The crave for
profitability by
operators of the
National Health
Insurance Scheme is
breeding bad ethics
and eroding quality
health care delivery for subscribers, NIKE POPOOLA writes
DISGRUNTLED ENROLEES
Mrs. Aderonke Korede works in a telecommunications firm
that registered its employees with a Health Maintenance
Organisation under the National Health Insurance Scheme.
She expected her health plan with the HMO to allow her to
deliver her baby through Caesarean section. However, when
the delivery time came, the HMO refused to bear the
responsibility, claiming that her health plan did not cover
such a procedure.
After unsuccessfully persuading the HMO to live up to its
responsibility, her husband agreed to pay the hospital bill
when his wife’s health showed signs of deterioration. The
Koredes felt the HMO’s refusal to pick the bill had defeated
the essence of having a health insurance in place.
Aderonke’s husband, Babatunde, says, “The experience was
really traumatic. I could not stand the attitude of the HMO
and risk the lives of my wife and our unborn baby; so, I had
to go back to the money we were saving to roof the small
house we are building in Ikorodu to fund the operation.
“Almost a year after, we’ve not been able to raise enough
money to roof the house because of other contending
issues. The development has left us at the mercy of our
troublesome landlord and my wife is even sceptical of going
to the hospital even for services covered by her health
insurance package with the HMO.”
Different complaints emerge daily from both the enrolees,
who are registered with the HMOs, and the hospitals, which
are designated as health care providers under the NHIS.
On the other hand, the HMOs are also complaining about
the treatment that the hospitals are meting out to them,
especially when it comes to money matters. The relationship
between the HMOs and the hospitals can best be described
as that between a cat and a mouse, because they are always
suspicious of each other.
The strained relationship between the HMOs and the
hospitals has left the enrolees at the receiving end of
terrible services.
Yet, amid the challenges militating against the ability of the
scheme to provide quality health care services, little is being
done to address the issues by the regulator of the scheme.
Unlike the financial services sector, where the regulators
take strict and decisive actions, players in the health
insurance sector in the country have continued to do things
their own way.
The NHIS ensures the pooling of funds from different sectors
of the economy, with many people contributing money but
only a few of them expected to fall ill at a particular time.
The essence is to guarantee free health care for the
contributors whenever the need arises.
While the importance of a virile health insurance scheme
cannot be over emphasized, experts are of the view that
majority of those on the NHIS enjoy cover only for minor
ailments.
When there is a need for surgery or an expensive treatment,
the HMOs always require the hospitals to take permission
from them. If not, they end up not paying for the enrolee’s
treatment.
In most cases, enrolees have to pay from their pockets for
such treatment. In times of emergencies, the hospitals may
either have the challenge of reaching the HMO; or the HMO
simply refuses to pay.
An enrolee, who works in an oil company, Mr. Tunde
Atolagbe, will rather pay for his treatment than to depend
solely on his health insurance plan because he lacks
confidence in the cheap services being rendered by the
hospitals in their bid to make profits.
“I use a particular hospital alongside my colleagues in the
office through our HMO, but you find that the types of drugs
that they are giving you may be different from when you are
paying from your pocket,” he says.
Mr. Adeolu Oyeniran works in an oil company. He says he
stopped getting free treatment in his hospital last
November.
“Whenever I go to the hospital, they say they cannot treat
me because the HMO has stopped service to my
organisation. I am sure my employer has not been paying
the HMO and this money is removed from my salary,” he
laments.
HMOs VERSUS HOSPITALS
Common complaints by the hospitals against the HMOs
include default in paying capitation (the amount payable per
head irrespective of whether the person draws from pool of
funds or not for a certain period of time); paying ridiculously
low capitation; and delay in payment, even when the HMOs
have collected their premium from the enrolees.
The hospitals are in a dilemma because they stand to be
disengaged if they make official reports of HMOs
indebtedness to them.
This hostile condition of doing business is forcing the
hospitals to render very cheap services that may leave the
patients worse off.
According to the result of a health insurance survey
conducted by the Lagos Chamber of Commerce and
Industry, majority of the enrolees are absolutely displeased
with not receiving commensurate treatment for the
premiums paid compared to when they visit their family or
personal hospitals where they pay on the go.
The Director, Research and Advocacy, LCCI, Mr. Vincent
Nwani, says the survey found out that many enrolees were
actually opting out of being treated by HMO-registered
hospitals, preferring to patronise their personal doctors for
better treatment.
The average enrolee, according to the survey, thinks that he
is fully covered by the scheme irrespective of the nature of
the ailment.
Nwani says the hospitals are complaining that the capitation
fees being paid to them are very small; adding that the
present monthly capitation that the HMOs pay per person to
the hospitals is between N500 and N750, but adds that some
enrolees make regular visits to the hospitals even for minor
complaints.
Those with serious diseases and infections want perfect
treatment with the N500 or N750 paid by their HMOs
monthly, he says.
The LCCI investigation shows that complaints are not limited
to the hospitals. The HMOs too are not happy, because they
say that sometimes when their corporate clients go to the
hospitals for inspection, they get bad reception.
Some hospitals, Nwani says, accumulate bills for up to three
months before sending them, and at the end of the day, they
complain of delayed payment.
He also observes that the HMOs do not really explain in
details to their clients the plans they registered for. This, he
says, makes patients with the most basic plan to go to the
hospital demanding major surgeries to be performed on
them, or comparing their level of treatment to others with
more comprehensive plans.
Recently, one of the hospitals being owed a large sum, in a
mail to one of the HMOs, narrated how several attempts
made to recover the money had proved abortive, and how
the employees of the HMO had been lackadaisical to its
plight despite sending monthly bills.
In response, the HMO made it clear that it was doing the
health care provider a favour by having it on its register, and
expressed frustration that its gesture was not appreciated!
Presently, about 5.5 million Nigerians are registered under
the NHIS. Seventy-five per cent of these are Federal
Government employees who are mandatorily insured, while
the remaining are private sector employees.
The health insurance scheme, whose implementation began
about 16 years ago with the signing into law of the NHIS Act,
1999, has continued to grow at a very slow pace.
Under the scheme, 77 HMOs are licensed and they are
working with about 7,000 health care providers. The health
care providers are hospitals that should be well equipped,
but because most of them render services on credit, it has
been extremely difficult for them to meet set standards.
At the commencement of the scheme, the minimum
required capital base for each HMO was N30m. It was later
reviewed to N100m, and it is now N400m.
RISING FRAUDULENT ACTIVITIES
Instead of prioritising quality health care delivery,
fraudulent activities are prevalent among professionals in
the health insurance scheme. For instance, Nwani says the
results of investigations carried out by the LCCI WERE really
displeasing.
He says, “One of the HMOs we visited during the fieldwork
informed us that it had been receiving unrealistic bills from
the hospitals. A mystery shopping was carried out by the
HMO by sending one of its members of staff as a patient to
one of the suspected hospitals that normally sent exorbitant
bills. The disguised patient was treated for a very minor
ailment and was given drugs.
“The staff kept the drugs, waiting for the hospital to send the
bill. When the bill was received, it was discovered that the
hospital had inflated it and added some drugs that were not
given to him. The HMO took the drugs and the bill to the
hospital as a proof that it had been sending unrealistic bills,”
he notes.
Narrating another case, Nwani says, “One of the registered
hospitals sent a bill to a HMO that a client was treated for
dog bite. When the HMO called the parents of the boy to
sympathise with them, it was discovered that the boy was
never bitten by a dog. The hospital cooked up the case in
order to extort the HMO.”
BETWEEN HMOS AND ENROLEES
The Managing Director, Healthcare International, Mr. Tosin
Awosika, says HMOs actually have structures in place to
ensure quality health care delivery to the enrolees.
“Before we accredit hospitals, we would have inspected
them to ascertain what they can do and what they cannot
do. On a regular basis, we do quality assurance visits to
check what they are doing and how they are treating the
clients. We have a feedback system; if there is an issue, we
expect the clients to get back to us,” he says.
According to him, HMOs have the right to delist hospitals
that are not doing well and transfer the patients to other
hospitals for better care. With these measures in place,
Awosika says the hospitals will ensure efficiency because
they will not want to be delisted.
Many enrolees also erroneously believe that once they pay a
certain premium, they will enjoy full treatment for any
ailment throughout the year, but are shocked that their
health plans sometimes operate like the mobile phone that
goes off ones its credit has been exhausted.
The President, Actors Guild of Nigeria, Ibinabo Fiberesima,
says, “Some of my members, after the first and second visits
to the hospital, do receive text messages from the hospital
that they have exhausted their plan.”
The Managing Director, MetroHealth, HMO Limited, Mr. Kola
Awokoya, stresses the need to build the health insurance
scheme on trust. “The responsibility of enlightening the
enrolee on the coverage of his health plan lies with the HMO
and the employers,” he explains.
It has been found out that the quality structures put in place
by the HMOs are not working perfectly. A survey conducted
by The PUNCH, using questionnaires to collect information
from enrolees of different HMOs, showed that most of them
subscribed to the cheapest plans, which do not provide
treatment for the illnesses killing majority of Nigerians
presently.
It was discovered that none of the enrolees had ever been
called by their HMOs to either enquire about their welfare or
ask if they were satisfied with their health plans.
Despite the fact that their employers subscribed to health
insurance on their behalf, 30 per cent of respondents
preferred to go to their family doctors than visit the
hospitals recommended by their HMOs.
Mr. Gbenga Ilemobayo enrolled his family of five with a
HMO and paid a premium price for choosing a band ‘B’
hospital and subscribing to the ‘Gold’ plan, but when one of
his sons required an urgent surgery for a medical condition
called hernia, the hospital could not obtain authorisation
from the HMO to carry on with the procedure for more than
16 hours. The HMO’s customer care lines rang for hours
without anybody picking up the calls.
Ilemobayo explains, “Due to the severity of the boy’s
condition, the senior doctor at the hospital told me that the
operation had to be done immediately and I had to
approach my brother to lend me some money, which I could
deposit.
“It was a difficult period for my family because I had just
paid the school fees of my three children, who are all in
private schools. Their mother has been out of job for about
three years and my income leaves no room for any serious
savings.”
MULTIPLE COMPLAINTS
The immediate President, Nigerian Medical Association, Dr.
Osahon Enabulele, accuses some of the HMOs of not paying
their capitation to the health providers, adding that the issue
was raised during the Presidential Summit on Universal
Health Coverage held in Abuja in March this year.
“At the last presidential summit on universal health
coverage, the same allegation was made. It is very criminal
for any HMO to withhold the capitation of the provider
because that invariably will not motivate the provider to
provide the needed quality services,” he says.
As a result of default, he says that the HMOs are short
changing the insurance scheme and the health care system,
which will invariably impact on the patients, who may get
poor services resulting from lack of motivation.
Enabulele says a lot of disgruntled doctors have reported
their HMOs to the NHIS, adding that the NHIS leadership has
asked the doctors to provide information to establish that
some of the HMOs are actually owing the providers their
due capitation.
“It is criminal for any HMO to withhold capitation to the
provider and the NMA frowns seriously on that, and we
charge the leadership of the NHIS scheme to fish out such
HMOs and appropriately discipline them so that the scheme
does not die a natural death as a result of the poor
assimilation of the providers of care due to the antics and
acts of some of the HMOs,” he says.
The NMA boss notes that if a HMO is having grievances
against an employer who refuses to pay his premium, such
complaints should be tendered before the governing board
of the NHIS.
Enabulele explains that it is not in the power of the HMOs to
deny anyone of the services that they have promised to
provide if the customer has paid the agreed premium.
“The HMOs have to pay their own capitation to the
subscribers; once a portal has been allocated to a provider
for health care facility, it is under obligation. For anybody to
be allocated to a provider, it is assumed that the person has
paid up his premium and subscribed to the care,” he says.
The Healthcare Providers Association of Nigeria is the
umbrella body of the hospitals registered under the NHIS.
The National President, HCPAN, Dr. Adenike Olaniba, says
the major frictions between the HMOs and the providers are
low capitation, abysmally low tariff, indebtedness to the
providers by the HMOs, slashing of hospitals’ bills and non-
payment of capitation, among others.
Olaniba, who is also a consultant public health physician,
observes that many private providers’ clinics are closing
down as they cannot cope with the financial burden
imposed on them by health insurance.
She explains that in February 2012, a joint consultative
meeting was held in the premises of Healthcare
International HMO between the Health and Managed Care
Association of Nigeria (the umbrella body of the HMOs) and
HCPAN.
Some of the items on the agenda of the meeting, she says,
were the implementation of the new NHIS capitation, HMOs’
indebtedness to the providers, slashing of bills, care of the
chronically ill and standardised contractual agreement
between the HMOs and care providers.
“In order to fast track the review of capitation and tariff, the
HCPAN forwarded the report of its tariff and pricing
committee to the forum for consideration. No feedback has
been received from the HMCAN on this document,” she
adds.
If the issues are positively addressed, Olaniba says the
relationship between the two stakeholders will improve
tremendously.
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