Out-of-Country Health Care Policy for UAE Citizens, Article Writing Example

An Analysis of Out-of-Country Health Care Policy for UAE Citizens: Future Direction for Policy Development

Abstract

Since gaining independence from Britain in 1971 and forming the federation of the United Arab Emirates (UAE) in 1972, the UAE have had a policy of providing free out-of-country medical care for all those whose medical conditions cannot be adequately treated by medical facilities within the UAE. Over the years, the demand for this service has outstripped the country’s ability to cover the costs. In a series of regulatory and policy changes since 1972’s initial formal initiation of the program, the scope of such international medical payments has decreased steadily. At the same time, a July 2009 poll indicated that the majority of UAE nationals (57%) would prefer to seek treatment outside the country if they became seriously ill (Gornall & Underwood, 2009). In December 2010, the UAE Ministry of Health faced a major budgetary crisis. While outside consultants claimed it needed approximately a 20% increase in budget for 2011 to cover essential programs and services—including the out-of-country healthcare program—the proposed 2011 ministry funding was a 5% decrease (Shaheen). This crisis has led to an analysis of the out-of-country medical care program in this report. Four alternatives are proposed: (1) to maintain the current program and eligibility; (2) to reduce the amount and types of expenses covered by the program; (3) to reduce eligibility for the program based on economic ability to pay, but retain other essential features; and (4) to outsource out-of-country coverage to an international health insurer. Of these options, the most viable would be to retain the existing program, but to remodel this approach via campaigns to improve both the perception and quality of domestic healthcare service.

Introduction

The United Arab Emirates (UAE) offers health care for citizens abroad when no suitable medical treatments for their conditions are available within the country. This paper analyzes the current policy for paying for such out-of-country care, in an attempt to determine if the policy is adequate and presents a recommendation for how, if at all, the policy should be modified.

The UAE is a union of seven emirates, with the two most significant cities being Abu Dhabi (the capital), and Dubai. Matters of health policy are determined by the Ministry of Health at the federal level or at the local level. Standards of health in the UAE are generally high. For a total population estimated to be approximately 4.5 million in 2005, the UAE spent $436 million in healthcare from 1996 to 2003, spending just under $500 per person or approximately 2.9% of the country’s GDP (Library of Congress-Federal Research Division, 2007).

The extent of the country’s growth in medical resources and facilities can be seen by comparing the 7 hospitals in the country in 1970 to the 40 public hospitals in the country in 2007 (Ibid.). In addition, the Ministry of Health is actively expanding the number of medical facilities in the country, including hospitals, medical centers, and a trauma center, with an eye toward making Abu Dhabi and Dubai destinations for “medical tourists” (Ibid.,; Gornall & Underwood, 2006). Dubai in particular has created a “Dubai Healthcare City” which is a “health care free zone” (similar to a “trade free zone”) that offers “international-standard advanced private health care and provides an academic medical training center” Library of Congress-Federal Research Division, 2007).

Until 1982, the UAE offered free medical care to all residents. However, the rising costs, decreased revenues from oil fields, and cultural change in the approach to foreigners resulted in a change of policy. At that point, free medical care was rescinded for noncitizens except for emergency care, maternity care, and children’s care (Eastern Mediterranean Regional Health Systems Observatory, 2006).  Beginning in the 1970s, and with technical assistance from Egypt, there was a significant expansion of in-country medical services. By the mid-1980s, nearly all medical personnel were still foreigners, but by the 1990s, the UAE’s medical system was modern and partially staffed by nationals (Ibid.).  While most of the medical facilities are in either Abu Dhabi or Dubai, most of the population has access to clinics or other basic medical facilities (Ibid.).

Only 20% of the resident population of the UAE (as of 2009) are UAE citizens; the 80% majority are foreign nationals. Most of the foreign nationals (an additional 60% of the population) are from South and Southeast Asia, with much of the remaining foreign nationals from various other Arab-speaking countries (Library of Congress-Federal Research Division, 2007).

It is reported in the Medical Tourism magazine that a survey conducted by the National newspaper by the international research organization, YouGov, relates that 57 percent of Emiratis state that they would seek medical treatment overseas. Out of 866 individuals, 53 percent surveyed state that they would “prefer to return to their home countries for treatment, while 18 percent said they would seek treatment in other countries.” (Morris, nd ) It is reported that 71% of Asians and 57% of Westerners as well as 42% of Arab expats opted to leave for treatment in their home countries.” (Morris, n.d.). The largest percentage of respondents who have travelled abroad for medical treatment were 27% of Westerners. Destinations for medical tourism were diverse in nature with the most popular location for overseas medical treatment being that of India at 57% preference among those polled. The top destination for Emiratis–stated as 64%–was Thailand while the UK was the top choice of western expats stated at 61%. Both Thailand and the US attracted 17% each among western expats.” (Medical Tourism Magazine, 2011).

Also reported is a growth in demand for hospital beds in the United Arab Emirates, at the rate of 160% between the present to 2025. The number of beds per 1,000 people in the UAE is stated at two, which is below the international average of three. In addition, it is reported that private healthcare providers in the UAE receive 70% of their income from insured patients. (Guraraj and Kishan, n.d.) In addition, there is a rapid shift in health insurance in the UAE due to legislation. (Guraraj and Kishan, nd, paraphrased) Healthcare demands in the region of the UAE are expected to increase due to: (1) population growth; (2) the increasing number of the aging population; and (3) unique health-risk factors. (Guraraj and Kishan, n.d.). The expense of overseas medical treatment of UAE nationals is reported to be 2 billion USD annually. Thailand reports receipt of 90,000 Emirati patients each year and in 2007 Singapore Hospitals report receiving 40 million UDS on medical tourism from the UAE alone. (Guraraj and Kishan, nd, paraphrased) It is reported that 57% of UAE nationals seek medical treatment overseas. (2009 YouGov Agency Survey, cited in: Guraraj and Kishan, nd) UAE nationals are reported to place more trust in Western and South Asian Healthcare and there is presently a heavy dependence on the UAE government for overseas medical treatments.

2009 statistics from the World Health Organization indicated that the UAE government spends just under $500 per person per year on health care, with private funds accounting for an additional $180 per person approximately; total spending on health care in the UAE corresponds to 2.6% of the gross domestic product (WHOSIS, 2009).

Statement of the Issue and Rationale for Change

There is presently a high demand for traveling abroad for medical treatment and services and in addition, there is a great deal of social and cultural pressure for traveling abroad as many individuals who travel abroad for medical treatment are not eligible for out-of country treatment. There is presently an absence of trust for health care service provision and an absence of specific health care services in the UAE. Finally, the issue of paying for out-of-country medical care for citizens is more challenging, particularly if the desired care is in the U.S., where inflation in healthcare costs only adds to the financial cost. In addition, over the past 20 years, medical care within the UAE has become world-class, making it less essential to support out-of-country medical visits for those services available in the UAE. Thus, it becomes important to revisit the current policy and determine where and how (and if) it should be changed. The objectives of the research in this study are firstly, to conduct an analysis of the current policy on overseas treatment and secondly to make suggestions and recommend options for the policies regarding overseas medical treatment.

History of the Policy

The formal policy for paying for residents’ healthcare out of the country was issued early in 1972, only months after gaining independence from Britain. In this policy, the “Patient Treatment Abroad Regulation No. 7 of 1972,” residents of the UAE who require medical care not available within the country would be sent at government expense to an appropriate facility in another country for their care.[1] This included both nationals and non-nationals residing in the emirates. Those covered under this regulation included Abu Dhabi nationals (men, women, and children); expatriate staff of the government under any employment contract (whether foreign or local) who developed a disease either because of or while working for the government; and their wives and children who became ill while that expatriate was in government service. In addition to paying for the ill person’s travel and medical care, the government also paid for a medical companion (a doctor or nurse) and one family companion. Expenses paid included a daily allowance for both the patient and the companion(s).

This policy proved to require modification only five years later. The “Ministerial Resolution No. (17) of 1977 Concerning the Patient Treatment Abroad Regulation”[2] recognized that the stipends specified in earlier regulations needed amendment This regulation effectively doubled stipends for patients traveling to Egypt and India. This appears to be intended to encourage UAE patients to choose either of those countries for their out-of-country care, rather than traveling to more expensive venues such as the U.S. or Western Europe.

Fifteen years later, the “Cabinet Decree No. 13 of 1992 For Patient Treatment Abroad Regulation”[3] restricted the payment policy to UAE nationals; expatriate staff were no longer eligible for such government-paid care—except in the case of personnel in the Ministry of Defense. Furthermore, the criterion for eligibility for such treatment abroad was changed to state that the condition was impossible to treat or there was no treatment available within the UAE. At this time also, the Ministry was given veto-power over the destination of the treatment. While women were allowed to be accompanied by an “unmarriageable person” and to accompany their babies (as long as the child was not in isolation), travel was mandated to be by “economy class” and by “the shortest and most cost efficient means.” Further, once the patient was deemed by the attending physicians to be ready to return home, all stipends stopped.  Clearly, this was in response to perceived or actual abuse by patients and their families using “medical” trips to foreign (and expensive) locales.

In 1996 the government issued “Resolution of the Crown Prince, Chairman of the Executive Council, No. (2) of 1996 Concerning the Amendment of Some Provisions of Resolution No. (1) on Patient Treatment Abroad.”[4] This resolution allowed the Crown Prince and Chairman of the Executive Council to make exceptions to the formal policy.

In 2002, “Resolution No (2) of 2002 Concerning Patient Treatment Abroad”[5] consolidated the decision-making power and ultimate authority for out-of-country patient care to the Head of the General Authority for Health Services for the Emirate of Abu Dhabi. In effect, this centralized the decision-making power in a single authority, presumably to ensure that consistent decisions were made in all 7 of the UAE emirates.

Two years later, an update to the out-of-country healthcare policy was issued as “Cabinet Resolution No. (5) of 2004 Concerning the Amendment of Some Provisions of the Cabinet Resolution No. (13) of 1992 for Patient Treatment Abroad Regulation”[6]  This cabinet resolution acknowledged the budgetary pressures the out-of-country healthcare costs were causing and specified that the government would bear the out-of-country costs as long as there was Ministry of Health budget to do so. In other words, when the money ran out, so did the automatic coverage for such out-of-country costs.

Table 1. Changes in the Out-of-Country Policy from 1972 to 2004.

Current UAE Federal Policy

The current UAE policy still allows for government coverage of out-of-country medical costs, but the amount of such coverage has been dramatically reduced from 1972.  Table 1 illustrates the changes made in the years from 1971 to 2004. This policy is far stricter than the original version of 1972. This is in large part a reflection of economic pressures on the government. As noted earlier with the worldwide economic issues of the past few years, the UAE’s budgetary problems have grown. Demand for oil is down, and this constitutes about 45% of the nation’s exports and reflects about 25% of the country’s overall gross domestic product of approximately $240 billion (CIA, 2011). In addition, Dubai in particular has seen a significant loss of wealth as a result of depressed real estate values. Furthermore, healthcare costs in the Western world—the likely preferred destination for many such citizens—are climbing substantially faster than general inflation. Significant ongoing economic challenges for the UAE thus include the country’s dependence on oil, an expatriate workforce that constitutes 80% of the total resident population, and increasing inflationary pressures (Ibid.).

Adding to the financial issues are the overall world economic crisis of the past few years. The estimated 2010 per capita GDP has declined since 2008 by nearly 8% (Ibid.).  As a result, in December 2010, significant projected 2011 budgetary shortfalls were reported by major ministries of the UAE government—including the Ministry of Health (Shaheen). The ministry claimed in 2011 it would be in a “crisis” due to budgetary considerations (Ibid.). The budget allocated for 2011 represented approximately a 5% decrease over the previous year’s budget—but medical expenses, medications, and equipment were and are increasing in cost. The prime budget-buster according to the ministry is the rising cost of medicine (Ibid.).

An additional factor is that internal attitudes toward the medical care within the country are not positive. Despite UAE’s general standards of health care being considered quite high, a July 2009 poll in the UAE indicated that “more than 70 percent of UAE residents would seek medical treatment overseas if they fell seriously ill” (Gornall & Underwood). This included a finding that 57% of UAE nationals would prefer to seek medical care outside the country in the event of a serious illness. (Ibid.) Furthermore, among the expatriates, 71% of Asians, 57% of Western Europeans, and 42% of Arab expatriates would prefer to return to their home country for treatment, which may be expected—but a mere 26% of the UAE nationals preferred treatment within the country (Ibid.).  The most common reasons for such preferences were a perception of better medical treatment being available out of the country (33%) and a lack of trust in the UAE healthcare system (25%), with lower cost being a factor for 20% (Ibid.).  The perceptions of UAE nationals were even worse than the overall polled group: 40% of UAE nationals thought they could get better treatment elsewhere and 33% lacked trust in the UAE healthcare system (Ibid.).

Moreover, while the government in November 2008 estimated that as many as 11 million “medical tourists” would visit the UAE for treatment—much of it in response to the Dubai Health Care City development—in the July 2009 survey, fewer than one third of the respondents (both nationals and expatriates) believed that the UAE was “well equipped” to tap into the medical tourism market, while 28% believed it was “not well equipped” and 19% believed it was “not at all ready” to do so (Ibid.).

Results

In considering the out-of-country healthcare policy of the UAE, several issues have to be juggled. These include:

• The budget-busting result of the government paying for such medical care for UAE nationals.
• The long-standing tradition of ensuring equal (and quality) access to medical care for all UAE nationals.
• The accelerating cost of medical care in virtually all developed countries, including particularly the fast-rising cost of prescription medications.
• The internal drive to develop world-class medical care, particularly with the Dubai Health Care City.
• The government’s plan to improve the country’s economic and medical standing to become a medical tourism destination.
• The lack of confidence exhibited by UAE nationals in their own healthcare system.
• The overall financial crisis faced by the UAE and other countries, including tight international credit.

Because these factors conflict, priority decisions must be made to determine an optimal solution to the problem of paying for out-of-country medical costs while still satisfying perceived and actual needs of the citizenry to receive excellent medical care.

Four potential solutions to this problem will be assessed. These are:

• Retain the current policy with no significant changes, using money as needed from other Ministry of Health programs to pay for the costs.
• Reduce the number and type of expenses paid by the government under the program to cut costs while still retaining the overall essence of the program.
• Reduce the eligibility for the program either by considering ability to pay as part of overall program eligibility, or generating a sliding scale of the percentage of costs covered by government funds, or both.
• Outsource international medical care for UAE citizens by contracting with one or more international healthcare insurers.

Option 1: Retain the Program in Its Current State.

Under this option, no significant changes to the existing policy would be implemented. Thus, currently eligible UAE nationals would be able to continue to request and receive out-of-country medical care in the event of serious illness that could not be treated in domestic facilities. The process for determining eligibility for this service is laid out in the appropriate regulations (Cabinet Decree No. 13 of 1992, for example, a copy of which is provided in Appendix C.)  In this procedure, a medical committee is formed to examine the patient involved. That committee reviews the patient’s medical records and doing any type of additional tests they deem medically necessary to make a determination of eligibility.  They then prepare a report on the patient with their recommendations.[7]  If no in-country treatment is possible, the committee recommends the treatment destination and the initial period of treatment, though the Minister of Health may override the treatment destination.  In cases of an emergency, such as if the patient’s life is in immediate danger, the Minister of Health may send the patient for immediate treatment without referral to the committee.  The goal of this procedure is to ensure that out-of-country care is in fact medically necessary.

To ensure that this process is equitable to all, it is recommended that the only significant change in the above procedure is that the committee established to review the patient’s case should include the patient’s doctor who initially suggested the necessity of getting out-of-country treatment.  This is intended to ensure that the patient has a personal advocate, with appropriate medical knowledge of the case, on the recommendation committee.

The financial impact of this in the short term would be escalating medical costs as worldwide healthcare inflation increases, thus driving up the costs of the program to the Ministry of Health. A counterbalance to that would be the increasing capability of in-country medical facilities to treat serious illnesses. With the development of the Dubai Health Care City, with its extensive collection of medical specialists and state of the art facilities, fewer and fewer patients would fall into the category of being unable to receive adequate medical care within the UAE. Thus, while inflation would tend to increase the costs of the program, over time the continuing development of domestic medical resources would alleviate this trend and keep the program affordable.

Hand in hand with this is that the UAE citizenry would find retaining the existing program the most acceptable and palatable solution. As noted earlier, the majority of UAE nationals would prefer to go outside the country for serious illness medical care. Removing the option to do so would likely decrease citizen satisfaction with the government and the Ministry of Health in particular. Given the unrest roiling throughout the Middle East at this time, it seems prudent not to provide yet another cause for citizens to resent their government.

The positive aspects of this option are thus first, that this continues to provide the citizenry with a popular program that many have taken advantage of in the past; second, that it does not generate further cause for unrest at a time when the entire Middle East is on the edge of uproar; and third, that over time as domestic medical facilities and staff develop, the number of people who will be eligible for the program on a “no in-country care available” basis will decrease, thus keeping costs within bounds.

The negative aspects of this choice are that the costs of the program are likely to continue to rise over a period of several years and at a time when severe budgetary constraints are in place.  Furthermore, making this option available is, in some sense, an admission that the government has not succeeded in developing UAE’s own healthcare system to the desired world-class level. This in turn, reduces the ability to attract international “medical tourists” and thus decreases the diversification of the UAE economy away from oil and gas.

In general, retaining the existing policy has a high financial cost, but the human cost is low (i.e., all citizens would continue to be able to get needed health care), and the social cost would be minimum since it retains the status quo of allowing people with serious illnesses to choose to seek medical care elsewhere. This option would be most successful if a large-scale campaign is put into place to educate the citizenry about the quality of healthcare available within such facilities as the Dubai Health Care City. Also, given that a major criticism of the existing healthcare system is that the medical staff are “arrogant” and are not “patient-centered” in their approach to their patients, it would be important to establish a significant effort to change how patients are perceived within the system to ensure that patients are listened to and treated respectfully and capably across the board.

Option 2: Cut Back on the Number and Type of Expenses the Government Pays For.

In this option, the general outline of the program would be retained, but the amount and type of expenses the government covers would be reduced. For example, under the current policy, the government pays for:

• Actual medical costs for the patient, including doctors’ fees, hospital expenses, tests, medications, etc.
• Travel costs to and from the medical center for the patient and for a companion.
• Daily stipends for the patient and for the travel companion.
• Other transportation costs for the patient (i.e., air ambulance, etc.) to get him or her to the destination medical facility.
• Charges for the patients’ preparation and transport in the event the patient dies while abroad.
• Entry visa fees for the destination country for both patient and companion.

Under Option 2, some of these payments would be eliminated. For example, travel fees for companions to adult patients could be eliminated, as could stipends to cover miscellaneous out-of-pocket costs. While air ambulance or other special-needs transportation could be retained, general airfare on regularly scheduled airlines could be eliminated also, along with the various fees such as entry visas where needed. Thus, the patient would be responsible for going to the destination facility, and for covering general living expenses while there.  Essentially, only the actual costs of treatment would be paid by the government.

The positive aspects of this option are that this would indeed cut the costs of implementing the program. By cutting out all travel expenses (except special-needs cases) and the cost of companion travelers (except for the case of children and those who cannot medically handle the trip alone), the overall cost of the program would be reduced somewhat. Furthermore, because the patient and his/her family would be expected to bear a substantial portion of the overall trip cost (i.e., travel costs and daily living expenses while out of the country), the number of people choosing out-of-country health care will be substantially fewer, thus keeping the overall cost of the program within budgetary bounds.

The negative aspects of this option, include that the overall cost-cutting process does not address the real budget-buster aspect: the cost of medical care itself. While other costs have been fairly stable over the past few years, with only moderate inflation, healthcare costs worldwide are escalating dramatically. So while cutting transportation costs may help a little, the real source of inflation is the medical costs that would still be covered under this option.  A second problem with this option is that it will make it infeasible for substantial numbers of citizens, which certainly reduces costs, but it also creates a rising tide of resentment towards a ministry that already clearly lacks the support of the overall population. Again, this is a dangerous step to take at a time of political and social upheaval throughout the region.  Finally, it seems clear that a policy on this order would result in some number of citizens who become financially unable to get healthcare that is genuinely needed. The human and social costs of this option are high, and the financial costs are not well contained.

Option 3: Change Eligibility for the Program and Implement Sliding Scale for Payments

The third alternative available would be a two-pronged approach. The first element would be to change the eligibility of the program based on family income of the patient. Those who have sufficient family income above some level would not be eligible for free medical care. Those who fall below that income level would receive more or less the same benefits as the current policy has.  In addition, a sliding scale, based on ability to pay, could be implemented to reduce the percentage of expenses the government pays. Specifics of where the line is drawn for overall eligibility and how the sliding scale is implemented would  have to be based on statistics that are not available at this time. However, by looking at prior usage of the program and income levels of those who used it, some estimated levels could be tried, and then adjusted as needed over the course of 2 to 5 years.

The positive aspect of this program is that it seems intrinsically fair to everyone: Those who can afford to pay for their own healthcare do so; those who cannot still have it supplied, in whole or in part, by the government. It does not take away a benefit that the citizens have grown used to over nearly 40 years. Instead, it helps keep costs within line, while still meeting human needs for quality healthcare and budgetary limitations. Because there would be an additional burden of proof of eligibility placed on the patient, it is likely that some will be deterred from seeking out-of-country care, and simply seek domestic treatment when that is possible to do.

The negative part of this program is that it would be difficult to administer in a timely way.  Determining where each individual fits in the sliding scale of eligibility and payment levels could be challenging to do, particularly if decisions are needed for urgent medical treatments. Furthermore, each person’s finances really are individual to them in that every family or individual has their own set of financial burdens and pressures. Finally, while this may not actually deny appropriate and necessary medical care to anyone, it may have the perception of denying such care. This can lead to social dissatisfaction and unrest at a difficult time in the region.  It is also likely that implementing this policy would require establishing a significant level of bureaucracy that may itself both be burdensome and swallow up a significant portion of the overall savings.

Option 4: Outsource International Medical Care for UAE Citizens Abroad

A final option for providing UAE citizens with healthcare outside the UAE is to outsource that medical care to an international healthcare insurer.  This has the attraction of creating a third-party (i.e., the insuring company) to handle the claims from healthcare providers all over the world. It also provides healthcare coverage for UAE citizens when they are traveling outside the country.

Most such insurers’ coverage programs are intended for multinational corporations who regularly send their employees overseas, either temporarily or as long-term assignments. On the plus side, this means that the better insurance policies include such coverage as emergency retrieval from the site of the injured or ill person to an appropriate medical facility, even if the facility is in a different country.  At the higher end of coverage, many pay 100% of customary and usual costs and even cover preventive care (vaccines, wellness exams, and so on). They can also include return of the healed person back to their home. Furthermore, these insurers already have worldwide contacts with hospitals and healthcare providers and have established payment processes in place for each of these. This would substantially reduce the burden.

There are difficulties with this option, however. One key problem is determining who would be a “member” of the insured group. In a multinational company, the insured group is clearly defined as the employees of the company and their immediate families (spouses, children). Generally speaking, a corporation would provide such coverage only on employees who are either stationed abroad or who regularly travel abroad (i.e., executives, etc.).  Typically, the approximate number of such employees can be determined with excellent accuracy since corporations know their staffing levels in all locations.

In the case of the U.A.E., however, the group requiring coverage would by implication be the entire citizenry, approximately one million citizens. Of these, of course, only a small fraction would need coverage in any given year, however, determining which citizens should be covered at any given time is challenging. The easiest method, of course, would be to maintain coverage on all citizens; this, however, would lead to unnecessary costs. An alternative would be to impose a “departure” tax on all nationals who leaves in the UAE, with that tax to apply toward some fraction of the premiums for the insurance.  This imposes a substantial processing burden on the Emirate’s bureaucracy to insure that departing citizens are provided with appropriate insurance information in time.  Another option to deal with this problem would be to impose an annual “passport” tax on all citizens with passports. This restricts the coverage to those who may possibly need healthcare out-of-country; a citizen without a passport cannot need out-of-country healthcare.

While actual costs per person of out-sourcing healthcare coverage are impossible to determine prior to negotiating a contract with an international insurer, it is likely that costs will be similar to or greater than current Ministry of Health costs. In effect, the UAE has been self-insuring citizens since 1972.  Self-insurance basically means that an insurance fund is set aside for healthcare costs. If costs are lower than planned, the unspent money can roll over into the following year’s fund; if costs are higher than planned, additional money has to come from other sources to make up the shortfall.[8]  One reason corporations choose to self-insure is that they have closer control over healthcare costs by doing so; they also can typically provide better coverage at lower cost to employees and to the company because the healthcare fund is not intended to generate any profit. It is merely there to cover actual costs.  In contrast, insurance companies are profit-making organizations, so their premiums are planned to be higher than expected annual payouts. Thus, self-insurance, if well-handled, can be less expensive than working through a profit-making insurer.

Furthermore, an outsourcing solution gives a substantial amount of cost control to the insuring company. Healthcare costs are rising substantially worldwide, and those costs will be reflected in increasing insurance costs, along with (potentially) reduced benefits. These costs will change annually, requiring careful, ongoing negotiations every year.

Another serious problem with this option is that international insurers typically refuse to pay for treatments for pre-existing conditions. In other words, UAE citizens who are diagnosed with a serious disease, such as a rare form of cancer, who need to go to an out-of-country facility to get proper treatment for their condition simply would not have coverage for that because their condition would in fact be “pre-existing” before their trip abroad. Since the intention behind the UAE out-of-country coverage of medical costs is to provide exactly that type of coverage, outsourcing to an international insurer will not accomplish the goals of the Ministry of Health. The only way around that problem, since there is no way to pre-determine who in the country will develop such a condition, would be to cover all citizens and negotiate with the insurer an exclusion from pre-existing condition requirements, or to have the Ministry of Health cover the costs for those with such pre-existing conditions.

Decision Matrix

A decision matrix among these options is shown in Table 2.  This matrix reflects the positive and negative aspects of each option. In constructing the matrix, five key considerations have been considered. These considerations include first, whether the expectations of UAE citizens for health care will be met by the option. A second consideration is the financial impact of the option on the budget for the Ministry of Health. A third consideration is how easy the option is to implement and whether it involves creating a larger bureaucracy or entails significant implementation issues. A fourth consideration is how the option impacts the existing and planned healthcare system within the UAE.  Finally, the fifth consideration is what is the human cost of the option; by that it is meant whether citizens who genuinely need out-of-country medical care will be able to receive that care at a price that is affordable to them. The decision matrix on the following page reflects these considerations. Weightings for each consideration are shown, along with the weighted decision score for each option. When applying the decision matrix, weighting the decision score for each option can be done by multivoting of a group/team (panel). The role of this panel is to select stakeholders to evaluate the criteria and prioritize all options. Then, score each option with each criteria with a consideration of cost and resources (Nancy, 2004).

Table 2. Decision Matrix for Options 1-4

In this matrix, a higher weighting factor (i.e., 5) means that consideration is believed to be more important than a consideration with a lower weighting factor.  Individual considerations for each option are given scores of 1 to 5, with the higher numbers being better. The decision score is computed by multiplying the weighting factor by the scores in each column, then adding those together for a final score.  The best decision is the option with the highest decision score, in this case, Option 1, which is highlighted in green.

Recommendations

While Options 2 and 3 provide some degree of cost-cutting, ultimately, they are unsatisfactory choices. Option 2 results in modest financial savings, but incurs strong costs at both the human and social levels. Option 3 results in more significant savings, but then incurs extra costs to implement due to the need of more bureaucratic effort to determine eligibility and cost-share percentage. In addition, it too is likely to result in human hardship and social resentment as citizens perceive that their long-held benefits are being eroded. Option 4 removes some of the burden by shifting much of the administration to the insurer. However, costs are determined not internally but externally by the insurers on an annual basis. In addition, those citizens who most need out-of-country care due to the lack of in-country medical expertise in their condition may not have coverage at all and the Ministry would still bear those costs separately. In addition, coverage of some healthcare costs is uncertain and determined by the insurer rather than by the Ministry of Health.  Determining the specifics of the number of people covered and when that coverage starts and ends are also problematic in Option 4.

The best option seems to be the one of continuing with the current policy. In the short run, this will show escalating costs as healthcare costs continue to rise worldwide. However, as in-country medical facilities continue to develop, fewer and fewer people will be required to go out-of-country to obtain necessary medical care. Given that the policy is only available for those patients who cannot find adequate medical care within the UAE, this means that as healthcare facilities and skills develop, fewer and fewer people will be eligible for the program. Thus, while individual cases may need more and more money, the total number of such cases is likely to decline as only the most extreme cases require out-of-country care. In the long run, as UAE has world-class medical facilities, very few patients will need to take advantage of this policy.

In addition, implementing two additional, fairly low-cost programs can help ameliorate the cost of the program in the short-to-mid-term. The first of these is a public relations campaign to persuade UAE nationals of the quality of the healthcare facilities that already exists in the country and the affiliations with international facilities among hospitals in Abu Dhabi such as Cleveland Clinic and Johns Hopkins Hospital. The goal of this campaign will be to reduce demand for the out-of-country medical care program. As noted earlier, in July 2009 the majority (57%) of UAE nationals would prefer to seek medical care out of the country if stricken with a serious illness. If a substantial portion of these people can be convinced that UAE healthcare is of very high, even world-class quality, the number of people who want to go out-of-country for healthcare will drop substantially, thus dramatically reducing budgetary pressures.

Yet a public relations campaign to convince people that UAE has excellent healthcare will fail unless people actually do receive quality healthcare when they go to their local doctors and hospitals. Thus, a second program that should be implemented is to raise awareness within the healthcare community of the essential importance of delivering patient-centered care that is sensitive to the needs of the patient rather than the needs of the staff.  In that July 2009 survey, medical staff at UAE medical facilities were described as being “arrogant” and that they “don’t listen” to the patients. A series of “patient satisfaction” programs and surveys should be implemented to identify key trouble spots in personnel, and in overall procedures and flow of patients through healthcare facilities. This survey would pinpoint what types of changes have to be made to make the patients’ experiences with the healthcare system more satisfying and less challenging. Hospitals, clinics, and even doctors’ offices should be put on notice that patient complaints will be taken very seriously by the Ministry of Health and facilities that consistently receive high complaint levels will be punished (or fail to receive rewards) in significant ways.

Such a combination of improved public relations, and improving actual patient experiences within the healthcare system should gradually reduce the demand for out-of-country care. In addition, it would serve another purpose, of increasing the demand for UAE healthcare services from international patients. Given that the Ministry of Health has identified making the UAE a “destination” source of medical care, such a combined effort serves two purposes  of reducing the budgetary burden of out-of-country care, and of increasing the flow of international patients to the UAE, bringing their cash into the Ministry’s coffers.

While this proposed set of recommendations is not a “quick fix” for the current Ministry of Health’s budgetary woes, it does provide a practical, viable path for significantly reducing overall costs for out-of-country healthcare, while also increasing overall citizen satisfaction with the Ministry of Health’s ability to meet the medical needs of the UAE. In addition, it contributes significantly to the Ministry of Health’s larger goal of increasing medical tourism to the UAE, thus also increasing overall revenues.

Conclusions

The UAE, like many other countries, is facing a budgetary crisis, particularly in the healthcare field. The country’s long-term policy of paying for out-of-country healthcare for those who cannot be provided with adequate care within the UAE stretches the Ministry of Health budget—and as healthcare costs worldwide escalate, the strain just worsens. Moreover, UAE citizens have little faith in the competency of their healthcare system, even though it is considered by objective observers as “good” to “excellent” (CIA, 2011).  The result is that when serious illness strikes, there is a high demand for out-of-country healthcare.

This paper suggests that the best course for the Ministry of Health is to maintain the current policy on out-of-country healthcare, while taking active steps to reduce demand for those services. This can be done first, by initiating a major public relations campaign to change the perception of UAE citizens toward their healthcare system and convince them that they have one of the best medical services systems in the world.  Second, to ensure that their experience of the system matches the public relations efforts’ claims, a significant push to improve the quality of healthcare from the patients’ perspectives should be implemented. The Ministry of Health should begin to monitor patient satisfaction from those who move through the healthcare system at all levels, and should implement educational campaigns for medical staff of all levels to convince them of the critical importance of implementing patient-centered policies and protocols in their daily work routines.

Such patient-centered care, with its attention to the needs, fears, and emotions of the patients and their families, is the key toward turning around the attitude of the UAE citizenry toward their healthcare system. As that turnaround begins to be accomplished, the overall demand for out-of-country healthcare will diminish and the cost of maintaining the current policy will drop considerably.

The suggested approach also provides additional benefit of enhancing UAE’s already high-quality healthcare even more, thus substantially contributing toward the Ministry of Health’s ultimate goal of making the UAE a medical tourist destination.

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[1] See Appendix A for the text of this regulation.

[2] See Appendix B for the text of this regulation.

[3] See Appendix C for the text of this cabinet decree.

[4] See Appendix D for the text of this resolution.

[5] See Appendix E for the text of this resolution.

[6] See Appendix F for the text of this resolution.

[7] Initially, this report went to the Ministry of Health as described in the text above. In later decrees, changes include giving the Crown Prince, Chairman of the Executive Council, authority to override decisions (1996, Appendix D of this report); moving authority for the decisions to the head of the General Authority for Health Services for the Emirate of Abu Dhabi (2002, Appendix E of this report); and adding the ability of the Ministry to substitute in-UAE private medical facilities instead of out-of-country facilities (2004, Appendix F of this report).

[8] Typically, to ensure such a rollover, the funding for self-insurance must be maintained in separate accounts from all other organizational monies. This generates a significant accounting burden on the organization, but it can be accomplished with effort.