Sick health insurance scheme leaves patients helpless (1)

 

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.