we have over prescription of tests. A lot of times when you go for outpatient services they will say they’d want to admit you overnight for observation even when it is not necessary,” he says.
“The other problem is the diagnosis. One may have a fractured hand in which case an X-ray would be the best tool, which is cheaper. Some hospitals would, however, recommend a CT scan,” he adds.
Fluctuating medical costs, he adds, are another trigger of huge sums payable for outpatient services, which account for 60 per cent of medical insurance claims.
The changing costs have had serious consequences rising healthcare inflation to twelve per cent last year, double the general inflation rate of 5.7 per cent.
The double-digit inflation rate has resulted in a low penetration rate of about 2.7 per cent, amid cutthroat competition as players struggle to undercut rivals.
According to Shah, medical costs payable to hospitals have in some cases gone up by 30 per cent further compounding the financial risk covered by insurance companies.
“The major hospitals increase their rates two to three times a year yet insurance companies cannot increase premiums determined at the onset of a two-year contract with a client,” he says.
Fees charged by doctors have also contributed to high healthcare cost, according to Ashok, the other factors being the cost of prescription medicine and diagnosis.
“We would like to see the costs come down to a reasonable level so that we can afford to lower our premiums as insurance companies.”
The insurance industry has also been faced with an increase in fraudulent requisitions with claims processed steadily increasing over the past few years.
In 2017 for instance, the industry reimbursed claims worth Sh56.2 billion, an upward of Sh1.4 billion compared to Sh54.9 billion paid in 2016.
The Ministry of Health recently adopted recommendations by Kenya Medical Practitioners and Dentist Board which will see fees charged by medical practitioners and dentists reviewed downward by 20 per cent, in a bid to lower medical costs.