Gorah Healthcare Limited Managing Director / Managing Director Mr. Michael Olayinka explains how the health insurance scheme works in this interview with NIKE POPOOLA
What are the challenges of achieving universal health coverage in Nigeria?
There are many challenges. These include the mismanagement of the program by the federal government, the lack of adequate legislation, the lack of understanding of health insurance and how it is successfully practiced in other parts of the world. . There are also differences in the perception of each state government on the need for universal health care for their citizens. Other factors are low funding for primary health care, unemployment, poor knowledge of general principles of health insurance, cultural and religious beliefs, poverty and a rigorous accreditation process for promoters of health insurance activities. the health maintenance organization in Nigeria.
How does the National Health Insurance Scheme work?
The National Health Insurance Scheme is to provide social health insurance in Nigeria to all people residing in Nigeria. The health services of (registered) plan contributors are paid from the pooled fund contributed by plan members. Health maintenance organizations register people in the program; registrants pay a premium to the HMO while hospitals (healthcare providers) provide health services to registrants and send medical bills to the HMO for payment from the pool of funds generated by the premiums paid by registrants. The NHIS also regulates private health insurance plans operated by HMOs.
Nigeria’s average life expectancy is low compared to many advanced countries. How can health insurance be used to increase this level?
Nigerians’ life expectancy is low as many people die needlessly in the country because they do not have easy access to quality health care when they need it.
Affordable and effective health insurance coverage will ensure adequate medical care when they need it. It will also provide them with the annual well-being medical check-up that will identify any health problems before it is too late.
GORAH healthcare plans provide access to information, raise awareness of healthcare, and reduce the incidence of alternative medical treatments and self-medication.
What do you think the advanced countries have done well with their health insurance system that we have not been able to do in Nigeria?
Our Nigerian health sector leaders have not been able to put in place a comprehensive and universal health policy for the people. There is no trusted health system or organization for the effective management of health service delivery in Nigeria. The huge annual health care figures in the regular annual budget do not reach ordinary citizens in need of medical care and medical education in Nigeria is limited.
We also need to deploy technology that will enable people in rural areas to access health care effectively. The government at all levels should provide health services while the structure of health care delivery should be simple and close to ordinary people. There is a need to increase human resources in the health sector to meet the changing health needs of the growing population.
What is the level of health insurance penetration in Nigeria?
Nigeria’s health insurance penetration level is less than five percent. Fewer than 10 million Nigerians currently have health insurance.
What can the government at different levels do to ensure better coverage of Nigeria?
Local government can provide many more primary health care centers that will be easily accessible to communities in local government areas. The state government can provide more funds to support hospitals, teaching hospitals and health centers to improve their capacity to care for more patients. At the national level, there should be an increase in the supply of health care in the annual budget for all geopolitical areas of the country.
How much does it cost to get health insurance coverage?
Health insurance is not expensive to buy. The lack of understanding of most people in the country precipitates their perception that Medicare is expensive.
Health insurance is much cheaper than the cost of obtaining proper medical care.
People think it’s easier to get quality treatment when you pay your hospital bill directly than when you get treatment through health insurance. What do you say about this?
Health insurance guarantees quality treatment for people enrolled in the HMO at primary and secondary health care provider levels.
The use of HMOs is essential in emergency situations when money may not be available. Health insurance creates a medical community with effective networks of health care providers who are responsible for their well-being.
Health insurance provides the tool to manage family and business budgets effectively. It allows registrants appropriate access to modern medical practice which guarantees rapid recovery.
HMOs and healthcare providers typically compete for premiums and payment for services. How does this affect the quality of health care?
HMOs have two different contracts with the two groups of people; one with the registrants and the other with the carers. Both relationships have risk management issues.
If the risk assessment is not adequately managed, the HMO will not be able to meet financial obligations to the healthcare provider when claims for reimbursement are submitted for payment. And when there is a failure to promptly pay medical claims, healthcare providers will be reluctant to provide additional medical care to registrants, thereby minimizing their exposure to the failed HMO. There will be poor service for registrants who in turn will respond to HMOs. These are the main sources of conflict between HMOs and healthcare providers.
Why can’t health insurance plan meet chronic health needs like cancer, liver, kidney problems, among others?
The health insurance plan addresses chronic health needs if they are declared at the time of registration with the HMO. These needs are called pre-existing conditions of registrants.
The HMO assesses the risk of each condition and revises the premium upwards to account for the additional risk resulting from the member’s pre-existing conditions.
In some cases, these conditions are not declared to the HMO at the time of registration.
At Gorah HMO, what products have you introduced to make health insurance accessible and affordable?
Gorah Healthcare Limited has introduced five major health insurance products to the Nigerian market. These are the Gorah Business Plan, Gorah Standard Plan, Gorah Silver Plan, Gorah Gold Plan, and Gorah Prestige Plan.
Gorah Individual Plans include Basic Gorah Plan, Gorah Life Plan, Gorah Premium Plan, and Best Gorah Plan.
We have the Gorah Senior Citizens plans (for people over 60) which include the Gorah Diamond plan and the Gorah Platinum plan.
There is the Gorah Student Plan, Gorah International Plan and Gorah Customization.
All GORAH health plans are available for customization. We do this in two ways. Customers can request additional benefits from any of our standard products for a higher premium (for example, additional benefits from our Gorah Silver plan will be customized as Gorah Silver Plus). The other way is for clients to enter their medical budget for each staff and have Gorah customize the medical benefits for each category of staff.
In addition to business services, do you also provide services to individuals and family units?
Yes. Our Gorah Individual Plans, Gorah Senior Citizens, Gorah Students Plan, and Gorah International Plans are all individual health insurance plans.
How do you monitor health care providers to make sure they are providing quality treatment to your registrants?
We regularly organize a forum for healthcare providers where we share our vision and our mission with our providers and the feedback from our registrants.
We also perform a medical audit of randomly selected healthcare providers. Our medical unit visits hospitals on an unannounced basis and reviews some of the registrants’ files for compliance and verification.
We also make sure to pay our healthcare providers promptly. Once we receive their complaints, we carry out the necessary control (by our complaints management unit) after which our accounting and finance unit audits the complaints. Approved claims are paid subject to observation through the Company’s verification and audit process. Healthcare providers are informed of the reasons for non-payment of any claim.
We also receive regular feedback from our registrants and do a random sample of registrants who have visited hospitals to verify their visit and the medical services they have received and to record their experience and evaluation of hospitals.
What advice do you give to employers and the self-employed on purchasing health insurance?
My advice to employers is: consider the health of the workforce as a critical factor in the growth and development of the business. Health insurance is a proven means of financing health care around the world. It allows employers to manage the medical budgets of their staff and ensure the well-being of their staff and family members at all times.
The employer must have health insurance for all categories of staff at all times. Indeed, the new law on health insurance (which was adopted by the National Assembly on April 17, 2019) requires all employers, including private sector employers, to have health insurance for their employees.
Registered self-employed workers can also benefit from health insurance by obtaining the appropriate health insurance package and maintaining an adequate annual welfare check provided by most HMO plans.
In this way, the self-employed will continue to operate at a very high level of productivity while effectively managing their annual medical budget.
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