How social is social health insurance?
Social health insurance is one of the means to create more accessible health care, which is one of the main priorities of Georgia’s National Health Care Strategy 2011-2015, issued by the Ministry of Labour, Health and Social Affairs. As a result of the new policy, more than 900,000 citizens living below the poverty line are receiving state funded medical insurance, a number that was only 40,000 persons five years ago. While the Ministry of Health often reports about successful stories of people who have the social insurance, we heard stories that were less positive from patients and experts. The main problems that are usually mentioned are (1) vague wording within the legislation allows insurers to refuse to pay for an examination or treatment and (2) the fact that insurance companies are free to set up their own list of the medicines they will reimburse. This results in a situation where some insurance companies only reimburse the medicines of one specific pharmaceutical company.
In Chiatura we met Dushiko, a 78-year-old woman, who lives with her husband, daughter and two grandchildren. They all live on the pension of Dushiko and her husband. Dushiko has asthma and needs to buy a GEL 7 inhaler five times each month. She also needs a specific medicine that she has to use with the inhaler.
While her social insurance contract requires her insurer, Alfa, to pay GEL 50 for her medicines per month, the company does actually not pay the GEL 50 for the medicines she needs. She said that Alfa mainly reimburses medicines of Aversi, as Aversi is the company that owns Alfa. While she has tried to use Aversi's medicines, they do not help her condition and she needs a medicine of another brand. While her social insurance should, theoretically, release her from this burden, it does not in practice and she ends up paying for all her medicines herself.
About a year ago Dushiko got a hernia for which she needed a surgery. She visited the doctor in Chiatura, but, without giving a clear reason, he refused to give her the form that she needed for the hernia treatment in the hospital. The doctor in Chiatura also serves as Alfa's representative in Chiatura, which raises doubts about his judgment as a doctor, as he represents different interests as well. Next to being an insurance representative and doctor he is also deputy manager of the hospital.
The two problems Dushiko faced are also mentioned in an interview we had with Zurab Putkaradze, project director for Healthy World, an NGO that assesses social insurance in Tbilisi. The first problem he mentioned is the vague wording of a paragraph in the legislation, which allows representatives of hospitals or insurance companies to interpret a diagnose differently than a medical professional, and to restrict the provision of laboratory and instrumental tests needed for non-urgent surgical intervention. This results in situations where insurance companies refuse to give a certain treatment or deny access to a patient to be treated, as was the case with Dushiko. The second problem is that insurance companies have considerable freedom to set up their own list of medicines to be reimbursed. Putkaradze said that Aversi/Alfa only reimburses its own medicines, as there is no standard list of medicines to be reimbursed. This leads to a conflict of interest and a misuse of market power, especially in the Georgian case where big pharmaceutical companies have a strong position in the insurance sector.
An issue that aggravates these two problems is a change within the social insurance system: The transition from a voucher-based system where people had the freedom to select their own insurer, to a regional system where one company insures the entire population of a region. Under this new system, people are deprived of the possibility to choose their own insurer. Because of this, they have become dependent on the decisions of the insurance company operating in their region, without having the possibility of switching to another insurer.
The lack of clear rules and the freedom that insurance companies have in terms of deciding whether a patient needs treatment or not, and determining which medicines are to be reimbursed, along with the fact that the people cannot choose their own social insurer, are the sources of the kind of problems that Dushiko faces. The government's first attempt to set up a mediation service for insurers, hospitals and patients is a good step toward addressing these kinds of problems. However, better legislation that defines the obligations of insurance companies and the establishment of a standard list of medicines to be reimbursed could play an important role in making social health insurance more social.