Garth Rattray | Proactive health insurance, please | Commentary – Jamaica Gleaner

I first realised that something was amiss when, many years ago, one of our popular health insurance providers wrote to inform me that I, a primary healthcare provider, was being dropped from its list of providers. The reason given was that the number of patients I was seeing did not warrant the paperwork needed to keep me on their books. I explained that I was seeing approximately four times the minimum number of patients that they quoted.

Nevertheless, they wrote back a very terse letter reiterating their position and I, still thinking that it was all a clerical error, sent documentary proof to back up my assertion. I further explained that they should not drop those providers that see few patients, because the fewer insured patients that access their health plan, the better it is for their profit margin. That is why insurance companies go into business. Furthermore, primary healthcare providers/family physicians/general practitioners are the only doctors that manage all aspects of patient care and carry out all-round risk management of diseases. Dropping family physicians did not make any sense and was, in fact, counterproductive to good medical care.

The ‘health insurance’ company went ahead and fabricated a lame excuse for dropping many of us; they claimed that they were thinking of concentrating on using medical centres as providers. This denied many patients, and entire families, access to their family doctors, because that company dropped many providers. It also significantly affected our income. After many years, that same company began sending patients to me for ‘insurance medicals’; that was how I learnt that I, and others, had been quietly reinstated.

QUESTIONING THE VALIDITY

This left me questioning the validity of some of their top-level decisions. I have come to realise that the people in the upper-management echelons are not necessarily rational. Often, they are penny wise and pound foolish. These thoughts coalesced in my brain after attending a very informative Caribbean College of Family Physicians Regional Distinguished Lecture webinar. The keynote speaker was Dr Jeff Markuns, deputy director, Primary Health Care Performance Initiative and president of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, North America. The relevant part of his talk, as it pertains to the matter at hand, is – the current global landscape on advancing primary healthcare as a development and health priority.

Dr Markuns was knowledgeable, fluid and persuasive in presenting the very interesting facts. His (North American) figures showed that increasing the number of family physicians (FP) by one FP per 100,000 population, is associated with 70 fewer deaths in that same population. Although specialists are obviously essential, increasing their number by that same proportion did not yield a positive result. Adding more FPs could save more lives annually than the number of people killed by all infectious diseases combined. And, the expected increase in quality of life would also be positively impactful. He went on to show that adding one FP per 100,000 population would eliminate 25 per cent of all heart diseases, 30 per cent of all cancers, reduce kidney diseases, liver disease, and result in a noticeable reduction in strokes and lung diseases, among other very important health benefits for the country.

Despite Dr Markuns’ informative and encouraging presentation, I have practical concerns regarding the transition from his expected positive benefits to reality. Even if we increase our number of FPs, the authorities will need to convince our citizenry to actually go in to see a doctor. And, even if and when patients see us, a major cause of failure to reduce morbidities, lessen premature mortalities, and for therapeutic failures of specific short-term treatments is patient non-adherence. Many patients hate and distrust medications. Some opt for taking their chances with their chronic diseases, like hypertension and diabetes. Some resort to unproven bush medicines. Usually, those individuals return to the FP when things are so bad that they are irretrievable.

MAJOR CONCERN

My other major concern is the harmful policies of our health insurance companies regarding what they will cover. If I request a colonoscopy for screening purposes, because the patient is at the age when he or she should be screened for the possibility of developing colon cancer, I am always told that the insurance companies request a specific diagnosis. Simply writing ‘screening’ will not be covered. This is counterproductive, since the ideal goal of colonoscopies is to save lives by preventing the development of colon cancer through screening. It is therefore prudent for the company to save lives and money by prevention, instead of trying to diagnose patients who may have already developed colon cancer and could require expensive major surgery, and, perhaps, chemotherapy and radiotherapy.

The same goes for blood investigations. Companies refuse to pay for ‘routine’ blood works aimed at preventing the serious complications of several (hidden) problems and chronic diseases. It is only if and when the patient has a diagnosis of (say) hypertension, or kidney failure, or liver disease or whatever, that these companies will pay.

It is far better for the patients, our country, and even for the health insurance companies if they pay for screening and checking before illnesses arise, than it is to pay for treating dangerous and chronic health problems.

Garth A. Rattray is a medical doctor with a family practice. Send feedback to columns@gleanerjm.com and garthrattray@gmail.com.