Nigerian Unreliable Scam HMOs  – Number 1 Scam is Reliance HMO !

Nigerian Unreliable Scam HMOs – Number 1 Scam is Reliance HMO !

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LAGOS – In any society, the longevity of life and raising a healthy, disease-free generation is partly dependent on society’s access to quality healthcare. Over the decades, one of the key initiatives that ensure citizens accesses quality health care is the development of Health Management Organisation (HMO). Unfortunately, the dream and vision of those who instituted the HMO system is different from the reality today.

In Nigeria for example, the reality of HMO is much different from what it was created to be. For this reason, patients and HMO users or HMO enrollees as they are called suffer the consequence of not accessing quality health care.

Saturday INDEPENDENT came across a couple of tweets on social media a few weeks ago by some doctors, each detailing ugly experiences with most HMOs in Nigeria.

In a Twitter thread dated January 24, Dr. Olawale Star said, “My hospital has gone through financially troubled times lately. And 90% of the problem is as a fact that HMOs have decided not to pay after we have rendered service. I am in no mood to drag anyone, but HMOs should stop delaying Healthcare providers after we render a service.”

In response, another social media user with Twitter handle, @9jaPhysio had said in reply, “About 12 HMOs were delisted from my hospital lately because of delayed/lack of payment leaving patients to their fate. It’s really bad.”

In the following thread, Star said, “Many of their patients actually think we’ve been paid and we’re refusing to do work after payment has been done.

“Some will owe you three months, six months, some, one year, some two years. And they expect you to keep seeing their patients, the same patients who by the way are made to think they have paid us for the work and feel entitled. It’s not their fault because the HMOs have the money.

“Most HMOs aren’t really helping the healthcare space rather they’re playing a big Ponzi Scheme on Healthcare Providers (HPs). They take from Corporate Organisations, refuse to pay HPs (or pay peanuts) and let the patient think the HPs have been paid. NHIS should look into this.”

Going further, Star shared in the thread, “Let me give an example; You visit the hospital and you need to be given IV Rocephin. IV Rocephin costs about N3,500 to N5000 depending on where you buy it. But you know how much the HMO wants to pay the HPs for giving you Rocephin? N2000. Who runs business at a loss?

“I’m really pained right now because I, as well as many of my staff (who I sincerely appreciate), have suffered so much delay in salaries. Morale is down, they’re resigning. I cannot blame them at all. Don’t even ask if I’ve even been paid. HMOs are really bad for HPs right now.

“This is why people like me either prefer our patients to pay by themselves or Corporate Organisations work directly with us. Because we’re the ones doing the real job here. And if all fails we close shop and leave this country. But it’s quite unfortunate I’m not built that way. It’s 2020.

We should not be having these kinds of conversations. My hospital runs about 20+ HMO organisations and by God’s grace, if they don’t improve in fulfilling their own end of the agreement, all hell may be let loose.”

As an endnote, Star explained, “Just to add: 1) Seeing any HMO patient costs real money. Money used to procure drugs, materials, workforce, logistics. And this is what they refuse to pay for, deny, or delay the payment. Tell me, is this fair?”

Based on Star’s analysis of the system and the further responses from social media users, one would realise that the HMO system in Nigeria is one that is fraught with problems yet to be solved, while it remains largely unregulated.

Speaking with other respondents, Saturday INDEPENDENT discovered that the trend is the same everywhere.

Dr Adenike Lamar, a general surgeon with a prominent private hospital in Abeokuta, Ogun State said: “While HMOs have a role in the health care space, which I feel is important, the problem is that some of them are rogues. For them, HMO is just a money-making scheme. They have taken it as a means to extort, and even with all their flaws and faults, they put the majority of the blame on the health providers, making it look like we are not doing the job.”

For gynaecologist, who simply preferred to be called Dr. Michael, HMOs are a necessary evil. While pleading anonymity since he runs a family-owned hospital and wouldn’t want to be targeted by HMOs, the new system of HMO is a bad one. “I feel that yes, some health providers also have their own issues and problems, but that is not where it ends. The thing is health providers are the ones that give the service to the enrollees for the HMOs. So the HMOs get these clients through companies and organisations. Before, they operated on decapitation model that an HMO approaches the health provider and says that the hospital should service their enrolees and they would pay a certain sum ahead for the projected amount of people that will come. That is what is called capitation. They give you capitation and that used to be the standard. Later on, they realised that some health providers started inflating. And in some cases, because they were not seeing so many clients and they were still paying lots of money, the model changed to ‘fee for service’. Most HMOs now work on this fee for service model where you see a patient and after you have seen that patient, that is when you get paid.”

Even with the fee for service model, the problems are numerous as many hospitals still complain of unpaid services rendered to HMO enrollees.

Speaking with Dr Soyinka Coker, owner of a small private hospital in Lagos, Saturday INDEPENDENT gathered, “Some of these HMOs, when you see their clients, you don’t get paid for two, three months, even up to a year.

“What really makes me interested in this conversation is that one of the top HMOs in Nigeria, which I would not name is very guilty of this. They are a very prominent HMO.

There are some other HMOs that are doing really well. Reliance HMO, for example, pays 48 hours after you have seen their enrollee. They even pay in full, not piece-meal.”  THAT WAS Two Years Ago Today THEY ARE WORSE THAN THE OTHERS !

Dr. Soyinka further explained, “For some HMOs, their payment model ensures that they pay on a certain day every month. But it still turns out that you have to chase them for it. This is after you have followed all the rules and submitted your claim, processed it, got a code for the claim. They just don’t pay attention to hospitals. They feel that health care providers are playing second fiddle in health care, so they don’t even offer an explanation for the delay in payment.”

An embattled former staff of a Hygeia HMO, David Mark (not real name), speaking on the lack of accountability of HMOs said, “The NHIS is supposed to regulate the activities of HMOs, but they don’t do anything, even though they are the major financiers for the HMOs. Corruption is not letting them be the proper regulators that they should be. The people who were fighting for proper regulation in the system were kicked out.

“The truth is that the problem is a Nigerian problem, not an insurance problem. A lot of people do not want to do business correctly, they don’t want to be credible and they don’t want to have integrity. Greed is a major factor at play here. A lot of people want to maximise profit without any losses.”

Dr. Soyinka, also commenting on the lack of accountability of most HMOs in Nigeria also shared. “In trying to maximise profit, they are trampling on people and we are part of those they trample on. For example, they give these tariffs that when you look at it in all honesty, it is just useless. You want to charge for a medication below market price. That is why HMO enrollees cannot get the best antibiotics because which HMO really wants to pay the premium on a drug? Some of them don’t even revise their tariffs. NHIS’s last tariff review was over eight or 10 years ago, even with the changing economy and new exchange rates. Some HMOs review it after two years, others do yearly. HMOs get away with that by promising hospitals a large number of patients. Hospitals are also constrained. We cannot advertise to get patients, so we rely on word-of-mouth for people to come to our hospital. If people don’t come as much as you have projected, it means you still have to operate according to that tariff you have signed and agreed to. You can never break even that way.”

When asked if their oath as doctors doesn’t require them to tell patients of HMOs the truth, he said, “Unfortunately, the contract we sign with HMOs means that we are not allowed to talk price with enrollees, we are constrained by the contract.

“Most of the drugs we give as healthcare providers usually can come under any other brand name. However, there are generics that created that brand and have a standing name, just like we use Maggi to describe any other seasoning.

“For example, augmentin is a popular drug and it goes by many names. But the real generic name of that drug is amoxicillin/clavulanic acid. The problem now is that there are different types of augmentin in the market, there is the brand and then there are also substandard brands. When the pharmaceutical companies come, they tell you that their new drug is also like augmentin, but when you use it on patients, you might see like 60 per cent efficacy. But they usually come at a lower cost, so health care providers are forced to use that for HMO patients. But for people who will pay out of pocket for drugs, we give them the real deal.”

Soyinka further advised, “With the current arrangement and situation in Nigeria, it is always better for patients to pay for treatment out of pocket, because there is a lot of corruption in the system. Many of these HMOs even get their payment upfront. A lot of financial mismanagement goes on especially on the part of the HMOs. Ideally, it is the NHIS that should regulate, but there are several problems.”

An HMO officer at a popular hospital in Abuja also revealed that the NHIS is sorely lacking in its duties. “Most HMOs are run by corporate elites and they run it purely for profit. The oversight function of the NHIS is very poor. For example, as of 2015, there was this letter of indebtedness that every HMO was supposed to collect from all health providers under their network. That means that before NHIS will renew your HMO license for the year, every hospital you work with must have submitted a letter of indebtedness that you are not owing their hospital. Now, it has been bypassed because there are lapses in the oversight functions. So in the past four years, HMOs have been in operation even without getting the letter. At least as the principal HMO officer of my hospital, I know we have not issued any letter in the past four years.”

Another HMO officer in an upscale hospital in V/I, Lagos, Nkechi Iyama said, “There is a scam that some HMOs run. They walk up to a hospital and say they would give them a certain number of patients at a certain premium. They would also approach an organisation and promise to cover them at a certain premium less than what the same organisation is being covered by another HMO that is servicing them. The unsuspecting organisations go for the lesser HMO that doesn’t have the perfect financial structure to sustain it and then the HMO suddenly folds up. The problem now is that health providers like us would have given the service to the patient. Who pays for our wastage? That is fraud. This is minus the fact that we are paying tax, staff, and all other overhead costs. It is barely enough that we can pay the salaries of our staff, yet some agencies still try to fine us on other technicalities.”

Dr. Ajike Adams, a Nigerian doctor practising in the United States said, “The health setting in Nigeria is a scary one. In other countries, it is not the same. In Germany for instance, their HMOs are not set up to run for profit, they are set up to service the needs of the healthcare users, so the government backs them. They even lobby for clients, so they keep getting better. There is also the government standard HMO that anybody who is living in Germany can access. Many countries still have challenges with their HMO structure, but Nigeria’s own is just too glaring.

“NHIS cannot perform its oversight duties properly when it’s operating on a 3 per cent health budget. Aside from financial misappropriation, the government has not paid enough attention to health. There needs to be proper funding of the health sector. Based on the current structure, Nigeria pays N2000 for the healthcare of an individual for a whole year, how can that work? Except there is a restructuring, nothing will change. The Nigerian healthcare system is rigged for massive fraud.

“When I worked in Nigeria, I advised patients to ask health care providers if HMOs are actually paying. When you inquire you the contract that hospitals have signed with the HMOs does not require them to lie. If you come to me as a patient and your HMO has been owing me for several months, you can’t expect me to give you service with happiness. That will be difficult.

To solve the problem Saturday INDEPENDENT gathered that a number of companies and organisations in Nigeria bypass the system and pay hospitals directly. That way the hospital is on a retainer and everyone gets paid in a timely manner.

On their own side, a senior staff at a Nigerian owned HMO said “A lot of HMO officers in these hospitals are rogues. Some of them inflate the sum of what should have been collected. Health provider fraud is real, many of them are not honest. So it is a two-way street. You cannot blame HMOs for trying to investigate claims before paying, many hospitals are fraudulent too.”

In 2017, the former Executive Secretary of the NHIS, Professor Yusuf Usman, while making a presentation during a review of HMOs in the operation of the NHIS expressed happiness that a day for reckoning for the HMOs had come. It had been argued that the continued existence of HMOs was no longer necessary following the mismanagement of funds paid to them for effective health delivery in Nigeria. The Ministry of Health had stated that HMOs had recorded abysmal failure in the health coverage of Nigerians which has resulted in many avoidable deaths.

Usman said, “For 12 years, the HMOs have never been called to account for their misdeeds. More than 70 newborn babies and over 100 women die daily from avoidable mortality, even though they are on the scheme. Millions die across the states and there seemed not to be time to fight these anomalies until now. When I came to the agency, I saw the potential and I felt the NHIS should perform its duties of helping vulnerable Nigerians to access quality health care.

“The number of Nigerians covered by the NHIS after 12 years is 1.5 per cent of the population. Countries like Kenya and Rwanda have achieved better health care delivery without HMOs and health care financing in Nigeria is nothing but a huge fraud. I know all these things because I signed the cheques and nobody has been brought to book in the last 12 years.

“My way of making the scheme work is to hold the HMOs accountable. We are told that they are powerful and untouchable because they are owned by some powerful Nigerians, but I have news for you that I’m here to rock the boat. We must sink this boat of corruption that has killed the health care sector of our country. They have never been brought to account for the 12 years. The NHIS is supposed to enhance the standard of health care delivery and crash the cost of health care in Nigeria, but covering just 1.5 per cent of Nigerians in 12 years, have we achieved the objective?”

In addition to the dire numbers shared at the time by the embattled Usman, Professor Isaac Adewole, former Minister of Health in Nigeria said a whopping N351 billion has been expended on HMOs so far without commensurate result.

On Thursday, February 13, Prof. Mohammed Sambo the new Executive Secretary, National Health Insurance Scheme (NHIS), shared that the scheme has provided support to 17 state governments through the Basic Health Care Provision Fund (BHCPF), to enroll the vulnerable in society.

“Already, we have disbursed monies to 17 states in Nigeria so that they can enrol the vulnerable segment of the population’’, Sambo said.

He further hinted that NHIS would fine-tune the framework of how the health insurance could be under one roof and used towards achieving Universal Health Coverage (UHC).

According to him, state and local governments were supposed to join the scheme when the NHIS started but because it was not mandatory they did not join.

Sambo said that only employees of the Federal Government and those in the private sector were participating in the scheme, noting that the trend led to decentralisation of the scheme.

Irrespective of the new plans and schemes, the truth remains that Health insurance management in Nigeria is far from structured and remains a major problem for the entire Nigerian populace.

The post Nigerian Unreliable Scam HMOs – Number 1 Scam is Reliance HMO ! first appeared on SwordPress.NG !.

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