Evidence-based care to control over-prescription of drugs29 December 2017
Over-prescribing medications and referring patients for needless procedures are inflating the cost of healthcare in the UAE. Eliminating financial incentives for doctors is one of the major ways to burst the bubble. Neil Buckley, CEO at King’s College Hospital UAE, speaks to Bradford Keen about new regulations to protect patients and insurers, and why he believes evidence-based care will bring change to the region.
You have got a nasty head cold, so you book an appointment to see the doctor. A needle goes into your arm, blood is drawn and tested multiple times, and you leave with a bagful of four or five different medications. The whole episode will cost about AED3,000 ($817), and the doctor may well advise follow-up consultations be booked.
Over-prescribing drugs is just one aspect of a greater problem with the UAE’s healthcare system. Doctors taking commission from pharmacies and hospitals for prescriptions and referrals have cost insurance companies as much as AED 3.67 billion ($1 billion), according to industry figures quoted by The National.
UAE doctors can earn 25–50% of the total revenue they generate for hospitals through consultation and medical procedures, including surgeries. Prescribing lab tests can rake in 20–30% commission.
It is not good for insurers and the corporates offering health insurance to employees, and it is bad for patients too. King’s College Hospital UAE conducted research with around 2,000 patients and found that 32% didn’t trust the healthcare market. They felt it was run with too much focus on business and not enough on healthcare.
“There is a line and, on occasions here, that line gets crossed... certainly not by all providers, but by some,” says Neil Buckley, CEO of King’s College Hospital UAE. The problem is that financial incentives for doctors take the focus away from quality of care and shift it to generating revenue.
“To develop trust in the market for residents and to fulfil the country’s 2020 vision of increasing medical tourism, we need to make sure that our house is in order,” Buckley says. “Therefore, the transparency, the way we behave and the evidence basis we use for our care needs to improve [so we can] deliver to patients healthcare they can trust.”
Evidence-based care dictates that doctors’ actions be informed by medical research and best practice.
Take the expository visit to the doctor in the opening paragraph. In a situation like that, there would be very little evidence supporting motivation for the prescribed treatment, according to Buckley. Ideally, a patient with a head cold or chest infection should pay for the consultation fee and go home with painkillers at most.
“About 99% of the time, it’s viral not bacterial, so there is no point taking any drugs or prescribing any medication,” Buckley adds. “Basically, the patient needs to rest.”
What happens instead is, after the blood tests, patients are told to use nasal sprays, inhalers and drops, as well as antihistamines “that probably don’t alter the course of the disease at all”.
Unsustainable costs to insurers
Imagine this single case and multiply it across the UAE. The cost an insurer faces is, over the long term, unsustainable for business. Eliminating financial incentives will save billions of dirhams, which can be allocated to develop treatment for cancer and cardiovascular diseases.
“Resources are being wasted on trivial matters when spending needs to be optimised so it can actually benefit patients or make an impact,” Buckley argues. He adds that the industry’s focus is all wrong: instead of doctors being encouraged “to do more things to the same number of patients, I will encourage them to get as many patients as they can. I want them to go out and market themselves, and provide patients with excellent experiences so they will want to come back, but we will be auditing [doctors] very closely with our sister hospital in London.”
King’s College Hospital London has a long history with the UAE. In 1979, former UAE president Sheikh Zayed bin Sultan al-Nahyan gave a donation to help establish the hospital’s liver research centre, which now ranks among the top three in the world.
Nowadays, King’s College Hospital has a medical centre in Jumeriah, as well as a medical and surgical centre in Abu Dhabi. In early 2019, it will open the AED 734-million ($200-million), 100-bed multi-speciality facility at Dubai Hills, in Mohammad bin Rashid City.
At all of its medical facilities, King’s College Hospital UAE pays its medical staff salaries, helping to change the context in which financial incentives have thrived.
“When the hospital opens, if I have an orthopaedic surgeon who’s converting every one of his or her patients into surgeries, I will be looking at that very closely,” Buckley states. “I will expect the surgeon to justify why he or she is doing that, and there will have to be very good clinical reasons.”
Oversight is essential
Comparing data against other King’s College Hospital doctors in the UAE and the UK will help to expose anomalies. Of course, there may be valid reasons for high conversion rates. “Some doctors attract more complex patients for that particular skill,” Buckley adds. “If there isn’t that reason, then we really need to question why that practice is different from his or her peers in terms of quality and cost.
“It’s about auditing and monitoring doctors through a clinical, not financial standpoint. We are very much of the opinion that, if you take care of quality, the revenue takes care of itself. Patients will come to us because they trust the care they are getting.”
Unnecessary caesarean deliveries (c-section) are also inflating healthcare costs. King’s College Hospital UAE is working towards reducing these procedures in favour of natural births. While the national average sits at 25%, King’s team in Abu Dhabi has brought this down to 20% and aims to maintain that number, even as its presence grows in the UAE.
“Many mothers want to have a c-section and that is fine. There is a big element of personal choice involved. What we want to do is ensure our doctors have a conversation with a patient, and explain the benefits and the downsides. It’s about making an informed choice,” Buckley states.
Another way King’s College Hospital UAE has been lowering healthcare costs is by reducing unnecessary travel for patients. Some procedures cannot be performed in the country, including liver transplants. This will change when King’s Hospital opens in Dubai Hills. It will be the first healthcare facility in the UAE with the resources to perform this procedure and provide care to countries in the GCC and Middle East.
At the moment, patients who need this type of treatment are forced to travel, which drives up costs. Buckley uses the example of a child with a poorly functioning liver. Generally, a close relative will donate part of their liver to the young patient. That donor needs to travel to a facility to be screened and vetted to test biocompatibility. Many donors fail this vital requirement. This means new candidates have to come forward and be tested, following the same process and raising costs.
Providing pre- and post-operational treatment, such as donor compatibility, can help to reduce unnecessary financial burdens. That is why, from 2018 right up until the new hospital opens, King’s will be bringing its liver transplantation team from London to the UAE to administer care before and after surgery.
It is not just the work being done at King’s College Hospital UAE that is helping to change the way the healthcare system is run. The Health Authority Abu Dhabi (HAAD) has recently implemented new regulations to eliminate financial incentives.
According to a report from legal firm Al Tamini & Co, HAAD now regards kickbacks as insurance fraud and has introduced a standard provider contract that enforces insurers and providers to meet minimum standard terms and conditions. Healthcare fees are also subject to a mandatory tariff, which dictates the price paid for basic services.
HAAD is also curbing tendencies to seek advice from other doctors. “Lack of trust from patients drives them to seek other opinions because they don’t quite trust the first, second or third,” Buckley says.
If a patient sees a cardiologist and wants to see another within too soon a time frame, he or she has to get authorisation from HAAD to do so. Too many calls about a particular doctor will probably suggest a problem and reason to investigate. Not only does it aim to keep doctors in check, but it also encourages patients to think about the way they use healthcare, pushing them towards better care.
Value for money
The other effect of this regulatory framework is reducing cost. Dubai is an increasingly expensive place to live. “To sustain a double-digit inflation in your healthcare spend isn’t feasible anymore,” Buckley says. Insurers and companies that provide private health insurance to employees are looking to control these costs.
Regulation and better auditing at hospitals and medical centres will help drive change in the UAE. “People want value for money,” Buckley says, adding that “It’s about optimising care, not withdrawing it” in order to guarantee quality healthcare.
“I believe that most corporates and employers want to control these costs without reducing coverage or saying ‘You can’t have this service, or go to that hospital’.” Buckley is confident that with a change in rules and behaviour from payers, insurers and medical centres, a new market standard will be set for healthcare. While the responsibility lies at the hands of payers, providers and regulators, patients can also play a part in improving the healthcare system.
“Ask questions of your doctor,” Buckley says. Find out why blood tests are being taken and what the results will be used for. Question the medicines being prescribed and what they are meant to achieve.
“Patients should feel free and empowered to ask questions,” Buckley says, who is promoting a dialogue-driven philosophy with patients at King’s College Hospital UAE. “It’s not a patriarchal doctor-patient relationship.”
Another important safeguard for patients wanting cost-effective care is to find a trustworthy family medicine doctor.
“They know who the good specialists are because they send multiple patients to them,” Buckley explains, “and when you do get sent to another doctor, you have someone to come back to, and question what that specialist was saying about the pros and cons of what has been applied.”
This is an important part of promoting individual responsibility for health. Ask questions about healthcare, eat better, exercise more and cut out smoking. “We cannot continually think ‘get sick and get better’, we have to think about wellness and prevention,” Buckley advises.
Being more aware about personal health may also inhibit patients from seeking treatment for a basic head cold.
Regardless of the behaviour of individual patients, regulation and more prudent insurers will help to reduce the proliferation of dubious kickbacks. Medical centres employing doctors in the area will be well advised to follow the lead from Buckley’s team. After all, evidence-based care that puts patients at the centre will also be good for business.