June 22nd 2006 Meeting Summary
Scaling-up of Private HMO Networks in Nigeria through National Health Insurance
PSP-One’s fourth Network Exchange centered on the rapid expansion of private HMO networks in Nigeria as a result of the recently implemented National Health Insurance Scheme (NHIS). Participants from Nigeria, Kenya, Ethiopia and the United States joined the conference call to learn more about the evolving role of HMOs in Nigeria and ask questions about how the NHIS program is being phased in.
Taara Chandani of PSP-One began the discussion with an update on the collaboration between PSP-One and Total Health Trust (THT), one of 8 HMOs currently contracting with the NHIS to provide health care services. PSP-One is developing a training program to assist providers in managing their service provision within the capitated insurance model, one that is new for most practitioners.
Although the law creating the NHIS was passed in 1995, roll-out of the scheme was initiated in 2005. The NHIS is currently being extended to federal employees, such as the military and police, with eventual plans to include the informal sector, such as self-employed urban and rural communities. Providers are categorized into three levels of care: primary, secondary, and tertiary. The primary care provider serves as the gatekeeper to secondary and tertiary services.
Summary of questions and responses
1) What is the role of HMOs within the NHIS?
Dr. Ladele (Clearline International Limited): Nigeria’s private health insurance market, in which HMO’s have played a central role, has been developing since the mid-late 1990’s. The Health and Managed Care Association of Nigeria (HMCAN) was formed with the intention of advocating for the industry and sharing tasks and overhead costs such as publicity, training and media to promote the role of HMO’s.
2) What are the cost-sharing requirements?
NHIS cost-sharing requirement is for employers to pay 10% of employee salary, and employees to pay 5% of salary for total of 15%. However, government has implemented a 2-year ‘grace period’ whereby the government is paying the employee’s share for two years. The NHIS benefit package is part capitation (a fixed up-front payment to the provider for each enrollee) and part re-imbursement (fee-for-service on a selected list of specialist services and drugs). There is a 10% patient co-payment for medications included on the essential drug list.
One of the barriers to adequate utilization of the scheme is the lack of public awareness about how the NHIS scheme is intended to work. There is a need to educate consumers on exactly what their benefit packages entail and how to access care. Providers also need the tools with which to guide patients.
3) How many beneficiaries of NHIS at present?
There are currently 2 million beneficiaries covered by NHIS. The HMO’s also have private clients through employer groups that account for approximately 500,000 beneficiaries in total. The NHIS beneficiaries receive care managed by the 8 HMOs.
4) Given the rapid expansion of beneficiaries (from 500,000 to 2,500,000 in less than a year) what are some of the challenges faced by HMO networks?
Capacity building (for providers). Providers who were used to a fee-for-service payment system, must now learn about operating in a managed care environment under fixed capitation. They are finding it necessary to be more discerning about ordering tests, limit their prescriptions and promoting preventive health care.
Meanwhile, to meet the rapidly growing enrollee pool of NHIS, there has been a rush by NHIS to accredit providers. HMOs are finding that the NHIS standards for accreditation are lower than what has been used by HMO’s in the past. The question of who/what entity is best positioned to accredit providers, remains on the table for resolution.
5) What services are provided under the NHIS benefit package? Is this different from services covered under private employers (through the same HMOs)?
The NHIS service package is comparable with most private schemes in terms of the service offerings (however, based on corporate demand, HMO’s do offer schemes that are more expensive and comprehensive in addition to their basic packages).
The NHIS benefit package includes:
- Primary care (child immunizations, routine child wellness)
- Ante and post natal care routine deliveries (up to 4 births)
- Complicated deliveries (reimbursed to the primary care physician)
- Drugs included on the Essential Drugs list
- Hospitalization up to 15 days covered under capitation
Family planning commodities are excluded from the basic package and are paid for by the consumer. Interestingly, although OCs are included on the Essential Drug list, FP products are excluded from the benefit package. It is not clear why FP products are excluded, but this area is one to be further explored.
Note: Although FP products are not covered technically, in practice some providers are offering FP under the capitated payment (and are not charging patients for these).
6) What is the current status of NHIS roll-out, and what are the plans to include the informal sector?
- Federal l employees (current)
- State employees (negotiations underway with state agencies)
- Informal sector: rural populations, urban self-employed, vulnerable populations, including the aged and disabled
7) What is the status of plans to implement a quality assurance mechanism?
NHIS currently is accrediting providers, but is questioning whether this should be done bya public or private entity.
Topics for Future Network Exchanges
- Quality Assurance
- Higher level clinical services
- Implementing MIS systems (specific to Nigeria)
- Training providers on managed care (specific to Nigeria)
- Potential to add HIV/TB services to existing private health networks
PSP-One’s fourth Network Exchange centered on the rapid expansion of private HMO networks in Nigeria as a result of the recently implemented National Health Insurance Scheme (NHIS). Participants from Nigeria, Kenya, Ethiopia and the United States joined the conference call to learn more about the evolving role of HMOs in Nigeria and ask questions about how the NHIS program is being phased in.
Taara Chandani of PSP-One began the discussion with an update on the collaboration between PSP-One and Total Health Trust (THT), one of 8 HMOs currently contracting with the NHIS to provide health care services. PSP-One is developing a training program to assist providers in managing their service provision within the capitated insurance model, one that is new for most practitioners.
Although the law creating the NHIS was passed in 1995, roll-out of the scheme was initiated in 2005. The NHIS is currently being extended to federal employees, such as the military and police, with eventual plans to include the informal sector, such as self-employed urban and rural communities. Providers are categorized into three levels of care: primary, secondary, and tertiary. The primary care provider serves as the gatekeeper to secondary and tertiary services.
Summary of questions and responses
1) What is the role of HMOs within the NHIS?
Dr. Ladele (Clearline International Limited): Nigeria’s private health insurance market, in which HMO’s have played a central role, has been developing since the mid-late 1990’s. The Health and Managed Care Association of Nigeria (HMCAN) was formed with the intention of advocating for the industry and sharing tasks and overhead costs such as publicity, training and media to promote the role of HMO’s.
2) What are the cost-sharing requirements?
NHIS cost-sharing requirement is for employers to pay 10% of employee salary, and employees to pay 5% of salary for total of 15%. However, government has implemented a 2-year ‘grace period’ whereby the government is paying the employee’s share for two years. The NHIS benefit package is part capitation (a fixed up-front payment to the provider for each enrollee) and part re-imbursement (fee-for-service on a selected list of specialist services and drugs). There is a 10% patient co-payment for medications included on the essential drug list.
One of the barriers to adequate utilization of the scheme is the lack of public awareness about how the NHIS scheme is intended to work. There is a need to educate consumers on exactly what their benefit packages entail and how to access care. Providers also need the tools with which to guide patients.
3) How many beneficiaries of NHIS at present?
There are currently 2 million beneficiaries covered by NHIS. The HMO’s also have private clients through employer groups that account for approximately 500,000 beneficiaries in total. The NHIS beneficiaries receive care managed by the 8 HMOs.
4) Given the rapid expansion of beneficiaries (from 500,000 to 2,500,000 in less than a year) what are some of the challenges faced by HMO networks?
Capacity building (for providers). Providers who were used to a fee-for-service payment system, must now learn about operating in a managed care environment under fixed capitation. They are finding it necessary to be more discerning about ordering tests, limit their prescriptions and promoting preventive health care.
Meanwhile, to meet the rapidly growing enrollee pool of NHIS, there has been a rush by NHIS to accredit providers. HMOs are finding that the NHIS standards for accreditation are lower than what has been used by HMO’s in the past. The question of who/what entity is best positioned to accredit providers, remains on the table for resolution.
5) What services are provided under the NHIS benefit package? Is this different from services covered under private employers (through the same HMOs)?
The NHIS service package is comparable with most private schemes in terms of the service offerings (however, based on corporate demand, HMO’s do offer schemes that are more expensive and comprehensive in addition to their basic packages).
The NHIS benefit package includes:
- Primary care (child immunizations, routine child wellness)
- Ante and post natal care routine deliveries (up to 4 births)
- Complicated deliveries (reimbursed to the primary care physician)
- Drugs included on the Essential Drugs list
- Hospitalization up to 15 days covered under capitation
Family planning commodities are excluded from the basic package and are paid for by the consumer. Interestingly, although OCs are included on the Essential Drug list, FP products are excluded from the benefit package. It is not clear why FP products are excluded, but this area is one to be further explored.
Note: Although FP products are not covered technically, in practice some providers are offering FP under the capitated payment (and are not charging patients for these).
6) What is the current status of NHIS roll-out, and what are the plans to include the informal sector?
- Federal l employees (current)
- State employees (negotiations underway with state agencies)
- Informal sector: rural populations, urban self-employed, vulnerable populations, including the aged and disabled
7) What is the status of plans to implement a quality assurance mechanism?
NHIS currently is accrediting providers, but is questioning whether this should be done bya public or private entity.
Topics for Future Network Exchanges
- Quality Assurance
- Higher level clinical services
- Implementing MIS systems (specific to Nigeria)
- Training providers on managed care (specific to Nigeria)
- Potential to add HIV/TB services to existing private health networks
