- Health Maintenance Organisations react
National Health Insurance Scheme (NHIS) enrollees have cried out over poor services by their Health Maintenance Organizations (HMOs) and primary health care providers saying the scheme has continued to fail them when they need it most.
The NHIS which took off in 2005 as a corporate body was established under Act 35 of 1999 by the Federal Government of Nigeria.
The scheme was set up to protect families from the financial hardship of huge medical bills, limit the rise in the cost of health care services, ensure equitable distribution of health care costs among different income groups and to maintain high standards of health care delivery services within the scheme.
However, enrollees who make monthly contributions in percentages to the scheme have continued to groan over poor services from hospitals.
While some described the services as below standard, others complain of outright denial of treatment as well as receiving substandard drugs.
An enrollee, Ismail Wahab, told Daily Trust that he has not been enjoying the desired services because it has been problematic whenever he visits the hospital for treatment with members of his family.
According to him, eight months ago he was at his hospital in Kubwa, where he was using but was not attended to on the basis that his HMO had not been remitting money to the hospital.
“I went back to the Human Resource department of my office to complain and they promised getting across to the HMO but nothing has been done because I went back and was still denied attention.”
Since then Wahab said every medical treatment for him and his family has been out of pocket even though his NHIS contribution from his place of work was still been deducted on a monthly basis.
Another enrollee, John Daudu, said, “Recently my wife delivered a pre-mature baby and there was need for the baby to be put in incubator which the hospital did.
“Everything was going on well until after two weeks when I was called and informed that I exceeded the amount recommended for such service to the tune of N150,000 and the bill had accumulated to N500,000.
“I kicked against that because I was not informed in the first place that I had a limit neither was I told when I exceeded that amount. The HMO, Novo kept approving the bill and the hospital was rendering the service without my knowledge. If I were told, I would have known how to go about it. Where do they want me to get N350,000 balance? I had to report to my office and am in the process of changing my HMO,” Daudu said.
A female enrollee, Asia Daudu, said she had not for even a day enjoyed health services due to one challenge or the other.
She said they keep moving her from one hospital to the other because of the problem most of the hospitals had with the HMO.
“I was moved to two hospitals within Kubwa because they complained that my HMO, Clearline, was not remitting money until they eventually moved me to Arewa Hospital in Utako.
“Just recently, I took ill and went to Arewa Hospital but was told they could not treat me because all NHIS patients under my HMO would not be attended to. I contacted the HMO on phone but was not responded to and even as I speak with you, I am yet to hear from them,” she added.
David Ojo, another enrollee, said “My major challenge is that each time I went to the hospital, if there is a request of a drug of N1,000 to N2,000 they will tell us they don’t have in stock and they would write the drug for you to go get it outside the hospital or they say their drugs will come on a later day. But because I don’t want to play with my health or that of my family, I usually get the drug outside.
“But the one that raised my curiosity was when my wife went to the hospital this month. She was given a prescription but told the drug was not available in the hospital. The doctor referred her to two pharmacies in Mararaba where she could get the drug. When she told me, I went to one of the pharmacies around zone 4 to confirm the drug but was told they didn’t have the brand written.
“When I inquired about the price, I was told it is N4,000 while the brand written was N7,000. I then wondered whether I was not covered to be given a medication of such amount.
“I called my HMO and reported but the person who spoke to me said he would take it up.”
According to him, based on this experience, he could not blame the HMO but the hospital, adding that he would rather change the hospital than the HMO.
He advised that since there is law guiding the operations of NHIS, the government should follow it to the latter through constant monitoring.
“To me, it is a very good scheme. If I were to be paying for health services out of my pocket it would have been too expensive. The HMOs are not the issues because they are just like marketers,” he said.
Another enrollee, Nwagwu Ogonna, who said he uses a private health insurance whose HMO is still regulated by the NHIS, said one serious challenge he has noticed is delay in attending to patients.
He said “The last time I went to the hospital I spent the entire day just to get a scan. When I got there, they had to first of all run a diagnosis, then they called my HMO with the diagnosis to get clearance before they could go ahead to treat me.
“But for them to get across to the HMO it took them like 30 minutes to one hour and I sat there doing nothing. They had to call again to get clearance for drugs; even to get paracetamol. I find that very frustrating.”
Based on this challenge, he said he had to change from a public hospital to a private hospital because the HMO refused to pay monthly capitation to those government hospitals.
To another respondent who simply gave his name as Reuben, the NHIS scheme works but many people still don’t understand how it does.
He said “I was one of them because I had insurance but didn’t use it until I got married and had my child. When I began using it, I couldn’t tell the difference between private insurance and NHIS. They were still charging me 10% because I didn’t know. I was still paying 10% of every cost that was involved until I realized that in private insurance, you’re not supposed to pay anything, from registration to card to admission. Even food in hospitals you’re not meant to pay anything because they are all covered.”
He said without the knowledge of the service, one may not be able to access it adding that the HMOs have their own package they cover while the hospitals also have services they offer.
The Abuja Regional Manager, Novo Health Africa, Ayodeji Oduwole told Daily Trust that one of the challenges is that many enrollees don’t even know what their cover benefits entail.
“When we are giving our access card to our enrollees there is a slip in it which states all your cover benefits. The enrollees should also read their cover benefits so they can understand what it entails. By reading they will realize, for instance, that we have a portal that grants them access for registration anytime they want to register themselves or their dependents,” Oduwole said.
He said at the primary care level, no code is required before enrollees can access care but the request is needed for secondary care and it is because some hospitals might want to be fraudulent to say enrollees have done some particular things which they did not actually had access to.
In terms of responding to enrollees when they call, he said an average Nigerian does not prioritize health issues until there is a concern adding that they respond speedily to their clients when issues arise to make sure things are in order.
On giving substandard drugs, Ayodeji said HMOs usually receive such complaints but noted that in an HMO business there is what is called branded drugs and generic drugs.
Also responding, the Regional Manager, Clearline International Limited, HMO, Dr Adu Oluwatosin, said “Why people normally have difficulty sometimes is probably if the hospital is an oversubscribed one and they want urgent attention not minding the people they met there. The HMO cannot do any magic in such cases. However, doctors know when there is an emergency and treat one when seen as such.”
On remittance, he said “Remittance is a big issue; we have institutions that have finished a quarter and have not paid us but they are still going to the hospital and we cannot cut them off because they are on medical treatment.”
He further said there are lots of moral hazards whereby service a provider will tell enrollees that his HMO does not approve this drug but if you are paying out of pocket, we will give it to you.
“Another challenge is the practice whereby hospitals send bills saying an enrollee went through a CS even though it was normal delivery; this is a moral hazard. Of course, there are mechanism put in place to checkmate such but they do happen.
He said some enrollees go to the hospital to impersonate. “Someone will go to the hospital with his sister and say she is my wife even without an ID card to show for it. The hospital also helps out and sends the bill to the HMO believing the enrollees for their word. How do we tackle such issues? It is a call for everyone to do the right thing,” Oluwatosin said.
We are aware of challenges faced by enrollees- NHIS
The Executive Secretary, NHIS, Prof Muhammad Sambo, had at an interactive forum recently in Abuja said he was aware of the challenges facing enrollees from service providers while promising that enrollees under his watch will enjoy every service they want to access.
“I have observed the challenges that stand in the way of health care service delivery under NHIS and I am not oblivious of the challenges of which you enrollees encounter when you go to hospitals to access health care services,” he said.
