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Overutilisation of healthcare services

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Ineffective processes and proposed approach to reduce overutilisation.

One of the biggest impediments for the delivery of high-quality healthcare is the prevalence of overuse/overutilisation of medical services. Overuse of medical services is identified as the top factor driving up medical costs and whilst the full impact of the pandemic is yet to be realised, medical costs in the GCC region are expected to be more than 8 per cent in 2021 (Willis Towers Watson, 2020).

Browsing through public media in the GCC region, supports the claim that local healthcare market suffers from significant high level of overutilisation, waste and abuse:

“The UAE Ministry of Health conducted a survey revealing that 28 per cent of respondents had been advised to undergo unnecessary tests, designed to inflate provider bills” (Stirzaker, 2017)

“UAE Authorities estimate around 5 per cent of claims are a result of abuse or fraud and are pushing up the cost of insurance premiums by 20 per cent to 30 per cent” (Willis, 2015)

Overuse occurs when doctors admitted patients when this may not be required, keep patients in hospital longer than may be needed, use a higher level of care than may be indicated as well as order greater numbers of often more expensive tests than are medically necessary. Some practices in particular drive-up costs, even though they appear to have no explicable basis, and this global problem also exists in the GCC region - “89 per cent of physicians admitted that there is an overuse in the UAE” (Pharmacy Practice, 2010).

Some estimates suggest that a fifth of mainstream clinical practice brings no benefit to the patient at all (Chassin MR and Galvin RW, 1990). Overuse of unneeded services can damage patients physically and psychologically and can harm health systems by wasting resources and deflecting investments in both public health and social spending (Cheung A, 2009).

The last few years have been difficult for local healthcare organisations already before the COVID-19 pandemic. Cashflow problems lead to consolidations and bankruptcies, and companies will have to resort to new initiatives to assure their financial viability and to lower their claims costs. When looking at the main reason for the increase in claims costs, a study by Willis Limited, concluded that

“Overuse of care through medical practitioners recommending too many services” and “insured people seeking inappropriate care” are the two most significant factors driving medical costs.

Healthcare market players in the GCC region (Healthcare insurance providers and TPAs) are aware of the risks and challenges that overutilisation brings and strategies to tackle cases of fraud and abuse are constantly being updated and implemented. However, despite many processes, systems and analytical tools, significant rates of overutilisation are still evident in the private healthcare system.

If overutilisation is so well documented, has high awareness levels and is being tackled by endless efforts and initiatives, how come it is still so widespread in the GCC area?

MedRev (Medical Reviews International), an Ireland-based utilisation and clinical reviews organisation is tackling the global issue of healthcare overutilisation. MedRev, through a combination of Artificial Intelligence technology, analytics, and its network of medical specialists, helps healthcare organisations to lower overutilisation levels and improve outcomes quality. According to the author, healthcare insurers and their TPAs are barking up the wrong tree when attempting to lower overuse and abuse levels. The focus is almost exclusively on payment eligibility and processing of “correct and proper” cases.

There is an over-reliance by self-administered insurers and the TPAs on data analytics and automated software solutions that authorise health insurance cases almost exclusively based only on data factors. Sophisticated systems are deployed to look at correlation between services rendered and tariff codes charged, they look for trend outliers based on predictive modelling, they check prices, billing and coding issues utilising data mining tools, and using behavioural analytics and claims adjudication rules. Professional teams and Special Investigating Units / Forensic teams are involved only when a case deviates from the pre-defined data rules and is flagged as outlier.

According on MedRev’s international experience of reviewing tens of thousands of cases, if the question of medical necessity is posed, about 40 per cent of the reviewed cases are determined as Medically Inappropriate, they fail to deliver best clinical outcome to patients and are wasting funds to the system. This means that four out of 10 patients undergoing medical procedure would have been better off by an alternative course of action. This is a global average for a whole wide range of orthopaedic, cardiovascular, oncology and neurology procedures, amongst others.

Considering the amount of effort and systems used to approve cases and the fact that overutilisation still exists, it’s easy to conclude that the current processes are falling short of effectively tacking overuse, and a new approach should be implemented to deliver better results and long-lasting impact.

According to MedRev, what physicians do and how they render medical services determine the quality and efficiency of healthcare, wellbeing of patients and a country’s healthcare costs. Considering physicians’ unique and central role in medical care, this is where change needs to happen, based on a new approach that changes physicians’ practice and behaviour.

Physicians are as sensitive to performance feedback as any other profession, and when they know that their work is reviewed by a peer specialist – they positively change their practice by tighter adherence to clinical standards and higher consideration for conservative care.

The process behind this is where high-volume of cases are reviewed individually by specialty-matched physicians to determine if services provided were necessary based on evidence-based literature and established standards of care. Independent specialists that are external to the cases authorisation process, are best at reviewing the quality of the proposed care and determining its medical necessity. Their written reports are an effective structured approach that delivers an immediate positive impact on the treating physician’s practice and behaviour.

This approach has been implemented in several international markets and the results are consistently positive, according to MedRev’s client’s experience. This is a subtle cost-effective method which is effective in reducing overutilisation levels, improving patients’ safety and promoting good healthcare practice.

Gulf region market players are well aware of the problems and challenges that overutilisation brings and are investing considerable resources in tackling overuse. In the post-COVID-19 period, healthcare insurers and TPAs will have to focus their attention on implementing the right processes and methodologies, rather than expect better results from managing the same processes time and again.

Based on international best-practice combined with local physicians’ network, this approach of external specialists’ reviews for medical necessity will deliver better patient’s outcome, reduce overutilisation levels and lowers healthcare costs for the benefits of patients, insurers and the market as a whole.

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Nir Kaminer

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

TAGS: Quality
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