Proposals for reorganizing the relationship between doctors and insurance companies

In this context, the former Director of the Royal Medical Services and member of the Advisory Committee at the National Policy Council, Dr. Adel Al-Wahadneh, presented a set of proposals to address the roots of the crisis in a study that examined the repercussions of the dispute between the Medical Association and insurance companies in Jordan.

This study, which "Al-Rai" reviewed, is based on the principles of health economics, aiming to achieve a balance between the rights of doctors and the ability of insurance companies to bear costs, while preserving the right of patients to receive healthcare.

Al-Wahadneh confirmed to "Al-Rai" that the continuation of the dispute is not limited to financial aspects, but carries potential repercussions for the stability of the health sector and the confidence of patients and investors, stressing the need to move from managing the dispute to addressing its causes according to clear and fair standards.

He called for assigning the responsibility of setting pricing equations for medical services to independent specialists in health economics, rather than leaving it to the directly interested parties—whether doctors, hospitals, or insurance companies—to avoid conflicts of interest, which he considered one of the reasons for the failure of previous attempts to reach acceptable equations.

Al-Wahadneh explained that fair pricing should not rely on supply and demand alone, but on a set of criteria including the doctor's experience, the nature of the specialty, the time required for the medical procedure, the level of risk associated with the patient's condition, and the actual costs of the service.

He pointed out that the absence of unified and clear standards has contributed to widening the trust gap between doctors and insurance companies, as some doctors resort to setting their fees individually, while insurance companies object to some claims or reduce their value, which exacerbates financial and professional disputes.

Al-Wahadneh presented a mathematical model to determine the value of a medical consultation, based on years of experience after obtaining a specialty and sub-specialty certificate, considering that professional experience is a factor that should be taken into account when determining fees.

The model assumed a base consultation fee of 20 dinars for a newly specialized doctor, to which 5% of the base value is added for each year of experience after the specialty, and 10% for each year after the sub-specialty.

According to the example provided in the study, a doctor with ten years of experience after the specialty and five years after the sub-specialty would have a consultation fee of 40 dinars according to the proposed equation.

The study emphasized the importance of adopting objective criteria that ensure fair compensation, noting that these figures represent an illustrative model and not an approved tariff.

Regarding medical and surgical procedures, Al-Wahadneh suggested adopting pricing that takes into account the varying levels of risk among patients, rather than applying uniform fees to cases that differ in their complexities and treatment needs.

The study divided patients into three categories according to risk level: low, medium, and high, taking into account health status, chronic diseases, and the potential for complications.

It provided a mathematical example in which the costs of a medical procedure vary between 4,125 dinars for low-risk cases, 5,100 dinars for medium-risk cases, and 11,125 dinars for high-risk cases.

The cost elements in the model include medical team fees, supplies and medicines, hospital stay, medical evaluation before and after the procedure, risk fees, and additional expenses.

According to the study, this vision aims to link fees to actual costs and the requirements of each case, which enhances transparency and helps patients and insurance companies with financial planning.

The study addressed the problem of overpricing some specialized surgical operations, considering that the resort of some doctors to raising their fees as a precautionary measure may push insurance companies to apply general reductions to other medical procedures, which harms doctors who adhere to moderate fees.

Al-Wahadneh suggested addressing these practices through precise pricing standards for each procedure, rather than generalizing reductions, in addition to establishing clear foundations for consultations and medical advice.

He also called for strengthening the role of hospitals in issuing detailed and fair invoices, which would allow for knowing the true costs of the services provided and limit unnecessary procedures and disputes over financial claims.

He warned against adopting what he described as a "contracting" system in providing medical services, by setting a predetermined financial package for the procedure without considering the possibility of complications that require additional intervention and increase the actual cost of treatment.

Al-Wahadneh pointed out that the fears of some doctors regarding legal accountability may push them to request additional tests or keep patients under observation as a precaution, even when some of these procedures are not medically justified, which increases the financial burdens on the health system.

He also indicated that the absence of a clear and agreed-upon definition of emergency cases may open the door to disputes between doctors and insurance companies regarding the necessity of medical interventions and the coverage of their costs.

He called for establishing clear professional and financial controls for these cases, in a way that protects necessary medical decisions and limits disputes related to insurance coverage.

The study warned that the continuation of the conflict could reflect on the quality of health services and lead to a decline in the confidence of patients and investors, in addition to increasing the likelihood of some medical talents working outside the Kingdom in search of more stable professional conditions.

It also raised the issue of delays in paying doctors' dues by insurance companies and the resulting additional tensions, alongside the varying pressures faced by private hospitals between the demands of doctors and insurance cost-control policies.

The study addressed the potential risks of doctors refraining from providing services as a means of pressure from an ethical and legal perspective, warning of the reflection of any cessation of necessary care on the health and safety of patients.

Al-Wahadneh noted the necessity of government intervention to establish a clear regulatory framework for pricing medical services and to oversee fair agreements between doctors and insurance companies based on health economics standards that take into account the interests of all parties.

He stressed the importance of enhancing cooperation and community awareness, which contributes to restoring trust and achieving stability in the sector.

Al-Wahadneh considered that addressing the dispute requires moving from negotiations based on conflicting interests to applicable scientific equations that ensure fair wages and the sustainability of health insurance, without the patient bearing the consequences of the dispute between the concerned parties.