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NHIS REPORT ASSESSMENT OF NATIONAL HEALTH INSURANCE SCHEME IN LAGOS STAT E. September, 2013. research@lagoschamber.com. Outline. Objective of the study. Methodology. Detailed Findings. Summary of Findings. Field Experience.
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NHIS REPORT ASSESSMENT OF NATIONAL HEALTH INSURANCE SCHEME IN LAGOS STATE September, 2013. research@lagoschamber.com
Outline Objective of the study Methodology Detailed Findings Summary of Findings Field Experience
It has been observed that there is a slow growth of NHIS since the establishment in 1999. Hence the need for this study. • The following specific objectives were covered: • Awareness of health insurance scheme among the target audience • Penetration in terms of usage • Profiles of the users (who and who is using the scheme) • Plans available and amount for each plan • Challenges faced by the enrollees, HMOs and the hospitals • Lesson to learn from past experiences • The way forward Objectives
Four categories of respondents were interviewed: Individual = 350 Target Groups HMOs=10 Company=100 (All sectors) Respondents Hospitals=40
All the nocks and crannies in Lagos State were covered. Coverage
Awareness Of National Health Insurance Scheme There was an over-whelming awareness of National Health Insurance Scheme at corporate level (78%) and hospital (100%). However, awareness among individuals was less than average (38%).
Awareness Summary • There was an over-whelming awareness of National Health Insurance Scheme at corporate level (78%) and hospital (100%). However, awareness among individuals was less than average (38%). • It is pertinent to point out that National Health Insurance Scheme is gradually becoming popular in Lagos metropolis compared to the past when individual awareness for the scheme was as low as 15%. The proliferation of Health Maintenance Organisations in strategic locations in the State has necessitated the increase in awareness though they are not doing much on media. • It was also learnt that some big Microfinance Banks include health insurance as part of the holistic package for their group lending product portfolio. Those that have saved a minimum of N100,000.00 in their personal account apart from paying back the group loan are automatically enrolled in the health insurance scheme. This has tremendously impacted on the awareness of the scheme in the informal sector.
Patronage Of National Health Insurance Scheme Finding revealed a low patronage of National Health Insurance Scheme – individual (18%) and corporate (38%). Further probing on the individual usage of the scheme pinpointed that some of them are enjoying the benefit from their spouse or relation’s place of work.
Patronage Of National Health Insurance Scheme by company size Surprisingly, the high awareness of the scheme by corporate organisations did not transcend to patronage. Observably, majority (91%) of the small scale enterprises with less than ten employees have not yet embraced the concept. Conversely, majority of large/medium companies with fifty and above employees (73%) engage the service of HMOs.
Reasons For Non-patronage Of National Health Insurance Scheme • Below are the reasons adjudged for not currently using National Health Insurance Scheme:
Health Maintenance Organisations Patronized By Individual Users 100% distribution of individual users among the HMOs
Health Maintenance Organisations Patronized By Corporate Users 100% distribution of corporate users among the HMOs
HMOs’ Clients Classification Interviews conducted with Health Maintenance Organisations revealed that they have more corporate clients (69%) followed by government (27%) and a handful of individual (4%). The informal sector that constitutes bulk of the population is completely neglected. Notably, only the top players render services to the three categories of clients.
Patronage Summary • Finding revealed a low patronage of National Health Insurance Scheme – individual (18%) and corporate (38%). Further probing on the individual usage of the scheme pinpointed that some of them are enjoying the benefit from their spouse or relation’s place of work. In actual fact, individual registration may not have grown to 18%. • Surprisingly, the high awareness of the scheme by corporate organisations did not transcend to patronage. Nearly all the small scale enterprises with less than ten employees (91%) have not yet embraced the scheme. Reverse is the case with large/medium companies with fifty and above employees as 73% of them visited engage the services of HMOs. • Over three-quarter (77%) of the hospitals visited are currently working with HMOs. Only few (23%) particularly the small hospitals are yet to sign a contract with any HMO because they lack the necessary facilities. • Interviews conducted with Health Maintenance Organisations revealed that they have more corporate clients (69%) followed by government (27%) and a handful of individual (4%). The informal sector that constitutes bulk of the population is completely neglected. Notably, only the top players render services to the three categories of clients.
Patronage Summary (Cont’d) • Some of the HMOs claimed that they only provide services to corporate bodies at the moment because government has their own preferred HMOs. They were of the opinion that there should be equitable distribution of government ministries and parastatals to the HMOs rather than concentrating on few ones. • It is pathetic to note that a lot of people at the bottom of the pyramid prefer to visit local chemist for self meditation or use native herbs popularly called ‘agbo’ whenever they fall sick. There have been cases of unwarranted death due to self prescription and indiscriminate consumption of native herbs (‘agbo’). To maximally fulfill the primary obligation of setting up the scheme (providing easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems), both government and HMOs should rise up to the occasion of spreading the services to the general publics.
Product Categories Of HMOs • Full, unlimited general out-patient consultations • Specialist consultation • Supply of drugs and medicaments prescribed • Laboratory investigations, Radiology • Medical hospitalization in general ward at designated hospitals • Emergency treatment for injuries • Minor surgery (appendectomy, hernia repair etc) • Basic gynecology, Physiotherapy • Family planning • Counseling (Nutrition, HIV, Child care) • Emergency Out-of-station care • Childhood immunization as per NPI schedule • Blood transfusion service • +Primary Dental care – simple extraction, amalgam filling and dental hygiene • +Basic Eye examination/treatment Average price Category ‘A’ N20,875 N33,500 • Contents of Category A • +intermediate/major surgery • +Full maternity care Category ‘B’ N50,000 • Content of Category B • + Major Surgeries • +Lenses and Frames • + Admission in semi-private rooms Category ‘C’ N97,500 • Contents of Category B • +Admission in private wards • +Supply of regular Lenses and Frame Category ‘D’
Future Patronage Intent of National Health Insurance Scheme +=93% += 73% +=73% The scheme received good reception when it was briefly explained to the respondents. Majority of the individuals (73%), corporate (73%) and hospitals (93% ) consider it a laudable idea as it will afford enrollees the opportunity to attend hospital when they don’t have money at the time of falling sick.
Key Drivers For Patronage Of National Health Insurance Scheme
Top Challenges Users (Individual & Corporate) Have With HMOs
Product/NHIS’ evaluation summary Customers’ Reactions To Service Charge • It was gathered from HMOs that majority of their clients (74%) consider the price for the various policies/plans moderate; while 13% each consider it high and too high. This could be as a result of the caliber of customers (big corporate, government and upper/middle class individuals) they are dealing with at the moment. • A feed back from the end users was not pleasant. They lamented that they don’t receive commensurate treatment for the premium paid compared to when they visit their family or personal hospitals. • There was a case of a company with over 250 employees that approached one of the HMOs. The company was asked to pay annual premium of N25 million for all the employees. The management carried out comparative cost analysis of the HMO cost against what they presently incurred on medical bills per annum which stands at N13million. This implies that if they had signed the contract with the HMO they will be incurring additional cost of N12 million on medical per annum.
Product/NHIS’ evaluation summary (Cont’d) Level Of Acceptance Of National Health Insurance Scheme • Finding indicates a low acceptance of the National Health Insurance Scheme despite the fact that it has been in operations for the past decades. 87% considers it low and 13% very low. This low level of acceptance may be attributed to the low media support for the scheme. Majority of the populace are yet to know about the scheme and even those that have heard about it lack the knowledge of what it entails, features, plans available, its benefits, registration processes and where to get the HMOs. • The testimonials of the present enrollees are not helping matters because a lot of them have been receiving sub-standard treatment each time they visit the hospital. There are cases of some enrollees suspending treatment at the HMOs’ registered hospitals to meet their personal doctors for a better treatment. This category of enrollees considers the money paid for the scheme a waste. • Another important element that may cause the low acceptance is lack of educating the enrollees on the limit of their plan/policy. An average enrollee believes that he/she is 100% covered with the policy irrespective of nature of ailment.
Product/NHIS’ evaluation summary (Cont’d) Future Patronage Intent of National Health Insurance Scheme • The scheme received good reception when it was briefly explained to the respondents. Majority (73%) of them consider it a laudable idea as it will afford them the opportunity to attend hospital whenever they fall sick even if they don’t have money. • It was garnered during an interactive session with some of the respondents that the scheme will be widely acceptable if the following variables are provided: - Quality plans/policies at an affordable price - Extensive campaign with emphasis on the product features and benefits - Quality treatment. Carrying out necessary test before commencing treatment rather than just administering paracetamol and other analgesic drugs for chronic ailment. - Good hospital network that will enhance easy accessibility of the registered hospitals - Prompt response in case of emergency - Presence of qualified doctors in the hospitals
Awareness & Campaign • Aggressive campaign should be embarked upon to create adequate awareness for the scheme. Various channels of communication such as television, radio, print, social media (face book, twitters, linkedin etc) should be employed in the awareness creation. • There should be public enlightenment on what the scheme entails, its benefits, available plans, features of each plan, limitation of each plan and registration processes. • The Health Maintenance Organisations should make themselves visible. Many potential users that have interest sometimes discouraged because they don’t know any HMO to register with. This can be effectively achieved by engaging marketing officers who are well knowledgeable about the product offering to do direct marketing. • There should be streets and market activation (roadshow) to create more awareness for the scheme particularly in the rural areas. It is not enough to concentrate on government and large/medium companies because the scheme is meant for all Nigerians.
The Way Forward (Cont’d) Patronage • The HMOs should spread their marketing tentacles to all the sectors of the economy. Small and medium scale industries should be sensitized about the scheme and the need for them to enroll their employees. • People in the informal sectors and rural areas should be given adequate attention. As a matter of fact, they are the ones that need the scheme most. The upper/middle classes can afford medical bills at any time. They may not really attach much important to the scheme because of the erroneous impression that they will not be properly treated going through third party to finance their medical bills. Some of them preferred to take treatment oversea or engage trusted personal doctors. • Flexible mode of payment should be introduced particularly for the informal sectors and rural areas. In this case, they should be encouraged to be paying gradually as soon as they have money or via monthly installment. • Different policies should be introduced to accommodate those that cannot afford the present plans. A low plan that will not exceed N500 per month will suffice in the informal sectors and rural areas.
The Way Forward (Cont’d) Patronage • Hospital should submit their bills regularly and the bills should be settled within the agreed period. • Hospitals should be transparent in dealing with the HMOs. Issuance of unrealistic bills should be discouraged. • HMOs’ patients should be given good reception at the hospital. Hospitals should stop practicing discrimination between HMOs’ patients and their direct patients. • Hospitals should improve on the treatment of HMOs’ patients. Administering just paracetamol for typhoid fever is deadly. • The health status of enrollee should be determined before putting them on a plan because those with internal diseases and infection demand more medical attention and treatment. • There should be continuous evaluation of the hospital performance. This will serve as check and balance on how they relate with HMOs’ patients. • Doctors in the hospitals should stop uttering negative things about the HMOs and their policies to the patients or company’s representatives that visit the hospital for inspection before signing a contract with the HMO.
The Way Forward (Cont’d) Legislation & Enforcement • There should be a law mandating all employers of labour to enroll their employees in the National Health Insurance Scheme. It could be a situation of joint sponsorship where the employer pays 75% and employee in turn contributes 25%. • There should be a regulatory framework on the prices of the various policies/plans to avoid unnecessary exploitation. • There should be a regulatory framework on the minimum capitation for each policy/plan so that enrollees can get value for their money. • Government should subsidize National Health Insurance Scheme to make it affordable to all Nigerians.
Unrealistic Bills From Hospitals 1) “One of the HMOs visited during fieldwork informed us that they have been receiving unrealistic bills from the hospital. A mystery shopping was carried out by the HMO by sending their staff as a patient to one of the suspected hospitals that normally sent exorbitant bills. The disguised patient was treated for a very minor ailment. He was given only drugs. The staff kept the drugs waiting for the hospital to send their bill. When the bill was received it was discovered that the hospital inflated it and added some drugs that were not given to him. The HMO took the drugs and the bill to the hospital as a proof that they have been sending unrealistic bills.” 2) “One of the registered hospitals sent a bill to a HMO that a client of theirs was treated for a dog bite. When the HMO called the parents of the boy to sympathize with them, it was discovered that the boy was never bitten by a dog. The hospital cooked up the case in order to extort money from the HMO.” CASES (1)
Hospitals Delay Sending Bills to the HMOs 3) “The HMOs also complained that sometimes when their corporate clients go to the hospitals for inspection, they get bad reception and discouragement about the plans/policies. 4) “Some hospitals accumulate bills up to three months before sending them. At the end of the day they complain of delay payments.” CASES (2)
Poor Orientation of the Enrollees by the HMOs 5) “The hospitals complained that the capitation fee is very small. The present monthly capitation fee HMOs pay per person is between N500.00 and N750.00. Some enrollees make regular visits to hospital even for a minor ailment of headache. Those with internal diseases and infection want perfect treatment with just N500 or N750 paid by their HMOs for a month”. 6) “HMOs do not really explain in details to their clients the plan they registered for. Patients with the lowest plan come to the hospital demanding major surgery to be performed on them using the plan or comparing their level of treatment to others with a higher plan.” CASES (3)
