The National Health Insurance Scheme has sanctioned 39 Health Maintenance Organisations for failing to raise the N400m minimum capital base required of them to be in business.
The NHIS Executive Secretary, Dr. Femi Thomas, who announced the sanction at the meeting of the NHIS HMOs Standing Committee in Abuja, said the decision was part of its measures to strengthen the scheme.
An assessment report, Thomas said, found the affected HMOs “unhealthy.”
The NHIS had given 77 HMOs in the country till August 31, 2014 to raise the funds or be delisted from its transactions.
HMOs are organisations that provide group and self-funded health insurance package to subscribers. They act as intermediaries for the NHIS, hospital owners and the subscribers.
Only five million of over 160 million Nigerians have access to the health insurance policy inaugurated 15 years ago in the country.
Thomas said, “We have announced the results and the HMOs that didn’t meet up have been sanctioned so they will have to make up whatever deficiency they have before we register them. This decision is part of quality assurance that will ensure that only healthy HMOs will help us to drive our programmes. So it is going to add value to whatever we are doing and that is the way forward.”
The PUNCH, on September 1 and 2, had published a two-part investigative story, which revealed how some HMOS were short-changing the scheme by offering services not commensurate with premiums paid by enrollees.
The story highlighted unethical practices of some HMOs and complaints from disgruntled Nigerians who enrolled for the scheme.
Meanwhile, patients who subscribed to the affected HMOs have expressed fears that their hospitals may deny them treatment.
Efforts to reach the NHIS management to speak on how this would be resolved were not successful. But a source said the NHIS may take over the assets and liabilities of the affected HMOs and reassign their patients to functional HMOs if they fail to come up with the N400m minimum capital base by the end of September.
He said, “When a bank goes underground, it does not mean that the depositors’ fund in its custody is completely gone. The Nigerian Deposit Insurance Corporation comes to absorb the responsibilities of the bank, including its management, assets and liabilities and pay all the depositors.
“In this situation, the NHIS will absorb those assets and liabilities and take responsibilities for the payment of the depositors and later set up an interim management.”
Among firms that passed the HMOs re-accreditation exercise are InvestCorp Medical Limited, Total Health Trust, Healthcare International, United Healthcare International, Hygeia HMO Limited, Managed Health Care Services, Premium Health, Maayoit Healthcare and Defence Health Maintenance.
Others are Royal Health Prepaid Medicare, Prepaid Medicare, Health Partners, Oceanic Health, Princeton, Royal Exchange Healthcare and Salus Trust.
The HMOs, which received provisional accreditation, include Doma Healthcare, Avon, HMO, Reginix Healthcare, Redcare Health, Well Health Network, Bupar Healthcare and the Police HMO.
Thomas added that the NHIS was sensitising stakeholders on the enrollment of pupils in public primary schools nationwide as well as the repackaged tertiary institutions health insurance programme.
“All these are things we would begin to see later in the year”, he added.
Already, the NHIS said it had contracted Price waterhouseCoopers to audit the functional HMOs with a view to ascertaining their preparedness to drive the NHIS initiatives.
SEPTEMBER 1, 2014 BY NIKE POPOOLA
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
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.”
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.
SEPTEMBER 2, 2014 BY AGENCY REPORTER
In the concluding part of the story on the sorry state of the health insurance scheme in the country, NIKE POOPOLA writes on how it can be saved
OPERATORS CONCERNS AND SUGGESTIONS
A Consultant Radiologist, Lagos State University Teaching Hospital, Dr. Olukayode Adegboyega, points out that the health care providers need funds to be able to acquire up-to-date infrastructure to treat their patients.
He says the delay in payment or outright denial of capitation to the health providers has enormous effect on the services being rendered because the motivation may just not be there to render the best services.
Adegboyega says the health care providers’ inability to get their money from the HMOs will definitely affect their ability to purchase relevant equipment.
Citing the diagnostic aspect of health care service, he says without funds, hospitals will resort to treating patients without proper investigations.
He says, “For instance, if the HMOs are paying N1,000 or N500 on an individual to the hospital for an ailment like malaria, the doctor may not advice the patient to do malaria parasite test when drugs alone can take up to N200 or N300. How does he pay his nurses, maintain the infrastructure and cover other expenses?
“So, it boils down to the fact that all stakeholders in health insurance management should agree on an appropriate billing system.”
Another effect of poor capitation payment on the health providers, according to him, is that it hinders the development of the health insurance scheme, because more people will continue to travel to countries like China and India for better treatment, thereby worsening the capital flight problem in the country.
Adegboyega stresses the need for stiffer regulation of the health insurance system in which the HMO will be sanctioned if it fails to remit due capitation to the health provider out of the insurance pool that has been built.
He also counsels the government to motivate and support artisans and low income earners in the country by paying a part of the premium on their behalf from the taxes paid by the citizens in order to enable them to have access to free health care.
According to him, if more of the artisans, middle class and high income earners in the community can be introduced to the health insurance scheme; there will be huge premium that will help to develop the health sector.
Adegboyega observes that Nigeria has huge population, majority of who are not presently in the scheme but may as well join and increase the premium accruing to it.
The Managing Director, Capex Expartcare Limited, one of the HMOs in the country, Mr. Bimbo Banjoko, highlights some of the frictions between the HMOs and the hospitals, and suggests way out of the quagmire.
Firstly, he says most HMOs are being managed by doctors and it will be unreasonable to think that they will run down their colleagues managing the hospitals.
He says some employers actually default in premium payment but that the HMOs need to encourage them to stay in the scheme and not to opt out, especially the private sector employers.
“If you have been in a relationship with an organisation that has been paying premium for four years, and because it is having some financial challenges, it cannot pay immediately, will you cut it off, especially if it had been paying you promptly before then? Of course, a lot of that happened in 2009 and 2010 when there was a meltdown in the financial market. It is just that a lot of people did not know that the HMOs actually faced a lot of financial challenges too,” Banjoko says.
In such situations, he notes that the HMOs still have to pay the health providers, adding that any default in the sector may not have been deliberate.
Again, he says the principle of health insurance thrives on large numbers, but that many of the HMOs have few enrolees registered with them.
While only few of the HMOs are big players with developed facilities, he observes that the small ones may actually not be making enough money to do well in business.
Banjoko says unless patronage is improved and more people subscribed to the scheme, most of the providers will still be at the receiving end.
“We should collectively accept the responsibility to get majority of Nigerians into the health insurance scheme. If 10 per cent of Nigerians subscribe and they all pay N10,000; you can imagine the amount of billions in premium that will go to the health fund, which should be properly managed in a scientific way. So, the real problem is that because the pool is not very large, providers are under strain, and so are the HMOs,” he explains.
Banjoko urges the health providers to collaborate with the HMOs to develop the market in their environment.
Citing the example of a low density population area in Lagos, where there are many hospitals, he says it may be difficult for the health providers to get enough patients to stay in business.
“For instance, in Ilupeju, there are six to eight hospitals and Ilupeju is a low density area. So, how do those hospitals actually want to break even? Businesswise, those hospitals are set up for failure except they get referrals from outside the zone. But if all they want to deal with is the population of people in Ilupeju, that is a fundamental problem,” he notes.
The health insurance expert observes that some hospitals that registered early with the HMOs are actually getting about N20m capitation monthly and such will want the HMOs to survive.
These, he says, have been able to build their pool because they got into the business early enough and have been able to accumulate a large number of enrolees as opposed to those who came later and have small numbers.
“If there are defaults, I am sure it is not because people want to be fraudulent, that is far from it,” he adds.
Suggesting the way of out for the hospitals that complain of low capitation being paid by the HMOs, Banjoko says it will be good for the health care industry to come up with unified billing processes to solve the challenge of care givers charging different rates.
He explains that predictability is an essence of insurance, whereby the hospitals must have been able to come to some consensus on their claims pattern because they are predicting based on a particular billing process.
Banjoko notes that in the private sector segment of the scheme, there is a lot of unpredictability because there is no unified tariff system and the claims pattern is not very predictable, adding that the HMOs that are doing private business are really bold.
When contacted to respond to allegations of fraud and measures to sanitise the health insurance system, the NHIS refused to make any comment.
Several weeks after sending enquiries on efforts to ensure that enrolees truly get value for their lives to Mr. Ayo Osinlu and Mr. Terso Adagher of the media department of the NHIS, no response was given.
Nwani, however, suggests that the scheme will be widely acceptable if some measures are put in place such as stepping up quality plans at affordable prices; extensive campaign with emphasis on the product features and benefits; and quality treatment involving carrying out necessary tests before commencing treatment rather than just administering analgesics for chronic ailments.
Others are accreditation of good hospital network that will enhance easy accessibility of the registered hospitals; ensuring prompt response in cases of emergency; and the availability of qualified doctors in the hospitals.
He also suggests that the registered hospitals should submit their bills regularly and the bills should be settled within the agreed period; while the hospitals should be transparent in dealing with the HMOs and desist from sending unrealistic bills.
Nwani stresses that HMO patients should be given good reception at the hospitals and the health providers must stop discriminating between them and their direct patients.
To check the lapses of the HMOs and boost the services of the hospitals, experts say the memorandum of agreement between the Nigeria Employers’ Consultative Association, HMCAN AND HCPAN, which was signed by their representatives in November 2011, should be implemented.
According to HCPAN, this legal instrument, which consists of 16 sections, has not been implemented by the HMOs and providers.
NHIS sanctions 39 HMOs over insufficient funds….Sick <b>health</b> <b>…</b>