by dr (mrs) adenike olaniba fmcph, fagp. consultant public health physician national president...
TRANSCRIPT
BY
DR (MRS) ADENIKE OLANIBA FMCPH, FAGP.
CONSULTANT PUBLIC HEALTH PHYSICIAN
NATIONAL PRESIDENT
HEALTHCARE PROVIDERS ASSOCIATION OF NIGERIA (HCPAN).
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RELATIONSHIP MANAGEMENT BETWEEN HMOs, AND PROVIDERS:
MATTERS ARISING
Definition of Relationship Management:-
Relationship Management is a strategy employed by an organization
in which a continuous level of engagement is maintained between the
organization and its audience. Relationship Management can be
between a business and its customers (Customer relationship
Management ) and between a business and other businesses
(business relationship Management .
• It aim to create a way to identify potential cross-sales of products and
services.
It creates a partnership amongst the businesses involved.2
Definition of Relationship Management:- 2
The Relationship between the HMOs and Providers was
supposed to be a business relationship which should have
resulted in
• A better business process
• Improved Communication
• Better policies and procedures
• Mutual Cooperation
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THE HEALTHCARE PROVIDERS.
• These are Primary, Secondary and Tertiary healthcare
facilities that are licensed/accredited by relevant
authorities to provide services to the populace.
• NHIS Accredited Providers are those healthcare
facilities that have been accredited by NHIS to provide
healthcare services to its enrollees.
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THE HEALTH MAINTENANCE ORGANIZATION(HMOs)
A private or public incorporated company that provides health
coverage with providers under contract. It differs from the
Traditional Health Insurance by the contracts it has with its
Providers.
• These contracts allow for premium to be lower, because the health
providers has the advantage of having patients directed to them.
This occurs under the concept of Managed Care, but under NHIS
enrollees are allowed to choose their preferred Provider.
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EVOLUTION OF NHIS.
The National Health Insurance Scheme (NHIS) was signed into law
in 1997.
The statutory Instrument that set up the scheme is the NHIS Act
35 dated 10th May, 199.
Health Insurance in Nigeria was first mooted in the Parliament by
the Halevi Committee in 1962 but no action was taken to actualize
the concept.
Formal Launching of NHIS 1997
Formal flag off by General Olusegun Obasanjo of the Formal Sector
Programme took place on 6th June 2005.
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AIMS AND OBJECTIVE OF NHIS
Section 5 of NHIS Act 35 of 1999 sets out the objectives of the
scheme to include:
• Ensure that every Nigerian has access to good health care services
• Protect families from the financial hardship of huge medical bills.
• Limit the rise in the cost of healthcare services.
• Ensure equitable distribution of health care costs among different
groups etc.
• The NHIS is a special social security arrangement based on concept
of solidarity and equity
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OPERATION OF THE SCHEME
The scheme operates through four basic or major
stakeholders with the following roles and
responsibilities:-
i) Contributor:- Can be either an employee and or employer or any
individual
- expected to make a determined contribution at specified time as
prescribed in the plan.
ii) The Health Maintenance Organization (HMO)
Limited Liability companies accredited by the NHIS solely to manage
the provision of health care services through Healthcare Providers
accredited by the Scheme.
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OPERATION OF THE SCHEME - 2
Effect timely payments to Healthcare Facilities. Ensure effective processing of claims (Secondary and Tertiary
Services) Carry out continuous quality assurance of healthcare
services Ensure timely approvals of referrals and undertake necessary
follow up to complete referrals Carry out continuous sensitization of enrollees
Market approved health plans to employers/enrollees
Collect appropriate contributions and make necessary
payments to appropriate pools in a timely manner Effects necessary returns to NHIS in line with the
Operational Guidelines9
OPERATION OF THE SCHEME - 3
iii) The Health Care Providers (HCPs) These are Primary, Secondary and Tertiary health care
facilities that are licensed/accredited by relevant authorities to provide services to the populace.
Secure appropriate Accreditation with NHIS
Provide services as agreed with HMOs in the benefit package.
Comply with NHIS Operational Guidelines
Sign contract with NHIS through HMOs
Ensure enrollees satisfaction
Provide returns on utilization of services and other data to
NHIS through HMOs
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OPERATION OF THE SCHEME - 4
Report any complaints to HMOs and NHIS Limit the delivery of service to level of accreditation.
The Organization:
• The NHIS is the regulatory and supervisory body For Health Insurance
in Nigeria.
• Under the Scheme, health care services are paid for from the common
pool of funds contributed by the participants of the Scheme.
As evident from above, the roles and responsibilities of the HMOs, and
Healthcare Providers are highly significant determinants of the
successful implementation of the scheme.
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PARTICIPATION OF HEALTHCARE PROVIDERS IN MANAGED CARE AND NHIS-1
The concept of Health Insurance was quite alien to many Providers
as a means of Health Financing.
Many Providers were used to the previous method of Out of Pocket
payment and Retainership method especially in the Private Sector.
The paradigm shift affected many Private Practises adversely as
many or all of their patients were swept under the Private Health
Insurance Programme (Managed care ) inaugurated by the HMOs
in the organized Private Sector.
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PARTICIPATION OF HEALTHCARE PROVIDERS IN MANAGED CARE AND
NHIS-2 Private Health Insurance Programme by the HMOs commenced in
the late 1990s before the take off of NHIS in 2005.
In the early years of Managed care, the relationship between the
HMOs and Providers was far from cordial.
It was viewed by Providers as a “Master-Servant” Relationship
In response to this situation, some concerned Providers met to
discuss way forward
At the end of their deliberation the Healthcare Providers
Association of Nigeria was formed.
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INAUGURATION OF THE HEALTHCARE PROVIDERS ASSOCIATION OF NIGERIA.
The Healthcare Providers Association of Nigeria (HCPAN) was
formed in compliance with decree 35 of 1999 setting up the National
Health Insurance Scheme (NHIS) with particular reference to part 1,
section 11 subsection 2 (g) and part 11, section 6 subsection 2(c),
2(d) enumerating the role and place of providers in the country.
The Association was formally inaugurated on 12th August, 2004 and
the attendance was highly commendable. The First Annual General
Meeting (AGM) was held on 25th August 2005 and was formerly
registered with the Corporate Affairs Commission (CAC) of the
Federal Republic of Nigeria in 2006. 14
AIM AND OBJECTIVES OF THE HEALTHCARE PROVIDERS ASSOCIATION
OF NIGERIA.
To moderate a smooth relationship between the Providers and all
relevant Stakeholders in Health Insurance Industry. These include the
NHIS, HMOs, NECA, NLC, and other relevant organizations.
To maintain high standard of health care delivery and provide quality
care for enrollees at affordable cost.
To ensure adequate compensation to the Providers for services
rendered for both capitation and fee for service. To ensure continuing education of the providers through Capacity
Building Workshops and Training on the varied operations of Managed Care.
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AIM AND OBJECTIVES OF THE HEALTHCARE PROVIDERS ASSOCIATION
OFNIGERIA-3
To vet contractual agreements between the HMOs and
Healthcare Providers in Managed Care
To ensure the success of the operation of Health Insurance in Nigeria in
order to improve the Health Indices of the Nation and the Achievement
of Universal Health Coverage.
As you can see from the enumerated objectives above, the Healthcare
Providers Association identifies with the aims and objectives of the
NHIS in providing qualitative care to all Nigerians at affordable cost,
We believe in the achievement of Universal Health Coverage for all
Nigerians, however many challenges were identified in the
implementation of both Private Health Insurance and the NHIS.
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CHALLENGES IDENTIFIED BY HEALTHCARE PROVIDERS
Since the inception of NHIS on the 6th of June 2005, there has
been no review of the NHIS Act. The Operational Guidelines
which has just been reviewed and released recently is still
undergoing amendments. We believe that the reviews of these
documents are long overdue. Other identified challenges
include;
LOW CAPITATION /GLOBAL CAPITATION; We appreciate the
fact that after a lot of advocacy the initial capitation of #500
paid by NHIS was reviewed to #750 in February 2012. This was
7 years after the commencement of the NHIS
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CHALLENGES IDENTIFIED BY HEALTHCARE PROVIDERS-2
Meanwhile in this same year there was partial removal of fuel subsidy.
Minimum wage as at 2005 was #750 and as today it stands at #18,000
an increment of more than 300% yet capitation was reviewed upward by
36% does creating a huge deficit in funding at the Healthcare facility
level.
ii) The capitation has not taken into consideration the disparity in the
cost of goods and services and rent between the urban and rural
practices in the country.
iii) The Association wishes that Global capitation should be expunged
and that all Providers should be paid either as Primary Care Providers or
Fee- For-Service for Secondary /Tertiary care Providers
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CHALLENGES IDENTIFIED BY HEALTHCARE PROVIDERS-3
LOW FEE-FOR-SERVICE/TARIFF FOR SECONDARY CARE.
Participation of Secondary and Tertiary Institution in the delivery of Primary Care Services.
HMO Indebtedness to Providers/Slashing of Bills/Non Payment of
Capitation.
Registration of new lives should be done by NHIS and not by HMOs
Dual role of some HMOs Slow pace in the accreditation of Healthcare facilities by NHIS.
- Some facilities have been inspected but not registered
- Some have been accredited but do not have a single life 19
.
CHALLENGES IDENTIFIED BY HEALTHCARE PROVIDERS-4
Inequitable distribution of lives to Providers.
More than 72% of Providers have enrollees less than 500 and these are
in the Private Sector.
Complicated contractual agreement between the HMOs and Providers
on the Private Health Insurance( Managed Care).
Provision for Arbitration
Regulatory role of NHIS not effective.
The need for Capacity Training for Providers and other stakeholders.
A functional and informative website of NHIS/Robust IT Platform.
Lack of participation of State and Local Government in the NHIS.
20.
RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-1
The HMOs and Providers are identified major stakeholders in the NHIS and Managed care
With different roles and responsibilities in the scheme.
Common denominator is to actualize the objective of NHIS to achieve
Universal Health Coverage.
Many identified challenges in Managed care and NHIS can be
resolved by a mutual collaboration between the HMOs and Providers.
The two most contentious issues between HMOs and the Providers
are the Low Capitation and abysmally low Tariff.
In order to improve the relationship between the two stakeholders the
following strategies were initiated by the Providers.
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-2
1) Inauguration of a bilateral forum of HMCAN/HCPAN to
review the challenges identified by HCPAN and proffer
solution to them.
2) Constitution of a HMCAN/HCPAN TARIFF Committee to
review the Tariff paid for Secondary and Tertiary care
services, and the review of capitation upward At the end of a crucial meeting of the committee held on the
28th April,. 2010 the Benefit package to be covered by capitation was determined. This included:-
(i) Registration (ii) G.O.P consultant (iii) Drugs for Primary care (iv) N.P.I
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-3
(v) Admission for 24hrs with treatment with essential
drugs.
(vi) Basic Laboratory Tests i.e. MP, Urine analysis,
PCV/HB.
(vii) Minor O.P procedures – minor laceration, I & D,
Dressing
(viii) Preventive care/Health Promotion
(ix) Primary Dental Care
(x) Simple Eye Test and Treatment
It was also resolved that the capitation for the content
enumerated above should be #750 minimum.
All HMOs were to go back and harmonize on minimum
premium based on new contact and cost
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-4
All HMOs to review their contractual agreements with
Providers less Legal franca
HMCAN to Endeavour to get every HMO to become member
HCPAN to ensure all Providers become member
The Tripartite Committee (NECA/HMCAN/HCPAN)
The HCPAN observed after a year following the agreement as
above that many HMOs did not change their Modus
Operandum
- Capitation remained the same
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-6
- Fee-for-service/Tariff not reviewed
- Private Providers Clinics were closing down as many could not
cope with the financial burden imposed on them by Health
Insurance.
- HCPAN approached the Nigerian Employers Consultative
Association (NECA) to intervene in the dispute between HMOs and
Provider and as a result of this, the Tripartite Committee was
inaugurated in February 2011.
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-7
The objective of the Tripartite Committee was to establish and
continue a stable, peaceful and harmonious relationship between the
members of HMCAN and HCPAN.
- To examine the areas of conflict among the two parties
- To promote and enhance Health Insurance in Nigeria.
- Several meetings were held by the Tripartite Committee which were
Presided over by the Director General NECA, Mr. Segun Osinowo.
- In November 2011, the Tripartite Committee came up with a
memorandum of Agreement between NECA, HMCAN and HCPAN.
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-8
MEMORANDUM OF AGREEMENT(MoA) BETWEEN
NECA, HMCAN AND HCPAN
The Memorandum of Agreement was signed by the
representative, of the 3 parties at NECA House on the
11th of November 2011.
The MoA consists of 16 section.
Section: the objective of the Tripartite Committee was
adopted for the MoA.
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RELATIONSHIP MANAGEMENT BETWEEN HMOs AND PROVIDERS-9
Particular attention is being drawn to section 8 of the MoA which
recommended that HMCAN and HCPAN should continue dialogue on matters
of Mutual interest. To this end a Joint Consultative Meetings between the
representatives of HMCAN and HCPAN was recommended.
- Section 10 deals with Grievance Procedure. It enumerated 5 stages for the
speedy resolution of grievances between HMCAN and HCPAN to ensure a
harmonious relationship.
Section 14 deals with the Governing Law for the MoA which in all respect by
and be construed in accordance with the Laws of the Federal Republic of
Nigeria.
I am constrained to declare that this legal Instrument has not been fully
utilized by the HMOs and Providers
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JOINT CONSULTATIVE MEETING BETWEEN HMCAN/HCPAN
In compliance with the recommendation of section 8 of the MoA a Joint
Consultative meeting of representatives of HMCAN and HCPAN was
inaugurated.
The inaugural meeting was held within the premises of Healthcare
International HMO on the 13th of February 2012,
The Agenda slated for the meeting included:
1 Report on the implementation of the agreement between HMO and
HCPAN on Benefit Package under Managed Care proposed at the
bilateral meeting held on the 28th of April 2010.
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JOINT CONSULTATIVE MEETING BETWEEN HMCAN/HCPAN - 2
Review of Capitation/Implementation of new NHIS capitation
Review of fee-for-Service tariff diagnosis related tariff.
HMO indebtedness to Providers/slashing of bills
Free admission for the first 48 hours overhead cost challenges
Care of the chronically ill
Professional fees for Primary/Secondary care providers under Fee-
For-Service.
Standardized contractual agreement between HMOs and Providers
Dual role of HMOs.
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JOINT CONSULTATIVE MEETING BETWEEN HMCAN/HCPAN-3
Implementation of Memorandum of Agreement (MoA) of the Tripartite
Committee
Setting up of arbitration panel
Service levels
- Stigmatization of prepaid enrollee
- Acceptance of scheme with good intent by providers
Data Managements-return of Encounter data to HMOs promptly
Front desk management (patient flow)
Arbitrary increase in tariffs
Termination of service without notice to HMOs
A.O.B
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JOINT CONSULTATIVE MEETING BETWEEN HMCAN/HCPAN-4
In order to fast tract 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 HMCAN on this document.
HCPAN believe that if the Agenda enumerated by the Joint
Consultative forum is positively addressed the relationship
between the two stakeholders will improve tremendously.
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CONCLUSION
Providers are the people in the healthcare industry who are the custodians of the services to be purchased.
The HMOs who are purchaser of the services should negotiate favourable terms with providers for the beneficiaries.
The MoA should be utilised as a tool for policies and procedures in the management of relationship between the HMOs and Providers.
There must be improved communication and mutual cooperation between the two parties for effective and efficient implementation of Health insurance in Nigeria.
Nigeria Health Indices and healthcare system is poor compared with other countries with similar socioeconomic background.
The Presidential directive is to achieve 30% Universal Health Coverage by 2015.
We must all join hands together for the achievement of this goal. THANK YOU ALL FOR LISTENING.
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