Norbert Boruett-Innovating in Medical Education

One reply to “HMD 225 Health Risk and Insurance


    1: Critically appraise five health insurance providers in light of the lesson that we have covered.

    I am going to appraise the health insurance packages provided by;
    – Jubilee Insurance
    – Madison Insurance
    – APA Insurance
    – UAP Insurance
    – Britam

    A: Jubilee Insurance; J Care Medical Insurance
    It has access to a network of over 200 medical providers around the country and the J CARE medical insurance gives customers the flexibility to choose where and how they receive treatment.
    Adults between the age of 18 years and 60 years and children between the age of 1 months and 17 years are eligible for this cover however members above 50 years will be required to undergo a medical examination at specific providers before membership and eligibility of cover can be confirmed. This medical examination will be at the applicant’s cost. The problem with this clause is that very people over the age of 60 actually get health insurance policies with Jubilee.
    Key Benefits of J Care:
    – There are 5 levels of comprehensive cover; maternity, outpatient, dental and optical
    – Cover for pre-existing chronic, psychiatric conditions and HIV/AIDS
    – Countrywide provider network
    – Overseas in-patient referrals on a cashless basis
    – Cover for inpatient dental and optical treatment
    – Post-hospitalization benefit
    – Funeral expenses benefit
    – Direct access to treatment while travelling in East Africa
    One of the main problems with J Care is the waiting periods that clients who have chronic conditions and cancer have to endure. In the case of cancer it is 2 years whereas for most chronic conditions the waiting period goes up to one year.
    B: Madison Insurance; KPSA Medical Cover
    Madison KPSA Medical Cover includes the following;
    – Hospitalization costs net of NHIF rebate
    – Bed charges – inclusive of ICU & HDU charges, operating theatre cost
    – Doctor’s fee and Surgeon/Anaesthetist fee
    – Diagnostic Procedures, Dressings, Pathology, X-ray, MRI Scans
    – Inpatient day case procedures
    – Inpatient Physiotherapy, Radiotherapy, and Chemotherapy
    – Cover for treatment abroad if treatment unavailable locally
    This health insurance cover has a number of issues;
    – The problem of hospitalization cost net of NHIF rebate probably means that one may still have to pay a tidy sum in the event of admission.
    – It is good that most diagnostic procedures which may be quite costly are covered.
    – The cover for treatment abroad has very vague terms as it is said “If unavailable locally” because the treatment may actually be available local but if it nos up to standard then we may find ourselves at a disadvantage.
    C: APA Medical Insurance:
    APA Medical Insurance offers 9 different comprehensive healthcare packages which will help most clients in finding a package that is suitable for them.
    The Jamii Plus Cover:
    Jamii Plus will pay for both INPATIENT & OUT PATIENT expenses arising out of an illness or accident for you and your family. The cover is tailored to match a family’s needs and budget. Among the costs covered are bed charges, doctor’s fees, drugs and diagnostics.
    Afya Nafuu Cover:
    This is another APA medical insurance cover. They say it is very similar to the Jamii Plus cover but they did not explain it to me.
    Individual Health Insurance:
    The APA individual and family health cover insurance is designed to provide total peace of mind in case of hospitalization. The product is run by a team of medical and insurance personnel who guarantee quality and efficient services at all times. The cover provides a comprehensive and flexible hospitalization (in-patient) cover.
    Corporate Health Insurance:
    APA Insurance offers flexible tailor made corporate products for groups with ten or more employees. The cover includes in-patient hospitalization, outpatient, dental and optic, maternity, pre-existing conditions like HIV, congenital cover, group excess of loss, emergency road and air evacuation, critical illness expenses as well as funeral expenses.
    Self- Funded Schemes:
    A self-fund scheme is whereby the client deposits a specified amount of money with APA Insurance. Any medical claims arising are settled from these funds. The rules of administration of these funds are drawn by the client and these rules are usually in line with the client’s terms of employment. This cover offers complete flexibility and is ideal for large corporates.
    Femina Plan:
    Femina Plan is a cash benefit for any policy holder diagnosed with Breast or Cervical cancer.

    Critical Illness:
    The Critical Illness Insurance policy covers major diseases like Coronary heart diseases, kidney failure, cancer, paraplegia or major organ treatment.
    ER Card:
    The APA ER Card is an exclusive insurance card that covers one for treatment in the first 48 hours of a health Emergency. It was created with the understanding that the first 48 hours are the most crucial and with the need for immediate hospitalization arising, ER card provides you with that benefit, giving your family and friends time to organize themselves if need be for further stay and treatment in the hospital.
    Globetrotter Travel Cover:
    It provides security for the unexpected emergencies and peace of mind that you will have assistance whenever you travel

    UAP Insurance offers five different products
    Afya Imara:
    It offers medical benefits with flexible packages for yourself, family, groups and the self-employed.
    Afya Imara County:
    This enables you to get quality medical attention for yourself or family from county hospitals across the country.
    Afya Imara Seniors:
    This is for seniors between 66 and 80 years. Once on board, you can renew the cover for life.
    Afya Imara Executives:
    Get a personalised health plan offering a worldwide geographical coverage to meet your specific medical needs.
    Afya Imara Junior:
    Get your child covered and you’ll have one less thing to worry about. This is health cover for children below 19 years.

    E: Britam
    Britam offers an array of health insurance solutions;
    – Milele Health Plan and Kinga Ya Mkulima cover individuals and families
    – Mediflex corporate cover, offers a flexible inpatient cover and a fund- managed outpatient cover for employees and their dependants. Mediflex is ideal for registered companies, NGOs, as well as Chamas with more than 10 members.

    2: Discuss five risks that you think Kenya health providers face:

    The risks affecting healthcare providers in Kenya emphasizes the importance that we must place towards effective Health Care Risk Management. In Kenya today the health care industry faces a number of emerging risk issues related to health care reform.
    The healthcare industry is facing many changes that pose new challenges to healthcare organizations both big and small. In particular, the fast-evolving government regulations, technological innovations, and patient expectations create a new environment .

    The five major challenges faced by the healthcare industry in Kenya and in fact in most countries today are;

    1. Cybersecurity

    Due to the highly sensitive patient information collected by healthcare organizations, the industry has become a prime target for cybercriminals. The healthcare sector has experienced data breaches, exposing patient records.
    This trend will continue as many healthcare providers are still slow in responding to threats while the decentralized systems make them more vulnerable to attacks. When a breach occurs confidential patient information is compromised.

    2. Invoicing and Payment Processing
    Collecting payment has become more challenging as patients are becoming responsible for a larger portion of their medical bills. To meet patient expectations and improve the user experience we should strive to make sure that billing statements are patient-friendly. We should offer paperless statements and a variety of payment options such as Mpesa and credit cards via an online patient portal.
    The problem we have in Kenya is that it is often challenging for health providers to set up such invoicing and payment processing systems in-house. Not only do they have to negotiate terms with each payment processor and build the infrastructure (e.g., patient portal, secure payment processing) but they also must absorb the ongoing administrative cost of maintaining such technologies.
    Additionally, healthcare providers are required to follow strict guidelines to protect patient information. You need to ensure that your payment portal and processing system are fully compliant, or they risk incurring a hefty penalty.

    3. Price Transparency
    Besides difficulty submitting payments due to lack of options, another leading reason for consumers failing to pay their financial responsibility is confusion due to a lack of price transparency. Because of this, healthcare systems are now opting to make their service prices accessible. Doing so reduces patient confusion and surprise billing issues.
    Many patients are now researching service pricing for various health systems before making a decision as to which practice they book an appointment with. Any system that does not make their pricing public may be dropped from consideration altogether and that can be catastrophic for the healthcare provider.

    4. Patient Experience
    The medical insurance landscape has experienced some significant changes in recent years. Due to the fact that more and more patients are now responsible for a larger portion of their healthcare bill, they naturally demand better services from their providers. Healthcare providers in Kenya will thus face tougher competition in attracting and retaining patients who demand an experience that matches the level of customer service they expect from other consumer brands.
    5. Effective payment model
    Payers and patients are demanding new payment models such as;
    – Bundled payments
    – Disbursement to patient-oriented care providers
    – Global payments
    – Shared savings
    However, there are many challenges in implementing these new models and monitoring the processes within the existing systems so healthcare providers should pay close attention to the development of this trend so as to test these new payment models to understand how best to reduce cost and improve patient outcomes while staying profitable.

    6. Big data
    In spite of the fact that more and more healthcare data is being generated, it’s scattered across multiple parties and systems including payers, providers, and patients. There’s no single “source of truth” that providers can use to optimize patient experience.
    For example, when patients switch insurance plans or healthcare providers, most medical practices rely on patients’ self-reporting to reconstruct their records. As a result, not all the information is transferred properly and it’s very challenging to harness the power of data and generate accurate insights.
    In addition, healthcare data comes from many sources in a variety of formats. Currently, there’s no single system or technology infrastructure to retrieve, store, and analyze data from various sources at scale. For healthcare organizations to successfully harness the power of big data, leadership needs to embrace data-driven decision-making. The use of analytics should be woven into the organization culture to develop a trust in data so the insights can be used to support decision-making at the executive level.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this:
close-alt close collapse comment ellipsis expand gallery heart lock menu next pinned previous reply search share star