NHIF portability will not happen any time soon

It is unlikely that NHIF will roll out portable medical care in the near future. FILE PHOTO | nmg
 By ANNE NDUNG'U

It would have been the ultimate trade off: portability but limited outpatient visits. Giving with the left hand, the National Hospital Insurance Fund (NHIF) late last year simultaneously sought to take with the right and it was not an unreasonable strategy.

Portable medical care comes with many advantages, the first being an improvement in access to medical attention.

The difficulties that transpire when people fall sick far away from their chosen outpatient facility would have been resolved and it would also have catered for personal choice by allowing beneficiaries to choose the best doctor for a particular ailment.

There are drawbacks however, which made NHIF seek to limit the number of visits. Portability necessitates a renegotiation of payment terms with contracted health facilities and it also heightens the risk of fraudulent activities.

The debacle that followed forced NHIF to revert to its old system of limiting beneficiaries to their pre-selected facilities.

This incident sheds some light about future NHIF outpatient plans. For one, it is unlikely that NHIF will roll out portable medical care in the near future. Under the current system, NHIF uses full capitation to pay accredited outpatient facilities.

It makes quarterly upfront payments to service providers for the treatment of each person registered at a facility whether or not the beneficiary seeks medical services. The amount paid is usually an average adjusted using various weights to cover for their expected medical needs.

READ: Meridian clinics sue NHIF for Sh1.5bn

Portability would cause a disruption of this current system and force the public insurer to adopt another type of capitation.

Anything touching on its financial processes, claims system and method of payments would be too complex and would require a pilot rollout followed by gradual implementation of the same.

Let’s not forget service providers who play an important role in capitation because they absorb part of the risk associated with treating patients.

A change to another capitation model would affect their systems and necessitate training which would take time. The fee-for-service model is also out of question as it volume-based and therefore too expensive.

It is also highly unlikely that NHIF would dabble in emerging Alternative Payment Models such as bundled payments.

Another factor that makes portable medical care difficult to implement, though not impossible, is the fact that NHIF has stated that it will finish rolling out the installation of biometric devices in all its accredited facilities in three years.

Limiting outpatient visits was a built-in control to contain embezzlement. Without these administrative and technological safety nets, NHIF would be unable to rein in fraud.

While this whole experiment is proof that NHIF is awake to the realities of market demand, and that it is willing to adopt new approaches. It is also indicative of a painful public health insurance reality, that change doesn’t come easy or fast.

Primary healthcare is integral to a country’s public health system as it is normally the first port of call for a patient.

If done right, it can create all manner of positive outcomes, such as early detection and prevention of diseases and a reduction of costs in other areas, such as inpatient, that tend to consume more resources. It is therefore an important area for NHIF.

Anne Ndung’u is communication specialist.