Gyn Chronicles
On Health Insurance And Patients Rights
By Dr. Maureen Owiti
We are indeed living in very interesting times when Social Health Authority( SHA) is on the brink of collapse, if it has not collapsed already, taking down with it the entire Country’ s Health sector. However, that is not the primary reason for this particular column piece. As we await to see how this saga will unfold, my article will focus on the unprecedented move by Health Insurance Companies to indirectly deny patients access to the highest attainable quality of care.
This may sound sensational but in truth this is what is currently happening. There has been a trend by some Insurance Companies to write memos to hospitals indicating that they will not pay for certain equipment or appliances and one by one when the public and hospitals have kept quiet, they are all slowly following suit.
Enter Stella-Marie( not her real name). She has been my patient for several years. I have delivered 2 of her children and the last one was following surgery for removal of uterine fibroids- myomectomy. She now presented with heavy bleeding, headaches and an abdominal mass that was giving her both lower abdominal and back pain. From the history alone especially in view of the fact that her last delivery was 7 years ago and previous history of fibroids I was pretty certain that she had fibroids.
Following my teachers’ advice not to assume anything on face value, I did the usual physical examination and indeed found she was somehow pale, and her uterus was quite enlarged. Had she been pregnant the uterus as it presented would have been the size of a 4-month pregnancy or about 16 weeks. Usual pre-op preparation- we took a sample for pap smear and ordered for Ultrasound to confirm the diagnosis, checked her blood levels and gave her something to stop / reduce the bleeding, boost her blood levels. Once her blood levels were sufficient to allow for surgery, we did the usual preauthorization for a Total Laparoscopic Hysterectomy( TLH).
On the said day we went for admission as we had planned to do the surgery first thing in the morning. At admission the hospital sent the preauthorization and we got the interesting news that the Insurance had given a go ahead for the surgery but had declined to pay for one of the instruments required to achieve hemostasis( seal blood vessels to stop bleeding). At face value this was not a big deal and we proceeded to request the patient to pay for the device. The patient was categorical that she was not in a
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Patients and human resource professionals should keenly evaluate their health insurance providers and shun any provider that denies them access to services that are known to reduce their risks and improve the quality of care received and particularly with the high cost of health insurance.
position to add the extra amount being asked for to use the device. After, talks we agreed with the patient to change the scope of surgery and opt for the open approach rather than the laparoscopic approach.
The questions then arise, what was the best approach to doing this surgery? Did the patient sign up to be denied services despite paying hefty premiums to access health care? You can see even from her own history she had hardly used her insurance cover, yes we agree it is the numbers game, but when she really needed a prop up, the insurance company did not provide her with the services she required. Did denial to pay for this service deny her freedom to access the highest attainable health care as enshrined in the Kenyan Constitution 2010?
I am surprised that rights groups and particularly the Consumers Federation of Kenya( COFEK), has not picked this up and advocated for rights of patients. Use of these devices is not experimental and increases patient safety during surgery. Yes, there is a fallback option on how to perform the surgery but this is what would have been the most ideal and safer.
Advantages Of Laparoscopic Surgery
The National Institutes of Health( NIH), which is the primary agency of the United States government responsible for biomedical and public health research, gives the following advantages of laparoscopic surgery over open surgery:
Faster Recovery and Reduced Pain: Patients experience less post-operative pain because of smaller, or " keyhole " incisions, resulting in less trauma to muscle and tissue. Patients often return to work or daily activities within days, rather than weeks.
Less Blood Loss and Fewer Complications: Enhanced visualization with high-definition cameras, combined with precise instruments, leads to less bleeding.
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