HEALTH INSURANCE AS A VEHICLE FOR PROVIDING QUALITATIVE HEALTH CARE IN NIGERIA DR. ISE OLUWA AWORINDE MEMORIAL LECTURE 2015.

HEALTH INSURANCE AS A VEHICLE FOR

PROVIDING QUALITATIVE HEALTH

CARE IN NIGERIA

DR. ISE OLUWA AWORINDE MEMORIAL LECTURE 2015.

PREPARED & PRESENTEDBY

DR. ADEYEYE ARIGBABUWO(MB.BS;MBA;PG.DIP.MARKETING;PG.DIP.FAMILY MEDICINE; FMSEC; DMP.)

@ NECA ON TUESDAY 8TH DEC, 2015 ON THE OCCASION OF HCPAN 11TH NATIONAL AGM 2015.

Three clauses are key in this subject matter

HEALTH INSURANCEBy Health Insurance we mean calculated and

predictable certain amount of cost / money usually referred  to as premium for unpredictable events and benefits on health packages being a game play and risk market between the Insurer and the insured.

Insurers are also known as Underwriters . The insured is known as the beneficiary.

Health insurance is prepaid or pre-purchased usually by the employer for the benefit of the employee. And depending on the arrangement, co-payment of cost of premium may be agreed upon or in some cases the employer may take absolute responsibility for the premium.

There are phenomena that are key or home to health insurance Premium Pre-payment Population Probability Possibility Pool Percentage Policy Trust

Time Risk Capitation Claims Accessibility Affordability Availability Acceptability

STAKEHOLDERS: Purchasers e.g. Government, Corporate Employers, Families,

Individuals, NGOs, Adoption Groups etc. HMOs (Health Maintenance Organizations): Usually in the

middle of the game as Fund Managers / Corporate Underwriters. May play dual roles with features of Brokers. When there is good distinctions, the Brokers may play the role of helping in reinsurance as well as assisting in claims.

Healthcare Providers: Facilities and Operating Owners. Better to address facilities rather than Characters or persons or owners.

Roll out of service in relationship with HMOs may address issues of Network Model; Staff Model or Mixed Model of HMO Care relationship and structure with Providers.

NHIS (NATIONAL HEALTH INSURANCE SCHEME): As established by Act 35 of 1999. They are the Regulators of Health Insurance and Managed care in Nigeria .

Enrollees : They form the matrix of end users, and are usually seen as patients.

Civil Society: They form community policing and serve as social watchdog.

All these and many more idioms are usual vocabulary we read and hear about health insurance.

QUALITY

This simply refers to degree of excellence or value.

NIGERIA A noted country in Africa South of Sahara.

   Population: In 2013, the World Bank had put Nigeria's Population at 173.6 Million. But Worldometres had put the population at 178,516,904 as at  1stJuly  2014. ( Compare the population of 45.2 Million in 1960 ) This population is 2.46% of the World's population. With a population density of 193 per sq. meter, Nigeria ranks 7th in the world in terms of population size. The country has one of the largest population of youth in the world.

It is comparable in size to Venezuela, and about twice the size of the state of California in the USA. Or the size of California, Nevada, and Arizona put together. Abuja, now the new capital, replaced Lagos in December 1991 because of its more central location with other reasons considered. Lagos still remains the commercial capital. Other major cities in Nigeria include Ibadan, Kaduna, Kano, Maiduguri, Jos, Port Harcourt, Enugu, Calabar, Abia, Benin, Aba etc.

Nigeria has over 250 ethnic groups.  Nigeria is located in West Africa and borders the Gulf of Guinea, with Benin on the west and Cameroun on the east. The average area is 923,768 sq metre ( 356,376 sq. miles ) In year 2000. the sex ratio were at 1.02 males to 1,0 females. Life expectancy was 51.58 years for males, and 51.55 years for females.

           In planning and epidemiological survey, the real population for Nigeria till date is very difficult to capture for it is  usually tied to representation at the National Assembly and distribution of the National "cake" The figures are therefore easily skewed  by various groups vying for one political office or the other or for economic advantage. Where we battle with this till date it is difficult to know how many people live in Nigeria except by estimate. This has always led to very hot debates.   Without a very sound knowledge of the Socio-political order as well as demographic and ethnic structure of the corporate entity called Nigeria , it will be difficult talking about health insurance driving plan not to talk of quality care .   The 2015 structure of Nigeria is better shared with you visiting :Nigeria Wikipedia, the free encyclopedia by @UC Browser :

https://en.m.wikipedia.org/wiki/Nigeria.

You are home and dry if you have the basic features of ban entity you are discussing. Three types of people have been identified often:

Those who make things happen Those who watch things happen Those who do not even know that things happen

around them

We should not be discussing quality service in a country that we do not even have an idea of its "quality" structure.

Just a rough guide of a country we are discussing. It is not about Lagos alone. Not about Port Harcourt or Warri. And neither are we talking about Maiduguri alone in this case. The country we are considering is a Big nation with Unity in diversity. Jamhuriyar Taraiyar Nijeriya.............Hausa Ohanjiko Ohaneze Naijiriya...................Igbo Orile-ede Olominira Alaapapo Naijiria.....Yoruba.

Motto: " Unity and Faith, Peace and Progress“.

Capital : Abuja Largest City : Lagos Official Languages : English  Major Languages: Hausa; Igbo; Yoruba. Other Languages: Urhobo-Isoko; Edo; Efik; Fulani; Idoma;

Ijaw; Kanuri; Itsekiri; Igala; Igbira; Nupe; Ibibio; Gwari; Tiv; Birom; Margi; Jukun ; Katab.

ETHNIC GROUPS:(As at 2014): Yoruba : 21% Hausa : 21% Igbo : 18% Fulani : 11% Urhobo-Isoko : 9% Efik-Ibibio : 7% Kanuri : 4% Edo : 3% Tiv : 2% Nupe : 2% Bura   : 1% Others : 8%

Demonym: Nigerian Government: Federal presidential republic. President: Muhammadu Buhari Vice -President: Yemi Osinbajo Legislature: National Assembly Upper House: Senate Lower House: House of Representatives Independence: From the United Kingdom Unification of Southern and Northern Nigeria: 1914. Declared and Recognized: 1st October 1960 Republic Declared: 1st October 1963. Present Constitution: 29th May 1999. Area: Total Estimate now: 923,768 sq. km.(356,667 sq.

miles.) Water:   1.4 %

2015 Estimated Population: 182,202,000 2006 Census: 140,431, 790.

GDP (PPP) 2015 estimates:   ** Total ..................................$1.109 trillion ***Per Capita  ............................$6,204

***GDP ( Nominal) ..........................2015 Estimates Total ..............................................$573.652billion

*** Per Capita .......................................$3,298 CURRENCY : Naira  ( NG#)

HEALTH SYSTEM IN NIGERIA The NIGERIAN Health System remains a three prong pattern viz: PRIMARY, SECONDARY, TERTIARY.

Health care financing had remained essentially OP (Out of Pocket) for several decades. In a Corporate way the tradition had been 'Medical Retainers" form of relationship between the corporate organizations and organized providers of healthcare delivery.

  Also in Nigeria there is preponderance of Private Healthcare provision in excess of public facilities and care volume. It is statistically relevant to observe that over 65% of the healthcare of the nation is provided by the private sector. This is a far cry from a country like Rwanda where over 90% of the care is of Public Sector business.  It is in this respect I will always want to remind our people that it is always good to compare apples with apple and never orange with apple. This background will soon be seen to be very relevant when we discuss or visit the issue of quality.     We should also bear in mind that the issue of quality is broad and equally relative.   Quality moving without equity is also synonymous with discriminations and may be a glorified form of 'apartheid'. However, I am quick to differentiate between 'equity' and 'equality '. In health insurance there can never be expectation of equality.

No matter the model and the pattern, especially if we have need to adopt the American model. While equity will address the issue of providing according to need equality will preach egalitarianism be it if need, necessity, or desire. It will simply be shouting 'Equal Rights'. Yes having access is issue of equal right but having across board benefit package is issue beyond the sermon of Health Insurance with ''Total  and absolute uniform Quality Assurance '. Somebody somewhere sometime somehow somewhat will always be asking for 'Top ups ' depending on ability, opportunity , and chance of occurrences.

  In America today, and elsewhere users are eager to be on competitive healthcare provision and consumption, but almost always expecting the best of care no matter their ability or inability.

     Quality is an issue that borders on degree of excellence. It is not always measured by flamboyant stuff of structural layout or grandiose of Health personnel. It is not always about big equipment or highbrow location of facility. More importantly it is a measure of chain of related tools and inputs that are interested to forecast   an acceptable outcome that seems to say: This is the best '.

  For example   simple as it may be or sound   the waiting time in a healthcare facility is as important a quality factor as the qualification of an attending physician. The aggregate of what we expect as outcome is the integration of the various components that inform the user if the facility and or practitioner is ideal for care delivery.

   Structure that is converted for use as a healthcare facility will surely differ in outlay as well as spatial comfort when compared with a purpose built facility with say a certificate of standard.   When task shifting and task sharing becomes preponderance compare with appropriate and adequate division of labour, then there will be differential issue of quality matrix.  

HEALTH INSURANCE AS A KEY TO QUALITY HEALTHCARE

Health Insurance formats a direct relationship between providers and HMOs. In Nigeria this fund Manager pays capitation and claims to the providers. No need of HR Managers as well as Company Admin Managers to process bills thereby leading to compromise and tendency of corruption. The caregiver bow concentrates on competitive care delivery that ensures quality in all ramifications.   

FACTORS THAT HERALD QUALITY CARE FROM PROVIDERS, HMOs, NHIS, AND ENROLLEE PROVIDERS

    Also prepaid capitations make it possible for facility owners to preplan for physical development and purchases of commercial advantage for consumables in hospitals and clinics. Equipment can either be directly purchased in advance or procured by lease. Property can also be acquired, renovated or put on merger basis. All these are good requirement for quality operation. With access to predictable income the facility becomes more bankable than ever before. This again is an opportunity to access funds. The ripples effect you have on this is greater ability to encourage staff training, promotion, procurement of modern Medicare equipment, etc. All these HERALD QUALITY.

Also there is a paradox of better dedication and commitment to duty and greater determination on work plan. For example subscribers or insured individuals or corporate bodies will only be prepared to pay for services rendered to them. It is therefore going to be difficult to want to collect payment for services not rendered as accountability is better assured in health insurance. The paradox here is that health workers who go on strike will not expect ENROLLEE'S or buyers of Health Insurance to agree to pay them for services not rendered. This is the paradox of quality healthcare on grounds of assurance of regular access and availability the year round. Also breach on this direction will bring issue of accountability which is a necessary requisite to promote litigation.     Consumer charter is thereby ensured and breeds quality assurance.

Because of autonomy to make free choice of facility by end users, and opportunity to change a 'non-performing' facility by the end user, the providers are put on their toes to ensure quality care.

The competitiveness in the open market that promotes perfect competition in healthcare industry in the era of Health Insurance opens way to quality care as users will naturally flow to facilities with structural, administrative, and professional care givers of excellence.

Providers that are no more exposed threats by Unionized workers who somewhat encouraged or were partakers on corporate abuse during Retainership era are now just at liberty to carry out their professional duty without compromise of joint culpability with other stakeholders to 'cheat' at any level of care dispensing or plan . Compromise of quality care just to save cost is no longer the order of the day.

Working with Regulators, HMOs, as well as other organized stakeholders will always help HERALD QUALITY.

Facilities that go through accreditation, regulation, random inspection, and need for data rendition on regular basis including encounter experiences are all tools that promote quality care

HMO FACTORS FOR QUALITY CARE

Appropriate Pricing of Healthcare Delivery (Actuarially Determined Tariffs)

The Danger of Under Insurance. Periodicity of capitation as well as claim payment. Premium vs. Benefit package negotiation with the

purchaser of health insurance in a perfectly competitive market: What is the minimum acceptable Premium for what benefit package: Appropriate Pricing of Healthcare service ???

Quality Assurance Department functionality of the HMO.

Criteria for enlisting healthcare facilities on Provider Network List. Solo practices participation vs. Group practice and ria sharing Assurance.

" Model of Insurance adopted by the HMO: Staff model, Network model, Mixed model … Advantages and disadvantages as they impact on quality.

Capacity building and Skills acquisition/development for staff

Capital base of the HMO and the issue of recapitalization as well as reinsurance: Solvency issue, distress, and Management structure of the HMO.

HMO performance bond vs. Provider performance bond Issue of Indemnity Insurance as it affects quality care.

Vision and Mission statement as they affect the organization core values with adherence.

Front Desk Officer syndrome: HMO/Provider axis.

ICT: Information / Communication Technology. Time management and Case Response policy and

timeliness Reward and Sanction policy. Trust, Transparency, Credibility, pedigree, Reputation,

Character, Culture, and Tradition: Perception and application.

Enforcement of SOP on Providers: STANDARD OPERATIONAL PROCEDURES.

Minimum number of ENROLLEE to make break even point by both HMO and PROVIDER.

Need to streamline contents of bundle of benefit package, and define their matrix of distribution into Primary /capitation and Claims (fee for service).

Identification of Basic Benefit package vs. Top ups: The quality outcome of “what money can buy syndrome”.

Benefit derived from harmonization of the various scattered program.

Community participation and role play in health insurance being marketed by the HMOs.

Creating a Universal Common Insurance Pool Basket for all forms of programs to pave way for Quality Health Insurance across board.

Division of Labour: The need to allow the various professional groups attend to their various roles and duties in healthcare delivery for better quality care   devoid of unnecessary hospital economy that may short change the patient. All issues should be patient centered.

Relationship of HMO with Providers as well as the Regulators (NHIS) MUST be based on quality assurance without compromise.

International best practices adoption.

Continuous investment on quality will yield quality Consumer, quality Provider, and yield quality care and quality ENROLLEE. If is cause and effect.

All other issues are on axis of overlap. 

NHIS FACTORS ON QUALITY CARE DELIVERY

NHIS AS THE HEALTH INSURANCE REGULATOR: The issue of regulation is key to quality care delivery. If we adopt the American system, a third party picks the bills

and pay. If we adopt the British system the generality if the people are directly treated with the Tax of the people.

Where the HMOs are not engaged the issue of religious regulatory oversight does not exist on this category of Fund Managers. Usually there have been models with Private Providers Organization.

There have also been instances where independent find Managers are engaged.

Most parts of the works where the HMOs are engaged they are seen as interface /mid role player or the Conveyor through which health insurance can be negotiated for purchase and through which it can be sublet or deployed to the end users appointing Providers who are care givers using appropriate business relationship.

Countries like Rwanda and Ghana in Africa do not employ the services of HMOs. Using then as a prototype study for the NIGERIAN environment may just be like comparing apple with orange. This same scenario plays out in the United Kingdom. In all o these countries government agencies are put in place to do oversight function on monitoring as well as creating Claims units and departments where providers are paid after a monthly or quarterly audit of service.  Where providers are overpaid and it appears no response like raising of alarm by the recipient, then disaster will strike if those charged with whistle blowing are the first to discover this. It may warrant Sanction or penalty for the recipient. Fraud detecting mechanism forms a major part of Quality Assurance of the scheme.

The NHIS is charged by law to undertake the regulatory functions of the stakeholders in the scheme. This regulatory oversight is supposed to cover both the Public Health Insurance Scheme as well as the Private insurance healthcare business. But how much of this regulatory function is being actively undertaken by the NHIS? Well only recently do we see some HMOs being sanctioned or punished for flouting the law as it were. This might be in the true spirit if changing the way we have been doing our things.

It is key to note that Health Insurance may be of the Social health Insurance as it applies to a lot of programs by the NHIS or it may be of PRIVATE health insurance as introduced in the late 90s. Much has been said about the evolution of health insurance as initiated by the late    Dr. Majekodunmi of blessed memory in 1962. The issue of quality transcends beyond introduction or evolution of health insurance. It is a continuum.

The action and / Or inaction of NHIS have a lot to tell on the issue of quality care and sustainability of the scheme.

**REVIEW OF TARIFF   FOR CAPITATION AND FEE FOR SERVICE CLAIMS   :

In a couple of African countries where health insurance is practiced, there is mechanism for periodic review of TARIFF of all sorts of payments to keep pace with The Time value of money as well as inflationary trend. In a Nigeria, and since the inception of the Social health insurance and NHIS unveiling for 10 years and excess, we have not been able to execute a review of tariff for the scheme. One way or the other we have blamed unavailability of adequate and regular data rendition as well as robust encounter data returns. Buy the obvious is being acted like a drama. It's almost becoming that someone will still accept if we take Accra to be the Capital of China.

Whether we like it or not the there has been the obvious in virtually all the sectors of the economy with the downward strength of the naira over the period if one decade in the case at hand.

The providers only hold the stethoscope, the mortal for compounding drugs for the Pharmacist, the infra red lamp by the Physiotherapist, the Nurses watch of Nightingale, the chest market by the Radiographer, the Test tube by the Lab Scientist. None of us is holding a Crystal ball. The mystery that surrounds the relatively poor quality healthcare delivery in Nigeria today does not require the oracles or the forecast of the crystal ball. Inappropriate pricing of Healthcare, Under insurance, No responsiveness to the time value of money and inflationary dictates, delayed or denied payments etc have created an abysmally unacceptable negative economic balancing for the endangered Provider who devices survivalist strategies at the very expense of the ethics of the individual professional groups but to the detriment of the very patient we are all on oath to serve. This is one big reason quality seems to be eluding us the more we chase it. Quality is not free. Again it is not all issues of quality that bothers on money. But if you say the issue of money is secondary, kindly wait to see what poverty can buy.

** The approach to Universal health coverage should go with the sermon of quality assurance taking into consideration the socio-cultural belief and geopolitical order in Nigeria.

Use of appropriate technology is key on managed care. But none the less, we should all continue to emphasize the minimum quality standards acceptable to us in this country no matter where the end user is located or where he/she resides.

** As the slogan now is Universal health coverage, quality becomes the watch word.   Just as this presenter was a member of the maiden Quality Committee of the NHIS between 2006 /2010, with no official meeting if the committee summoned, we do know better now that things are changing as they have changed.

We must commend the role and action of the NHIS recently in practicing what they preach concerning issues of regulatory penalty to any stakeholder trying to undercut or attempting a “smart one”.

SUMMARY OF HEALTH INSURANCE AND QUALITY EXPECTATIONIn summary, thus paper has attempted to broaden our already ignited knowledge to spark excitement on ACHIEVING QUALITY CARE THROUGH HEALTH INSURANCE. (1) NO MATTER WHAT TYPE OF HEALTH INSURANCE, QUALITY

SERVICE IS ONE OF THE CARDINAL FEATURES AS EXPECTED END

(2) WE HAVE PUBLIC SOCIAL HEALTH INSURANCE AND PRIVATE HEALTH INSURANCE

(3) STAKEHOLDERS DETERMINE THE TYPE AND VALUE OF QUALITY THEY WANT IN THEIR HEALTH INSURANCE PACKAGES AND PLANS

(4) QUALITY IS IN POLICY, PREMIUM, PLACE, PERSON, PACKAGES, PERCEPTION, PLAN, TIME, FUNDS, MATERIALS, AND CORE VALUES, VISION, AND MISSION.

(6) QUALITY IS NOT CHEAP SO NIGERIANS SHOULD NOT TAKE HEALTH INSURANCE OR MANAGED CARE TO MEAN CHEAP OR POOR OPTION OF HEALTHCARE   FINANCING (7) UNDER INSURANCE IS A NEIGHBOUR BELOW AVERAGE

AND CAPABLE OF SIMULATING POOR QUALITY HEALTHCARE DELIVERY

(8) TRUST IS A NECESSARY INGREDIENT TO HERALD QUALITY. A PARTNER WHO OPERATES IN AN ENVIRONMENT WHERE TRUST IS ERODED IS LEAST CONCERNED ABOUT QUALITY OF SERVICE RENDERED

(9) GROUP PRACTICE WILL SPREAD RISKS ACROSS STAKEHOLDERS IN PROVIDERS WORLD M IT SHOULD BE ENCOURAGED

(10) TIMELY PAYMENT OD CAPITATION, FEE FOR SERVICE, AND APPROPRIATE PRICING OF HEALTHCARE WILL ADDRESS ISSUE OF GOOD QUALITY EXPECTATION IN HEALTH INSURANCE

(11) DIVISION OF LABOUR WILL   MAKE QUALITY EASILY   ATTAINABLE AND SUSTAINABLE. EACH PROFESSIONAL GROUP IN PROVIDER NETWORK SHOULD RECEIVE PAY DIRECTLY FROM THEIR EMPLOYERS. GLOBAL CAPITATION DOES NOT FAVOUR QUALITY CARE DELIVERY.

(12) RESPONSIVENESS TO TIME VALUE OF MONEY AND INFLATIONARY DICATATES HELP ATTAIN AND SUSTAIN QUALITY IN HEALTH INSURANCE

(13) INSURANCE IS A GAME OF NUMBER. A GOOD POOL ON PERSON AND OTHER RESOURCES IS A PROMISING FUTURE OF GOOD BUSINESS AND QUALITY ASSURANCE.

(14) FINALLY LET US ADOPT MOTIVATION OF STAFF AND APPRECIATE PERFORMANCE. IT WILL SURPRISE US HOW SMOOTH WE CAN DRIVE QUALITY HOME!

Thank you for listening!

PREPARED & PRESENTED

BYDR. ADEYEYE ARIGBABUWO