Patients at a sub-county hospital in Nakuru County. Many Kenyans do not
know where to take complaints against their medical insurers. FILE PHOTO
| NMG
Last week, a political activist took to social media to express
his disappointment with a medical insurer. The disagreement revolved
around a rejected claim for medical management and hospitalisation.
In
the ensuing digital media engagements, lots of Kenyans opened up over
similar experiences. Most being bad, but a few had positive sentiments
to share. The overall assessment was that the industry regulator has not
been responsive to many consumers’ complaints. This is vital if we have
expectations of streamlining the sector.
The Insurance
Regulatory Authority (IRA) puts a target of 85 percent customer
satisfaction as its target for 2018. What the achieved metric was is not
shown, but judging from the online backlash, many people are not happy
with IRA’s job.
As the referee, frequent monitoring and
arbitration is a key performance indicator of the Insurance Regulatory
Authority. The mere fact that most Kenyans with insurance covers do not
know or have never interacted with IRA is not impressive.
To
use a football analogy, often times it feels like a soccer match where
some teams score with their hands, do not follow offside rules,
notwithstanding the referee’s presence on the pitch during the match. In
the new soccer era, Video Assisted Refereeing VAR has come in to settle
contestable decisions. This is what IRA should aim to be.
But
to understand why this is happening, one needs only look at IRA’s top
level management. As a strategic plan, its shortcomings is the
composition of both the board and management: both have no single health
worker or doctor.
Quite absurd, given medical will
soon be the biggest if it is not already branch of insurance premium
holders. The medical insurance uptake is growing (data suggests it is
the biggest across the general class, and could potentially be larger
than motor vehicle if NHIF is included. IRA’s data says Medical and
Motor classes contribute 30.7 percent and 35.8 percent of premiums
respectively.
A shocking revelation from the
discussions is that consecutive year medical class losses predict dire
consequences for stakeholders. Apparently over the last decade, out of
the 30-40 or so odd players in the sector, those operating profitably
are very few.
From the patients’ perspective, this may
mean paying out of pocket in some cases. From the hospitals’
perspective, even tougher financial inflows as the average time it takes
for bills to be settled after service delivery increases. This last
point highlights just the tip of an iceberg of the industry-wide problem
and should be the top task to be addressed: irrational payments to a
select group of hospitals.
For industry insiders the
only way to rationalise this loss making is to adopt outcomes based
payments for all players. Twenty hospitals cannot consume more than a
quarter of the payments and still have a viable market.
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