SEHA: A CRIT­I­CAL EU­LOGY

TWO AND HALF YEARS AF­TER ITS AM­BI­TIOUS LAUNCH, QATAR’S UNI­VER­SAL HEALTH IN­SUR­ANCE SCHEME SEHA LIES IN RU­INS. IN THE NOBLE PUR­SUIT OF EN­SUR­ING QUAL­ITY HEALTH­CARE FOR ALL, THE COUN­TRY HAS HAD TO LEARN SOME EX­PEN­SIVE LESSONS, THE HARD WAY. IN OUR COVER STORY

Qatar Today - - INSIDE THIS ISSUE - BY AYSWARYA MURTHY

Two and half years af­ter its am­bi­tious launch, Qatar's uni­ver­sal health in­sur­ance scheme Seha lies in ru­ins. In the noble pur­suit of en­sur­ing qual­ity health­care for all, the coun­try has had to learn some ex­pen­sive lessons, the hard way. We peek be­hind the in­ner work­ings of the scheme, and the com­pany that ran it, to di­ag­nose what may have gone wrong and un­der­stand the road to re­cov­ery.

Not un­like think­ing back on past re­la­tion­ships with the added ben­e­fit of hind­sight, in ret­ro­spect the signs were all there that Seha was just not go­ing to work out. The en­tire pop­u­la­tion, both na­tion­als and ex­pats, were sup­posed to have been cov­ered by at least the end of 2015. But in­stead, the scheme was barely half­way into the roll-out when the sus­pen­sion was an­nounced. The first phase, launched in July 2013, in­cluded Qatari fe­males aged 12 and above. The se­cond phase was then launched on April 30, 2014 to in­clude all Qatari cit­i­zens. The Na­tional Health In­sur­ance Com­pany (NHIC), the fully govern­ment-owned en­tity that funded and op­er­ated Seha, was con­vinced that full im­ple­men­ta­tion, though de­layed, was def­i­nitely around the cor­ner. More data had to be gath­ered, it said. Pri­vate health­care providers were over­whelmed, it said at an­other point. Then re­ports started trick­ling in of fraud, abuse and gross over­spend­ing. Coun­ter­claims were is­sued and erring providers were sus­pended, and all the while, the mur­mur of dis­sat­is­fac­tion among pri­vate in­sur­ance com­pa­nies con­tin­ued to grow. As late as Oc­to­ber of last year, the NHIC had said that the next phase will be­gin in 2016 and the fi­nal phase, which in­cluded cov­er­age for all blue-col­lar ex­pats, will also be com­pleted, co­in­cid­ing with the open­ing of new hospi­tals planned for sin­gle work­ers this year.

And then, out of the blue one week be­fore the new year, Qatar News Agency car­ried a brief and terse an­nounce­ment, nes­tled in be­tween other min­utes of a weekly cab­i­net meet­ing, that Seha will be sus­pended ef­fec­tive from De­cem­ber 31, 2015. “In sup­port to the pri­vate sec­tor, the cab­i­net de­cided in­stead to rely on pri­vate in­sur­ance com­pa­nies with ex­pe­ri­ence in the field to pro­vide health in­sur­ance ser­vices,” the re­port went on to say. The Supreme Coun­cil of Health (SCH) re­leased a state­ment say­ing it would be­gin the ten­der process for pri­vate in­sur­ance com­pa­nies to bid to join the new sys­tem in Fe­bru­ary, 2016 which will be rolled out on June 1. As­sess­ment of bids, se­lec­tion of the com­pany or com­pa­nies and sign­ing of con­tracts will be done in May, and the cab­i­net will set up a spe­cial com­mit­tee to over­see the work. The Min­is­ter of Pub­lic Health was later re­placed in a ma­jor cab­i­net reshuf­fle. And then, ra­dio si­lence.

Scour­ing this in­for­ma­tion void for an­swers has been chal­leng­ing. Any­thing in the way of clar­i­fi­ca­tion from the govern­ment was not go­ing to be forth­com­ing. None the less, we wrote to NHIC to ask them: Can you please rank the fol­low­ing points in the or­der in which you con­sider them to have im­pacted Seha's sus­pen­sion? a. Fall­ing govern­ment rev­enue due to low oil prices; b. In­creased in­sur­ance fraud; c. Pres­sure from pri­vate in­sur­ance com­pa­nies; d. Hasty im­ple­men­ta­tion of the scheme, or; e. Other (please spec­ify). At the time of go­ing to press, we were still wait­ing to hear from them.

Fi­nal days

Over the course of the last few months of 2015, the for­mer Min­is­ter of Pub­lic Health Ab­dul­lah bin Khalid Al Qah­tani and Act­ing CEO of NHIC and As­sis­tant Sec­re­tary Gen­eral for Pol­icy Affairs at the SCH, Dr Faleh Mo­hamed Hus­sein Ali, held sev­eral meet­ings with the press to put to rest many of the ru­mours swirling around Seha and they were re­ported in de­tail by the Qatar News Agency. It was re­vealed that the value of med­i­cal bills from the pri­vate sec­tor for Qatari cit­i­zens within Seha was QR1.285 bil­lion from July 2013 un­til Oc­to­ber 21, 2015, and not QR10 bil­lion as it had been re­ported. The min­is­ter also re­vealed that the NHIC has re­fused to pay in­voices amount­ing to QR317 mil­lion from the pri­vate health sec­tor since the in­tro­duc­tion of the in­sur­ance sys­tem, while the amount of re­cov­er­able funds to­taled QR103 mil­lion, point­ing out that the NHIC ap­plies con­trols in pay­ing bills to pre­vent ser­vice providers from un­jus­ti­fied re­peated vis­its and the un­nec­es­sary as­sign­ment to other dis­ci­plines. There is also a de­tailed and man­ual au­dit, he said, for all the claims made by the ser­vice providers, as well as check­ing of med­i­cal files. The min­is­ter

"Med­i­cal costs ap­plied by NHIC are de­fined by the SCH and not by ser­vice providers. The price sched­ule has been pre­pared by two in­de­pen­dent ad­vi­sory bod­ies that are recog­nised in­ter­na­tion­ally." DR FALEH MO­HAMED HUS­SEIN ALI Act­ing CEO, Na­tional Health In­sur­ance Com­pany As­sis­tant Sec­re­tary Gen­eral for Pol­icy Affairs, Supreme Coun­cil of Health

spoke about cases of fraud and forgery in the bills, not­ing that two res­i­dents had re­cently been ar­rested af­ter they used cit­i­zens' per­sonal cards to ben­e­fit from treat­ment in pri­vate hospi­tals un­der the health in­sur­ance sys­tem. Work was also sus­pended with a cer­tain health ser­vice provider be­cause of false in­voices and the amount of QR5 mil­lion had been re­cov­ered.

Dr Ali went to great lengths to ex­plain the mech­a­nism in place to pre­vent fraud. He noted that the au­dit sys­tem in the com­pany is very strict; bills are sub­ject to au­dit be­fore and af­ter pay­ment, point­ing to the ex­is­tence of some cases of fraud. He added that med­i­cal costs ap­plied by NHIC are de­fined by the SCH and not by ser­vice providers. The price sched­ule has been pre­pared by two in­de­pen­dent ad­vi­sory bod­ies that are recog­nised in­ter­na­tion­ally. The com­pa­nies worked closely with the SCH through a study that took nearly a year to be com­pleted. He noted that the price sched­ule is be­ing re­vised pe­ri­od­i­cally in co­or­di­na­tion with the SCH on the ba­sis of the data re­ceived through the claims and ex­pec­ta­tions and changes in the prices of ser­vices in the sec­tor in or­der to achieve a fair price for all par­ties. Fur­ther­more, each dis­ease is sub­jected to a par­tic­u­lar pack­age of ex­penses, and each treat­ment un­der the in­sur­ance sys­tem is of­fered with the same price in all hospi­tals and clin­ics join­ing the in­sur­ance sys­tem, and there­fore the bills can­not be ma­nip­u­lated as each pack­age of treat­ments or ill­nesses has a spe­cific price in ad­vance.

Clearly, in the months pre­ced­ing the an­nounce­ment, a lot of stress had been placed on how the pri­vate sec­tor was us­ing Seha to “loot” the govern­ment. In June last year, a mem­ber of the Shura Coun­cil pointed out how pri­vate hospi­tals had in­creased prices many­fold since the in­tro­duc­tion of Seha and called for ur­gent ac­tion. And go­ing by pub­lic sen­ti­ment af­ter the sus­pen­sion of Seha, it would ap­pear that many do blame fraud and abuse for the cur­rent predica­ment. But in­sur­ance fraud is as old as the in­dus­try it­self. You can min­imise fraud, abuse and waste but never elim­i­nate them and it is nec­es­sary to build them into the cost of your op­er­a­tions, as many com­pa­nies ac­tu­ally do. So what was unique about Qatar? Was the preva­lence of fraud so bad and wide­spread that it crip­pled the whole sys­tem? How can we safe­guard the fu­ture mod­els against th­ese is­sues? Th­ese were the ques­tions we set out to ask. And the an­swers sur­prised us.

Au­topsy

“Could fail­ure in fraud de­tec­tion have brought down Seha? Frankly, I don't think so,” says Jad Bi­tar, Part­ner and Man­ag­ing Di­rec­tor at Bos­ton Con­sult­ing Group. “Fraud is one com­po­nent of health­care costs. It doesn't fully ex­plain the cost in­crease. Most in­sur­ers and third party ad­min­is­tra­tors (TPA) have fraud de­tec­tion and con­trol mech­a­nisms in place. For ex­am­ple, soft­ware that can flag anom­alies and pro­file providers who have larger ten­den­cies to fraud. I don't think fraud is a larger prob­lem in Qatar than in any other pri­vate health­care sys­tem. In the US, Medi­care pros­e­cutes providers for fraud all the time. It hap­pens in ev­ery health­care sys­tem.” But he does point out that the

"It’s dif­fi­cult to guess what may have gone wrong with Seha; it was a closed sys­tem that was not trans­par­ent. But I be­lieve that if there is no in­cen­tive for the payer, providers and pa­tients to be care­ful with the re­sources, it is set to fail." HERVE BOUREL Chief Ex­ec­u­tive Of­fi­cer Da­man Qatar

fee-for-ser­vice model which Seha was us­ing to fund pri­vate providers is more prone to abuse. In fund­ing health­care the “how” is just as, if not more, im­por­tant that the “who”.

"The fee-for-ser­vice model adopted by Seha was a mis­take and I be­lieve it rushed into this with­out fully as­esess­ing the con­se­quences of this model. It was ex­pected that it would lead to in­crease in ser­vice avail­abil­ity and also an ex­plo­sion of health­care costs. And this is ex­actly what hap­pened,” says Bi­tar.

One ad­van­tage of this model is that it mo­ti­vates providers to in­crease ser­vices, he adds. “In a sup­ply-con­strained mar­ket, where there aren't enough doc­tors, hos­pi­tal beds or other health ser­vices, fee-for-ser­vice is a great tool to in­cen­tivise in­vestors to of­fer more ser­vices but you end up wast­ing a lot of money.”

Ex­as­per­at­ing this sit­u­a­tion was the fact that there was no in­cen­tive for any of the stake­hold­ers to limit con­sump­tion. The way the sys­tem was de­signed was flawed and was a disas­ter in the mak­ing. Herve Bourel, the Chief Ex­ec­u­tive Of­fi­cer of Da­man Qatar, made the same ob­ser­va­tion. “It's dif­fi­cult to guess what may have gone wrong; it was a closed sys­tem that was not trans­par­ent. But I be­lieve that if there is no in­cen­tive for the payer, providers and pa­tients to be care­ful with the re­sources, it is set to fail. On the pa­tient level, there is no co-pay sys­tem. Go­ing to the clinic doesn't cost you any money, so why should you bother. I heard an anec­dote about some­one who went to the hos­pi­tal to get an MRI not be­cause some­thing was wrong with him but be­cause he had never had one and wanted to ex­pe­ri­ence it,” Bourel laughs. “This is what we call 'shop­ping' for med­i­cal ser­vices. You don't be­have like a pa­tient any­more but like a con­sumer.” Ad­di­tion­ally, not only were the providers given ac­cess to a big box of money, but the pay­ers, i.e., the NHIC, were do­ing a poor job man­ag­ing risk. “It's not enough to just process the flows; you also have to man­age it,” he says.

The news about Seha came as a sur­prise to some re­gional in­dus­try ex­perts like Laila Al Jassmi, Founder and CEO of Health Be­yond Bor­ders, a Dubai-based health­care con­sul­tancy firm. Be­fore start­ing her own com­pany, she worked for two decades in the pol­icy and strat­egy depart­ment of the Dubai Health Au­thor­ity (DHA) and so has an in­ter­est­ing van­tage point. “When we started for­mu­lat­ing the manda­tory health in­sur­ance model in Dubai, we had stud­ied what Qatar was do­ing and thought they would be quicker to achieve full im­ple­men­ta­tion. Qatar was the only GCC coun­try that had a na­tional health ac­count, some­thing that we started in Dubai in 2012 in or­der to ben­e­fit from Qatar's ex­pe­ri­ence,” she says. (This, iron­i­cally, back­fired in Qatar's case. Cit­i­zens didn't have to ap­ply for an in­sur­ance card but could use their ex­ist­ing health card. This made it eas­ier for peo­ple to ben­e­fit from the scheme.) Ac­cord­ing to Al Jassmi, it all comes down to lack of prepa­ra­tion. “The uni­ver­sal health in­sur­ance model should not be rolled out with­out proper re­search into the mar­ket and a lot of stake­holder en­gage­ment. Look­ing at this from the out­side, I would say that there wasn't enough in­ter­ac­tion be­tween the reg­u­la­tor, pol­i­cy­mak­ers and the mar­ket.”

The mar­ket. Here is a seg­ment that was less than happy with Seha. A story that be­gins with “Once upon a time there was a mo­nop­oly” rarely has a happy end­ing. In in­sist­ing that all na­tion­als and ex­pats must be in­sured for ba­sic ser­vices through the NHIC, the govern­ment was freez­ing the mar­ket and leav­ing pri­vate in­sur­ance com­pa­nies out in the cold. Back in April last year, dire pre­dic­tions were made in th­ese very pages about the di­rec­tion in which Seha was head­ing. “The NHIC should be com­ple­men­tary to the pri­vate sec­tor in ev­ery sense of the word and not a re­place­ment. Oth­er­wise, it would be dry­ing the mar­ket and sim­ply forc­ing pri­vate health in­sur­ers out,” Elias Che­did, the COO and Deputy CEO at SEIB In­sur­ance, had said. “Ul­ti­mately, while you will see ben­e­fits in the short term of hav­ing a sin­gle in­surer, in the long term we run the risk of com­pla­cency un­der­pinned by a lack of in­no­va­tion due to lack of com­pe­ti­tion.” This sen­ti­ment was echoed by Ali Saleh Al Fadala, Se­nior Deputy Group Pres­i­dent and

"The fee-for-ser­vice model adopted by Seha was a mis­take and I be­lieve it rushed into this with­out fully as­esess­ing the con­se­quences of this model. It was ex­pected that it would lead to in­crease in ser­vice avail­abil­ity and also an ex­plo­sion of health­care costs. And this is ex­actly what hap­pened" JAD BI­TAR Part­ner and Man­ag­ing Di­rec­tor Bos­ton Con­sult­ing Group

CEO, Qatar In­sur­ance Group. “The NHIC is now aim­ing at pro­hibit­ing all pub­lic en­ti­ties in the coun­try from us­ing pri­vate in­sur­ance, vir­tu­ally end­ing any sort of com­pet­i­tive en­vi­ron­ment and re­mov­ing the pri­vate sec­tor. This is a step back­wards in my opin­ion,” he said, adding that costs of the pro­ject are al­ready run­ning over bud­get. “Given cur­rent de­clines in oil prices, we doubt the scheme will be able to cover all ex­pa­tri­ate res­i­dents in the coun­try as orig­i­nally in­tended.” And this came to pass within a few months.

Da­man is a com­pany that has been on both sides of the equa­tion. Partly owned by the Abu Dhabi govern­ment, Da­man is fully in charge of in­sur­ing its na­tion­als, and has a ma­jor­ity mar­ket share in the Emi­rate. Da­man Qatar, how­ever, be­gan op­er­a­tions just as Seha was be­ing an­nounced. They were at risk of be­ing squeezed out of the small but grow­ing two-mil­lion-plus mar­ket. Had NHIC rolled out sub­se­quent phases as they had planned, Da­man and other pri­vate in­sur­ance com­pa­nies in Qatar would have had to com­pete for a sig­nif­i­cantly tiny mar­ket of in­sur­ing ser­vices not cov­ered by Seha's ba­sic pack­age and also cov­er­age abroad. In no sce­nario would this have been sus­tain­able. So in a way this is good news for Da­man and its com­peti­tors.

“I un­der­stand the ra­tio­nale be­hind want­ing to have tighter con­trol over the in­sur­ance for your na­tion­als. You'd ob­vi­ously want to en­sure the best qual­ity of ser­vices for your cit­i­zens and also be able to con­trol that. I can't imag­ine, for ex­am­ple, that the Ger­man govern­ment would al­low the pri­vati­sa­tion of their so­cial health sys­tem by in­ter­na­tional com­pa­nies. So it's fully un­der­stand­able and fair that the Qatari govern­ment tries to re­strict that space,” Bourel says. But the ex­pat mar­ket should be fair game, he adds.

Friends, fam­ily and neigh­bours

Across the GCC, the tra­di­tional wel­fare state model is un­der tremen­dous pres­sure and sev­eral gov­ern­ments have been test­ing the wa­ters of manda­tory health in­sur­ance. A rapidly grow­ing pop­u­la­tion that is grow­ing obese and more prone to chronic and non-com­mu­ni­ca­ble ail­ments such as di­a­betes and heart dis­ease and an ex­tra­or­di­nary rise in the per­cent­age of el­derly cit­i­zens have de­manded the im­ple­men­ta­tion of in­no­va­tive schemes that not only ease pres­sure on the pub­lic health sys­tems but also in­crease qual­ity by en­cour­ag­ing com­pe­ti­tion be­tween the pub­lic and pri­vate sec­tor. So pa­tients get a choice be­tween providers. And it serves to at­tract new in­vest­ment in health­care. Un­til re­cently, Qatar was thought to have been run­ning a rea­son­ably func­tional model. But now that we are go­ing back to the draw­ing board, it be­hooves us to con­sider how our neigh­bours are han­dling this mam­moth chal­lenge. Dubai, Abu Dhabi, Saudi Ara­bia, Kuwait and Oman all have dras­ti­cally dif­fer­ent mod­els, and most peo­ple we spoke to were di­vided in their opin­ion of which one could be called a proven suc­cess. The fact is that it's prob­a­bly too early to make that call, con­sid­er­ing many of them, like Seha was, are in the middle of roll-out.

Abu Dhabi's uni­ver­sal health in­sur­ance model could be con­sid­ered the clos­est to Qatar's (still with sig­nif­i­cant fun­da­men­tal dif­fer­ences). Da­man was cre­ated to­wards the end of 2006 and was a joint ven­ture be­tween the govern­ment of Abu Dhabi, which owns 80% of the com­pany, and Mu­nich Re. Be­gin­ning 2006, they started rolling out manda­tory in­sur­ance, al­most in par­al­lel, for na­tion­als and res­i­dents. Da­man is the ex­clu­sive in­surer for the 700,000 na­tion­als un­der the Thiqa pro­gramme and also the ba­sic pack­age for all res­i­dents who earn less than $1,300 a month. Both th­ese

schemes are funded and sub­sidised by the govern­ment, re­spec­tively. For the ex­pat mar­ket there is free com­pe­ti­tion be­tween the var­i­ous pri­vate in­sur­ers (in­clud­ing Da­man, which has a con­sid­er­able priv­i­lege). While Abu Dhabi also has adopted the fee-for-ser­vice pay­ment model (which ac­cord­ing to Bi­tar con­tin­ues to be a ma­jor headache for the govern­ment, be­cause of the sub­se­quent in­crease in costs) it also started in­tro­duc­ing strong mech­a­nisms fo­cused on preven­tion, data an­a­lyt­ics and dis­ease man­age­ment. On blue­print, Abu Dhabi was meant to go the Seha route with Da­man poised to ex­clu­sively han­dle even the ex­pat mar­ket, Bourel re­veals. But they even­tu­ally de­cided against it. “We saw com­pe­ti­tion as an en­cour­age­ment and mo­ti­va­tion to be bet­ter and it also dra­mat­i­cally im­proved the ser­vices in the mar­ket.”

Dr Saif Al Jaibeji is the Re­gional Gen­eral Man­ager Unit­edHealth Group in Middle East & Africa, a di­ver­si­fied health­care com­pany which of­fers so­lu­tions to re­gional gov­ern­ments, health in­sur­ance com­pa­nies and health­care providers. So Dr Al Jaibeji has deep knowl­edge of the health­care sys­tems in Abu Dhabi, Dubai and even Seha, on ac­count of the work they did with SCH on health pol­icy, in­sur­ance pol­icy and ca­pac­ity de­vel­op­ment. While he is not al­lowed to talk di­rectly about Seha, he tells us about his time work­ing with the Dubai govern­ment back in 2007-8, when they were plan­ning to launch the manda­tory health in­sur­ance pro­gramme. “Even­tu­ally it had to be de­layed be­cause the fi­nan­cial cri­sis had a neg­a­tive im­pact on com­mer­cial busi­nesses and the scheme would push cost of health­care to em­ploy­ers, plac­ing be an ad­di­tional eco­nomic bur­den on busi­nesses back then. How­ever once the econ­omy re­cov­ered DHA launched the scheme. It's im­ple­mented in phases and soon ev­ery­one in Dubai will be cov­ered by manda­tory pri­vate in­sur­ance. The Dubai model al­lowed pri­vate health in­sur­ance com­pa­nies to pro­vide manda­tory health cov­er­age – once they match the reg­u­la­tory re­quire­ments. To­day, the govern­ment has li­censed about nine in­sur­ance com­pa­nies to com­pete in the mar­ket. Any new player who wants a slice of the mar­ket needs to meet cer­tain cri­te­ria to en­sure the best qual­ity of ser­vices for the cus­tomers and ap­ply for per­mis­sion to pro­vide in­sur­ance. For ex­am­ple, they have to be lo­cal or have lo­cal pres­ence, a min­i­mum num­ber of em­ploy­ees, a par­tic­u­lar claims man­age­ment sys­tem, etc.,” he says. So the govern­ment is a purely reg­u­la­tory body; it doesn't fund any­thing and there isn't any sub­sidy for pri­vate mar­ket. The roll-out is due to be com­pleted in June this year and Al Jassmi pre­dicts that in three to five years the mar­ket will be opened to com­pa­nies be­yond the nine that are now li­censed. She says in the be­gin­ning it was only re­stricted to three in­sur­ance com­pa­nies and there was a re­vi­sion be­cause in­dus­try feed­back in­di­cated that the mar­ket is big enough and can be shared. So it grew from six to eight to nine, al­low­ing even a few Is­lamic Taka­ful com­pa­nies to par­tic­i­pate. This is why she em­pha­sizes the need for con­stant di­a­logue be­tween health­care providers, pol­i­cy­mak­ers and health in­sur­ance as­so­ci­a­tion rep­re­sen­ta­tives, and for try­ing to un­der­stand ev­ery stake­holder's per­spec­tive.

At the 11th an­nual Health­care In­sur­ance Fo­rum which was held in Dubai in Jan­uary, the im­pact of manda­tory health­care in­sur­ance dom­i­nated dis­cus­sions through­out.

"With manda­tory in­sur­ance, you need to lo­calise any im­ple­men­ta­tion. There is no uni­ver­sal so­lu­tion, even among the GCC coun­tries. Ev­ery Emi­rate has its own pop­u­la­tion mix and reg­u­la­tory and mar­ket re­quire­ments." DR SAIF AL JAIBEJI Re­gional Gen­eral Man­ager United Health Group, Middle East & Africa

Dr Al Jaibeji, who led a panel and a work­shop at the event, says, “The con­clu­sion from the fo­rum was that with manda­tory in­sur­ance, you need to lo­calise any im­ple­men­ta­tion. There is no uni­ver­sal so­lu­tion, even among the GCC coun­tries. You can't just copy what an­other city is do­ing. Ev­ery Emi­rate has its own pop­u­la­tion mix and reg­u­la­tory and mar­ket re­quire­ments.”

But there are some com­mon is­sues all GCC coun­tries are grap­pling with; pric­ing, for in­stance. “Both providers and in­sur­ance com­pa­nies in the re­gion can ben­e­fit from trans­parency in cost­ing struc­ture. While cost­ing, or in other words, pre­mium cal­cu­la­tion, is usu­ally based on ac­tu­ar­ial anal­y­sis and pre­vi­ous claims. Un­der Seha's re­im­burse­ment scheme in Qatar, ev­ery hos­pi­tal gets paid a pack­age amount. This was nec­es­sary step to roll the scheme and en­cour­age pri­vate hospi­tals to join the net­work. How­ever it was not a sur­prise that cost went high and there was no in­cen­tive to in­tro­duce qual­ity and ef­fi­ciency gains. In Dubai ev­ery provider has a dif­fer­ent price list for dif­fer­ent in­sur­ances, cash pay­ments, etc., but they are not built on trans­parency.”

"We don't have legacy sys­tems in the re­gion, and we don't have to wait for years un­til the cur­rent sys­tem fails - there is a golden op­por­tu­nity for reg­u­la­tors, and equally, for stake­hold­ers, to con­sider in­no­va­tive ap­proaches to in­tro­duce sus­tain­able health sys­tems; like the ACO, or ac­count­able care or­gan­i­sa­tion, model. When eval­u­ated for lo­cal im­ple­men­ta­tion, it shows a lot of po­ten­tial in terms of cre­at­ing mean­ing­ful part­ner­ship be­tween hospi­tals and pay­ers. There is no loss or profit, ev­ery­one is paid fairly but those who achieve bet­ter out­comes will be paid more. So there is no pres­suer on providers and they have an in­cen­tive to be bet­ter. This is dis­rup­tive and many ma­ture mar­kets like the US and UK are adopt­ing or look­ing to adopt this," says Dr Al Jaibeji.

Mov­ing on

For the mar­ket in Qatar, dras­tic and con­stant changes are not good. Not only does it throw providers off bal­ance, it is also very dis­rup­tive to peo­ple's lives. “When it comes to health­care, you want to en­sure pre­dictabil­ity. You are deal­ing with peo­ple's lives and the last thing you want are sur­prises and ma­jor shifts in pol­icy,” says Bi­tar. “The way Seha was sus­pended – abruptly and in the middle of De­cem­ber – does not bode well for the NHS. Some­thing as fun­da­men­tal and ma­jor hap­pen­ing in this man­ner was not how NHS planned the evo­lu­tion of the health­care sys­tem in Qatar. If you look at the strat­egy, there was a roadmap with spe­cific im­ple­men­ta­tion mile­stones and Seha's elim­i­na­tion is not part of this plan. I am still try­ing to as­sim­i­late and make sense of what's go­ing to hap­pen,” he says. His best hope is that the govern­ment will go back to the NHS and start from there.

For in­sur­ance com­pa­nies too, the an­nounce­ment dra­mat­i­cally changes their long-term plans in the coun­try, not even three years af­ter they were forced to reeval­u­ate their strate­gies in the wake of Seha. Is there a cer­tain fa­tigue, we ask Roger Phillips, part­ner at Pin­sent Ma­sons, which counts many in­sur­ance com­pa­nies among its clients. “I am not sure ‘fa­tigue' is the right word. In­sur­ers un­doubt­edly want more pre­dictabil­ity and too much change is dam­ag­ing but the pri­vate in­sur­ers in Qatar have been lob­by­ing for some time now in ef­forts to get more ac­cess. So they will feel pos­i­tive the govern­ment is lis­ten­ing. Hav­ing said that, in re­spect of the sus­pen­sion, the pri­vate sec­tor will be con­cerned to know more de­tails on the new ar­range­ments in­clud­ing ben­e­fits and pric­ing model. An­other sig­nif­i­cant in­ter­est for the in­sur­ers is the con­tin­u­ing in­vest­ment and de­vel­op­ment in re­spect of new hospi­tals and health­care fa­cil­i­ties, pri­vate and pub­lic. This will ob­vi­ously be key to growth and qual­ity health­care in­sur­ance in Qatar,” says Phillips.

He also asks in­sur­ance com­pa­nies to ex­pect a fun­da­men­tal re­work of the reg­u­la­tory frame­work this year. “The Qatar Cen­tral Bank will be su­per­vis­ing and while the new In­sur­ance In­struc­tions are not yet fi­nal, the reg­u­la­tions which are out ‘for con­sul­ta­tion' are ex­tremely oner­ous in terms of pru­den­tial re­quire­ments, in­ter­nal con­trols as well as con­duct of busi­ness and ser­vic­ing. This

"When we started for­mu­lat­ing the manda­tory health in­sur­ance model in Dubai, we had stud­ied what Qatar was do­ing. Qatar was the only GCC coun­try that had a na­tional health ac­count, some­thing that we started in Dubai in 2012 in or­der to ben­e­fit from their ex­pe­ri­ence." LAILA AL JASSMI Founder and CEO Health Be­yond Bor­ders

will be a chal­lenge for the new QCB su­per­vi­sory teams and for in­sur­ers to com­ply with. There will be sig­nif­i­cant in­creases in com­pli­ance costs and changes will take years to bed in,” he warns, adding that the new reg­u­la­tions are likely to be in force around March. Yet he is see­ing a lot of ac­tive plan­ning among th­ese com­pa­nies. “Even with tran­si­tion pe­ri­ods for some rules, it re­quires fur­ther early in­vest­ment in sys­tems and con­trols. Also, there are in­creas­ing signs of col­lab­o­ra­tion and ‘part­ner­ing' be­tween lo­cal and in­ter­na­tional in­sur­ers to pro­vide more com­pelling propo­si­tions. TPA ar­range­ments are also be­ing as­sessed very closely with the like­li­hood of new par­tic­i­pants and im­proved of­fer­ings. Ad­vanced sys­tems ca­pa­bil­ity for an­a­lyt­ics and dis­ease man­age­ment as well as claims will be a con­sid­er­able ad­van­tage and key to Qatar's plans for im­prove­ments in health­care,” he says.

Cur­rently the whole sys­tem is in limbo. Cit­i­zens are no longer sure if they are still in­sured, providers are won­der­ing if they are get­ting paid and the in­dus­try is wait­ing for some sort of sign of what's com­ing next but the si­lence from the govern­ment is deaf­en­ing.

Mean­while, Bourel is cau­tiously op­ti­mistic. “This re­think­ing of the in­sur­ance model in Qatar is good news for us if we are al­lowed fair ac­cess to this mar­ket. Is it go­ing to be re­stricted to play­ers who are, for ex­am­ple, QFCreg­is­tered or listed on the Qatar Stock Ex­change? We are all wait­ing to see the ten­der con­di­tions. My rec­om­men­da­tion is that the govern­ment put the ex­pat busi­ness on the open mar­ket so that they can profit from the com­pet­i­tive­ness, ex­ter­nal ex­per­tise and in­ter­na­tional ex­change. Com­pa­nies can also po­si­tion them­selves de­pend­ing on the seg­ments and qual­ity of ser­vice they want to de­liver.”

But it's go­ing to be a tough few months for ev­ery­one go­ing ahead. “I am hear­ing that there is in­tent to in­tro­duce some mech­a­nisms like co-pay, co-in­sur­ance, de­ductibles, lim­its, etc. But it will be painful to im­ple­ment be­cause over the last few months the pop­u­la­tion has been used to get­ting any­thing they wanted for free. This is un­der­stand­able from their per­spec­tive; this is why it is nec­es­sary to, and I use this word cau­tiously, ed­u­cate the pub­lic. I hope the govern­ment will con­sider this and try to com­mu­ni­cate on that. It takes time. I don't ex­pect the sav­ings and im­prove­ment that the govern­ment is hop­ing for (and has the right to hope for) will hap­pen overnight,” says Bourel.

Just open­ing up to the pri­vate sec­tor is not some sort of panacea. “Will this solve the prob­lem of fraud? In­creased cost? Med­i­cal in­fla­tion?” Bi­tar asks. “All you are do­ing is mov­ing ad­min­is­tra­tion of the in­sur­ance and dis­tribut­ing it among pri­vate in­sur­ance com­pa­nies. First, I don't be­lieve the mar­ket size can sup­port so many com­pa­nies; they will be below scale and will in­crease risk to the econ­omy.” So what is the prob­lem we should be try­ing to ad­dress? “One is ac­ces­si­bil­ity. There isn't the kind of ca­pac­ity to pro­vide the kind of qual­ity care that the pop­u­la­tion ex­pects. Ser­vices and qual­ity have to be built across the pub­lic and pri­vate sec­tors and can be done in a com­ple­men­tary man­ner. For ex­am­ple, Ha­mad Med­i­cal Cor­po­ra­tion and Sidra, when it opens, can han­dle ter­tiary care (across the GCC, the pub­lic sec­tor is bet­ter pre­pared to han­dle heavy cases) while pri­mary and sec­ondary care can be han­dled by the Pri­mary Health Care Cor­po­ra­tion and the pri­vate sec­tor.” With the ex­pats mak­ing up the ma­jor­ity in of the pop­u­la­tion in most GCC coun­tries, the chal­lenge is to pro­vide na­tion­als with qual­ity health­care while avoid­ing sub­si­dized care for the ex­pat pop­u­la­tion. That's a tough bal­ance, he says.

But maybe it's not nec­es­sary to start from scratch. There are some ad­van­tages of the self-funded scheme that NHIC had adopted. “In a self-funded scheme, you can con­trol the ben­e­fits and costs,” says Dr Al Jaibeiji. “Yes, when you are fully in­sured you are trans­fer­ring all the risk to one com­pany but the prob­lem is when, for what­ever rea­son, you have to change the in­sur­ance com­pany, you'll have to change ben­e­fits, costs, providers, cards... So self-fund­ing is good from pri­mar­ily a cus­tomer ex­pe­ri­ence per­spec­tive. Some in­sur­ance com­pa­nies will man­date that pre­mi­ums are paid at cer­tain times of the year; if you are self-funded you can be more flex­i­ble. In the Gulf, the pop­u­la­tion thins out dur­ing the sum­mer months and there are fewer claims to process, mean­ing you can con­trol your fi­nan­cials.” So NHIC def­i­nitely had some sound mech­a­nisms in place; it re­mains to be seen what it will re­tain and what will be thrown out.

It is ob­vi­ous how com­plex the in­sur­ance land­scape in Qatar and the GCC is. No one yet knows all the an­swers and mis­takes are in­evitable. It's pos­si­ble that, had the oil prices shown some re­cov­ery, the govern­ment might have de­cided to power through with Seha and at­tempt to iron out the kinks on the go. By not be­ing af­forded that lux­ury (and this is ex­pected to hap­pen of­ten till the oil prices pick up) means the SCH has had to bin the whole thing and start again. What the re­sult of this will be is still largely a mys­tery but with al­most three years' worth of lessons to draw upon, the com­ing it­er­a­tion will def­i­nitely be Seha's bet­ter-evolved sib­ling. Qatar, mean­while, should be proud of what has been achieved. Uni­ver­sal health in­sur­ance is worth striv­ing for and we got pretty close. More im­por­tantly still, Seha has man­aged to cre­ate aware­ness about the ben­e­fits of med­i­cal in­sur­ance that had pre­vi­ously been se­verely lack­ing. The pub­lic that will be in­tro­duced to Seha 2.0 is a bet­ter in­formed one with higher as­pi­ra­tions. And that can never be a bad thing

Source: De­liv­er­ing Uni­ver­sal Health Cov­er­age, WISH 2015

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