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09 January 2019
By Ahmed Faiyaz, Advisor at the Health Investment & PPP’s Department, Dubai Health Authority (DHA)
The GCC has seen significant growth in health infrastructure over the past decade, with the mushrooming of several types of specialised clinics serving the needs of the communities, as well as large medical cities and general hospitals that have been set up to offer secondary, tertiary and quaternary care across specialties.
While access to care has improved considerably and is also supported by mandatory health insurance programmes in many countries and city states, there still exists gaps in the health system largely driven by the lack of specialised and highly experienced clinical talent and a lack of trust and poor perception of quality of services for a number of specialties and complex conditions. The next wave of investments in the GCC has to largely focus on bringing in highly specialised clinical talent, and offering multi-disciplinary, coordinated care to address the growing needs of the patient population.
The investment focus thus needs to shift to value-based care models and innovation that can enhance and improve clinical outcomes, and further build trust in the health ecosystem. Among the most important challenges that need to be addressed is the seven to 10 per cent growth in health spending year-on-year over the past four to five years. This increase is unsustainable as it affects and impacts both the GCC governments and businesses in a negative way resulting in growing healthcare budgets and rising premiums for healthcare plans thus increasing the cost of doing business.
The public sector health facilities in the GCC region, however, face a bigger challenge with the growing challenge of attracting and retaining highly qualified and experienced clinical talent, especially as the private sector facilities in most cities in the GCC have seen a faster growth in inpatient and outpatient utilisation. Driven by mandatory health insurance reforms, patients are preferring to visit private sector facilities for non-urgent elective care, particularly when they have insurance coverage. Amongst the several reasons for this include the long waiting times for diagnostics and surgical procedures, poor perception of patient experience (related to admissions, discharge, appointments and billing) in the public sector, and a lack of insurance coverage of services in many pockets, although this is now changing. The slower growth of the public sector is leading to spiralling costs especially as many pockets of the private sector healthcare market continues to be fee for service and utilisation driven. Since there are significant incentives and referral fees being paid to doctors and facilities that is linked to utilisation, it results in overutilisation and challenges with claims approval and settlement with the health insurance companies who are focused on curbing utilisation and optimising costs.
Most GCC health systems have also seen a growing spending on nationals through the overseas treatment programmes, with costs rising disproportionately to the increase in the number of patients. On the other hand, businesses are struggling with the rising costs of health premiums, and many organisations are shifting to lower coverage plans with restricted networks, which constraints and seriously limits the access to health services for the patient population. Health insurance companies and their third-party administrators (TPA’s) across most GCC countries have started sending patients to the home country (more often South Asian countries) for elective procedures and treatment for health conditions ranging from obstetrics to cardiac surgeries and interventions (particularly for low to middle income segments of the insured population) and are covering this through insurance reimbursement at significantly lower costs, which has impacted patient flow and volumes for the private sector facilities addressing the mid and low-income populations.
GCC health systems thus need to drive efforts and investment to support the following:
Technology adoption for care coordination in the health systems: A big positive is the fact that there is evidence of technology adoption driving savings in costs and reducing or curbing utilisation of services through early stage interventions. The focus should be to evaluate and adopt technologies to support a more coordinated care model for patients with chronic conditions (such as Type 1 diabetes, respiratory conditions, etc) where predictive models and analytics can identify risks and trigger early stage interventions. This could bring in nurses to support these services or can be managed to care coordinators thus avoiding frequent and unnecessary hospitalisation and re-admissions when the condition gets worse. Technology investments should be made in devices and systems that can improve health system efficiency and access to care in the public and private sector, as well as improve the quality of care and response time to patient needs.
Integration of hospitals and medical cities with home-based care and telehealth: The focus here is to effectively integrate electronic health records across the health system thus allowing seamless access to patient data and interventions that can enable home-based monitoring, follow ups and telehealth supported services through real time monitoring via smart devices or applications, which will allow physicians and/ or nurse practitioners to intervene where necessary. Evidence of implementing such models across integrated delivery systems in the U.S. as well as in health systems in Europe has shown that this can significantly reduce costs particularly for emergency admissions and visits, and has helped reduce lengths of stay, while also improving clinical outcomes for patients with chronic conditions. Better integration would also enable patients to be transferred to nursing homes or long-term care centres, which are largely nurse-managed and have a lower cost base, and would unlock capacity that is taken up at acute hospitals for long stay patients. This would also support a growing convergence for health services delivered between large hospital systems and smaller clinics and pharmacy clinic models that can support chronic disease management programmes and early interventions with greater convenience and lower costs.
Specialised centres for tertiary services: GCC health systems need to target and facilitate investments in smaller, more convenient and efficiently set up Centres of Excellence to treat a number of advanced specialties and sub-specialties (e.g. Oncology, Cardiology, Neurology, Orthopaedics & Rheumatology among others) aimed at addressing the needs for screening and early detection of chronic conditions, appropriate diagnosis and treatment from outpatient to inpatient services including extended rehabilitation and/or physical therapy. These centres need to focus on and support clinical education programmes, research and affiliation with best in class international providers to bring in effective clinical pathways and enable the use of the most advanced technologies to treat patients thus focusing on improved clinical outcomes and patient trust, and reduced lengths of stay and readmissions.
Encourage the set up of urgent care clinics: It is well known and widely reported that 60-70 per cent of patient visits to ER in GCC hospitals are for services that are non-urgent in nature and can be treated in outpatient centres. Efforts need to be made to drive and encourage the set up of smaller urgent care clinics across communities that work round the clock, led by GPs and are mostly staffed with physician assistants and nurse practitioners, to address the challenge of rising costs, and to treat these minor conditions and ailments in a less expensive setting. Many such models have proven to be cost-effective, thus offering quicker access to patients with no compromise in quality of care, given that the clinical staff is well trained and has the experience of seeing a constant flow of patients having similar conditions. Telehealth applications and services could also collaborate with urgent care clinics and ambulatory care centres to triage patients, reduce waiting times and improve patient access and convenience. Dubai and Abu Dhabi in the UAE are witnessing the growth of such models and the rest of GCC can follow suit and support these cost-effective models.
While innovative and disruptive models need proactive investment facilitation support by regulators, it is imperative for the regulators to review policies and legislations that could enable the licensing of these facilities and applications, and encourage their roll out and set up to improve access to patient services. The success of innovative models listed above need close collaboration between regulators and insurers to effectively reimburse and support patient flow to such models that could address the rise in cost of health services, and improve patient access, experience and clinical outcomes for the sustainable future.