Soaring cost of tests, treatment threatens NHIS

…as more providers exit scheme

Many private health providers under the aegis of the Association of Nigeria Private Medical Practitioners (ANPMP) have pulled out of the National Health Insurance Scheme (NHIS), with many more signifying the intention to quit over rising costs of treatment, Business Hallmark can report.

The providers grouse, BH, learnt, is fuelled by the refusal of Health Maintenance Organisations (HMOs) to effect an upward review of the existing tariff plans for services rendered by providers to subscribers of the scheme despite rising cost of treatment.

Based on the National Health Insurance Scheme Act of 1999 that set up the insurance scheme in 1999, and the new National Health Insurance Act (NHIA) 2022 meant to enhance it, the nation’s health insurance scheme operates through three arms, the National Health Insurance Authority (NHIA), HMOs and Health Service Providers (HSPs).

While NHIA oversee and regulates the scheme; HMOs are the middlemen between Health Service Providers (HSPs) and the NHIS.

After HSPs have rendered medical services to subscribers, NHIS disburses funds to HMOs every three months to pay the health service providers monthly for the health services rendered to patients, who subscribed to the health insurance scheme and visit the hospitals for treatment.

However, the scheme is currently facing an existential threat with the about 14 million Nigerians enrolled on the platform risking losing their insurance cover as the feud between HMOs and private health providers lingers.

It would be recalled that ANPMP and the HMOs had for some time been having a running battle over the refusal of health maintenance organisations to offset the huge backlog of debts owed ANPMP members, as well as their refusal to approve an upward review of existing tariffs paid to its members.

The disagreement between the two worsened recently, with the umbrella body of private health practitioners asking all its members across the country to stop rendering services to patients with insurance cover from August 2024, if the HMOs failed to increase their tariffs and renegotiate service agreements with its members.

Part of their demands include the upward review of their tariff from the present rate of between N3,700 to N4,000 for the treatment of malaria.

According to BH findings, current cost of treating a patient has ballooned beyond what HMOs currently pay providers,

For instance, while the average cost of laboratory tests for detecting common ailments like malaria, typhoid and sugar level in the body is in the region of N2,000 to N5,000, depending on hospitals and laboratories, malaria drugs start from N1,500 (for quine based drugs, which most Nigerian facilities rarely prescribe) to N3,500 upward (for artesunate based drugs), depending on the maker.

Apart from these, associated costs like energy, medical waste disposal, equipment purchase and maintenance, as well as workers wages and allowances have skyrocketed.

The medical director of a medical facility in the Ifako-Ijaiye area of Lagos, who did not want his identity revealed, lamented that it cost at least N8,500 to treat malaria using the cheapest drugs and laboratory test.

“I don’t think you can do any malaria test for less than N1,500 today anywhere in Nigeria. By the time you add the cost of consultation, treatment, drugs and other costs, you are talking of between N7,500 to N15,000 at the least.

“Also, the cost of disposing medical waste has gone up, while hospitals are charged commercial rates for electricity consumed by distribution companies.

“Despite being aware of all these, NHIA, through HMOs, have refused to review the amount paid to us, forcing us to collect N750 for one treatment.

“Whatever happens at the end of August ultimatum given to the regulating authority and HMOs, I have made up my mind to exit the program, as it is not worth it, not at all”, declared the medical director.

BH also gathered that participating hospitals still receive the same N55,000 for a caesarian section and N35,000 for each appendixentomy performed they were paid at the commencement of the programme in 2005.

However, the average fees paid for a caesarian section in major cities like Lagos, Abuja, Ibadan, Port Harcourt and Enugu is N450,000 and appendixentomy N350,000.

Due to the soaring costs of treatment, many hospitals that can not afford to leave the scheme have devised several means of pushing the cost of treatment to patients.

For instance, many subscribers complained to our correspondent that their providers now refer them to laboratories and diagnostic centres for tests after stopping to conduct tests in their facilities.

“The last time I visited my clinic, I was told to go and do tests outside. However, I noticed that the new arrangement affected only patients that subscribed to the National Health Insurance Scheme.

“Tests were conducted for private patients in the hospital, who readily pay up the high bill of N5,000 to N75,000, depending on the test.

“I plan to change to a public hospital, where tests are done largely for free as I can no longer afford to continue with the new arrangement”, Mrs. Sola Ojo, an NHIS subscriber told our correspondent.

BH also learnt that some providers have also started sending patients enrolled on NHIS using their hospitals to pharmacies, where they purchase drugs and medical needs with their own funds.

Speaking on the development, the President, Association of Nigeria Private Medical Practitioners, Dr. Kay Adesola, threatened that members of the association will pull out of the national health insurance indefinitely at the expiration of the notice given to concerned bodies and government agencies.

According to the ANPMP president, government has refused to response to their demands for a tariff increase that reflects the rising costs.

“Change in price occurs almost daily. Nigeria has not witnessed price somersault as it has done in the last two years.

“No cost of medication, medical consumables, medical devices, medical equipment, food items and general cost of living has remained the same.

“Energy bills alone account for more than 40 percent of hospitals’ overhead costs. While Nigerians are adapting and adjusting to spending more for everything else in the environment, hospitals and clinics are rather expected to charge less than they were charging despite the obvious course of inflation”, he noted.

The ANPMP president pointed accusing fingers at the leadership of the NHIA for failing to live up to its responsibilities of regulating the health insurance sector.

“HMOs are allowed to accept extremely ridiculous premiums they know will not pay for the providers’ services, just to secure the business.

“HMOs in negotiating premiums for the different insurance plans undercut one another, accept extremely ridiculous premiums they know will not pay for the providers’ services, just to secure the business.

“Such HMOs end up delaying claims payment, some fail to pay, others pay whatever they feel like paying and dare the providers. And yet, others have liquidated with the providers’ claims unpaid.

“This is why today, well over N15 billions of providers claims across the country is trapped with the HMOs under various guises. Following that outing, the HCPAN constituted a joint tariff review committee to actualise the proposed minimum service tariff, and today, here we are.

“We (health providers) have become burden bearers of the nation’s insurance project as due process, standards and accountability have been negated.

“Health insurance is managed care but the only way its principles can stand is when the conditions necessary to drive a successful health insurance scheme are met and they include appropriate premium pricing, appropriate service tariff pricing amongst others” the ANPMP president stated.