By Jereaghogho Efeturi Ukusare
Health Management (or Maintenance) Organisations (HMOs) are companies that provide or arrange managed care for health insurance, self-funded health care benefit plans, individuals and other entities, acting as a liaison with health care providers – hospitals, doctors et cetera – on a prepaid basis.
In Nigeria, HMOs are expected to deliver quality health care to a designated population in a cost effective manner through health care providers that are paid either a fixed budget or discounted fees. The value-driven system is one of managed care, to provide affordable health services. The financial burden or the risks of over-using health services are borne by the HMO, it’s service providers or both. There exists various explicit and implicit rules which governs the risk-sharing. The member must receive health care from an HMO approved provider.
HMOs have exclusive provider networks. On certain occasions, they also use primary care providers (PCP) as gatekeepers. Gatekeepers are responsible for arranging a patient’s referral to a specialist or admission to a hospital.
In 2017, Nigeria’s House of Representatives’ Committee on Health Care Services organised a two-day investigative hearing where Nigeria’s Minister of Health Prof. Isaac Folorunsho Adewole revealed that the sum of N351 billion ($1Billion) had been expended on health management organisations (HMOs) so far without commensurate result. The Government of Nigeria pays 5% of consolidated salary as a premium to NHIS which in turn pays HMOs. By law, 70% of this fund is required to be paid immediately to health care services providers to provide care for those paid for. Failure to make immediate transfer is a punishable offence by law. It is pertinent to note that there is immense private sector participation in this scheme as there are 59 HMOs in this country.
It is mind boggling that this revelation was made last year and up till now no action has been taken to punish offenders in the system. No HMO has been sanctioned. No service (care) provider sanctioned. This deliberate silence quickly brings to mind the pathetic nature of the corruption in Nigeria. More than 70 new born babies and over a 100 women die daily from avoidable mortality despite the fact that they are on the National Health Insurance Scheme.
It is still not clear what exactly is going on at this time. However, one thing is clear and it is the fact that it is only in a corrupt society that a huge amount of money as this will be embezzled or mismanaged and the culprits will walk away free. The misery of the Nigerian masses will only be continually magnified by the mysteries of the disappearance of this money as justice is not served on the masterminds.