The Essay On TPA

Are the employees of UAE are aware of the role of TPA in health insurance?

Are the people residing in UAE are able enjoy the health benefits under the health insurance scheme proposed by the government?

What are the health threats or possible complications experienced by the UAE population in relation to health insurance policies and its associated TPA?

United Arab Emirates (UAE) is a federation of   seven emirates (Abu Dhabi, Ajman, Fujairah, Sharjah, Ras Al Khaimah, Umm Al Quwain and Dubai) and was established in the year 1971. The discovery of oil influenced massive economic growth in UAE. This growth bolstered massive influx of migrant workers leading to a huge change in the demography with a majority being of pre-retirement (Suliman and Al-Junaibi 2010). This high influx of workers caused high population growth in UAE (Al-Jenaibi 2017). According to the census data, the population of UAE is highest in the world with 95% of population are less than 50 years old and male: female ratio is 3:1 (U.A.E National Bureau of Statistics 2012).

Increase in the population along with increase in the number of immigrants caused high rate of disease occurrence in UAE and this in turn lead to the increase in health care costs. The cost of the both the amount paid by the insured person and insurance company has increases significantly in UAE. In order to reduce this escalating cost of health care, government of UAE introduced mandatory health insurance (Loney et al. 2013). Under the “Thiqa Program”, the government of Abu Dhabi provides comprehensive medical coverage for all UAE nationals residing in Abu Dhabi (The Official Portal of the UAE Government 2017). Under this scheme, the citizens are assigned with the “Thiqa” card, which grants complete health therapy access to a huge group of private and public healthcare providers who are registered under Daman’s network. However, in order to qualify for the “Thiqa Program”, UAE national under the age bracket of 18 to 75 years are required to pass through “Weqaya” test conducted by Department of Health, Abu Dhabi. This screening is done in order to identify the cardiovascular risk factors (The Official Portal of the UAE Government 2017).

Apart from this, in the year 2015, UAE government has also launched new health insurance program. This program was designed to support the nationals who are not covered under any government funded health insurance schemes (United Arab Emirates Healthcare Service 2016). The Dubai Health Authority (DHA) in June 2016 announced that all the residents of Dubai should be covered under the health insurance that will be tied to renewal and issuance of their UAE residence visa (United Arab Emirates Healthcare Service 2016).  

Moreover, the government of UAE has made it is mandatory norms for the employers to provide health insurance to their employees along with their dependents. There are currently two emirates, which mandate the employers to provide coverage of health insurance to their employees, Dubai and Abu Dhabi (The National. 2016). Dubai’s Employer Sponsored Health Insurance Scheme for company employees, faces trouble while regulating scheme under the influence of the economic downturn.  This is because in Dubai it is mandatory for employers to pay for the medical insurance to all the dependents including the domestic worker. The scenario is different in Abu Dhabi, which has strictly enforced the employer sponsored medical insurance scheme (The National. 2016). However, if the employee has a big family then the onus of the employer only bears up to the fourth child (The National. 2016).

Aims and Objectives

Rule of health insurance in UAE are different. In Abu Dhabi there are two insurance schemes one is Thiqa for Emirates and another one is Abu Dhabi Basic Plan for expatriates, bestowed by the National Health Insurance Company (Daman). In Dubai, there is Essential Benefits Plan, which is procured by 12 companies. In Abu Dhabi, all the employees who are under Abu Dhabi Basic Plan are required to pay half of the insurance policy in order to get premium service for their dependents (wife and children). However, they are required to bear the cost of their dependent parents (The National 2016). According to law of UAE, the maximum amount of insured coverage in Dubai is Dh150,000 and in Abu Dhabi is Dh250,000. However, this overage plan may not include emergency or ongoing treatment and also exclude dental, vaccination eye care costs (The National 2016).

However, in the midst of numerous insurance policies and their different norms, the people of 7 different emirates lack a clear picture of the insurance plans, their premium schemes and the extent of coverage. Despite the claims made by the Health Authority Abu Dhabi (HAAD), the majority of low income workers lack the clear approach about their health insurance rights (Zaman, 2010). Although they are happy with the government policy to provide health insurance coverage but they are confused with the concept of network of coverage that is clinic or hospitals they should visit (Zaman 2010).

So the rationale of the research is to elucidate the problems experienced by the people of UAE while availing the benefits of the health insurance policies. The research will also aim to highlight the possible health benefits or health threats experienced by the UAE population who are under the health insurance schemes. At the end the research will try to recommend the potential ways in which this gap between the understanding of the health insurance schemes and the role of TPA in providing the health insurance among the people in UAE can be negated. For this research, the researcher will only focus over the population of Dubai and Abu Dhabi as these two have proper structure of the health insurance policies in comparison to other emirates.

The main objectives of the research will be

1. Analysing the role of TPA in health and health insurance under the perspectives of UAE
2. What are health benefits offered by TPA to the population residing in UAE
3. What are possible health threats imposed by TPA on the health of the population residing in UAE
4. Possible recommendation in relation to health insurance and TPA towards optimal health care access of UAE population

Health system reform has been implemented in many countries globally to achieve best health outcome. The Emirate of Abu Dhabi, UAE is also one region that moved towards the journey of health care reform by introducing the mandatory insurance coverage scheme for employers. The statutory agency, the Health Authority-Abu Dhabi (HAAD) is the statutory agency that implements regulations for health care providers and insurance companies. The Emirati law makes it mandatory for employers to provide coverage of health insurance to their employees. Currently, three insurance schemes operates in the country (Paulo, Loney and Lapão 2017). The Thiqa scheme is for Emirati nationals, the basis cover is for unskilled laborers and enhanced cover for higher skilled workers. Thiqa cardholders comprise about 40.1% of the market and basic insurance holders consist of 26.5% of the market (Sharif et al. 2013). The payment scheme for individual members differs based on different insurance company. The difference in Thiqa cover and basic cover is mostly seen from difference in expatriate and national population.

Overview of health system reform in UAE

Koornneef et al. (2012) has reviewed the health system reform in Abu Dhabi and gave insight into the main components of the reform. The key driver for reform in the health care system was the President’s Sheikh Zayed bin Sultan Al Nahyan vision of improving access to high quality health care for consumers. More than 50% of the GDP of Abu Dhabi comes from their oil reserves. However, reducing dependence on oil exports paved way for diversification of the health care system of the country. With discussion on the three insurance schemes available in the Emirate of Abu Dhabia, the study gave idea about the way health insurance has been distributed among national and expatriate population. The main strength of the evidence by Koornneef et al. (2012) is that it has pointed out to the gap in achieving affordable and sustainable health care for payers and providers. Secondly, it discussed about increase in competition through privatization of many health service contract, however no data has been provided to prove that competition between providers changes the provisions for affordability of care. Evidence by Collins et al. (2015) has showed that health care reforms increase health care coverage and affordability. Hence, poor health coverage in UAE despite health care reform is an area of future research.

While evaluating the insurance coverage scheme by looking at the health system reform in Dubai, Sharif et al. (2013) has revealed that Dubai does not have compulsory health insurance requirement for expatriate workers compared to those in Abu Dhabi. The research also pointed to the challenges in UAE health system that needs attention in the future. The key challenges include responding to socio-demographic changes in the population and distribution of health insurance across all emirates.  Hence, the manner in which people receive coverage by third parties may also differ based on different cities of UAE. Research done on people specifically in one city may help to clarify how third party medical (TPA) administration plays a role in enhancing coverage.

The TPAs emerged in the health care field to provide better service to policy holders and eliminate negative consequences of private health insurance. They are involved in coordinating between health care consumers and providers and monitoring uses of services and resources (Kennedy and Bartlett 2014). The study Hamidi and Akinci (2015) mainly focused on evaluating health care payment reforms in Abu Dhabi. The mandatory health insurance system resulted in the introduction of many payment reforms in Abu Dhabi. HAAD has been mainly involved in regulating health care across UAE. Individuals, employers and government are the three main sources of financing in the city. The author explained that apart from for-profits insurance companies and brokers, 13 TPAs are also involves in operating health insurance scheme. Many regional companies like Oman Insurance and Green Crescent are large payers and small payers outsource administration to TPAs. The significance of the Hamidi and Akinci (2015) study is that it gave idea about the impact of these reforms of health care consumers and providers. The positive side of health reform implementation was that it resulted in rise in demand for medical service among expatriates. Expatriates workers got the advantage of letting go off out-of-pocket payments. However, to address the issue of environment sustainability in the future, there was a need for more research to critically examine the impact of TPAs in harmonizing payment system and promoting transparency in hospital financing. This is necessary because Hoo and Lansky (2016) has argued that health care cost mainly remain unsustainable and applying principles of incentive alignment may help to fulfill shared goals.

Although there are very few research which has examined the role of TPAs particularly in UAE, however research evidence has given insight into potential role of TPAs in health care system of UAE in the future. Alshamsan et al. (2017) aimed to evaluate percentage of individuals who borrowed for medical reasons and those people who failed to get adequate funds in Gulf states. This research was importance in an effort to realize the goals of universal health coverage and preventing heavy health investment. The research was mainly done in four countries of Saudi Arabia, Kuwait, UAE and Bahrain. The common characteristics for all this country were oil and gas as the main source of income, large percentage of expatriate population and high possibility of increase in demand of health services.  The study findings demonstrated that poor respondents were mainly borrowing money for medical purpose and the common reason for this was that they could not get emergency funds. the main significance of this work is that it points out to equity concerns in health insurance schemes in Abu Dhabi. Hence, this drawbacks points to the need for health care reforms particularly for pore people in Gulf states. This research also points out to the future role of TPAs in enhancing consistency in terms of quality of care. Hoo and Lansky (2016) also supported the fact that utilization of TPAs by employers is necessary to manage alternative payment designs and handle challenges in health insurance plans .

People living in Dubai are now in a better health condition because Dubai Health Authority (DHA) has made sudden reforms in health care and health insurance system in Emirates (Jones 2017). This reform enables almost every travelling or residing to Dubai to enjoy the coverage of the health insurance. This change has improved health related outcomes across a broad range of patients as people of Dubai now feel free to visit doctors in case of even minor health related complications which was previously a fear arising out of sheer financial burden. However, cancer, the leading cause of death among the Dubai, is not included under the coverage of the Essential Benefit Plan of Dubai (Jones 2017). However, DHA is now taking significant efforts to include cancer treatment under the health insurance plan as per the requirement laid by the mandatory health law. These changes are expected to come into enforcement by 2018 (Jones 2017). However, the insurance companies have given mixed response in regards to the DHA Health Funding Department decisions. This is because, cancer will lead to the increase in the reinsurance cost along with an increase in the premium of the Essential Basic Package under the banner of the Dubai’s mandatory health insurance schemes. Moreover, the third party administrator (TPA) are also not willing not include cancer under the health insurance schemes (Asia Insurance Review 2017). According to the Managing Director of Global Net, Dr. Sanjay Paithankar, earlier only 1/3^rd of the total insured people were aware of the optimal use of the health insurance card. However, at present more than 80% of the insured group are utilizing health benefits leading to increase in cost along with reinsurance. Now including cancer in the under the plan will further lead to a hike in cost (Asia Insurance Review 2017).

UAE has different insurance schemes for different sectors and this creates confusion among the UAE residents. The research carried out by the Health Monitor showed that people in UAE are now undertaking more onus in safeguarding the health future of their family members. This increase in awareness is getting reflected in the increase in the take up of the critical illness insurance schemes (increase by 16% in 2016). However, this tendency is more prevalent among the female population in comparison to the make population. However, 40% of the total respondents participated in the survey carried out by the Health Monitor are confused with the mandatory insurance assured by the employer and critical illness insurance (Wealth Monitor 2017). According to the managing director of Friends Provident International (FPI) of Middle East and Africa, Chris Divito, “It is worrying that the number of respondents claiming to have critical illness insurance, and indicating that it is provided by their employer, has increased in the last year. I am concerned they may be confusing their mandatory health insurance with critical illness insurance, which is not something typically provided by an employer as part of a benefits package. These are two completely different types of insurance and these people may not be as well protected as they might think”(Wealth Monitor 2017).  Thus the people of UAE is failing to understand the basic difference between health insurance and critical illness insurance. Health insurance is designed only to cover the nursing insurance and the amount payable is dependent on the cost of the actual medical treatment. Long-term recuperation, home-care service and therapy are not included under the health insurance schemes (Wealth Monitor 2017). Critical illness insurance schemes can be used in a variety of way by the policyholders depending on their circumstances. Chirs Divito is of the opinion that the people must consider critically illness insurance as an important addition to their mandatory health insurance is they have an extended family who is totally dependent on them. On the other hand, the health insurance will take care of the cost of medical bills in short term but may not replace the earning that may get endangered in terms of critical illness (Wealth Monitor 2017).

The same discrepancy in understanding is being reflected in terms of the mandatory health insurance policy. In Abu Dhabi, the low wageworkers do not have a clear idea about their health insurance rights. They are not familiar with the hospitals or clinics, which are under the coverage of the health insurance policies (Zaman 2010). According to the reports published in the Gulf News, one Indian construction worker has found complaining that none of the hospitals that he visited accepted his insurance card and hence he was compelled to avail the health care facility in his own expense. The excerpts of his statement, “I did not know where to go, and was forced to pay one-third of my monthly salary when I sustained a neck injury and needed treatment. I also asked my family back home to send me the prescribed medicines” (Zaman 2010). However, when the spokes person from the company was interrogated, he said that the workers could have approached the respective supervisors in the head offices in order to fetched relevant information (Zaman 2010).

The mandatory health insurance for expatriate employees was the main component of the health care reform in the UAE, however the issue that has been found in the research by Koornneef et al. (2012) is the uneven distribution and utilization of health care despite insurance of three health insurance plans. This gap in information gives direction to fulfill the research objective. It also gives direction towards investigating the reasons for lower utilization of the health insurance schemes. The study also gave little insight regarding the affordability of health care. Hence, conducting research on the role of TPA in health insurance coverage in UAE is necessary as it can give insight into the reasons for poor utilization of the scheme.  Collecting data directly from expatriate workers in UAE can give idea regarding what impact does mandatory health insurance system has had on the health care provisions of the country and how TPA support theme in claiming health insurance benefits.

Hamidi and Akinci (2015) discussed about health care payment reforms in Abu Dhabi. It gave idea about the impact of reform on health care providers, however specific role and contribution of TPAs in health insurance has not been covered in past research. Due to this limitation, the current research proposal is important. Literature review has given idea about challenges in health care reform in UAE context and role of different funding sources in coverage. As small parties mainly outsource their administration from TPAs, hence it would be interesting to evaluate the strength and weakness of TPAs in addressing health insurance issue in UAE.

The review of literature also provides an insight regarding how the government is trying to cover all the diseases under the mandatory health care schemes. The report published in Asia Insurance Review stated that the TPA in UAE is opposing the proposal of including the cancer coverage under the mandatory health insurance scheme. The reason cited by Jone (2017) is probable hike in the overall cost of the reinsurance. However, the review of literature did not highlight how the insured person is reacting to such policies undertaken by the government or what are their opinions in regards to the TPA's unwillingness to support cancer patient under the health scheme. This potential gap in the research opens the gate towards the analysis of the mindset of UAE population upon the proposal of including the health coverage of the cancer patient.

The review of literature also highlighted that the there lies certain confusion among the low-wage workers among the optimal utilization of the health insurance schemes (Wealth Monitor 2017). However, the review of literate did not provides any specific insight regarding how or why this confusion is arising among the low-wage workers. There are also lack of insight in how the TPA is helping these people to overcome this confusion or whether they are bothered to this problem. Thus this gap in the research has open the avenue for new research direction that will anlyse that whether this group of people who are facing difficulty in understanding the optimal use of the health insurance are aware of the help procured from the TPA in this regards or what are their understandings in the ground of role of TPA in health insurance policies.

The review of literature summarizes important elements of health care reforms in UAE and the role of mandatory health insurance scheme for improving access to health services for both national and expatriate population. However, research literature also pointed out to certain limitations in health insurance coverage such as poor utilization of services, issues related to affordability of services and lack of emergency medical funds for poorer people. Although specific role of TPA in health insurance for UAE context has not covered in research literature, however TPAs are likely to play an important role in regulating the health insurance industry in UAE.

The report by Nair (2018) explains that TPAs need to raise their game to comply with new requirements of health regulators. They have to play intermediary role in processing health insurance claims. The report also recommended that TPAs needs to become regional players rather than local operator of insurance. Before this requirement can be realized by TPAs, efficiency in their work can be enhanced by evaluating the strength and weakness of their current role in health insurance coverage. This research proposal topic and data coming out from research can give useful insight regarding the current role of TPA in health coverage and the changes needed in future to comply with new requirements in health insurance coverage

In this research work, the researcher will follow the research philosophy of positivism with a deductive approach. This will help to formulate the research hypothesis with the help of the theoretical framework. The researcher will select stratified sampling method (Saunders, Lewis and Thornhill 2015). This will help to select the focus group upon which the interview will be done. The overall research design is descriptive type design. Qualitative analysis method will be undertaken in order to analyse the answers of the respondents in the interview (Saunders, Lewis and Thornhill 2015).

For this research, the research will choose random stratified sampling technique. The criteria that will be taken into consideration while selecting the respondents for the interview are

1. Participants must be low-wage or medium wage workers
2. Participants must reside in Abu Dhabi or Dubai (permanent resident of UAE)
3. The participants must have a minimum qualification up to 10^th standard
4. All the participants are adult and above the age of 18
5. Participants must be enrolled under the mandatory health care policy of Dubai or Abu Dhabi
6. Participants must have minimum 1 year of work experience in Dubai or Abu Dhabi

On the basis of the above mentioned criteria 30 participants will be selected

It is duty of the researcher to abide by the Data Protection Act of 1998 while conducting the research (Saunders, Lewis and Thornhill 2015). The researcher will try to avoid biasness in the process of data collection and qualitative analysis of the data. Moreover, the research will also take informed yet signed consent from each of the participants before the initiating the interview process. The consent form will also ensure that the research will maintain the confidentiality of each of the participants via not disclosing their identity (Saunders, Lewis and Thornhill 2015). The research question will be framed such a way that it avoids any personal questions. Moreover, no participants will be forced to participate in the interview and will be allowed to leave at any point of the interview process as per their will. The researcher will also ensure that the data collected for this research will not be used for other research work in order to maintain the confidentiality of the research (Saunders, Lewis and Thornhill 2015).

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