Health Insurance Cost Escalation And Containment: The Study Case Employer Medical Scheme.

ABSTRACT

This study sought to examine the cost drivers of health care and cost containment measures in employer sponsored medical scheme. A retrospective case study was carried out. The study included the entire population of the scheme beneficiaries. Both quantitative data and document review were used. Quantitative data was expenditure in Kenya shillings, secondary data collected from the Electronic Medical Record (EMR) from 2011 to 2015. Document review of policy document and operation manual of the medical scheme was done to establish cost containment measures put in place by the medical scheme in study. A descriptive analysis was done on the data. The finding were, chronic conditions, pharmaceutical, medical technology, administration expenditure, length of hospital stay, doctors consultation had an upward trend. Doctors’ consultation expenditure was the highest in the five years. Chronic conditions had higher share than pharmaceutical expenditure. Higher escalation of cost was demonstrated in all the variables in 2013.This study contribute to the understanding of expenditure growth trends in an employer sponsored medical scheme. The study found that utilization policies and use of guideline play a big role to a scheme expenditure output. From the literature review, Cost containment measures have been used in different countries and have yield positive results. These measures range from government policies to incentives for both health care givers to patients. The study recommends policy reform and utilization of committees to contain cost. There is need to explore cost drivers individually in detail especially doctors’ consultation, chronic conditions, pharmaceutical, administrative and medical technology expenditure in different employer sponsored medical schemes.