The Hidden Burden To Consumers With Medical Insurance — Dr Kuljit Singh

APHM head Dr Kuljit Singh calls for national health insurance funded by taxes and lower admin costs that will “eliminate the need for private insurance firms, potentially lowering prices by allowing the government to negotiate lowest rates with insurers.”

Consumers should be informed that purchasing an insurance plan does not ensure unrestricted access to their preferred health care providers or facilities.

The health care system, which is dominated by the payer—the insurance company—is subject to tight regulations by individual companies that have a significant impact on treatment and hospital options.

Insurers have enormous authority in determining which health care providers and institutions are included in their network. Because of this narrow network, consumers may be limited to a small number of health care options, often neglecting personal preferences or individual medical needs.

This constraint is especially important for patients who require specialised care or have a strong preference for a specific hospital or doctor, which may be outside the insurer’s approved network.

Furthermore, insurers set the reimbursement terms for health care services. This control can result in situations where consumers must pay high out-of-pocket expenses for services not covered by their insurance plan, or worse, vital treatments and procedures are completely excluded from coverage.

When insurers withdraw cashless facilities from hospitals that they believe are too expensive, they frequently explain their decision by branding the hospitals as inefficient. This narrative is incorrect and overly simple. 

Efficiency should be judged not only by immediate costs, but also by the entire value given, which includes service completeness, investment in cutting-edge equipment, and the recruitment and retention of top medical professionals.

Private hospitals are sometimes regarded as pricey because they invest considerably in innovative medical equipment and specialised staff to efficiently manage difficult patients.

These investments are crucial for delivering comprehensive and high-quality treatment, which may be unavailable in less expensive facilities. 

By focusing simply on price, insurers ignore the overall value these institutions provide, diminishing their important contributions to health care excellence.

When these valuable hospitals lose cashless facility assistance, patients are compelled to pay high upfront fees or seek alternative care at already overburdened public hospitals.

This move puts a tremendous strain on the public health care system, which is not only underfunded but also unprepared to handle the rapid inflow of patients. 

Public hospitals, which are already dealing with high wait times and limited resources, would break under the additional burden, undermining the quality of care for all.

In order to adhere to the principle of continuous treatment when withdrawal of cashless facilities are triggered, patients are frequently requested to choose other private hospitals in the area, depriving patients of the ability and comfort of having the same doctor who has been treating them for years. 

It is almost impossible and unfair for patients who have paid rising premiums to be forced to switch to a new provider, with no room for bargaining unless they are willing to pay and claim. In special cases, the entire panel ship with the hospital is cancelled.

Consumers must thoroughly examine their insurance policies, paying particular attention to the network of providers and coverage details. Preparedness to advocate for one’s health care needs and negotiate with insurance companies is critical. Staying aware and proactive is the best way to manage the limits of this controlled system while ensuring access to vital treatment.

If insurers continue to withdraw financing from hospitals that provide innovative medical care, the entire health care system will suffer. This coming crisis demands quick attention and action from all parties to avoid a collapse that would leave countless patients without the critical care they require.

Insurers must shift their focus from cost efficiency to actual value, recognising the critical role that well-equipped, highly competent hospitals play in protecting public health.

Solutions For Insurers To Look Forward

As we look ahead, it is evident that the medical insurance environment will need to develop to suit the population’s evolving requirements and expectations. 

While the current system has several advantages, there are some problems that must be addressed to ensure that everyone has access to high-quality health care without depriving policyholders of the services they have been promised.

One of the most pressing challenges with the existing medical insurance system is its affordability. Premiums, deductibles, and out-of-pocket expenses have gradually increased, making it increasingly difficult for many individuals and families to afford the coverage they require. 

This is especially difficult for those with smaller salaries or who are self-employed, as they frequently struggle to locate plans that fit within their budget.

To remedy this, one possible option would be to adopt a universal health care system in which all citizens are automatically registered in a government-run insurance programme.

This would eliminate the need for private insurance firms, potentially lowering prices by allowing the government to negotiate the lowest rates with insurers. 

Furthermore, this system may be funded by a combination of taxes and lower administrative costs, making it more affordable to everyone. However, individuals who want a pleasant recuperation with selectivity of doctors may have to pay the premium out of pocket.

The future of medical insurance could include a more comprehensive, adaptable system that covers a broader range of services and treatments with several tiers of coverage.

By broadening the area of coverage, individuals will be better equipped to manage their health and wellbeing, resulting in better outcomes and lower long-term expenditures.

Finally, access to care is a crucial aspect for the future of medical insurance. Access to health care varies significantly across the country, with certain places underserved or lacking access to specialised services. 

To solve this, the future of medical insurance may include attempts to enhance the distribution of health care resources, such as incentives for health care providers to operate in underserved areas or the use of telemedicine and other cutting-edge technology to increase access to care.

Overall, the best path ahead for medical insurance in the future will most likely include a combination of these approaches, as well as a greater emphasis on preventive treatment, personalised medicine, and evidence-based decision making and also value driven outcome. 

By addressing the critical issues of affordability, coverage, and access, we can build a more equitable, efficient, and effective health care system, eventually leading to better health outcomes for all. Unfortunately, the current technique of removing cashless facilities and demanding reductions from health care providers would crush the entire system, leaving consumers short-changed.

In conclusion, consumers, government stakeholders, and regulators must keep a close eye on insurance companies’ methodologies, which may appear to control private health care costs, but consumers will continue to pay higher premiums in the future with no control over the type and choice of treatment. 

Private hospitals are willing to collaborate with insurers, and both sides should have a common understanding of the issues they face without using compulsion to reduce costs. Ultimately, we do not want consumers to end up with a bad bargain despite the high premiums.

Dr Kuljit Singh is president of the Association of Private Hospitals Malaysia (APHM).

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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