‘We’ve set up a committee to sanction culprits’

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Lekan Ewenla, Publicity Secretary, Health & Manage Care Association of Nigeria (HMCAN)

In a bid to solve the current problem in the health sector and for better compliance to set standards, The Health & Manage Care Association of Nigeria (HMCAN) has set up a joint disciplinary committee to begin to sanction offenders. In this interview with Franka Osakwe, Publicity Secretary of the association, Mr. Lekan Ewenla, throws more light on the cause of the conflict in the association, why the disciplinary committee was set up and the best way to handle the conflict among others. Excerpts:

Why set up a new committee on health insurance?
If you have been following up on the development in the industry in the last few months, you will see that there have been a lot of challenges, a lot of issues. This association, that is, the Health & Manage Care Association of Nigeria (HMCAN) was set up in 1998 to self-regulate and set standards for the Health Maintenance Organizations (HMOs). Because this scheme was designed and was meant to be private sector driven such that the federal government will regulate, private sector will drive Health Insurance Scheme to Nigerians utilising the services of both public and private hospitals.

Now, there has been private health insurance in the country as far back as 1992/93. HMCAN was set up to self-regulate the industry and in the last couple of years, we’ve had a lot of issues of conflict/confusion with the healthcare providers. We now said okay, the best way to address all of these issues is to carve a joint committee of Healthcare Providers Association of Nigeria and HMOs.

All the healthcare providers that are providing services on the public and private sector scheme must be accredited by the National Health Insurance Scheme (NHIS). Also, whoever is going to run an HMO in this country must equally be accredited by the NHIS. So what that translates to is that before any private or public hospital could be seen providing services on the platform of health insurance in this country, you must be NHIS accredited.

For the scheme to now run smoothly, the healthcare providers now came together to form an association of Accredited Healthcare Providers in the country. So that means any provider that is providing services on the health insurance scheme or platform must be accredited by NHIS; must be a member of the association.
So also with the way things are today in Nigeria, whoever is accredited by the NHIS as an HMO, whether you belong to this particular association or not, you must comply with the set standards, you must comply with whatever standard we have put in place because I tell you if you don’t comply with that set standards, that means you can continue to do whatever you like on your own and you can continue to discredit the other HMOs.

We’ve had cases in this country where HMOs will give enrollees to hospitals, those hospitals will provide services, send bills to the healthcare providers, and the bills won’t be settled by that HMO. Part of the issues that was raised by the suspended Secretary of NHIS was that the HMOs are bad, they don’t settle bills. So, long and short, what brought us to this level today, we set up this committee sometime last year, October precisely, and since then we’ve met twice but today’s meeting was designed to reinvigorate the association and to now begin to take the bull by the horn and not only to be seen being barking, we want to start biting and that’s why we call this meeting.

So we’ve now arrived at that terms that: Any HMO that is found not settling the bills of the hospitals based on agreed terms must be reported to this committee and once that HMO is reported to this committee, it will take this committee 30 days maximum to meet with that HMO. Same thing with the healthcare provider, if any provider is found culpable or found wanting, the HMO should also report the healthcare provider to the committee. It is the responsibility of the committee to now invite the healthcare provider within 30 days. After those 30 days, the facility will now be queried and whatever the outcome of that query is, will be sent to the national body, the National Health Insurance Scheme as regulator.

What’s the name of the association and could you throw more light on these terms of agreement?
The name of the committee is a Joint Ethics or Standard Compliance Committee. The terms of agreement is that from today, all the HMOs must work strictly by the operational guidelines that was developed by the NHIS. So, bills are meant to be paid within 30 days. All HMOs must comply with the directive. If a hospital sends their bills to the HMO, counting from the day the bill is given to HMO 30 days maximum, that was the instruction, HMOs must be seen settling that bill. If the HMO does not settle that bill, this committee suggested that maximum of two weeks moratorium should be added to those four weeks making six weeks. Failure for the HMOs to settle that bill, the healthcare providers should stop seeing their enrollees from that particular HMO and now do their report to this committee so that the committee can sanction.

The aim is to monitor the compliance standards, the compliance parameter by all the HMO and Healthcare providers. So, based on the operational guideline, all conditions, all parameters, all standards that were set in that operational guidelines must be seen complied forthwith; any HMO that does not comply with it should be reported to the committee. Then the committee will sanction.

If laws are set up and developed, it has to be complied with. So there is a standard operational guideline that was developed for this industry to be complied with by those that are critical stakeholders. When we say critical stakeholders we are talking about the HMOs, the Healthcare providers, they are both accredited by NHIS. If you are not accredited you can’t be a service provider.

Some people have not been complying with this and that’s why we have this issue of bad image, issue of blackmail. But as the key driver of health insurance in this country, we have decided to now take ownership of the business; we have now decided to take control of the compliance of set rules in the industry. So, whoever is seen not to be complying, we would castigate our decision to the regulator.

So it is not all HMOs that are actually registered under this platform?
Yes the picture is clear. Right now we have 59 HMOs, it is not all the 59 HMOs that are members of HMCAN. But our position now is this- as an association that was set up to self-regulate this industry, once you are an accredited HMO, you must be seen complying with the set standards. If you don’t we will sanction you because we wouldn’t say because you are not a member of the association we will allow you to continue to have a field day and continue to discredit the other HMOs that are doing things right. Don’t forget the fact that what brought us to this level was issue of the years of painting all the HMOs with one brush black and saying all the HMOs are bad, 59 HMOs can’t be bad. So it’s now left for us, we have now done what we call soul searching, we say we won’t wait for anybody to tell us who is bad, we now need to sanction those that are bad in the system so that we won’t allow them to continue to blackmail and discredit us that are good.

Let’s face reality here, if there are 59 oranges in a basket and two or three are bad, if they are not quickly identified and removed from that basket, they will spoil the entire oranges. So that’s what we are doing now. We are ready to sanction those HMOs that are bad and we demanded that the healthcare providers should feel free to report HMO to us. As a matter of fact, if NHIS should see that any HMO is not doing the right thing, they are at liberty to report that this HMO is not doing good. We will call the HMO straight away and we will sanction it.

In reference to this, what are Nigerians going to benefit?
We want Nigerians to begin to have value for their contributions on the health insurance platform. The era and the issue of enrollees on this scheme being treated like lepers, we want to eliminate it. We want to completely eliminate that, we want to get it right. So, whatever might be the cause of the enrollees not being given the desired quality of care, we want to identify it and convert it to opportunity.

What is the central message?
The central message now is that HMCAN has reinvigorated their joint disciplinary committee to begin to sanction whoever is found culpable and without minding whose ox is gored. It is not going to be the case of a sacred cow, we won’t spare anybody.

So any HMO that is found culpable would be sanctioned by us and we’ve now mandated even the enrollees too to now report their complains to the committee at the secretariat. All critical stakeholders, enrollees, Healthcare providers, HMOs we are now on the same page and the same paragraph. Any HMO that is found wanting should be reported to the committee we will deal with it within 30 days. This committee was set up last year, and this is our third meeting and this third meeting was called to reinvigorate the capacity of the committee so that we will now begin to look at issues critically and begin to sanction accordingly.
The clarion call now is whoever that is HMO now it is either you are a member of this body or not, it is not an issue, but you must learn to do the right thing, failure to do the right thing, you are sanctioned.

Why are those hospitals not in HMOs?
They are not too many of them I tell you. There is no any facility that is not part of the health insurance scheme, there are not too many. Majority of them probably don’t even understand the concept that’s why they are not part of it. You see, the health insurance scheme is a global phenomenon. We took this decision based on the fact that we are exposed to the international concept of health insurance, we have seen and we know that whatever we do in Nigeria today is a global thing. So whatever the challenges are that is drawing us back we are here to address it.