‘HMOs are committed to improve medical services ’



Dr. Kolawole Owoka is Chairman of Health and Managed Care Association of Nigeria (HMCAN), the umbrella body for Health Maintenance Organisations (HMOs) in Nigeria, and Managing Director of United Healthcare International (UHI). UHI is one of the HMOs accredited by the National Health Insurance Scheme (NHIS) to provide prepaid accessible, affordable and quality health services to all Nigerians. Owoka in this interview with The Guardian said the HMOs are committed to make sure that the health system in Nigeria improves and the best way to do so is through health insurance. Owoka accused the NHIS of double dealing as a regulator and operator even as he urged the scheme to stay as regulator and give the HMOs, which are the operator free hand to do their job. The medical practitioner among other things said Nigeria is the only country in the world where health insurance is not compulsory and where about 65. 87 per cent payment for health services is still out-of-pocket payment. CHUKWUMA MUANYA writes.

Recently the new Executive Secretary of NHIS, Prof. Usman Yusuf, berated the HMOs for not living up to their responsibilities. In fact he said the HMOs are corrupt and are not doing what they are supposed to do, and that they are the problem why the health insurance scheme has not worked well in Nigeria. Do you agree with this assertion?
Totally no. Everything is false, and that is why we have been looking for the opportunity to raise our own voice. We are patriotic Nigerians and we started health insurance in Nigeria as private health insurance. We were happy when in 1999 the government started talking that they want to do health insurance and we contributed a lot in terms of resources and materials to make sure that the programme starts. So you cannot start to help deliver a baby and want to truncate the development of that baby. We want to do every thing possible to make sure that the baby is well and good, and that health system in Nigeria improves. We are not happy about the indices of health like maternal mortality, under-five mortality that are bad; so we want it improve. In most developed countries like Netherland, their life expectancy is 83, in Germany, it is 81, but in Nigeria, it is 54 for female and 53 in male, that is not good. So we want to improve and we believe the best way to do so is this health insurance. But the only thing we want to do is to make sure the following are carried out. Let the NHIS, which is the government arm regulating this scheme stay as regulator, then give us the operator free hand to do our job. Look at Central Bank, they would not come and tell any bank not to do their job. They allow them to do their job, they would only monitor and have its hammer ready to make sure that any body that violates the rule is punished. The new NHIS boss said enrollees are treated as lepers. We support it because we are not the ones directly treating, that is for the health care providers to reply and we are doing our best to watch out that the health care providers do their best. And I also want to use this medium to let the enrollees know that we are like the watchdog, their own busman, so anybody that they think maltreats them, they should call us, it is our job to investigate and make sure they get appropriate treatment.

For misappropriation of funds, we cannot blame the HMOs because funds are housed by NHIS. So if NHIS pays the HMO every three month, it is their job as regulator to make sure that those HMOs that are not paying the provider are immediately either fined, sanctioned or have their license removed. That is why we say stay with your regulation, there is a lot if work to do, and do it well; it will help this scheme. Then any fund you give to us as HMO, we make sure the fund is kept and we pay what is called advance guaranteed bond. So that means you as a regulator if you determine any HMO that has not paid, you can collect your money from the bank through the advanced guaranteed bond. We pay for every penny the NHIS gives us, there is no way the question of misappropriation can be put on our doorsteps, because before I collect any money I pay bond and you can supervise me on whom I pay to. So if I don’t pay to them, you can deal with me, so you see that makes us free from fraud.

Misappropriation of funds doesn’t concern the HMOs. Then second is nonpayment of primary providers. I have mentioned to you and we support it, anybody the NHIS discovered have not paid, recover the money, either through advance guarantee bond we have paid or recover it and make sure you withdraw their license, we support it.

The debts the NHIS claims the HMOs owe have been over investigated; they are divided into two, capitation and fee for service. Capitation is the monthly one we pay per member anybody who doesn’t pay that doesn’t deserved to be spared. They should do their regulation, fish them out and punish them. Then the second one, fee for service is what we normally tell the providers that the days are gone when provider would say this is the amount we want to charge a patient. No we are there as watchdog to serve you and say these are the laws, this is the tariff we all agreed on and you must follow, anything beyond this tariff wont be paid. And that is why we want him to realize, when he was saying fee for service was worse than fuel subsidy, it is a lie. I pay N49 million instead of the N41 million the NHIS gave me two months ago. So why would you tell me the fee for service is worse than subsidy, there is an undergraduate at the University of Lagos, he has been in the hospital for two years, we paid the money and continue to pay, where as what they paid to us was just N4, 000 for the whole year, but someone has been on sick bed for two years and we are paying. It is part of the fee for service, so what are you now telling me? That means any exposure that is greater than what you pay me then you must be ready to pay it back, because we have plenty documents to show him that there are months that we pay more than that, it is part of the scheme. There is nothing hidden there, in a month I may be lucky it may not be up to that but there are months that am paying more and I have evidence to show, and I bear it because that is the risk am suppose to bear.

The NHIS are doing more than regulation, they are doing everything as if they are operators, because if I go out now to market I would meet them also marketing. What are they marketing? If they are doing sensitization and advocacy to let people know about their rights and scheme, beautiful, I like that.

But the NHIS feel that you people are not doing enough in terms of getting more enrollees?
All over the world, health insurance is for the rich and the poor, because if you say you want to do only the poor, the rich can fly away to India to do their own. So bring them in and make it compulsory for both the rich and the poor, and let us market them.

Another argument is that you people are so relaxed because of the money you are getting. You are not doing enough in term of enlisting more Nigerian and that is where the problem is because the target should be universal health insurance. So what is the hindrance?
The hindrance is very simple, I personally have gone through 50 different countries and their health system and there is no single one where health insurance is not compulsory. You can also check it out by yourself. In any country the first thing government has to do is to come out and make sure that health insurance is compulsory. If it is compulsory, it means all companies with more than five or 10 enrollees you must have health insurance. So we want the government to come out and make that compulsory.

Then the second thing is that it has been discovered that 65. 87 per cent payment for health services in Nigeria is out-of-pocket payment, which is one of the highest in the world, whereas by WHO standards it should be below 30 per cent.

So that means there is a lot of fund, all we need to do is to rearrange it so that government would make sure that this pre payment pulling system health insurance, that is what they call pre payment is what applies through out the whole country. So if that applies through out the whole country, this money would be redistributed inside and out of pocket among people would reduce. So the only thing left is there are some that cannot pay, because whether you like it or not, there is the poor and the vulnerable, the handicapped, the prisoners, all these government has to develop a political will to come out that I want to help these people.

We want what is called public private partnership; this is what started the scheme and made it transparent. We are the private sector, and as private organizations, you can sue us and we have our name to protect. But once it is public private partnership, we would be there as private partners and watchdog to make sure all the abuse, moral hazard, fraud is removed to make the scheme go forward because those are the things.

The HMOs have also been accused as middlemen, just taking the money and not doing anything. How true is this?
We are more than that. Let me tell you all our cardinal jobs, payment of provider is just one, anybody with I pad or computer can pay that.
The second thing is referral across the three levels, the primary provider would serve as gatekeeper, but before that gatekeeper can take it to the second level which is the secondary or tertiary level. The primary providers call us, so when they now calls us, we can now ask questions to give them a second opinion to patient treatment. Then if all doesn’t work then we give code and ask them to refer the patient. We are the ones that can do that and to make sure we do it well we have what we call, Call Centre, which is to 24 hours. Look we have been working since 2000, and I was challenging the NHIS boss when we had the retreat that they should visit the HMOs so they would see what facilities we have and do not have, and what we have been doing. Some HMOs have even joined with some international HMOs and attracted foreign direct investments, brought in billions to the country. Visit us, see what we are doing; we have 24 hours Call Centre. Doctors and nurses are there 24 hours to talk to you. We do that.

Then when we leave that Call Centre, we have what we call risk management strategies. It is our risk management strategies that have been keeping the job so it has never gone astray. To the glory of God and to the credit of the scheme, there is no month since 2005 when it was launched that they have never paid.

What are the fallouts of the retreat the NHIS and the HMOs had in Kaduna?
Very good, we have started talking and he has agreed that he would set up a technical committee between NHIS, HMOs and the primary providers and then he has also agreed that he would add enrollees to make it four, so that we would sit down and holistically look at all the issues and iron them out. We are waiting for that technical committee.

What plans do you have in terms of internal sanitization, discipline or mechanism to make sure that all these complaints are addressed?
In fact, we are happy for the new change, that is a new person is coming, that is why we want to make sure as possible our own side, we would help him realize, let them also state their own side and let all of us sit and identify individual faults. Let us itemize one by one and let him, you see there is an act set up called act 35 of 1999, let him sit down and say who are those following the Act and who are those not following. Look at the regulator, view, stay as a regulator, let me the operator do as the operator, if I offend fine me, sanction or withdraw my license, that is how we do and how we want it. Rule of law, we want corporate governance to be brought here, so we know that we are all following rules.

I do not owe, in fact as the chairman HMCAN, I try as much as possible to self regulate our members and I always challenge the health care provider anywhere I meet them that I do not owe and my HMO, United Healthcare they all know, I do not owe any penny to anybody, and have said it anywhere I go.

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