YOUR MOONLIGHTING DOCTOR IS A VICTIM ON NON PAYMENT BY INSURANCES, HOSPITALS AND NHIF

THE DIABETIC STATE OF THE DOCTOR

In a patient with untreated diabetes, there is a lot of glucose circulating in the blood. But because of a deficiency in insulin, which is the hormone that enables the sugar to enter the cells for the sugar to be utilized by the cells to produce energy, the circulating sugar is not useful to the cell. Doctors are living in a situation very similar to diabetes in regards to being paid for work done.

RICH ON PAPER BUT BROKE IN REALITY

When you see your doctor running around multiple hospitals and moonlighting, it is not that they desire to do so. Many insurance companies and many hospitals are owing these doctors millions of shillings. Many doctors, are thus rich on paper, but poor on real cash. The doctors have a list of invoices of monies that they are owed by insurance companies, health facilities and hospitals that they have worked in.The loss of time value of money very evident in the moonlighting of doctors. 

MOVING ON WITHOUT BEING PAID – THE VICIOUS CYCLE OF DOCTORS

In the year 2002 I met a surgeon who was owed one million shillings by a hospital where he had diligently rendered his services. He had stopped offering services to that hospital due to non-payment of his dues for work done. Instead, he had moved away and started working at another hospital, annoyed by the lack of payment. In his thinking, he was punishing the hospital by withdrawing his service. He withdrew his services quietly. The hospital swiftly replaced him with another younger surgeon, who suffered the same fate after a period of time. This story is not uncommon among doctors. Many young and older doctors are owed millions by hospitals and insurance companies. Unfortunately the cycle is perpetrated by doctors thinking that they will not be treated like their predecessors and agreeing to work without a credit limit. It is also perpetuated by doctors not telling fellow colleagues about their experiences on time. It is also perpetuated by the courts of law not processing court cases fast enough with the cases ending up costing the aggrieved doctors more than they are claiming.

GAZETTED DOCTORS FEES NOT HONORED

Whereas the doctors are an essential component of the healthcare business, doctors suffer the most from a scrupulous businessman, from hospitals and from insurance companies. In 2016 the Kenya Medical Practitioners and Dentist Board (KMPDC) gazetted the fees that doctors should charge for the services they provide. To date, hospitals and insurance companies have not implemented these fees. Instead governments have tried to revise these fees downwards instead of improving public health facilities. Insurance companies even go the extend of reducing doctors’ invoice amounts. So whereas all other fees and costs are going up including hospital fees, insurance companies and hospitals and even government have targeted the doctors’ fees, the soft underbelly that can be misused, by attempting to underpay or not to pay them for the services they render.

LEAST PAY GREATEST RESPONSIBILITY

For many years doctors have noted that when patients are unable to pay hospital bills the insurance companies and the hospitals reduce or even not pay doctor’s invoices, but the hospital bill is untouched. The hospitals even ask the patient’s to bargain with their doctor to reduce fees whereas they do not reduce theirs. This is ironic because the service would not have been possible without that doctor. This is because the doctor is a soft under belly who is in direct contact with the patients, and has learnt to move on even when they are not paid, so as to maintain cordial relationship with the clients.  And yet if something goes wrong it is the unpaid doctor who will be on the chopping board of the Kenya Medical Practitioners and Dentists Council (KMPDC).

ETIMS HAS ADDED ANOTHER LAYER TO DOCTORS WOES

In our effort to exempt medical services from the use of mandatory the Electronic Tax Invoice Monitoring System (ETIMS), we as doctors had many animated discussions with the Kenya Revenue Authority (KRA) teams. Our ask was simple – one should not be taxed for monies they have not been paid. My Aha moment of the root cause of the problems that doctors face came when we had a discussion on the 13th floor of Times Tower with the KRA team on ETIMS. The KRA team literally could not understand how someone could continue working when they are not being paid. The doctors’ team at the meeting explained that healthcare is different and doctors have been victims of non payment because of the nature of their work. When the doctors asked the KRA team what doctors should do when they had entered a transaction into the ETIMS portal that was eventually unpaid, the KRA team ridiculously suggested that the doctor should show proof that they had exhaustively attempted to collect the debt. Healthcare, unlike banking, does not work like that. Doctors work on referral and good name basis. A doctor may see many clients, charging small fees. It is that not possible for the doctor to start demonstrating how he followed up many KES 1,000 consultations in an attempt to get paid. In fact that attempt would cost the doctor more money than just leaving it and moving on. Moreover, the doctors hope that the patient who may be unable to pay may in future compensate by referring other clients to them because the service they received was of good quality. It is just ridiculous for KRA to cause a problem and expect it to be solved the way it is solved in another sector.

WE ARE NOT DEBT COLLECTORS – KRA

Still at the KRA offices the doctors suggested that it would be more beneficial for KRA to facilitate the payment of monies owed to doctors by insurance companies, NHIF and hospitals. KRA would then earn more tax from these payments. The KRA team said that they were tax collectors, not debt collectors. It is this attitude by government entities that leads to less tax being collected. Imagine what tax would be collected if KRA facilitated health facilities to collect the thirty one billion Kenya shillings owed by NHIF to health facilities? Unfortunately, because it is the same government owing health facilities via NHIF, KRA may be unable to do this. The same treasury is banking on KRA to collect money for them to pay for the services that Treasury did not pay for in the past. In light of this I suggest that health facilities be given a tax waiver by KRA, equivalent to what the health facility are owed (a fault of Treasury). 

WE INSIST – WITHDRAW ETIMS FOR MEDICAL CLAIMS

The opposition to the use of ETIMS for medical transactions comes from a historical point of view. 40% of medical claims are not paid by insurance companies and hospitals. Insurance companies are not limited to the private insurance companies. There, National Health insurance fund (NHIF) owes health facilities and health professionals millions of shillings in debt. Because entry of transactions into the ETIMS portal attracts tax it is senseless to provide ETIMS receipts for claims that may never get paid for. Doctors risk paying tax for claims they will never be paid for. Kenya Medical Association (KMA) sued the KRA for this. That case that has not yet been decided upon. KRA in an attempt to solve this issue, made some tax amendment rules in an attempt to exempt certain businesses that have a turnover of less than 5 million from mandatory requiring ETIMS. This is not enough because they were cunning enough to sat that those with transactions of more than 5 million would not be able to claim tax relief without ETIMS receipts even from those whose turnover is below 5 million. It was a clever attempt to silence the noise but it holds no water.

NON PAYMENT OF DOCTORS FEES PROMOTING CORRUPTION

By not paying doctors, hospitals and Insurance companies, including NHIF /SHA are forcing good people out of business and encouraging unscrupulous businesses.

CIVIL SERVANTS’ SCHEMES – LIMITED ACCESS PREFERENTIAL TENDER ALLOCATION

Worse still, civil servants in some public medical schemes are limited as to which doctors they can see, and to which hospitals they can go to for medical services. I suspect HR bosses are pushed to specific insurances companies, insurance administrators and specific hospitals. This is very frustrating for both patients and doctors as it limits access to some doctors and hospitals and it reduces the doctor’s ability to provide continuous quality care for specific clients who get shifted to other facilities yearly. Over the years, it has been noted that specific insurances and insurance providers are being allocated the huge civil service schemes, and civil servant directed to specific hospitals at the exclusion of others. Further, these hospitals are given preferential reimbursement from the national schemes. Theis goes against the tenet of universal healthcare of access.

PLIGHT OF DOCTORS AT VARIOUS STAGES OF THEIR LIVES

Many debates have been had about what action doctors should take in light of no payment of doctors fees by insurance companies and hospitals. The doctor fraternity is worried. The government attempted to misuse the medical interns recently, but a threat of closure of the healthcare system by all doctors has helped restore some dignity to the medical interns.  The young medical officer is currently faced with the challenges of getting decent pay for work done. This has exposed them to exploitation by hospitals and insurance companies who underpay them for work done. They medical registrars in the teaching hospitals are occasionally not paid at all for the work that they do yet the hospital and the universities earn from these registrars. The young consultant doctors who are just starting out in their practice are the most misused because they are unaware of the intentions of hospitals and insurance companies to underpay them. The older consultant is more cautious because they have suffered under the hands of insurance companies and hospitals for some time. Moreover they are more likely to have bigger financial responsibilities given they are standing in community, dependence of many family members both nuclear and extended. They are also likely to be doing bigger capital intense projects. Many older consultants simply stopped offering credit services to clients on whom the ETIMS requirement was forced on them. Because these clients have a relationship with the doctor, these clients are forced to pay out-of-pocket for the medical services and later make a claim from their insurance companies. For doctors, this shifts is the safest way to prevent liability of taxation for money not paid by insurance companies. Other consultants may continue treating clients who covered by insurance companies, but have a heightened awareness of the risks. 

SOLUTIONS TO NON PAYMENT OF DOCTORS BY INSURANCE COMPANIES, HOSPITALS, NHIF AND CIVIL SERVANTS’ SCHEMES

So what is the way forward in some of these issues. I propose the following measures.

1. A performance rating, released monthly, be done on the insurance companies, highlighting those that don’t pay doctors. Professional medical associations like the KMA could take this up. The performance rating would be done on the basis of data collected from its members and not from hearsay. 
2. RUPHA, KAPH and KHF have already initiated healthcare facility surveys that are providing extremely useful information that was previously scattered. This will go a long way into holding SHA accountable.
3. KMA to create a committee that would negotiate on behalf of its members with the insurance companies and with SHA with contracts that are binding. This will make reporting and analysis of performance easier. Over the past many years there has been no unified approach to identifying and stopping rogue insurance companies and Hospitals from exploiting doctors. 
4. Regular surveys be done on payments to healthcare facilities, and to doctors and these information made public.
5. Reports be made to the Insurance regulatory Authority (IRA) on performance of insurance companies and monitoring of the performance of IRA towards resolving many of the issues that affect its members.
6. An improvement of the terms of service of doctors in both public and private employment, so us to minimize the need for moonlighting.
7. KRA to give a tax waiver to hospitals and doctors equivalent to what they are owed by insurance companies, NHIF, SHA, and pending government deals.

Dr Simon Mucara Consultant Obstetrician Gynaecologist and the President of Kenya Medical Association, simonkigondu@gmail.com