Vanguard | Managed healthcare: More Nigerians place hope in HMOs

By June 23, 2015 No Comments

Adesimbo Ukiri, Chief Executive Officer of Avon Healthcare Ltd (Avon HMO) speaks to Sola Ogundipe on the benefits of subscribing to managed health care plans and steps that Avon HMO are taking to overcome some of the challenges enrolees face.

Following the 2014 reaccreditation of Health Maintenance Organisations, HMOs, operating in Nigeria, by the National Health Insurance Scheme, NHIS, more Nigerians have expressed greater confidence in the overall potential benefits of signing up for a health insurance plan in the country.

Currently, HMOs run Managed Health Care Plans designed to offer cost-effective medical care for health-seeking individuals that are under contract with a network of providers (physicians and hospitals) either to deliver or to arrange for the delivery of covered services. Enrolees (HMO members) receiving care under a managed health care plan, are encouraged to engage in preventive health and seek early treatment when they become ill. Managed care is offering reliable access through health insurance because the plan does not require claim forms to see a doctor or during hospital stays. The HMO member only has to present a card that states proof of insurance or registration, at the doctor’s office or hospital. The HMO charges a fixed monthly fee so its members can receive health care. With this HMO, fees can be forecasted unlike a fee-for-service insurance plan. Although freedom of choice is given up, out-of-pocket expenses are very low.

Quite a significant number of Nigerians are now enjoying access to comprehensive healthcare services, courtesy of the managed health care process through registration with an HMO. The whole idea has always been to ensure HMOs direct healthcare providers to re-position their services to become patient-oriented, so that enrolees can obtain the care that they desire whether they are seeking treatment through a third party arrangement, or paying at the point of service.

The goal is to ensure that through managed healthcare, patients are positioned for maximum attention and are not short-changed or receive preferential attention based on their access platform. For practical purposes, according to the Encyclopaedia of Public Health, managed care is the enrolment of patients into a plan that makes capitated payments to health care providers on behalf of its members, thus shifting the financial risk for health care from patients and payers to providers. The intent of this shift is to provide incentives to health care professionals to reduce their utilisation of  resources, ideally through measures such as health promotion and disease prevention among the group’s members. Ordinarily, HMOs do not require enrolees to pay at point of service, although there may be a co-payment each time services are rendered.

In an HMO, the premium that is paid is just enough to cover the costs. The members are “stuck” to a primary care physician and if managed care plans change, then the enrolee may need to upgrade. Surveys carried out by Good Health Weekly among enrolees, show a strong support for the arrangement and reflect a general provider commitment towards providing high quality care to patients.

A few enrolees expressed overall confidence in the ability of the hospitals where they seek healthcare, to deliver on the key aspects of care that matter most to them. For instance, Esther Adebayo, registered with Avon HMO Nigeria, noted that she and her family were always treated in this way just like any other. Another of the respondents expressed confidence and trust in her doctor – and equally so in the nurses. Patients’ also scored their care favourably in regard to being treated with dignity and respect agreed that.

Challenges: One challenge often mentioned generally is that it is difficult to get any specialised care because the members must get a referral first. Any kind of care that is sought that is not a referral or an emergency is not covered. The HMO plan is one of the fastest growing types of managed care in terms of expenses, even though the enrolee is restricted to the provisions of chosen health care plan.

As a welcome development, significant number of patients are reporting positive experiences, especially in the areas of trust and confidence in the staff, it is however not an excuse to become complacent. There are still quite a few persons who are not receiving the care that they need and indeed deserve. Areas such as involvement, communication and co-ordination all have significant room for improvement. But some patients actually noted that they did not feel that they were involved in decisions about their care and treatment. The general complaint is that doctors “always” answer questions in a way they could not understand.

The results combined underline the need for continued effort and support to both understand the potential impact of improving care quality and deliver on the critical aspects of person-centred care.Being involved in decisions about your care, understanding your medication and its side effects and having a care plan that fully takes into account your personal circumstance are vital aspects of quality care. Furthermore these areas have strong links to subsequent lifestyle choices, concordance with treatment, as well as avoidable readmissions including all areas where positive change will support the realisation of a sustainable health insurance.

In the views of Medical Director, Avon Healthcare Ltd, Ms. Adesimbo Ukiri, Avon Healthcare runs a patient-driven system. “It is a journey, but we are on the right track. So we are offering health plans for individuals and families. “Prior to this, such services could only be accessed by being part of a company or part of a group or association, but we felt the need to shift focus from client satisfaction to real enrolee satisfaction at the individual level,” she noted. Further, she stated: “We have since expanded our customer service function department, employed and trained more people, and the way our call centre functions has also changed. We now keep statistics they pick about customer enquries and customer complaints are these data are much more detailed.

Close Out: “We are not just engaging with the HR manager of a company, but engaging with people one-on one and attending to their needs. So for every complaint, we have a way of monitoring. One, what is the turn around time for resolving the issue, and two, close out. For every complaint, all our staff know how to obtain a confirmation from that person that the complaint is resolved. That is what we call close out. If you do not have the confirmation, and you log it, it is still open.” She said for most complaints, the turn around time is under five minutes, because most of the complaints have to do with things like, O, I’m in the hospital, they say my name is not on the register and the like. Common complaints like these are easy to deal with.

For other enrolees, complaints have to do with the services that are covered or not covered on their plan.“That is also an easy one because it is five minutes. Just talk to the hospital there and then. The ones that take up to 24 hours or more to resolve often occur when there is a dispute between the hospital and the enrolee. “Perhaps the enrolee has been dissatisfied with certain services or care provided and in order to resolve the issues amicably, you have to go there and hear their own side. This may take up to two or three days “We often get complaints from patients who allege being charged for services not rendered. We step in. If an enrolee has been asked to pay for a service for which he is covered, what we do, in such cases, is to refund the enrolee first, and then collect the money back from the hospital.”


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