Why Health Insurance Companies Should Look Beyond One-Year Economic Impact
What I’ve seen in Saudi private healthcare
I've noticed something about how insurance companies operate in KSA; they will not pay for something that is more expensive, even if it has an improved clinical profile. Also, insurance companies have been known to reject therapies that need more than 1 year to achieve cost savings. (Caveat: depends on strength of the patient's policy)
Is this behaviour right?
Case study: knee replacement
I find this question impossible to answer if we look at things generally so let's focus on 1 procedure:
Knee replacement
As above, I’ve heard that knee replacements are typically difficult to get approved at an insurer. So, is delaying surgery good or bad for the patient, the insurance company, the healthcare system and society as whole?
Short answer
Delaying the surgery is bad for all of the above, according to a systematic review published in 2017.
Long answer
In their systematic review of knee and hip replacement surgery, the authors of a 2017 publication identified 98 studies between 2004 and 2016, which covered 9 countries (North America, Europe and Singapore). The most common interventions were total knee or hip arthroplasty.
We will only look at knee replacement.
Comparing knee replacement with non-surgical methods (e.g., medication and physio), all 4 studies identified found total knee arthroplasty to be cost effective. This means that it was more expensive to do the surgery over an extended period of time, but the improved patient outcomes were worth paying the extra cost because it was small enough to be justified.
Comparing knee replacement with ‘a do nothing approach’ showed the same as above, surgery was cost effective (more expensive, but the added cost was small enough to be worth it).
What about delaying the surgery? Another study did the analysis and showed that knee replacement “without delay may be an overall cost-saving health care delivery strategy”.
My opinion
At the end of the day, insurance companies must generate a profit to survive. However, decision making on therapies that need more time to realise a cost saving or ones that provided added benefit for added cost must be evaluated through a different lens. The Council Of Health Insurance (CHI) have implemented the Essential Benefits Package, which does address parts of this problem, but it does not cover all disease that have therapies that fall in this bucket.
Perhaps the upcoming changes by the CHI will walk us one step closer to improved patient access to these therapies.
Important disclaimers
Sources
Inspiration: The idea is mine, but I used MS Copilot to sharpen into this article. AI was not used to write anything.
Kamaruzaman H, Kinghorn P, Oppong R. Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature. BMC Musculoskelet Disord. 2017 May 10;18(1):183. doi: 10.1186/s12891-017-1540-2