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Health Management Organisations and N350b Fraud, By Emmanuel Ado

By News Express on 10/04/2017

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•Emmanuel Ado.
•Emmanuel Ado.

The Health Management Organisations (HMOs) are very powerful, rich and well connected. They are the new mafias, though they hate being likened to the oil subsidy cartel that held Nigeria hostage for years - getting paid for premium motor spirit they never imported. The Health Management Organisations are right to a certain degree, as their health ‘enrollees scam’ has no foreign exchange component. It is naira denominated, unlike that of the oil subsidy cartel, which was in dollars. But N350 billion is a huge sum. It is the combined budget of three states. For 2017 fiscal year, Kaduna State budgeted N215.9 billion, while Nasarawa State budgeted N68 billion. This is the amount that less than 80 HMOs have ‘corned’ for themselves.

Prof Usman Yusuf, Executive Secretary of the National Health Insurance Scheme (NHIS), appointed last year by President Muhammadu Buhari, has dared to be different. And this is why, for the first time, the monumental fraud being perpetuated by the HMOs is making news.

“I said before and I will say it again, that the HMOs as they operate in Nigeria are a huge fraud. We are paying the HMOs three months in advance, on behalf of the enrollees, to pay the hospitals. But they don’t.” What a damning statement. Though the HMOs have denied the allegation and threatened court action, none has been forth-coming, an indication that there is fire behind the smoke.

Who are the HMOs and their functions? Health Maintenance Organisation is private or public incorporated company registered by the NHIS solely to manage the provision of health-care services through health-care facilities accredited by the scheme. The law establishing the NHIS gives it the power: to collect contributions of employers and employees; to register employers and employees and to ensure qualitative and cost-effective healthcare services to contributors through the health-care providers (HCPs).The HMO’s role in provision of health-care and medical services to enrollees of the scheme is key. They are to maintain a pool of health- care providers - hospitals, clinics, dental and optical clinics, etc - for the benefit of the enrollees.

The NHIS is solely for Federal Government workers. There are different packages. A worker under the scheme is allowed to register a spouse and four biological children. The least such a family can pay is N90,000. The other packages are calculated based on the consolidated salary and the establishment. And the NHIS spends N1,000 on each enrollee for administrative charge, etc. There is also a provision for employers having 10 or more than 10 employees. They are required to register their companies and their employees with an HMO, and to pay to the designated HMO contributions at such time and manner as provided in the guidelines issued by the NHIS Council or as agreed to with the HMO. Self-employed people or others described as ‘voluntary contributors’ and desirous of enjoying the benefits of the scheme are permitted to register and participate in the scheme by choosing an HMO of their choice. 

The Executive Secretary of the National Health Insurance Scheme has been frontal in his charge against the HMOs. He has promised to avail Nigerians with what the HMOs owe the “NHIS and the various health-care facilities.”  Members of the House of Representatives Committee on Health-care Services agree with him on the need to investigate the Health Management Organisations over alleged misappropriation of N350 billion, contributed by Nigerians under the National Health Insurance Scheme. Chairman of the House Committee, Chike Okafor, has ordered a stop to further payments. But the Senate Committee on Health chaired by Senator Lanre Tajuosho, seems more concerned about the employment of staff, and not the fraud. The Senate has ordered a probe into the allegation of employment of staff, on the grounds that it doesn't meet the federal character spread.

The fraud is perpetuated through and by numbers, as the HMOs and hospitals get paid based on the number of enrollees. The other way is the outright refusal to pay the hospitals, even though the HMOs are paid three months in advance. Why are they not able to pay, especially as the money is available? Not only is the money available, but it is cheap money. HMOs get N750 per head, whether or not the enrollee goes or doesn't go to hospital. In a year, an HMO can make N90 million for doing absolutely nothing. But just as Nigeria doesn't know the quantity of crude oil that it exports, so has the number of enrollees remained a mystery. Usman asserts that so far the NHIS has removed 21,000 ghost enrollees from the scheme, thus saving the NHIS more than N350 billion moving forward.

Like the Berlin Conference, where the major powers sat and shared out Africa, the HMOs in 2005 equally sat and shared the federal civil servants on equal basis to the existing HMOs for what they called “smooth and seamless activation of the Public Sector Social Health Insurance Scheme”, though with a caveat that any established case(s) of poor Quality Assurance and Relationship Management on the part of any HMO, the MDA would be at liberty to switch. What the HMOs did amounts to a breach of the fundamental rights of the enrollees to choose. This, and other shortcomings, portray them as buccaneers and not health-care providers.

Though guaranteed payment, the charges against the HMOs include failure to meet their part of the bargain: they owe the hospitals who in turn take it out on the patients. As a result, they are defeating the objectives of the scheme - improved access to health-care. Under the scheme enrollees are entitled to insured benefits, other services envisaged and enumerated include defined elements of curative care, prescribed drugs and diagnostic test. Maternity care for up to four live births for every insured person; preventive care, including immunisation, family planning, ante natal and post natal care, etc. The opposite is the reality that enrollees are confronted with.

Like everything Nigeria, the actualisation of universal health coverage for all Nigerians, particularly children, women, vulnerable groups and the unemployed across the country remains a mirage. Good thing the NHIS Executive Secretary Yusuf, has admitted these shortcomings on the part of the agency. It is a scandal that only 4 per cent of Nigerians are currently covered by the scheme, as against 60 per cent in our neighbouring countries.

The advantages of the NHIS – ‘pooled resources’ - for the benefit of all within the scheme, that will ensure equitable distribution of health care costs among different income groups, adequate distribution of health facilities, efficiency in health-care services, both in the public and private sectors, will never accrue to Nigerians due to unbridled greed. The battle line seems drawn between Usman and the HMOs, considering his resolve to recoup what they owe the agency and the hospitals. 

Moving forward, the NHIS management owes it to Nigerians to enforce the registration requirements for the HMOs. Any HMO without evidence of financial viability and insurance cover should be blacklisted. In the light of the revelations of ghost enrollees, the full disclosure of ownership has become imperative, as stories are being peddled of big wigs in the Federal Ministry of Health being the real owners of the HMOs. The HMOs are their automated teller machines. And it never runs short of money.

•Emmanuel Ado writes from Kaduna. He can be reached via mayad497@yahoo.com

Source News Express

Posted 10/04/2017 2:31:08 PM

 

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