Joseph Mureithi

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[Joseph Mureithi @Mureithihmugo]

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[The Kenyan Gyne (#HealthServiceCommission) @simonkigondu]

THE ORTHOPAEDICS DILEMMA: WHEN THE PATIENT HAS INSURANCE BUT CANNOT GET TREATMENT

Nothing illustrates the contradictions in Kenya’s social health insurance system better than the story of JM—not his real name.

JM was involved in a road traffic accident and suffered a serious fracture involving the head of his femur. He was in severe pain and required urgent orthopaedic intervention.

On paper, JM is insured.
He personally pays his annual Social Health Authority (SHA) contribution of about KES 40,000 following sha’s means testing formula. He is retired, but his spouse works for a public university and has also listed him as a beneficiary. A tidy sum is deducted monthly from the spouse’s salary towards SHA.
There was only one problem.
The university had reportedly deducted the statutory contributions but had not remitted them to SHA because the institution itself was financially distressed.
So here was a Kenyan who had paid for health insurance, whose family was still having money deducted for health insurance, lying in pain with a fractured hip—and yet unable to access the treatment that his insurance was supposed to provide.
Welcome to the orthopaedics dilemma.

INSURED ON PAPER, STRANDED IN REAL LIFE
JM went to a hospital that accepts SHA.
The hospital assessed him, administered first aid, relieved his pain and initiated the SHA authorization process for definitive treatment.
Then he was told to go home and wait for approval.
Nobody could tell him how long the approval would take.
Think about that for a moment.
A patient with a serious fracture, in pain, requiring time-sensitive surgical treatment, is asked to go home because the insurer’s computer and administrative processes have not yet authorized treatment.
Bones, unfortunately, do not wait for bureaucracies.
Neither do complications.
For many fractures and other major orthopaedic injuries, timely treatment matters. Delay can mean prolonged pain, immobility, more difficult surgery, longer rehabilitation and potentially worse long-term functional outcomes.
An insurance system designed to protect health should therefore never become the reason treatment is delayed.

THE THREE-REVIEWER PROBLEM
There is a reason SHA scrutinizes major orthopaedic procedures.
Historically, orthopaedics—particularly implants and joint replacements—has been vulnerable to fraud and abuse. Controls are therefore necessary. Public money must be protected.
But controls themselves can become harmful when badly designed.
Senior orthopaedic surgeons have raised concerns about the authorization process for major procedures. Requests may have to undergo multiple peer reviews before approval is granted. The reviewers are allocated through the system, and the treating surgeon does not necessarily know who they are or how quickly they will respond.
The intention is understandable: prevent fraud.
But what happens when fraud prevention delays legitimate, time-sensitive treatment?
A system must be able to do two things simultaneously: prevent fraud and protect patients.
It cannot prevent financial loss by creating clinical harm.
If a pre-authorization mechanism contributes to delayed fracture management, prolonged suffering or poorer mobility, then the authorization process itself has become a patient-safety issue.

THE SECOND HOSPITAL HAD ANOTHER PROBLEM
Still in pain, JM was advised to try another hospital.
The second hospital declined to accept SHA.
Why?
The facility was already carrying unpaid legacy NHIF bills as well as outstanding SHA claims.
This exposes another uncomfortable reality.
A hospital cannot continuously treat patients using medicines, implants, theatre supplies, electricity, staff time and professional expertise if nobody pays it.
Hospitals are not magical money-generating buildings.
Doctors are not free.
Nurses are not free.
Implants are not free.
Medicines are not free.
Operating theatres are not free.
When an insurer fails to pay providers, somebody must finance the gap.
Increasingly, that somebody is the healthcare provider.

THE SURGEON BECAME THE INSURER
JM’s condition could not wait indefinitely.
His orthopaedic surgeon was sufficiently concerned about the consequences of further delay that he offered to waive his professional fees completely. He did so partly because JM was his friend and partly because he wanted to reduce the financial burden on him.
JM and his family then did what millions of Kenyans have done for decades.
They looked for money.
Savings were mobilized. Family members contributed. A fundraiser was held.
Eventually, the operation was performed.
JM paid out of pocket.
Pause there.
A Kenyan who had health insurance contributions paid on his behalf—and whose household continued to have statutory health insurance deductions—ultimately required a harambee to receive healthcare.
What exactly, then, was the insurance insuring?
And the orthopaedic surgeon became the final shock absorber of the system.
He became doctor, patient advocate, financial counsellor and philanthropist.
He waived payment for the very expertise that had taken him years of university education, specialist training, examinations, mentorship and clinical practice to acquire.
We celebrate such generosity.
But we should also ask a very uncomfortable question:
Who is supposed to pay the surgeon?
Doctors also have families. They have employees. They pay rent, mortgages, school fees and taxes. They have invested decades acquiring the skills that society suddenly desperately needs when someone breaks a hip, develops cancer, suffers an ectopic pregnancy or needs emergency surgery.
A health financing system cannot be built on the assumption that healthcare workers will eventually work for free.

WHO IS ACTUALLY UNDERWRITING SHA?
This case exposes four fundamental questions that SHA must confront.
First is emergency and critical care. When an insured patient requires urgent treatment, what exactly is immediately available, and who pays? The expansion of emergency and ambulance services is welcome, but patients and providers need clarity on what is accessible in practice and how emergency care is financed.
Second is pre-authorization. Fraud controls are necessary, but clinical urgency must take precedence. Emergency and time-sensitive orthopaedic procedures require clearly defined turnaround times and escalation pathways. A computer workflow cannot be allowed to determine whether somebody walks properly again.
Third is provider debt. Legacy NHIF obligations and accumulating unpaid SHA claims are not merely accounting problems. They eventually become patient-care problems. A hospital that is repeatedly not paid will eventually restrict services, demand cash or stop accepting the insurer altogether.
Fourth—and perhaps most importantly—is provider sustainability.
For too long, Kenya has behaved as though doctors, hospitals and other health professionals have infinite capacity to absorb the weaknesses of our health financing system.
They do not.
Every unpaid claim is credit extended by a healthcare provider to the health system.
Every service delivered while awaiting uncertain reimbursement is being financed by somebody.
Every professional fee waived because a desperate patient cannot pay is philanthropy by a healthcare worker.
And every hospital that continues buying medicines, paying staff and operating theatres while waiting months for reimbursement is, in effect, lending money to the national health insurance system.
The provider is slowly becoming the insurer of the insurer.
That is unsustainable.

THE PEOPLE WHO TREAT PATIENTS MUST HAVE A VOICE
After this case, the senior orthopaedic surgeon called me to discuss his concerns about SHA.
I advised him to document these cases formally and write to the CEO of SHA, copying the Kenya Medical Association. I also encouraged engagement through the relevant orthopaedic professional society so that these concerns can be formally presented and discussed with SHA.
This is important.
Healthcare reform cannot be designed only by politicians, administrators, consultants, financiers, software vendors and insurers.
At the centre of healthcare is an encounter between a patient and a healthcare professional.
The person who knows whether an authorization process is delaying necessary surgery is the clinician treating the patient.
The person who sees the consequences when medicines are unavailable is the healthcare worker standing beside the patient.
The person who knows when an insurance rule is producing a bad clinical outcome is the provider trying to deliver the care.
Providers are therefore not enemies of health reform.
They are one of its most important sources of intelligence.

HEALTHCARE IS NOT FREE
Politicians love the phrase “free healthcare.”
But healthcare has never been free.
Someone always pays.
The real question is who.
In JM’s case, despite insurance contributions, the family paid. The patient paid. The surgeon paid through foregone professional fees.
The hospital system carried its own unpaid debts.
And the insurer remained an insurer.
That is the contradiction we must address.
We cannot declare universal health coverage from podiums while families continue holding harambees for operations.
We cannot claim that people are insured when hospitals increasingly demand cash because previous claims have not been paid.
We cannot celebrate mandatory deductions from workers’ salaries while an employee can have money deducted but remain unable to access benefits because an employer has failed to remit it.
And we cannot build a national health financing system whose final safety net is the goodwill and unpaid labour of doctors, nurses and hospitals.
JM eventually received his operation.
But his story should disturb us.
Because the success of social health insurance is not measured by how many people are registered on a database or how much money is deducted from their salaries.
It is measured at the moment of illness.
When a Kenyan lies in pain with a fractured hip and needs an operation, can the system deliver?
If the answer is, “Go home and wait for approval,” while the patient ultimately has to raise money from family and friends, then we still have work to do.
A functioning health insurance system must protect the patient, pay the provider and protect public resources from fraud.
It must do all three.
Anything less simply transfers the financial burden from the State to the hospital, from the hospital to the doctor, and eventually back to the very patient we claimed to have insured.
Dr Simon Mucara Kigondu
Obstetrician-Gynaecologist and Health Policy Commentator

[Joseph Mureithi @Mureithihmugo]

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