GA Insurance House, Ralph Bunche Road Nairobi, Kenya
Seating and waiting for a consultation, then waiting at the lab and then waiting in the queue at the pharmacy are all undesirable experiences for employees when suffering from a minor health condition. Even a simple checkup could take hours to resolve. This contribute to delays in seeking care, and absenteeism and loss of productivity when they do seek care.
Outpatient care in hospitals is expensive. Consultation fees have risen by 70% in the past 3 years. The cost of diagnostic tests and medicines have similarly risen faster than inflation. Patients with insurance cards tend to be prescribed unnecessary tests and predominantly branded medicines to max the member’s allowable cover. Private insurance companies and employers offering health benefits are overexposed to medical costs. Despite the year-to-year increases in employer-sponsored care, health benefits are never sufficient causing ongoing employee dissatisfaction.
Even when concerned about costs, employees still end up in the big hospitals and private clinics operated by specialists, even for simple check-ups. Patients have reservations about the quality outside the big hospitals. The cost of care has inadvertently become a proxy for quality of care despite little evidence of the same. HR departments are forced to be gatekeepers with the added burden of guiding employees when in need of health services in order to save on cost.
Employees also tend to want to extend their benefits beyond the nuclear family. It is not unusual for members to use their benefits for non-members. Thus 30% of medical claims covered by companies are fraudulent. Without controls, non-listed dependents receive care in place of members. HR departments can no longer rationalize the expenditure on the health benefits offered to employees. Most companies lack a mechanism to analyze and control fraud beyond the use of the SMART card, which at its essence does little to prevent members seeking to extend their benefits to non-covered members from doing so.
Even though non-communicable chronic disease (NCDs) represent 20% of claims, employees with NCDs need ongoing support to minimize the risk of catastrophic claims. Lack of support in the workplace results in delays in care and the disease worsens leading to inpatient admissions and high-cost claims. The rising incidence of lifestyle disease is a major concern as traditional wellness programs have demonstrated little or no effects on the rising cost of care associated with NCDs.