BOSIRE: Centralised database can curb insurance wastage

A mother comes home after work to find her baby coughing, with fever and vomiting. She rushes him to hospital, where tonsillitis is diagnosed and Augmentin (an antibiotic) and Panadol is prescribed.

In the morning, the fever has not gone down, so she decides to seek a second opinion at a different health facility. The boy is diagnosed with tonsillitis again, but the prescription is changed to Zinnat and Calpol.

The fever is still unremitting, so the next day she seeks a referral to a paediatrician who prescribes a three-day course of Ceftriaxone and Adol because the baby is vomiting and is unable to keep the medication down. The mother doesn’t have to worry about the cost of consultation, tests and drugs; her medical insurance is paying for it.

By the third day, the baby is getting better. The fever has subsided and the baby is sent home with a prescription of Cifex for five days.

By the end of treatment, the baby has two bottles of unused antibiotics at home. He also has two bottles of paracetamol formulations, from a previous prescription, that are open and due to expire before they are needed again.

The insurance company has settled the bills for all these wasted medicines, but it is difficult to prove if the change of antibiotics is what resolved the symptoms or whether it was simply a matter of time.

At initiation of treatment, even with the most powerful antibiotics, different infections take different times to respond to treatment adequately enough for symptoms to subside.

Therefore, every one of those antibiotics taken even for a day, contributed to fighting the infection. Given sufficient time, the first prescription could quite possibly have taken care of the infection and the symptoms, but it was stopped prematurely.

PREVENTING WASTAGE

If the baby’s records were accessible to all the caregivers handling him irrespective of the hospital or clinic where care was sought, it would have been possible to use what the baby already had at home efficiently and safely to prevent wastage.

While medical insurance allows beneficiaries to access care with ease, many providers confess that the product is likely to generate a loss. Fraudulent claims are blamed for the losses, but the focus should be on managing waste and deterring misuse of the cover.

Doctors who work in the outpatient setting will tell you that when the family outpatient cover is exhausted before the end of the year, hospital visits diminish as patients have to dig into their pockets to pay for treatment. But as soon as the cover is renewed, the visits increase and all non-emergency problems are addressed.

Private medical insurance eases the financial burden for many families, but if we run the medical insurance industry into losses, our options will be limited. To stay afloat, insurers will have to either raise premiums or lower the benefits package to the patient’s disadvantage.

MINI-PHARMACIES

How can we ensure this resource is not misused? Health management information systems (HMIS) interoperability may be of great help.

Frequently, a patient seeks care in different places for the same medical condition because they are not getting better fast enough. Each visit warrants a new consultation, a new battery of medical tests and a new prescription. All these are billed separately.

The same applies in diagnostic investigations, which may be repetitive just because the patient goes home without a copy of their test results, which could be used by the next doctor.

A patient gets a CT scan of the head, but the results are confined to the hospital’s HMIS, so change of doctor or facility means they have nothing to show from their previous caregiver. The new care team is forced to start all over again, at unnecessary cost.

Technology should make it possible for a centralised medical record database, accessible to patients’ care providers as needed, irrespective of location. This will promote prudent prescription practices and help fight antibiotic resistance.

It is time the medicine cabinets at home stopped looking like mini-pharmacies!