Reps and its investigation into N351bn health insurance payment

The two-day public hearing by the House of Representatives Committee on Healthcare Services on the utilisation of the estimated N351 billion paid Health Maintenance Agencies (HMOs) by the National Health Insurance Scheme (NHIS) in 12 years, was probably the most emotive investigation by the House in the last two years.

So charged was the atmosphere that two individuals who were in attendance had to be kept away from each by a security man right inside the venue of the meeting. Majority of attendees at the hearing weren’t silent either as they reacted opinion to the testimonies of the two respondents who took to the stage to speak on their experiences as enrollees on the NHIS.

While a pharmacist with the National Hospital, Olalekan Oluleti said not all of the 57 HMOs who work with the NHIS are as incompetent as they were portrayed at the hearing, judging by how he was attended to during a recent emergency involving a pregnant relative, another angry enrollee, Fatima Abdulkadir vehemently disagreed. According to Abdulkadir, a nurse and staff of the NHIS, weeks back had to take her sick son home to administer treatment by herself, when the hospital where he was rushed to said her card didn’t cover the level of treatment she hoped that her son would be given.

The Committee led by a member from Imo state, Chike Okafor held the hearing pursuant to the directive given by the House last December, to probe the quality of service rendered by Health Maintenance Organisations (HMOs) who act as middlemen between NHIS and healthcare providers, from 2005-2016. The mandate followed the adoption of a motion raised under matters of public importance entitled: “Inhuman Treatment of the NHIS Enrollees and Urgent Need to Investigate the Activities of Health Management Organisations and Healthcare Providers in Nigeria.” The motion was sponsored by Okafor and another member, Henry Nwawuba.

The House which in adopting the jointly sponsored motion described as below par the service provided enrollees on the National Health Insurance Scheme (NHIS) by HMOs also directed the NHIS to suspend the quarterly release of funds to HMOs pending the outcome of its investigation. The committee during the budget defence session of NHIS in February repeated this directive.

But it was discovered during the hearing that the Executive Secretary of the NHIS Prof. Yusuf Usman had resorted to paying HMOs monthly even as he accused them of mismanaging the billions paid them since 2005, for the provision of health services to federal civil servants.

Usman insisted that despite the huge sums paid HMOs in 12 years, they hardly meet up with their financial obligations to hospitals and this resulted in enrollees being turned back, while some are treated like second class citizens.

He vowed to recoup the N3.5 billion debts owed hospitals by HMOs. He also revealed that the weeding out of ghost enrollees would save the Federal Government N288 million annual payment for these fictitious patients.

“HMOs have been padding the number of enrollees they have with the complicity of NHIS staff in the ICT department, led by a former General Manager of the department, who later became Executive -Secretary of the NHIS.

“This is not hearsay. This has been investigated by the Independent Corrupt Practices Commission (ICPC) and the Department of State Services (DSS) and the reports are there”, Usman said.

If he shocked some who attended the first day of the hearing with the rate at which he listed allegations of fraud against HMOs and past leaderships of his agency, the NHIS boss didn’t let -up on the second day as he announced that he would only re-accredit HMOS, some of whom their accreditation had expired since 2013, when they clear the debts owed hospitals.

Usman who suggested that hospitals be paid directly and not through HMOs, equally expressed regret that with about N60 billion paid them from 2005-2016 just for Administration Fee, majority of enrollees have reports of disrespect and poor treatment meted out to them at health facilities.

“We are fixing the mistakes and you (pointing at HMOS representatives) are the big mistake, we are going to fix.

“There is corruption, through the ICT Department in NHIS; the number of enrollees was padded with 23 thousand names. We will pay hospitals straight from our office. This we will do to save Nigerians’ money. When I came I started asking questions nobody had asked. I asked for results for the money given HMOs.

“I speak based on data. There are documents which are from the investigations by the ICPC. These documents have names of HMOs and staff of NHIS. Today, I am exposing everything from our inadequacies as regulator, the fraud by HMOs and the recklessness of service providers”, Usman added.

The investigative hearing was indeed a time of reckoning for HMOs as stakeholders took turns to give frank assessments on these firms. The National Presidents of the Nigerian Labor Congress (NLC), Ayuba Wabba opined that HMOs were an impediment to enrollees getting first class service. The position of the National Trade Union Congress (TUC),  Bobboi Kaigama wasn’t any different as he scored HMOs very low.

“According to the provision of the NHIS operational guidelines, healthcare providers are supposed to receive capitation payment from HMOs two weeks before the month commences. But in most cases healthcare providers do not get paid promptly. Some HMOs pay in arrears, while some do not pay at all, thus leaving enrollees at the mercy of healthcare providers”, Kaigama said. On his part, minister of Health, Prof. Isaac Adewole declared his support for the investigation into the payments made to HMOs and the level of coverage attained by the NHIS. The minister who was represented by the Director Hospital Services, Dr. Wapada Balami advised that the committee looks into the role of HMOs in the provision of health insurance in the country.

He joined Usman in seeking an amendment of the NHIS law, with regard to cancelling the representation of HMOs on the board of the scheme.

“We believe that the investigation by the committee will include checking if enrollees are being used as conduit pipes and whether HMOs should exist or not”, the minister said.

Other stakeholders such as the Committee of Heads of Pharmacies in Federal Health Institutions, Healthcare Providers Association of Nigeria (HPCAN), and Guild of Medical Laboratory Directors, all took turns to speak on ways to efficiently run health insurance in the country.

Responding, representatives of HMOs denied the allegations made against them by the NHIS boss, saying he has often displayed “open hatred” towards them.

But in an unexpected twist, HMOs were represented by two different associations. Making a presentation on behalf Health and Managed Care Association of Nigeria, Dr. Lekan Enwenla stated that Yusuf lacked proper understanding of the administration of health insurance. “From day-one he (NHIS Executive-Secretary) has been displaying open hatred to HMOs. All the issues he raised are really about NHIS poor implementation of its regulatory role”, Enwela said.

Dr. Ademola Aderibigbe who spoke on behalf of ten HMOs under the Association of Health Maintenance Organisation and Practitioners of Nigeria, maintained that not all service providers have been fraudulent as members of his association have strived to be up to date with payments to hospitals.

With two days of hearing from all sides, members of the committee couldn’t hide their disappointment. A member of the Committee, Ayo Omidiran, opined that the committee must act speedily. “Now, our job is cut out for us, having listened to what people had to say the past two days”, she noted.

The Deputy Chairman of the committee, Muhammed Usman assured that the committee would be detailed in its investigation as corruption in the health sector which puts millions of lives at risk shouldn’t be tolerated.

“Complaints that enrollees are being used as conduit pipes to transfer money to HMOs has been a source of concern, hence the need for parliament to investigate why billions taken from tax payers hasn’t been used to provide standard care to Nigerians”, Usman stressed.

Aware that many eyes are on the investigation by parliament, chairman of the Committee, stressed that the ultimate goal of the House was to ensure that the corruption and wastage that has characterised health insurance is reduced to the barest minimum and funds meant for the provision of quality care are properly utilised.

Responding to policy statements made by Usman  such as the criteria that would qualify HMOs to be re-accredited and his maintaining  the newly introduced regime of paying HMOs monthly, jettisoning their quarterly payment; Okafor stated that any action to be taken by the NHIS boss must be done in conformity with the NHIS Act.

“I will look at the NHIS Act again and if it says you have to pay the HMOs every three months, you will have to keep to the law.

“If the law stays you must pay hospitals through HMOs, you have to comply until the relevant section of the (NHIS) law is amended. We are lawmakers, not law breakers and we have to ensure that the right thing is done”, he added.

Okafor assured on the neutrality of the committee, adding that improving the quality of care provided Nigerians should be the ultimate goal of all stakeholders.

The lawmaker further stated that the committee would fully support the debt recovery effort of the NHIS as patients are often denied treatment at facilities where HMOs aren’t up-to-date with payment.

He expressed confidence that the committee would come up with workable commendations which would assist in reforming health insurance in the country.

Speaker Yakubu Dogara, who declared the hearing open said that NHIS has a major role to play in ending out of pocket payment for health care services, hence the need for the National Assembly to ensure transparency and accountability in the interventions by the scheme. The Speaker was represented by the Deputy Minority Leader, Chukwuka Onyema on the occasion.

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