Dilemma Of Health Insurance Enrollees

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Pregnant Rukayat Olapade experienced persistent stomach pains and loss of appetite. Worried about them and relying on her health insurance with AXA Mansard, 31-year-old Olapade, who was three months pregnant, sought medical attention from her healthcare provider, Mercy Group Clinics in Abeokuta.
At the hospital, Olapade presented her Health Maintenance Organisation (HMO) identity card and answered few questions she was asked; yet, she was denied treatment.

Because of the urgent attention her situation needed, she paid for the treatment, after which her husband, who was the principal applicant, requested for refund but was denied it by the hospital's management.

Olapade's story is not isolated. Many enrollees of the health insurance scheme in Nigeria have narrated their ordeals in pursuit of adequate healthcare services.


These ordeals transcend gender, geographical regions and age demographics.
However, the situation has more impact on women, particularly pregnant ones, than men.
A man can go to a hospital for malaria treatment and decide, after waiting a long time for an approval code, to buy medication from a pharmacy.

A pregnant woman in the same situation will prefer to wait for long to avoid putting herself and her baby at risk.

According to Mrs Nike Omotoyinbo, a civil servant, she needed to have an ultrasound scan before delivery but was told by her healthcare provider that she had exhausted her HMO contribution.
Omotoyinbo paid for the scan out of pocket because the outcome was important for her antenatal care.

Mrs Mercy Odion, a journalist, went to her healthcare provider for treatment and encountered much delay for confirmation, from her HMO, whether she had access to services of the healthcare provider.
A client of Golden Cross Infirmary in Festac Town, Lagos State, who pleaded anonymity, could not access the hospital's services when she needed more medication.

The patient was told by the hospital that she was no longer registered with the facility.
Her HMO did not communicate with her or the hospital before it took her out of the hospital's services.
Dr Patrick Korie, the Managing Director of SUNU Health in Yaba, Lagos State, says it is unethical and unacceptable for a healthcare provider to ask a patient under health insurance to pay for treatment before it is given.

According to him, a hospital handling health insurance enrollee has a duty to give them basic medical services.

“At the entry point, that patient should first see a doctor and be given basic care.

“If there is need for a specialist care, that is when you start contacting the HMO,” he says.
Korie advises health insurance enrollees to contact their HMOs urgently if not given desired attention by their healthcare providers.

A survey conducted by the Women Radio Centre shows that expectations of individuals with health insurance in Lagos State are not being met to a large extent.
The survey supported by Mac Arthur Foundation shows that 65 per cent of those with health insurance are covered by the National Health Insurance Scheme (NHIS).

The investigation also shows that 65.4 per cent of those with health insurance have been denied services at one time or the other by their healthcare providers, while 61.5 per cent said they had paid out of pockets for treatments and services their insurance covered.
The investigation also reveals that enrollees feel very bad when denied services and go the extra mile to treat themselves or their dependants out of pocket.

A brands Manager, Mrs Fajems, is sad that she was denied services by her healthcare provider, compelling her to borrow money to run a required test.
Miss Ogonna Felicitas, a student of University of Ilorin, narrated how she ran around to get funds to cover her treatment when her illness became worse, because a healthcare provider with which she has health insurance would not oblige her.

Dr Celestine Okorie of the Health Reform Foundation of Nigeria (HERFON)
says everyone in the health insurance ecosystem, including the Federal Government, National Health Insurance Authority (NHIA), HMOs, healthcare providers and enrollees have critical roles to play to ensure accountability.

“If we want to get a better health insurance performance, we must take accountability seriously because where there are sharp practices, the performance of the scheme will be reduced,” he says.

According to Okorie, some key issues in Nigeria's health insurance that HERFON identified during its accountability reviews include lack of transparency, delayed payments, lack of approval for referrals, delayed periodic review of payments and deliberate treatment with drugs not included in the NHIA-approved list.

He says other challenges identified are inflation of bills for enrollees on co-payment plan, non-disclosure of total number on list of enrollees, enrollees' lack of knowledge of what their plans cover, and inclusion of unregistered relations for treatment, by enrollees.
“NHIA makes quarterly payments to HMOs, who are expected to pay monthly capitations to health providers.

”Instead of paying providers, some HMOs deliberately delay making appropriate payments so they can invest the funds for few months for profit.

“Many HMOs don't give enrollees approval to access treatment when referred to secondary facilities, even when the services are covered by NHIA.
”Women and children are adversely affected by this lack of accountability in the health insurance ecosystem because they are among the vulnerable population,” Okorie alleges.

The World Health Organisation (WHO) has identified 10 major health issues affecting women to include cancer, sexually transmitted infections, reproductive health issues, maternal health issues and mental ill-health.
WHO emphasises that Universal Health Coverage (UHC) requires everyone's access to quality, safe, effective and affordable essential healthcare services, medicines and vaccines, with protection from financial risks.

WHO estimates that, every year, 100 million people are pushed into poverty and 150 million people suffer financial catastrophe because of out-of-pocket expenditure on health services.
To achieve UHC in Nigeria, NHIA was established to ensure enrollees' access to quality healthcare.
HMOs serve as intermediaries between healthcare providers and health insurance enrollees while NHIA acts as the regulator.

HMOs have the responsibility of managing provision of affordable, accessible and standard healthcare services through a network of hospitals under their plans.
While the NHIA Act mandates all Nigerians and legal residents to be part of the NHIS, many Nigerians are yet to be enrolled.
There are conflicting figures on the actual number of people with health insurance in Nigeria.
According to Dataphyte, 97 per cent of Nigeria's population are not covered by any kind of health insurance.

Dataphyte records that three per cent of the population who have health insurance are under employee health insurance cover.
It says 56.7 per cent of Nigerians with health insurance are male while 43.3 per cent are female.
However, Dr Leke Oshunniyi, Chairman of Health and Managed Care Association of Nigeria (HMCAN), says about five per cent of Nigerians have health insurance cover.
Analysts are worried that women in Nigeria may be more prone to the diseases listed by WHO because of limited access to basic healthcare services.

Analysts are also convinced that Nigeria will need to do more to meet the 2030 target for UHC agreed to by UN member-states, as part of the Sustainable Development Goals (SDGs).
Nigeria's Coordinating Minister of Health and Social Welfare, Prof. Muhammad Pate, during the unveiling of the NHIA Operational Guidelines, had said that less than 10 per cent of Nigeria's population are covered by health insurance.

He, however, gave the assurance that implementation of the operational guidelines would ensure that more Nigerians would be covered.

Prof. Mohammed Sambo, a former Director-General of NHIA, says the Renewed Hope Agenda of President Bola Tinubu is considering providing health insurance for, at least, 50 million Nigerians.
According to Sambo, effective enforcement of NHIA Act and establishment of Vulnerable Group Fund will ensure access to quality healthcare services for all Nigerians in line with SDG 3, and contribute to poverty reduction. (NAN Feature)

In a recent interview on CNBC Africa, Pate said that the private sector, donor-agencies and philanthropists would need to contribute toward insurance coverage of the poorest populations, including traders and commercial bus drivers.

According to Pate, funds from the Basic Health Care Provision Fund will not be enough to protect those, who may not be formally employed, from high health expenditures.
Dr Richard Kalada, Chief Executive Officer of the Institute for Healthcare Finance and Management, emphasises that 70 per cent of a patient's recovery depends on how he is treated.
Kalada advocates a customer-centred approach to healthcare delivery.
He says patients expect safe, timely, effective and equitable care that is also patient-centred.

“When patients are unwell and visit the hospital, many are fearful and uncertain about their conditions” he points out.
Kalada believes that satisfaction is achieved when a patient's expectations are not only met but are exceeded.

A journalist, Mrs Olaitan Idris, is worried that some healthcare providers dispense only generic drugs which, sometimes, are ineffective.
Idris says she paid N288,000 out of pocket for 12 branded drugs to treat her son because the generic alternatives were deemed ineffective.
Dr Oshunniyi, Managing Director and Chief Executive Officer of AIICO Multishield HMO, highlights the challenge of meeting patients' lofty expectations with comparatively low premiums.

“To address affordability, NHIA partnered with 12 local pharmaceutical firms, aiming to ensure availability of quality and affordable medicines and promote confidence in generic ones.
Prof. Mojisola Adeyeye, the Director-General of the National Agency for Food and Drug Administration and Control (NAFDAC), has given the assurance that branding of 33 pharmaceutical products will play a crucial role in curbing spread of substandard and falsified medical products.

These medicines will undergo testing in WHO-prequalified NAFDAC laboratory, and the agency commits to ongoing monitoring to ensure their exclusive use within Nigeria's healthcare facilities while preventing unauthorised sale, according to Adeyeye.

Dr Ademola Yusuf, a family physician, has identified vetting of already agreed-on tariff as one of the contentious issues in healthcare delivery under insurance cover.
Yusuf says some hospitals conduct laboratory investigations that help in treatments, but won't be paid for it by some HMOs, even after explanations.

According to Dr Makinde Akinlemibola, Chairman, Association of Nigerian Private Medical Practitioners, the major challenge with health insurance in Nigeria is poor capitation.
Capitation is a fixed amount of fees usually paid monthly to healthcare providers by HMOs for providing services to patients.

“The capitation of N750 per individual monthly currently being paid was determined by actuarial survey done many years ago which has become obsolete.

”High inflation, rising cost of medicines and removal of fuel subsidy have made the current capitation unrealistic,” the chairman argues.
Akinlemibola proposes regular review of capitations to prevent financial strain on healthcare providers.
On what should be the minimum health insurance coverage, Akinlemibola says determining it will still have to do with capitation.

He argues that the current monthly capitation of N750 per individual has made it challenging for healthcare providers to meet up with current realities.
He says the capitation has been increased only once in the last 15 years, and urges an urgent increase in line with economic realities.

According to him, a proposal from the healthcare providers that the capitation should be reviewed to N1,500 per individual monthly is no longer realistic.
Also arguing, Okorie says there should be a special insurance plan for diseases such as cancer, kidney disease and other conditions that require long-time hospitalisation and high costs.
He, however, believes that the minimum insurance plan should cover common infections, malaria, tuberculosis, HIV/AIDS, prevention of non-communicable diseases such as hypertension and diabetes.

He also says minor surgeries and cuts, antenatal and postnatal care, maternal and child health, and reproductive healthcare should be captured.
Analysts call for an accountability framework that will address challenges in Nigeria's health insurance system.

They urge scrutiny from civil societies to encourage compliance, as well as public education to enhance enrollees' understanding of their insurance covers.

They also urge constructive collaborations between HMOs and healthcare providers as regards prompt updates on information about information on enrollees, as well as treatment codes, to prevent delays and complications. (NANFeatures)

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