Transcript RELATIONSHIP MANAGEMENT BETWEEN HMO,S AND …

RELATIONSHIP MANAGEMENT
BETWEEN HMOs, AND PROVIDERS:
MATTERS ARISING
BY
DR (MRS) ADENIKE OLANIBA FMCPH, FAGP.
CONSULTANT PUBLIC HEALTH PHYSICIAN
NATIONAL PRESIDENT
HEALTHCARE PROVIDERS ASSOCIATION OF
NIGERIA (HCPAN).
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Definition of Relationship Management: Relationship Management is a strategy employed by an organization in
which a continuous level of engagement is maintained between the
organization and its audience. Relationship Management can be
between a business and its customers (Customer relationship
Management ) and between a business and other businesses (business
relationship Management .
• It aim to create a way to identify potential cross-sales of products and
services.
 It creates a partnership amongst the businesses involved.
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Definition of Relationship Management:- 2
The Relationship between the HMOs and Providers was supposed to be
a business relationship which should have resulted in
•
A better business process
•
Improved Communication
•
Better policies and procedures
•
Mutual Cooperation
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THE HEALTHCARE PROVIDERS.
• These are Primary, Secondary and Tertiary healthcare facilities
that are licensed/accredited by relevant authorities to provide
services to the populace.
• NHIS Accredited Providers are those healthcare facilities that
have been accredited by NHIS to provide healthcare services to
its enrollees.
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THE HEALTH MAINTENANCE ORGANIZATION(HMOs)
 A private or public incorporated company that provides health coverage
with providers under contract. It differs from the Traditional Health
Insurance by the contracts it has with its Providers.
•
These contracts allow for premium to be lower, because the health
providers has the advantage of having patients directed to them.
 This occurs under the concept of Managed Care, but under NHIS
enrollees are allowed to choose their preferred Provider.
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EVOLUTION OF NHIS.
 The National Health Insurance Scheme (NHIS) was signed into law in
1997.
 The statutory Instrument that set up the scheme is the NHIS Act 35 dated
10th May, 199.
 Health Insurance in Nigeria was first mooted in the Parliament by the
Halevi Committee in 1962 but no action was taken to actualize the concept.
 Formal Launching of NHIS 1997
 Formal flag off by General Olusegun Obasanjo of the Formal Sector
Programme took place on 6th June 2005.
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AIMS AND OBJECTIVE OF NHIS
Section 5 of NHIS Act 35 of 1999 sets out the objectives of the scheme
to include:
• Ensure that every Nigerian has access to good health care services
• Protect families from the financial hardship of huge medical bills.
• Limit the rise in the cost of healthcare services.
• Ensure equitable distribution of health care costs among different
groups etc.
• The NHIS is a special social security arrangement based on concept of
solidarity and equity
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OPERATION OF THE SCHEME
The scheme operates through four basic or major
stakeholders with the following roles and responsibilities:i) Contributor:- Can be either an employee and or employer or any
individual
- expected to make a determined contribution at specified time as
prescribed in the plan.
ii) The Health Maintenance Organization (HMO) Limited
Liability companies accredited by the NHIS solely to manage the provision
of health care services through Healthcare Providers accredited by the
Scheme.
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OPERATION OF THE SCHEME - 2
 Effect timely payments to Healthcare Facilities.
 Ensure effective processing of claims (Secondary and Tertiary Services)
 Carry out continuous quality assurance of healthcare services
 Ensure timely approvals of referrals and undertake necessary follow up
to complete referrals
 Carry out continuous sensitization of enrollees
 Market approved health plans to employers/enrollees
 Collect appropriate contributions and make necessary payments to
appropriate pools in a timely manner
 Effects necessary returns to NHIS in line with the Operational
Guidelines
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OPERATION OF THE SCHEME - 3
iii) The Health Care Providers (HCPs)
 These are Primary, Secondary and Tertiary health care facilities that are
licensed/accredited by relevant authorities to provide services to the
populace.
 Secure appropriate Accreditation with NHIS
 Provide services as agreed with HMOs in the benefit package.
 Comply with NHIS Operational Guidelines
 Sign contract with NHIS through HMOs
 Ensure enrollees satisfaction
 Provide returns on utilization of services and other data to NHIS
through HMOs
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OPERATION OF THE SCHEME - 4
 Report any complaints to HMOs and NHIS
 Limit the delivery of service to level of accreditation.
The Organization:
•
The NHIS is the regulatory and supervisory body For Health Insurance
in Nigeria.
• Under the Scheme, health care services are paid for from the common
pool of funds contributed by the participants of the Scheme.
 As evident from above, the roles and responsibilities of the HMOs, and
Healthcare Providers are highly significant determinants of the
successful implementation of the scheme.
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PARTICIPATION OF HEALTHCARE
PROVIDERS IN MANAGED CARE AND NHIS1
 The concept of Health Insurance was quite alien to many Providers as a
means of Health Financing.
 Many Providers were used to the previous method of Out of Pocket
payment and Retainership method especially in the Private Sector.
 The paradigm shift affected many Private Practises adversely as many
or all of their patients were swept under the Private Health Insurance
Programme (Managed care ) inaugurated by the HMOs in the
organized Private Sector.
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PARTICIPATION OF HEALTHCARE
PROVIDERS IN MANAGED CARE AND
NHIS-2
 Private Health Insurance Programme by the HMOs commenced in the
late 1990s before the take off of NHIS in 2005.
 In the early years of Managed care, the relationship between the HMOs
and Providers was far from cordial.
 It was viewed by Providers as a “Master-Servant” Relationship
 In response to this situation, some concerned Providers met to discuss
way forward
 At the end of their deliberation the Healthcare Providers Association of
Nigeria was formed.
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INAUGURATION OF THE HEALTHCARE
PROVIDERS ASSOCIATION OF NIGERIA.
 The Healthcare Providers Association of Nigeria (HCPAN) was formed in
compliance with decree 35 of 1999 setting up the National Health
Insurance Scheme (NHIS) with particular reference to part 1, section 11
subsection 2 (g) and part 11, section 6 subsection 2(c), 2(d) enumerating
the role and place of providers in the country.

The Association was formally inaugurated on 12th August, 2004 and the
attendance was highly commendable. The First Annual General Meeting
(AGM) was held on 25th August 2005 and was formerly registered with the
Corporate Affairs Commission (CAC) of the Federal Republic of Nigeria in
2006.
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AIM AND OBJECTIVES OF THE HEALTHCARE
PROVIDERS ASSOCIATION OF NIGERIA.
 To moderate a smooth relationship between the Providers and all
relevant Stakeholders in Health Insurance Industry. These include the
NHIS, HMOs, NECA, NLC, and other relevant organizations.
 To maintain high standard of health care delivery and provide quality
care for enrollees at affordable cost.
 To ensure adequate compensation to the Providers for services
rendered for both capitation and fee for service.
 To ensure continuing education of the providers through Capacity
Building Workshops and Training on the varied operations of Managed
Care.
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AIM AND OBJECTIVES OF THE HEALTHCARE
PROVIDERS ASSOCIATION OF
NIGERIA-3
 To vet contractual agreements between the HMOs and Healthcare
Providers in Managed Care
 To ensure the success of the operation of Health Insurance in Nigeria in
order to improve the Health Indices of the Nation and the Achievement of
Universal Health Coverage.
 As you can see from the enumerated objectives above, the Healthcare
Providers Association identifies with the aims and objectives of the NHIS in
providing qualitative care to all Nigerians at affordable cost, We believe in
the achievement of Universal Health Coverage for all Nigerians, however
many challenges were identified in the implementation of both Private
Health Insurance and the NHIS.
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CHALLENGES IDENTIFIED BY
HEALTHCARE PROVIDERS
 Since the inception of NHIS on the 6th of June 2005, there has been no
review of the NHIS Act. The Operational Guidelines which has just
been reviewed and released recently is still undergoing amendments.
We believe that the reviews of these documents are long overdue. Other
identified challenges include;
 LOW CAPITATION /GLOBAL CAPITATION; We appreciate the
fact that after a lot of advocacy the initial capitation of #500 paid by
NHIS was reviewed to #750 in February 2012. This was 7 years after
the commencement of the NHIS
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CHALLENGES IDENTIFIED BY
HEALTHCARE PROVIDERS-2
 Meanwhile in this same year there was partial removal of fuel subsidy.
Minimum wage as at 2005 was #750 and as today it stands at #18,000 an
increment of more than 300% yet capitation was reviewed upward by 36%
does creating a huge deficit in funding at the Healthcare facility level.
 ii) The capitation has not taken into consideration the disparity in the cost
of goods and services and rent between the urban and rural practices in the
country.

iii) The Association wishes that Global capitation should be expunged and
that all Providers should be paid either as Primary Care Providers or FeeFor-Service for Secondary /Tertiary care Providers
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CHALLENGES IDENTIFIED BY
HEALTHCARE PROVIDERS-3
LOW FEE-FOR-SERVICE/TARIFF FOR SECONDARY
CARE.
 Participation of Secondary and Tertiary Institution in the delivery of
Primary Care Services.
 HMO Indebtedness to Providers/Slashing of Bills/Non Payment of
Capitation.
 Registration of new lives should be done by NHIS and not by HMOs

Dual role of some HMOs
 Slow pace in the accreditation of Healthcare facilities by NHIS.
- Some facilities have been inspected but not registered
- Some have been accredited but do not have a single life
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CHALLENGES IDENTIFIED BY
HEALTHCARE PROVIDERS-4
 Inequitable distribution of lives to Providers.
 More than 72% of Providers have enrollees less than 500 and these are
in the Private Sector.
 Complicated contractual agreement between the HMOs and Providers
on the Private Health Insurance( Managed Care).
 Provision for Arbitration
 Regulatory role of NHIS not effective.

The need for Capacity Training for Providers and other stakeholders.
 A functional and informative website of NHIS/Robust IT Platform.

Lack of participation of State and Local Government in the NHIS.
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-1
The HMOs and Providers are identified major stakeholders in the
NHIS and Managed care
 With different roles and responsibilities in the scheme.
 Common denominator is to actualize the objective of NHIS to achieve
Universal Health Coverage.
 Many identified challenges in Managed care and NHIS can be resolved
by a mutual collaboration between the HMOs and Providers.
 The two most contentious issues between HMOs and the Providers are
the Low Capitation and abysmally low Tariff.
 In order to improve the relationship between the two stakeholders the
following strategies were initiated by the Providers.
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-2
 1) Inauguration of a bilateral forum of HMCAN/HCPAN to review the
challenges identified by HCPAN and proffer solution to them.
 2) Constitution of a HMCAN/HCPAN TARIFF Committee to review
the Tariff paid for Secondary and Tertiary care services, and the review
of capitation upward
 At the end of a crucial meeting of the committee held on the 28th April,.
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2010 the Benefit package to be covered by capitation was determined.
This included:(i) Registration
(ii) G.O.P consultant
(iii) Drugs for Primary care
(iv) N.P.I
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-3
 (v)
Admission for 24hrs with treatment with essential drugs.
 (vi)
Basic Laboratory Tests i.e. MP, Urine analysis, PCV/HB.
 (vii) Minor O.P procedures – minor laceration, I & D, Dressing
 (viii) Preventive care/Health Promotion
 (ix)
Primary Dental Care
 (x)
Simple Eye Test and Treatment
 It was also resolved that the capitation for the content enumerated
above should be #750 minimum.
 All HMOs were to go back and harmonize on minimum premium
based on new contact and cost
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-4
 All HMOs to review their contractual agreements with Providers less
Legal franca
 HMCAN to Endeavour to get every HMO to become member
 HCPAN to ensure all Providers become member
The Tripartite Committee (NECA/HMCAN/HCPAN)
 The HCPAN observed after a year following the agreement as above
that many HMOs did not change their Modus Operandum
 - Capitation remained the same
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-6
 - Fee-for-service/Tariff not reviewed
 - Private Providers Clinics were closing down as many could not cope
with the financial burden imposed on them by Health Insurance.
 - HCPAN approached the Nigerian Employers Consultative
Association (NECA) to intervene in the dispute between HMOs and
Provider and as a result of this, the Tripartite Committee was
inaugurated in February 2011.
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-7
 The objective of the Tripartite Committee was to establish and continue a
stable, peaceful and harmonious relationship between the members of
HMCAN and HCPAN.
 - To examine the areas of conflict among the two parties
 - To promote and enhance Health Insurance in Nigeria.
 - Several meetings were held by the Tripartite Committee which were
Presided over by the Director General NECA, Mr. Segun Osinowo.
 - In November 2011, the Tripartite Committee came up with a
memorandum of Agreement between NECA, HMCAN and HCPAN.
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-8
 MEMORANDUM OF AGREEMENT(MoA) BETWEEN NECA,
HMCAN AND HCPAN
 The Memorandum of Agreement was signed by the
representative, of the 3 parties at NECA House on the 11th of
November 2011.
 The MoA consists of 16 section.
 Section: the objective of the Tripartite Committee was
adopted for the MoA.
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RELATIONSHIP MANAGEMENT BETWEEN
HMOs AND PROVIDERS-9

Particular attention is being drawn to section 8 of the MoA which recommended
that HMCAN and HCPAN should continue dialogue on matters of Mutual interest.
To this end a Joint Consultative Meetings between the representatives of HMCAN
and HCPAN was recommended.
 - Section 10 deals with Grievance Procedure. It enumerated 5 stages for the speedy
resolution of grievances between HMCAN and HCPAN to ensure a harmonious
relationship.
 Section 14 deals with the Governing Law for the MoA which in all respect by and be
construed in accordance with the Laws of the Federal Republic of Nigeria.
 I am constrained to declare that this legal Instrument has not been fully utilized by
the HMOs and Providers
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JOINT CONSULTATIVE MEETING BETWEEN
HMCAN/HCPAN
 In compliance with the recommendation of section 8 of the MoA a Joint
Consultative meeting of representatives of HMCAN and HCPAN was
inaugurated.
 The inaugural meeting was held within the premises of Healthcare
International HMO on the 13th of February 2012,
 The Agenda slated for the meeting included:
1 Report on the implementation of the agreement between HMO and
HCPAN on Benefit Package under Managed Care proposed at the
bilateral meeting held on the 28th of April 2010.
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JOINT CONSULTATIVE MEETING BETWEEN
HMCAN/HCPAN - 2

Review of Capitation/Implementation of new NHIS capitation

Review of fee-for-Service tariff diagnosis related tariff.

HMO indebtedness to Providers/slashing of bills

Free admission for the first 48 hours overhead cost challenges

Care of the chronically ill

Professional fees for Primary/Secondary care providers under FeeService.

Standardized contractual agreement between HMOs and Providers

Dual role of HMOs.
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For-
JOINT CONSULTATIVE MEETING BETWEEN
HMCAN/HCPAN-3

Implementation of Memorandum of Agreement (MoA) of the Tripartite

Setting up of arbitration panel

Service levels
- Stigmatization of prepaid enrollee
-
Acceptance of scheme with good intent by providers

Data Managements-return of Encounter data to HMOs promptly

Front desk management (patient flow)

Arbitrary increase in tariffs

Termination of service without notice to HMOs

A.O.B
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Committee
JOINT CONSULTATIVE MEETING BETWEEN
HMCAN/HCPAN-4
 In order to fast tract review of Capitation and Tariff the HCPAN
forwarded the Report of its Tariff and Pricing Committee to the Forum
for consideration.
 No feedback has been received from HMCAN on this document.
 HCPAN believe that if the Agenda enumerated by the Joint
Consultative forum is positively addressed the relationship between the
two stakeholders will improve tremendously.
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CONCLUSION
 Providers are the people in the healthcare industry who are the custodians
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of the services to be purchased.
The HMOs who are purchaser of the services should negotiate favourable
terms with providers for the beneficiaries.
The MoA should be utilised as a tool for policies and procedures in the
management of relationship between the HMOs and Providers.
There must be improved communication and mutual cooperation between
the two parties for effective and efficient implementation of Health
insurance in Nigeria.
Nigeria Health Indices and healthcare system is poor compared with other
countries with similar socioeconomic background.
The Presidential directive is to achieve 30% Universal Health Coverage by
2015.
We must all join hands together for the achievement of this goal.
THANK YOU ALL FOR LISTENING.
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