Payment pattern threatens NHIS scheme

… Most Nigerians in informal sector yet to benefit

Given the state of Nigeria’s health services, coupled with dwindling funding of healthcare in the face of rising costs, the National Health Insurance Scheme (NHIS), was established under Act 35 of 1999 by the Federal Government by erstwhile President Olusegun Obasanjo with the aim of securing universal coverage and make healthcare affordable through various prepayment systems in order to improve the health status of Nigerians.

The health scheme, which was officially launched on June 6, 2005, has attracted reactions from stakeholders in the health sector following the lawful payment mechanism of all levels of care in NHIS such as capitation, fee for service, to name but a few.

Explaining the payment mechanism in a paper titled “Management of Capitation under the National Health Insurance Scheme,” Hope Uweja, general manager, Technical Operations of NHIS, revealed that ‘capitation’ is payment made to a primary healthcare provider (hospitals, private clinics, primary healthcare centres, out-patient department of General Hospitals, University Medical centres etc.) for services rendered by the provider which is made regularly in advance for services to be rendered.

Uweja pointed out that the actual amount of money paid to the provider is determined by the range of service provided, the number of patients involved, period of time during which the services are provided as capitation rates are developed using local costs and average utilisation of services.

“A critical feature of the mode of payment is the shifting of financial risk from the payer to the provider. And because it offers health plans, the maximum risk reduction is done administratively in a simple fashion. For the provider, it improves cash flow planning and Individual physicians may find oneself at a disadvantage when compared to those in group or multi-speciality practice. Though the disadvantage of this payment scheme is the possibility of providers giving suboptimal care through under utilisation of care services,” Uweja disclosed.

Waziri-Dogo Mohammed, Executive Secretary/ Chief Executive Officer National Health Insurance Scheme, NHIS, 

 

Explaining the payment plan, Adeyeye Arigbabuwo, national secretary, Healthcare Providers Association of Nigeria (HCPAN), revealed that the poor capitation of N550 (Five hundred and fifty naira per person monthly) to healthcare providers as approved since the inception of NHIS and the abysmally low fee-for-service tariff had short-changed providers for long and could eventually have spill-over negative effect on the end-users of the scheme i.e. the enrollee of the scheme.

He opined that this amount (N550) is what the healthcare provider gets monthly for treating a patient and if in the long run the cost of treating enrollees keeps exceeding the amount per enrollee earmarked for treating those who attend NHIS accredited hospital, the enrollees would be on the verge of suffering as the healthcare provider may not be able to continue to bear the cost of treating these enrollees.

“Healthcare providers under the scheme are to provide the following to the contributors: Out-patient care, including necessary consumables; prescribe drugs, pharmaceutical care and diagnostic tests as contained in the National Essential Drugs List and Diagnostic Test Lists; consultation with specialists, such as physicians, pediatricians, orthopaedic surgeons, radiologists, ophthalmologists, etc.; and if the cost is increasingly borne over time, enrollees may not get the best of care except the numbers of enrollees that receive treatment the particular month is on the high side,” Arigbabuwo stated.

For Lanre Familusi, chairman, Pharmaceutical Society of Nigeria (PSN), Lagos Chapter, one big challenge of the NHIS remains the implementation of the unlawful concept of global capitation. Familusi explained that “Global capitation involves payment of capitation and all elements of other payments modes meant for other providers (secondary and tertiary) to the primary provider.”

According to the PSN boss, the global capitation concept is a shortcut devised by HMOs for administrative convenience but which allegedly short-changes other key stakeholders.

“This system short-changes the enrollee because he is not guaranteed the best drugs or diagnostic services since the primary provider who has been paid upfront for these services tries to maximise his profit from the advanced payment.

Given the Nigerian factor, the primary provider can hold the secondary and tertiary providers to ransom when he diverts monies collected for their services to other use. In such situations, how is the pharmacist, who dispenses upfront and waits for four weeks to be paid, protected adequately?” Familusi stated.

Familusi disclosed that this was why Health Maintenance Organisations must be made to pay secondary and tertiary providers after signing contract agreements in line with the provisions of the law. The PSN chairman said there was also the need to tackle the excesses of HMOs who have interests in some network providers or facilities and therefore, take advantage of their privileged position to divert a huge number of enrollees to these facilities.

Despite the society’s misgivings arising from poor implementation of the scheme, Nigerians most especially in the informal sector are still anticipating when NHIS, which is supposed to be one of the most credible alternatives for funding healthcare in the country, as it should facilitate fair financing of health care costs through pooling and judicious utilisation of financial risk protection and cost-burden sharing for people, against high cost of health care through institution of prepaid mechanism, prior to their falling ill.

Currently, less than eight million Nigerians, mostly in the formal sector, are in the scheme with a huge chunk of Nigerians mainly in the informal sector yet to be covered by the scheme despite huge amount of money earmarked for the operations of the scheme.

Though the NHIS may have invested tremendous human and financial resources as a responsible government agency to ensure smooth operation and sustainability of the scheme, there is the need to have a 3-tier quarterly interaction of the NHIS-HMOs-Providers (The Tripod) to allow for expression of differences, suggestions of better ways of operating the scheme, and collation of feelers from the grassroots since providers are the closest to the end users of the scheme. In addition, NHIS should be more visible in its obligatory role of regulation of managed care practice to prevent the situation where some HMOs deny the legitimate claims and reimbursement of healthcare providers, and diversion of funds for operation of the scheme to other ventures.