Beirut, December 2014 (Al Jumhuriya) – In the middle of one of the nights of March 2014 three hospitals shut their doors to the young Rita Akoum, a paraplegic since birth who was suffering from breathing difficulty and facial inflammations.
The refusal of private hospitals in accepting patients is something that thousands of Lebanese patients facing deteriorating health conditions, even those dying, have to deal with on an annual basis, despite the existence of an agreement between these hospitals and the ministry since the civil war.
This agreement forces hospitals to accept all uninsured emergency cases, at the ministry’s expense. This rejection is also in violation of a decision issued by the Ministry of Health in October 2006 forcing hospitals to accept all emergency cases especially after an increase in their refusal for admittance.
After a year of investigation, this reporter documents the manipulation of patients by hospitals including the refusal of private hospitals to treat them amidst negligence and lack of monitoring by the Ministry of Health, endangering the health of citizens. Adding to that is the tampering with hospital bills as well as the hospitals’ collusion with brokers, costing almost 50% of the Ministry of Health’s budget, according to Minister of Health Wael Abu Faour.
George Kataneh, Secretary General of the Lebanese Red Cross, reveals that “hospitals do not hesitate in rejecting arrivals from the Red Cross whenever the injured or patients are brought in, usually with the excuse of the unavailability of beds.”
Former MP Dr. Ismael Sukariyeh explains that “such practices deplete more than 50% of the Ministry’s allocations for those who are uninsured, estimated at 400 billion Lebanese liras ($266 million) per year. This equals one third of the Ministry’s 600 billion lira ($400 million) budget and 5% of the gross domestic product.
Our first stop was at the Ministry’s centre responsible for issuing health cards. Tens of Lebanese citizens show up there on a daily basis to finalise procedures for the admission of state-insured patients into private and government hospitals.
The process is not that easy. Over 70% of the applicants are rejected entry or asked for “huge” amounts of money to pay the difference between what the state pays for – 85% of the bill – and the 15% that patients have to cover.
This reporter visited the centre 20 times disguised as a university student preparing her thesis. I was permitted to meet with applicants. On one of the visits I noticed a man waiting in the middle of the queue carrying a stack of card and completing application procedures on behalf of patients.
When I asked a ministry official about him, I was told he is a representative of one of the hospitals who comes everyday to submit applications for more than 60 patients. He added that “it is unfortunate, but a number of these applications are for fictitious patients and/or diseases created by hospitals whose owners have political clout in order to gather illegal funds at the expense of the poor!”
But those in charge of the hospitals ignore this reality and say that this case does not apply to them. “Each of the representatives we deal with represents a certain political faction and he takes care of the patients who belong to that group within the Lebanese political system.” They all say the same thing: “our financial allocations are barely sufficient to cover the treatment of our patients, so how would we create applications for fictitious patients or diseases?”
This reporter has divided the brokers and agents into two groups:
The hospital uses the patient’s personal information when submitting an application to the Ministry of Health to cover the cost of treatment. Hence, the hospital gets paid twice: from the patient and from the ministry. This is done without the patient’s knowledge.
In an interview with this reporter, Minister of Health Wael Abu Faour did not refute these allegations. He did confirm that he had issued a decision on March 10th stipulating that “no brokers or clerks with treatment applications will be allowed into the ministry building or any of its departments.”
But this abuse did not end with the minister’s decision, says a ministry official who wished to remain anonymous. “The decision remains ink on paper”, he says.
Such procedures were implemented against “small” agents who were making barely five thousand lira ($3) per application while the real brokers were going about freely carrying out their false applications with no one monitoring.” The official added:“it is quite difficult to reign these brokers in as they have political and factional immunity.”
Abu Faour says the Ministry of Health provides medical insurance to half the Lebanese people, around 2 million for a cost of cost of $267 million a year. He stresses that “the patient who is covered by the ministry has rights and the hospital is not providing him a free service. He pays a premium for this service just as he would for any other insurance”. Abu Faour explains that the hospital fees are set “in accordance with agreements between the ministry and private hospitals”. He also points at “administrative lists included in the hospital fees to be adhered to by all.”
Prices for treatments and surgeries were set according to a study carried out by officials at the Social Security Corporation and according to the classification of each hospital. These rates were approved by the ministry.
This study, however, was last updated three years ago. Hence, hospitals alter prices to cover annual inflation rates in the cost of medicines and treatments.
In accordance with agreements signed between the Ministry of Health and the hospitals “the ministry promises to cover the Lebanese patients who do not enjoy any other coverage within the annual limits of the budget and in adherence with health and social priorities approved by the ministry.”
The agreement states that “the Ministry of Health covers 85% of the hospital bill including all medical tests and treatments available at the hospital. No medicines or medical equipment need to be bought. The ministry urges patients to take a receipt with the amount paid from the hospital. In return patients pay 15% of the total bill and those who carry disability cards are exempt from paying anything.
Despite the availability of state owned hospitals in several Lebanese districts, patients prefer to seek treatment in private hospitals for surgeries or treatments because they don’t trust the services/expertise of the government health sector.
This reporter documented the activities of brokers in four of 20 private hospitals she visited including Al Murtada hospital in Ba’albak. The ministry sets an annual ceiling for the hospital at 2.5 billion Lebanese lira ($1.666 million) in addition to extra amounts when the set limit has been reached.
I went through 30 treatment applications from the hospital. I contacted the patients whose names had been listed only to discover that 13 numbers were either out of order or unlisted. Five of the persons reached denied having had any surgeries at the hospital while nine said that they had indeed been admitted to Al Murtada hospital. Five of those said their stay at the hospital was not the same as the dates that were mentioned in the applications that I had.
The remaining four said that the surgeries they underwent were not the same as those listed in the applications.
My telephone conversations with these patients caused anger for those benefitting from these abuses. I received a threatening phone call telling me “not to play with fire.” I was also called by the owner and director of Al Murtada hospital Abbass Hijazi, who wanted to know why I was calling the patients. He stressed “the honesty of the administration of the hospital in its dealings with patients and with the concerned authorities, specifically the Ministry of Health” in contradiction of what ministry sources might say and what I have concluded.
This reporter also came across a written warning issued by the previous Minister of Health Mohammad Jawad Khalifa on March 18, 2010 to the Al Murtada hospital asking them to amend their violations concerning agreements with the ministry, as stipulated in the central inspection ruling issued in 2008. The memo lists a number of violations, indicating that the violations documented by this reporter have been going on for a number of years.
The central inspection ruling criticizes “the unavailability of a private office in the hospital for the supervising physician from the Ministry of Health” as well as “not providing the patients with copies of the hospital bills and adding consultations within the treatment bill for services that do not require consultations. This in addition to tampering with medical signs referring to procedures that have been carried out and the ministry’s pricing for medical work, in order to get more money for the hospital and the physician, and in the end wasting public funds.”
The ruling also states that the “operating theatre was closed for disinfection during the inspection visit,” which is the same excuse that was used when I visited the hospital last February.
The central inspection ruling was issued by the inspection committee consisting of the president and two members. It also adds: “in accordance with the coverage cards that were issued by the card issuing centre in Ba’albak, for the months of May and June in the years 2006, 2007 and 2008, the following has been revealed:
Thus it can be deduced from the above information that a number of false applications are submitted in the names of possibly real individuals, every year. It is possible that the illnesses are fictitious but because real names are being used it could explain the repeated admittance at the ministry’s expense. This may occur either without their knowledge or in collusion with the hospital in return for medical services or monetary sums, an issue that was not overlooked by the inspection ruling, which cast doubt on “the procedures of obtaining medical services for patients and the repeat treatment for one patient within a short period of time.” The ruling also adds that what takes place amounts to “the wasting of public funds and the illegal benefitting from general assets.”
It also states “that this is a matter that is being shouldered by both the treating physicians and the hospitals, as well as the supervising physician, who, had he been carrying out his duties in the proper manner and observing the procedures that are carried out at the expense of the ministry within the correct guidelines and in accordance with the law, would not have permitted such things to occur. He would have reported this to his administration and taken the necessary measures against these illegal acts.”
When this reporter requested to meet with Dr. Hijazi to provide him the chance to respond to these accusations, he avoided her citing “disturbances” in the Beka’a Valley, where a certain well-known faction is in control, as an excuse.
The most practised method in tampering with the treatment bills and making the patient pay double the amount of fees is blatantly obvious!.
With the assistance of one of the employees of the card-issuing centre at the ministry, I investigated the amount of expenditures of more than 200 bills presented by hospitals to the ministry and the discrepancies between the tariffs approved by the ministry and those put by the hospitals.
Pretending I was a ministry employee, I accompanied a patient who wanted to gain admission into the hospital. There I met Tony who was waiting his turn at the entrance of the “Middle East Medical” hospital in Bisalim (Mount Lebanon). He was finishing admission procedures for his aunt (S. Sh.) who had to undergo medical surgery to remove a cancerous part of her colon carried out in March 2014, at the ministry’s expense.
Tony said that “after seven months his aunt was in need of a second operation,” and revealed that he had spent, “after negotiation, he had paid $7000 out of the original $8000 bill of the first procedure despite it being at the ministry’s expense.”
When I asked him about the bill he said: “they refused to give me a copy and I ended up paying with cheques.” As for the second surgery he said: “the hospital is asking for $3000.”
After showing me photocopies of the cheques I asked Tony if I could accompany him to the hospital entrance. I told him to only pay half of the requested amount — even though the hospital insists on the full amount being submitted upon admittance. I insisted that he only pay $1500 and the remainder of the amount would be paid in a couple of days.
The hospital admissions employee could not explain to me why treatment costs were so high, despite the patient being covered by the ministry. The amount listed on the patient’s treatment bill and signed by the physician stood at 471,294 thousand Lebanese lira ($300 and not $3000). 15% of it was surgery cost.
After two days the hospital called to remind us of the second instalment; I accompanied Tony to the accountant’s office where he was asked to pay $1000 and the remaining $500 when the patient is discharged. The supervising doctor had decided that the patient (Salma) needed to stay for two extra days. And we were reassured that the extension would not cost us more.
When we returned Monday morning to take his aunt out, we were surprised by the demand of $1000. Tony asked the employee “why have you doubled the amount?” Her response was: “the paperwork before me indicates that your total amount is $3500.” Tony refused to pay the new extras.
I asked to see the attending doctor whom I had not encountered on any of my visits to the hospital. Again he was not there. We went back to the first employee who had processed our admission papers and he told us he would take the matter up with the administration.
After an hour he returned and said that the hospital administration was willing to overlook the extra $500!
In conclusion a surgical procedure to remove a cancerous growth from a colon in a private hospital cost a patient who is covered by the Ministry of Health $10,000!
Sukariyeh points out that the total cost of such a procedure as listed by the ministry and approved by the hospitals is 3,621,000 lira ($2400). The ministry pays 85% of the amount — 3,150,000 lira or ($2100) and the patient settles the remaining amount of ($315).
Dr. Henri Azar, the director of the Middle East Hospital put the responsibility on the shoulders of the supervising doctor Walid Salmon, Dermatology and Venereal Disease specialist. He said the latter “asks to be paid upfront and before any procedure is carried out. He refuses to wait for payment from the ministry, which is usually late and does not pay him the amount that he wants. The choice given to the patient is either to go with another doctor, covered by the ministry, or to cover the cost of the doctor he wants.”
As to the role of the attending physician, he said “the doctor needs to understand our situation or we will be forced to refuse the patients who are covered by the ministry.”
Dr. Salmon denied the accusation put forward by Dr. Azar saying:“all I made out of that surgery is $500.”
After a period of time I headed to the emergency at Al Makasid Hospital in Beirut claiming that my “old “ mother was waiting outside in the car with severe pains in her stomach. She wanted to be admitted at the expense of the Ministry of Health. Despite my pleading they refused to admit her until a deposit of $2000 was made.
The Makasid Hospital receives more than 5 billion lira ($3 million) from the annual budget for hospitals in 2013–2014 and in line with lists for private hospitals issued by the ministry under decree no. 10033.
The same scenario was repeated at the Manila Hospital Emergency in Tripoli, which receives 4 billion lira ($2.5 million) a year for patients. From there I headed to Al Mathloum Hospital which receives ministerial allocations of 1.7 billion lira ($ one million) a year. There I got the same answer: ”no ministry.”
When asked to respond to these facts, all hospital administrations denied that they do not accept ministry-supported patients and offered explanations. They said: “the allocations provided by the ministry were insufficient and are used up quite fast. Hence, we are unable to receive all patients. We also have a shortage of beds especially in intensive care.”
All our findings point to the absence of supervision and monitoring; this is what permits a patient to pay an augmented bill and for the hospital administration to choose patients and overlook severe cases. Where is the ministry’s supervisor who is meant to oversee the agreements with the hospitals?
Sukariyeh considers “the supervising physician as the weak point in the current system, for he/she rarely carries out his/her duties.” He stresses “the absence of monitoring and supervision of accounting bills as well as medical practises especially in the cases covered by the ministry as the main cause of overspending.” He points out that “the number of doctors who have signed on with the ministry as its supervisors at hospitals are 147”. Then he asks: Are you employees of the hospitals you are attached to or part of the ministry? Do you receive instructions from the owners of these hospitals or do you work on your own?”
Abu Faour said that the Health Ministry had suspended two supervising physicians in March 2014 because they were not carrying out their duties. He adds: “what is missing is a monitoring mechanism in charge of the supervising doctors and I will therefore submit a petition to parliament asking them to assign inspectors who will oversee the physicians in all governorates.”
This reporter carried out a number of calculations to determine if a strategy used by the insurance companies in Lebanon might be a good solution for the state-supported medical coverage problems.
Asa’ad Mirza, director of (Daman), a leading health insurance company, sees that it is possible to provide 100% coverage for the two million citizens at a cost of $267 million per year, the amount being spent by the Ministry of Health on its health insurance scheme..
Mirza explains: “if we divide $267 million on two million, the share of each individual would be $133.4. This is reasonable compared with the budget allocations that insurance companies use for guest workers in Lebanon in accordance with unified agreements between them and the hospitals”.
He goes on to say that “the state considers insurance for such workers vital for their employment in Lebanon. Relevant agreements stipulate that the lowest rate of insurance should be between $120 and $140 a year per guest worker which includes emergency and surgical treatment.”
Issam Hatti, president of the Insurance Company Brokers in Lebanon says “we submitted to the former minister of health Mohammad Jawad Khalifa a project involving mandatory insurance which would oblige the ministry to provide basic services to all citizens with no exceptions, through the budget. The coverage would be set within a limit and would include additional insurance for those wanting to be covered from private companies or support funds. The administration of this coverage would be with the private sector and the ministry would have a supervisory role.”
It appears that the health coverage problems in Lebanon will not be subsiding anytime soon. Prior to the conclusion of this investigation the media covered news of how al Nini Hospital in Tripoli turned away Tala Juma’a, 5, a leukaemia patient.
The family staged a protest outside the hospital, demanding a continuation of her treatment at the hospital, begun 20 days ago, at the expense of the ministry.
The Health Minister intervened and said her treatment would be covered. He also terminated the ministry’s agreement with the hospital and said if the latter repeated the same offence he would refer its owner to the court of cassation.
This investigation was carried out under the supervision of Arab Reporters for Investigative Journalism and coached by Safaa Kanj.