Health Maintenance Organisations (HMOs) have been cautioned to desist from actions contributing to the overall service failure of National Health Insurance Scheme (NHIS).
The Minister of health, Osagie Ehanire, gave the warning in his opening remark at the one-day strategic stakeholder’s engagement between NHIS management and HMOs in Abuja on Friday.
The minister said there were reports indicating grave concerns over the performance of HMOs which is collectively resulting in poor service delivery of the NHIS.
“Reports reaching me indicate that an overwhelming percentage of enrollees and healthcare providers have expressed grave concerns over the performance of HMOs, with areas of the concerns including, but not limited to, non-remittance of payments to healthcare providers, poor customer service delivery and inaccessibility to enrollees at critical moments of need,” he said.
“The collective results of these and many other cases of service failure in the industry is poor service delivery, poor quality of care and a worrisome reputation damage for the Scheme.
“Let it be noted today… that these anomalies are no longer acceptable because this government is determined to get it right with NHIS, in view of its status as a strategic tool for effective and efficient healthcare delivery system in the country,” Mr Ehanire noted.
This minister’s remark, read out by a representative from the health ministry and later made available to journalists reaffirmed several concerns over the activities of HMOs prompting calls for its removal from the NHIS.
Role of HMOs in NHIS
The relative poor coverage and financial irregularities bedeviling the NHIS have been traced to the structure of the scheme.
To deliver health services to enrollees (beneficiaries), NHIS deals with two major components: HMOs and Healthcare providers (hospitals).
The HMOs are the go-between. They sit between the beneficiaries and the healthcare providers. They are the managers of the scheme’s funds.
HMOs pays hospitals monthly for care provided to participants after collecting a quarterly upfront from the agency.
HMOs have operated freely without checks and reportedly received over N350 billion from the government in the 14 years of NHIS existence.
However, while coverage remained at barely 5 per cent, the few insured are complaining of not getting value for money.
They say the continued operation of HMOs was no longer needed following alleged mismanagement of funds paid to them since NHIS began.
‘NHIS will Collapse Without HMOs’
Speaking with PREMIUM TIMES at tea-break during the event, Kayode Obembe, the Chief Executive Officer of Premier Medicaid – one of the HMOs – said calls for the removal should not be entertained because HMOs “is the key to the survival of the scheme.”
Mr Obembe, a former President of the National Association of Resident Doctors (NARD), said without the intermediary functions of HMOs, the scheme will collapse like the defunct Nigerian Airways.
“If they scrap it (HMOs), we will all suffer,” he noted.
Mr Obembe, a gynaecologist said the problem with the agency is not HMOs but the collective noncompliance by stakeholders to laid rules and regulations guiding the scheme.
The medical doctor blamed both HMOs and healthcare providers (hospitals) for flaunting NHIS guidelines.
“The healthcare providers are bringing bills far more than what the government is paying to us (HMOs).
“Government pays N112.5 per enrollee every month and when you multiply that amount with the number of enrollees in a hospital it can amount to maybe N1.3 million for instance.
“But the hospital will come up with a bill up to N10 million which is way higher than what the government is paying. This is what happens when you hear people crying that HMOs are owing. It’s part of the abuse of guidelines,” he explained.
Mr Obembe, a former State Chairman and Vice-President of the Nigerian Medical Association (NMA), said some HMOs are not making themselves “readily available for authorisation codes…”
He said when you bring these matters up with the NHIS office in Abuja the erring stakeholders will still not adhere to cautions. “They will say nobody can dictate to them what to do”.
“Everybody is supposed to comply with the rules. It’s like a bank not complying with the rules of the central bank, the NHIS is our own central bank. They are the arbiter and when we take the case to them everybody is supposed to comply.
“Until we make every stakeholder obey rules of the business we are not going anywhere,” he noted.
The NHIS Executive Secretary, Mohammed Sambo aligned with the former NARD president on stakeholders not complying with regulations.
“Yes, it is a major part of the problem and I agree with him,” he told journalists at the event.
“If every player works in line with the regulations, I think all the NHIS problems will be dealt with. The HMOS and providers need to play by the rules so that enrollees will get the desired services they deserve.”
The official said the issue was the main reason his administration is engaging with all the stakeholders to identify the issues and tackle them head on.
“This is why we are here today.”
Healthcare Providers Counter
Meanwhile, Obioma Obikeze, a Health Financing Specialist and care provider disagreed with some points raised by Mr Obembe.
He, however, said the NHIS cannot stand alone yet without HMOs.
He said it is not true that hospitals are submitting bills higher than what government pays to HMOs.
“They (HMOs) are just hiding behind smoke to make mounting out of molehills,” he told PREMIUM TIMES on phone Friday evening. “There is a tariff structure everybody must adhere to”.
“The important thing is to ensure that for every item of service the bill presented is inline with the tariff structure given by NHIS. For example, if you give care for a caesarian section and the bill is N55, 000, it will be wrong for service providers to send a bill at N65, 000.
“If they send such bill, the HMO is at liberty to remind them that the money is in excess and discount the excess before paying them. If they (HMOs) have their data and present it to NHIS, there is no service provider that can be able to raise an eyebrow about it.
“If service providers do otherwise, they will be punished for publishing a lie,” he explained.
Mr Obikeze also countered Mr Obembe’s claim that NHIS pay N112.5 per enrollee.
“The scheme is paying N750 for every enrollee and then they top it with N125 for any referrals. The FMC in Yenagoa has 6200 enrollees, so if you multiply that with N750 which is the guaranteed payment and the additional N125 for referrals, you will get the total amount they receive monthly.
“Some of the things HMOs are saying is not correct. Service providers cannot give bills outside the tariff plan.”
Mr Obikezie said the scheme cannot function without HMOs.
“NHIS does not have the institutional structure to take care of what HMOs is doing. Nigeria needs HMOs to deliver NHIS services. Without HMOS a lot of sharp practices of providers will crumble the scheme in just two months,” he said.
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