Amman – (Al Ghad newspaper and Radio Al Balad) – Imad’s family went through a compounded tragedy. Not only was the 20-year old Iraqi diagnosed with cancer, but his family went into debt to pay for his treatment. In order to pay for his hospitalization a local private hospital, Imad’s loving family had to put their house up for sale.
Medical invoices provided to us by his brother, Ziad, have clearly shown that the family was exploited. A bill for a one-month stay at a private hospital exceeded JD20,000.
Medicines administered to him while in hospital came to over JD11,000. According to the Jordan Food and Drug Administration (JDFA), this means that the family was overcharged by JD2,024.
The Medical Director of the hospital – who spoke in the presence of the General Manager – justified the additional charge, citing a decision in 2000 by former Minister of Health, Dr. Tarek Izheimat, to allow the hospital to top up the prices of medicines by up to 100% of their cost.
He did not, however, provide us with any official documents to confirm the alleged decision. The ministry’s spokesman, Hatem Al Azra’ai, denied the existence of such a document, and stressed that prices of drugs in Jordan are unified by law.
In addition, the Fees Chart as issued by the Ministry of Health in 2009 stipulates that hospitals must “charge the official cost of the medicine, and add 20%”, i.e. in accordance with the JFDA’s prices.
Imad’s brother, Ziad, was also surprised that the hospital charged JD1200 for services at a specialized clinic run by the hospital itself. “Imad never left his room and never entered the clinic in question nor did he use the emergency room,” said Ziad. Still, Imad’s bill – a copy of which we obtained – includes JD94.50 for the ambulance service and JD54 for the cost of the emergency room.
The hospital’s general manager dismissed the allegations by saying that “not everything the patient says is true.” He insists that the patient was taken into ER, where an IV feeding tube was placed. He adds that “an ambulance was used to transport the blood to the patient while the clinic worked on treating the blood, confirming that all the technical and financial procedures are sound”.
Imad is not the only victim exploited by private hospitals. A controlled scientific survey conducted by two university professors for the purpose of this investigation revealed that 52% of patients believe that some private hospitals overcharge the patients and inflate the cost of their treatment.
This has led to an official complaint by the Saudi Embassy in Amman, after receiving a medical bill for Bandar, a 30-year old Saudi national who died after an 8-month treatment at a private hospital from injuries he sustained in a car accident in 2009.
Following the official complaint, which was registered at the Ministry of Health, a team from the Ministry visited the hospital to examine the file. The team acknowledged that “a total of JD38,814 was charged over and above the Ministry’s Fees Chart”. It instructed the hospital to reimburse the sum but did not sanction the hospital.
We contacted the hospital by fax. We also visited and called them several times to obtain details on Bandar’s bill but they did not respond to our request.
A total of 290,000 cases were admitted to 61 private hospitals in 2011 and another 839,000 consultations were registered that same year at specialized clinics associated with them, with 130,000 surgical procedures and over 54,000 deliveries performed.
This report, the first part of which was published yesterday, is the culmination of a one year long investigative, during which we examined Ministry of Health reports, met with officials in the medical sector, and visited 22 private hospitals, sometimes using a hidden camera. The investigation has revealed that the absence of effective monitoring by the Ministry of Health allows private sector hospitals to disregard the Ministry’s Fees Chart, conduct unnecessary medical and laboratory tests, x-rays and surgical procedures, and to prescribe medication that patients do not need. Such violations have maximized profits in the private health sector, harmed the health of patients, burdened them financially and also reflected badly on the medical sector, eroding people’s confidence in medical services.
‘Miscellaneous Fees’ amount to more than JD13,000 on one hospital bill
Fifty-year old Nabila was admitted to a privatehospital in Amman in April of 2012 to undergo cerebro-spinal fluid surgery. Her overall bill was JD18,000, out of which 13,000 were itemized as “miscellaneous fees”.
The General Manager of this hospital told us “this is not a con job”. We requested a detailed statement of the fees, but the list he provided only stated that the “miscellaneous fees” are “additional doctor’s fees/Al Hussein Medical City”.
When comparing Nabila’s bill with the Ministry’s Fees Chart regarding hospital accommodation and medical services, we found that charges for staying in the Intensive Care Unit (ICU) amounted to JD1,320 in comparison to the JD1,032 stipulated in the Ministry’s Fees Chart, a difference of almost JD288.
Even the charges for the ambulance used to transport Nabila from the airport to the hospital were inflated by more than JD22, topping the Ministry’s rates, which are set at around 100 JDs. Yet, neither Nabila nor her family filed a complaint with the Ministry of Health. The Hospital’s General Manager insisted that the hospital abides by the Ministry’s Fees Chart.
This was not an isolated incident. When the author compared the Ministry’s Fees Chart with those used by the hospitals, an estimated difference of between JD5 and Jd15 can be seen on every item.
Fees Charts Absent: Field survey documented using hidden cameras
Out of 61 private hospitals visited by the author of this report, a total of 22 (36%) do not display the Ministry’s certified Price Chart on their walls.
According to article 39 of the revised Private Hospitals Law number 9 of 1994, every hospital “must determine the cost of accommodations and the fees it will charge for treating patients and for its various services. With the exception of doctors’ fees, it must publicly display printed posters declaring its fees, both certified and stamped by the Ministry. These fees charts must be accessible, posted in visible locations around the hospital for everyone including hospital staff members and patients to review. The hospital is obligated to abide by the fees it announces”.
The Minister of Health, Dr. Abdul Latif Wreikat, acknowledged that private hospitals only display those charts when ministry inspectors go in for inspection visit. “Violations do happen but the Ministry needs proof if it is to impose penalties on those who are in violation of the law”, he added.
According to the President of the Private Hospitals Association and the General Manager of The Speciality Hospital, Dr. Fawzi Hammouri, “the chart is available to any patient who requests it. It is tens of pages long so we cannot display it on the walls but prior to admission, the patient signs an admissions form which clearly states the cost of the treatment”. When we later asked to see the Fees Chart at this same hospital, management and staff members stated that this was confidential information and they were not authorized to share it with us. We received the same response when we asked for fees charts at two other hospitals.
We obtained 27 medical bills from patients who received treatment in 8 different private hospitals, 25 of which showed the total cost without giving any details. Ten of the patients we met described how difficult it was for them to obtain detailed invoices for the cost of the treatment, medical expenses and various services that the private hospitals were asking them to pay.
The Yemeni embassy was not spared the procrastination of the hospitals and, according to the medical adviser at the Embassy, Dr. Abdul Wahab Alafi, the request for a detailed invoice was refused. He adds: “Matters should be clearer and more transparent. The bills are vague and lack detail, and it takes up to three or four hours for a hospital to provide us with detailed invoices”.
Former Minister of Health, Dr. Zeid Hamza, says the Ministry of Health should start monitoring the hospitals and impose heavy santions for violations “because the problem is not new”. Dr. Hamza says the weak monitoring system is due to what he describes as “the private sector’s dominance over the agencies of the state”.
On the other hand, the current Minister of Health, Dr. Abdul Latif Wreikat, denies this and emphasizes that the state is able to sanction any doctor or close any hospital that commits a violation.
But an examination by the author of the sanctions taken by the Ministry of Health against private hospitals between 2008 and 2012, revealed that the Ministry never sanctioned any hospital for violating the certified Fees Chart during that time, choosing instead to demand the reimbursement of the overcharged amount in 47 out of 167 cases where complaints were registered.
When we checked the Ministry of Health’s complaint registry, we found that out of a total of 47 cases where the Ministry asked the hospitals to reimburse patients for the difference, the hospitals complied in only 23 cases. We were not able to verify if the hospitals complied in the remaining 24 cases.
There is no clear legal text that allows the incrimination of hospitals that do not abide by the fees set for medical services. But public health law number 47 of 2008 gives the minister the right to partially or completely shut down a hospital or clinic – as long as this is preceded by a warning – if it does not take the necessary measures to redress the situation within the time frame set out in that warning.
Our survey showed that 44.1% of patients do not feel there is sufficient monitoring of health and medical services in Jordan.
Dr. Mohammad Shreim, a Medical Responsibility expert, asserts that “the medical system, in all its institutions, does not have a strategic plan to deal with the issues of patient exploitation and medical mistakes, which goes to prove that there is no monitoring plan in place”.
23% of all complaints over the past five years are related to tariff violations
The Ministry’s statistics show that the number of complaints filed by Jordanian patients against private hospitals for violating the fees charts over the past five years has been on the rise. It reached 104 complaints over that period, peaking in 2011 with a total of 32 complaints registered that year alone.
The measures taken by the Ministry of Health in response to these complaints included the filing of 64 out of the 104 complaints it received for following proper procedures. This translates into a percentage figure of 61.5%. The Ministry acknowledged that there was an inflation of fees in 24 cases, i.e. in 23% of all registered cases, while 12 cases went to court. A total of 38 out of 61 centers, over 50% of all private hospitals in the Kingdom, were implicated in these complaints.
The Ministry acknowledged that it contacted the hospitals where complaints had revolved around an inflation of the prices set by the Ministry, requesting that these hospitals reimburse the difference. This ranged from JD100 to JD3367.
The ‘culture’ of filing complaints is very weak
Arab patients do not file complaints because, according to former Minister of Health Dr. Nayef Al Fayez, “Arab patients do not have the time, the will or the determination to file a complaint, be that with the Ministry of Health or in a court of a law”, confirming that these forms of exploitation are not limited to Arab patients but extend beyond them to Jordanian patients as well.
A controlled scientific survey conducted for the purpose of this investigation indicates that only 4.2% of patients will register a complaint against hospitals for misconduct or malpractice.
Former Minister of Health Dr. Zeid Hamza links this to the lack of awareness and the fact that the culture of filing complaints is not well-established, calling on victims to take legal action, while the current Minister of Health Dr. Abdul Latif Wreikat takes issue with patients for not filing complaints under the pretext of “not wanting to deprive people of their livelihood”. He calls on patients to step up and complain so that severe measures may be taken against violators, be they doctors or private hospitals.
Arab patients: Swindled by 60% of the value of their invoice
We asked the Ministry of Health to provide us with the number and nature of complaints filed by Arab patients and their embassies over the past five years, but they did not reply within the legal timeframe. We had to file a complaint with the Jordan Information Council who ruled that the Ministry is obligated to provide us with the requested information, in compliance with the Right of Access to Information Act.
It took four months of exchanges with the Ministry to finally receive the requested information. According to the Ministry, 63 complaints have been filed by Arab patients and embassies against private hospitals, objecting to fees charged for medical services between 2008 and 2012. The number of complaints rose annually, with 14 complaints registered by mid 2012 and 23 in 2011 as compared to only 4 complaints in 2008.
Libya takes the lead with 14 complaints registered in the past five years, followed by Yemen with 12, Saudi Arabia with 11, Sudan with 9 and Iraq with 7.
The Ministry has ruled that 23 out of the 63 complainants should be reimbursed, while14 complaints are still being processed. Eleven complaints have been referred to the Jordan Medical Association, 9 filed away, 4 pending before the courts and two settled out of court with the complainants.
The 23 cases in which the Ministry of Health decided to reimburse the patients involved sums ranging from JD100 to JD39,000, with some invoices showing a 60% markup on the actual cost.
Dr. Fawzi Hammouri, president of the Private Hospitals Association says, “No one is perfect and while there are violations in every sector, in the private hospitals sector these are very limited. The issue of exploiting patients does not qualify as a phenomenon that warrants our intervention”.
Arab leaders and embassies complaining
The Medical Advisor at the Yemeni embassy in Amman, Dr. Abdul Wahab Alalfi maintains that Yemeni patients are indeed exploited by private hospitals and doctors in Jordan saying: “Yemeni patients are surprised by the high cost of treatment in Jordan”, demanding that “the patient be informed of the expenses and fees before the treatment is initiated”.
According to the former Jordanian ambassador to Sudan, Munther Qaba’a, the Jordanian embassy in Khartoum received many complaints from Sudanese patients about the inflated bills charged by private hospitals. In addition, many Sudanese newspapers had published reports that incorporated complaints of private Jordanian hospitals exploiting Sudanese patients.
In a recorded interview conducted during the inauguration of the Private Hospitals Association, former Minister of Health Dr. Nayef Al Fayez confirmed an earlier statement that “Arab leaders have complained to HM King Abdullah II about their patients being exploited in Jordan.”
A prominent Jordanian diplomat who asked not to be identified believes that the high sums billed to Arab patients by some private Jordanian hospitals can be attributed to the commissions that are paid along the way, starting with ‘brokers’ located in the country of the patient’s origin and ending with staff at Amman-based embassies. The sum involved is not inconsiderable and it adds to the final bill paid by the patients who are in this way rendered ‘helpless’.
The exploitation of Libyan patients
After the visit to Jordan of the Libyan Minister of Health, Dr. Fatima Alhourash, in mid-March 2012, the different facets of exploitation to which many Arab patients are subjected became the topic of the hour. In a statement to the United Press International, she described the sums charged to Libyan patients as “astronomical”, having exceeded the $90 million. She was certain that this dossier involved financial corruption, what with the Libyan government having only sent 300 Libyans abroad for medical treatment.
However, the former president of the Private Hospitals Association, Dr. Awni Al Basheer, stated that the number of Libyan patients treated in Jordan since the beginning of the Libyan revolution was well over 70,000 patients.
The author of this report repeatedly tried to call the Libyan Ministry of Health as well as the Libyan embassy in Amman, then faxed them both but was not able to get a response. Dr. Abdul Latif Wreikat, the current Minister of Health, however, acknowledged that there was exploitation and brokering at both the Jordanian and Libyan ends, but he said the ministry is only observing the matter from a distance, preferring to “wait and see where this gets to”.
The Ministry of Health did not give a detailed reply on its role in protecting Libyan patients, but the minister has threatened to use his authority and has asked the Libyan side to contact the Ministry if they needed any information about the real cost of treatment to their citizens.
Dr. Awni Al Basheer – who was President of the Private Hospitals Association at the time – replies by saying, “When the Minister of Health claims that there is corruption in the Libyan patients file, it means that he too is responsible for this corruption because he did not enforce the law and did not take any action”. We later discovered that Al Basheer himself had sent an official letter to the Ministry of Health confirming that Libyan patients were being abused by brokers and others trying to exploit them. There was a lot of meddling by intermediaries who sought to manage the distribution of Libyan patients around specific private hospitals in exchange for commissions, reaching 20% in one case according to the document of which we obtained a copy.
But Al Basheer insists that this document is not authentic, adding that the Private Hospitals Association is not responsible for it. He also sent a letter to the Libyan Ambassador in Amman –a copy of which we were able to obtain – reasserting a previous statement that the document was not issued by the Association.
Auditors: 75% of the Libyan patients’ bills are in line with the Price Chart
Dr. Rania Shawaheen, the Assistant General Manager of Scope, the firm in charge of auditing the bills of Libyan patients in Jordan, confirms that the financial claims made by private hospitals during the first stage amounted to JD30 million, of which it approved JD25 million for payment. It is now expected to approve only JD 60 million out of a total of JD70 million demanded by private hospitals from the Libyan side – as solely represented by the Libyan Health Office. This means a deduction of JD10 million from the overall cost of treatment.
The number of bills for Libyan patients did not exceed 150,000. About 75% of them are in compliance with the Fees Chart regulations. But half of the bills are not in compliance, according to Shawaheen, are due to the fact that doctors are not aware of how their fees were set in the Medical Fees Charts.
This investigation was by the Investigative Reporting Unit set up at Al Balad Radio with support from ARIJ.