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Dr Sami Al Hashimi, a specialist internist and cardiologist, says clear care guidelines will help standardise insurance coverage. Jeffrey E Biteng / The National
Dr Sami Al Hashimi, a specialist internist and cardiologist, says clear care guidelines will help standardise insurance coverage. Jeffrey E Biteng / The National

Calls for uniform medical guidelines to curb 'doctor shopping' in UAE

Health experts say the measures, called clinical care pathways, would help protect patients and increase transparency between healthcare providers and insurance companies.

DUBAI // Experts are calling for uniform medical guidelines outlining how doctors test for and treat prevalent conditions such as diabetes.

The measures, called clinical care pathways, would help protect patients and increase transparency between healthcare providers and insurance companies.

The calls by medics follow a study that looked at 598,000 insurance claims from across the UAE in 2011 and last year, examining the cost of procedures used to diagnose diabetes, hypertension, anaemia, thyroid disorders and Vitamin D deficiency.

The claims amounted to about Dh236 million, of which Dh20.4m, nearly 9 per cent, was disputed by insurance companies. They said the diagnostic tests were not medically necessary, according to their protocols.

Between 30 and 40 per cent of the disputed amount was because doctors did not prescribe tests deemed necessary by insurance companies, which led to more visits and follow-up appointments.

Most hospitals follow international guidelines but the lack of "unified medical clinical care pathways" that relate specifically to the UAE leaves room for disputes between health providers and insurers.

"The main reason why we are looking for this is to ensure the patient is being treated the best way at the most efficient cost, and to eliminate this experience we have when we go to different doctors and receive different feedback," said Dr Ayham Refaat, founder and managing director of AccuMedPM, a medical billing solutions consultancy.

Other doctors agree that having uniform guidelines would ensure consistency in care.

"Doctors go through a rigorous process before acquiring their licence here, but the question is what happens after that?" said a Dubai-based internal medicine specialist at a private hospital.

"Yes, there's continuing medical education and licences must be renewed, but all these doctors come from different backgrounds each one with their own idea of the best approach to treating.

"With individual insurance policies, things get more complicated. Having clear pathways will help guarantee that at least what is in the guidelines will be covered."

The study also looked at 25,844 cases of diabetes and found that between two and 12 laboratory tests were requested for the same diagnosis - at a cost of between Dh40 and Dh157 per case.

"Many would probably think that 12 tests is over-utilisation and two is maybe under-utilisation, but the problem is we don't know what utilisation is," Dr Refaat said.

According to the American Diabetes Association (ADA), which is used as the gold standard by hospitals in the UAE for diabetic care, only one of four tests that measure blood sugar is needed to diagnose the disease.

But once a diagnosis is made, the ADA recommends a comprehensive evaluation, including tests that measure cholesterol levels and liver function.

"The problem is many of these patients come in with advanced stages of the disease and we have to remember that diabetes affects the whole body," said Dr Prakash Pania, an endocrinologist at the Aster Jubilee Medical Complex in Bur Dubai.

"So we need to measure liver and kidney functions as well as cholesterol levels. This is why when we request an echocardiogram for a diabetic, for example, insurance companies will question us.

"But diabetics are two to four times more likely to have a heart attack and diabetes is considered a coronary artery disease equivalent."

In addition to clinical care pathways, clear definitions need to be established to help standardise insurance coverage, said Dr Sami Al Hashimi, a specialist internist and cardiologist at Medcare Hospital.

"I've had patients who are diagnosed after they've signed a contract with their insurance company, yet the company still rejects the claim stating that it's a chronic or pre-existing condition," he said.

"We need the government to sit down and clarify the definitions of what is meant by chronic and pre-existing. Each insurance company can't have its own definition."

The much-anticipated federal insurance law, which is awaiting approval by the Executive Council, will help address these issues, according to Abdullah Al Ahmadi, director of health insurance at the Ministry of Health.

He said the ministry was not looking at developing set guidelines, but should a case arise, they would benchmark it against international best practices.

"This is a major problem we're facing now, because doctors are requesting so many tests to make a diagnosis," Mr Al Ahmadi said. "Insurance companies offer many different products and it is the provider's responsibility to check the policy first and see what is covered."

Upon the approval of the federal law, bylaws would be developed to address the issue of defining legal terms, such as pre-existing conditions.

"The draft law sets the general terms for basic coverage," he said. "Once that is in place, bylaws will tackle the details. We have to work step by step to move forward."

mismail@thenational.ae

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