New NHIF measures will erode the gains made in healthcare

The main problem for the NHIF is that it is choosing to do too many things, some of which it should not even be venturing into. FILE PHOTO | NMG 

By EDWARD OMETE

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Summary

• Complaints with the outpatient capitation care in particular have seen many physician-staffed facilities pull out leaving less than three per cent offering doctor consultations in the OPD.
• The chief question is how medics can provide for the health needs of a patient at Sh300 for four months. This amount is meant to cover consultations, diagnostics and medicines.
• From an actuarial perspective, it can only work where efficiency is high and huge volumes of patients are channeled to such a facility, achieving a low-margins-high-volume model.
• The new strategy to expand accredited facilities means fragmented patient pools and barring magic from these facilities, a certain loss-making period.

The decision by the National Hospital Insurance Fund (NHIF) to cut down on some services it previously offered is a double-edged sword that could erode gains it had made in winning over customers.

Complaints with the outpatient capitation care in particular have seen many physician-staffed facilities pull out leaving less than three per cent offering doctor consultations in the OPD. The chief question is how medics can provide for the health needs of a patient at Sh300 for four months. This amount is meant to cover consultations, diagnostics and medicines.

From an actuarial perspective, it can only work where efficiency is high and huge volumes of patients are channeled to such a facility, achieving a low-margins-high-volume model. The new strategy to expand accredited facilities means fragmented patient pools and barring magic from these facilities, a certain loss-making period.

What is making it harder is also NHIFs inability to adhere to set financial and contractual timelines as was exhibited in the previous financial year.

Three affected services of the scheme are imaging, surgeries and renal care. Though previously hailed by renal physicians for including dialysis as a fully covered item with sessions based on the patient’s outcome and the physician’s discretion, this new directive will leave both the patient and the insurer none the better.

In medicine the adage half a loaf is better than none does not apply. Due to limited dialysis sessions, if a patient does not recover, the insurer still pays for the few session given.

If they deteriorate because of this they now become inpatients where the insurer will again have to pay for the bed stay. Essentially, this translates to the NHIF having paid twice for a service they would have paid for once.

In the unlikely event of a demise of the patient due to deterioration of renal function, especially for civil servants, the NHIF will have to pay for the life component of the cover. The main problem for the NHIF is that it is choosing to do too many things, some of which it should not even be venturing into. The life component in particular is baffling. For a struggling insurer with a product priced almost ten times below the market average, how it hopes to meet its financial needs is hard to envision.

Either the product is to be repackaged or the premiums raised. The anticipated increase in members of the public joining the scheme will also not help, if the fundamental flaws and hiccups experienced by the stakeholders are not addressed.

What do patients desire and what are service providers not happy about? Once these two are addressed a long term win-win situation will be arrived at.

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