Doctors fleece health insurers

Private doctors are reportedly "over treating" their patients by ordering unnecessary procedures like laboratory tests, x-rays and scans to milk health insurers.

This is despite the fact that Zimbabwe's healthcare costs are arguably the highest in the region. Medical aid societies allege that some doctors recommend Caesarian procedure for pregnant women in situations where they can deliver normally.Some doctors reportedly cash in on detaining patients in hospital for longer periods than necessary.

This has seen some patients incurring huge hospital bills.

Association of Healthcare Funders of Zimbabwe (AHFoZ) chief executive officer Mrs Shylet Sanyanga said this, coupled with the already exorbitant costs of medical care in Zimbabwe, resulted in members exhausting their cover limits prematurely.

She said once members reached their ceiling, they failed to access essential medical care when they needed it most.

"Over treating can best be described as abuse, misuse and waste. For example, a doctor may unnecessarily review a patient, may give too many medicines or even too many investigations," said Mrs Sanyanga.

"Somebody may present with a minor ailment but the doctor orders several investigations — a full page of laboratory tests and or x-ray and those are all wastages especially to the member's cover because it results in depletion of their fund such that when the member now requires a major procedure, they may have exhausted their limits," said Mrs Sanyanga.

In relation to the cost of medical care, Mrs Sanyanga said AHFoZ — in conjunction with the Zimbabwe Medical Association — were working towards a scientific tariff regime.

She said this tariff was expected to be compiled by experts such as actuaries or economists to determine the actual cost of different medical procedures.

"What we want to achieve is a tariff that is relevant to the economic environment, must be affordable in terms of the ability of the members to pay subscriptions.

"So we are expecting that whoever is going to carry out that study will look at the incomes that people are getting versus the cost of running a practice by a service provider so that the fee they come up with is sustainable," said Mrs Sanyanga.

She said current costs of medical care were not based on any evaluation.

"We are finding that our costs of healthcare are generally higher than anywhere else in the region so we think if we are able to carry out this research, we will be able to adjust accordingly so that we will all have one set of tariff that is not disputed," said Mrs Sanyanga.

She said ZiMA had since agreed in principal to conduct this study jointly with AHFoZ in an effort to break the long standing impasse between medical aid societies and service providers.

ZiMA secretary general Dr Shingi Bopoto, said the AHFoZ tariff was the way to go but quickly pointed out that without enforcement, current disputes would never be solved.

Dr Bopoto expressed concern over Government's failure to enforce the current tariff, which it set after both parties failed to agree on a common tariff.

"You will realise that Government has failed to take action on medical aid societies that failed to pay up service providers the current tariff that was put in place by the Government itself, so this scientific tariff might not necessarily change anything unless it is enforced," said Dr Bopoto.

Without ruling out possibilities of some doctors 'over treating' patients, Dr Bopoto said ZiMA believed that all practicing doctors were well trained to manage patients accordingly.

He, however, urged both the medical aid societies and individuals to report any suspected cases of misappropriate treatments either to ZiMA or to the doctor's regulatory authority.

He said the medical industry was heavily regulated compared to the medical insurance such that any reported cases were dealt with timeously.

"As ZiMA, we want to believe that a properly trained doctor will make the best decision for the patient at any given time.

"Anyone who suspects that they were given inappropriate treatment for their condition should report to the relevant authorities and action is usually taken immediately," he said.

Dr Bopoto said this year alone the Medicines and Dental Practitioner's Council of Zimbabwe, which regulates doctor's practices de-registered two doctors and sent several for retraining.

The dispute between medical aid societies and health service providers started way back with the former claiming that doctors were over treating patients and over charging their services.

On the other hand, doctors argued that medical aid societies were not paying for services given to their members even at their own rate.

This resulted in doctors demanding cash up front from patients on medical aid.

Deputy Minister of Health and Child Care Mr Aldrin Musiiwa, said his Ministry was hoped a scientific tariff would break the impasse between the parties involved.

"This would go a long way in addressing the issue of different tariffs that are currently in place. Once this is addressed, we are hoping the long standing dispute between the two parties will also come to an end," he said.