NHIS Capitation to be made national end of year
The National Health Insurance Authority (NHIA) will by the end of the year roll-out the Capitation Provider Payment method under the National Health Insurance Scheme (NHIS) across the country.
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Presently, the NHIA has extended the capitation to the Volta, Upper East and Upper West regions with beneficiaries of the scheme selecting their Preferred Primary-care Providers (PPP).
Preferred Primary-care Provider (PPP) is the healthcare facility a subscriber chooses to receive medical treatment from. The system allows for referrals to higher level healthcare facilities should a patient’s condition require that.
The PPP enrolment in the three regions, according to the acting Chief Executive Officer (CEO) of the NHIA, Mr Nathaniel Otoo, began on July 2, 2015.
In an interview with Mr Otoo, who until his appointment in June 2015, was the Deputy Chief Executive responsible for Operations, he said “providers in the three regions were expectantly awaiting the capitation programme as they have been properly educated and sensitised to it for almost a year now”.
He said the capitation pilot programme in the Ashanti Region was 95 per cent successful and, therefore, the need to roll it out in other parts of the country.
Capitation in Ashanti Region
Capitation, which is one of the most effective and efficient healthcare provider payment systems, was implemented on a pilot basis in 2012 in the Ashanti Region. The scheme initially faced stiff opposition and challenges from healthcare providers in the region.
The opposition faced, Mr Otoo conceded, was due to lack of adequate education and sensitisation to the project in the region, a challenge he said was one of the lessons the NHIA learnt in the pilot programme.
He said after the pilot, real implementation began in the Ashanti Region and the extension of the programme to the Volta, Upper East and Upper West regions brought to four, the number of regions implementing the new provider payment method.
Under capitation, service providers are paid in advance, a pre-determined fixed rate to provide a defined set of services for each individual enrolled with the provider for a fixed period of time.
The amount paid to the provider is irrespective of whether that person will seek care or not during the designated period and it covers only primary health care for out-patient attendance.
Mr Otoo said the capitation programme had made public and private healthcare services readily available to people.
He said so far, 65 to 80 per cent of all private hospital attendants were NHIS card holders while 90 per cent of all attendance in public healthcare facilities were NHIS subscribers.
Advantages of Capitation
One advantage of capitation, Mr Otoo said, was that it guaranteed the service provider a certain amount of money at the start of every month depending on the number of subscribers enrolled in that facility.
The pre-payment of claims under capitation, according to the acting CEO, was, therefore, an incentive which he believed made it easier for service providers to forecast and plan their activities without worrying about delays in claims reimbursement from the NHIA.
He said the programme would also enable subscribers to get better services from their selected PPPs as they could change their healthcare providers after every six months should they find treatment substandard.
Challenges
Mr Otoo said the NHIA had had a fruitful engagement with the government and was in the process of paying providers for February saying that it would put the service in arrears of four months.
With a total active membership of 10,545,428, he said, the service was bedevilled with the issue of quick escalation of prices of medicines which constituted about 50 per cent of total NHIS cost.
Mr Otoo, who was instrumental in the review of the NHIS enabling law, said the scheme was coming up with a strategy to ensure a more cost-efficient medicine regime and added that the introduction of the capitation would help stop people from “shopping around for medicine”.
Financial sustainability
On financial sustainability, he said, with prudent investments, the authority had managed to cover some of its costs but as the number of subscribers kept increasing, it had become difficult for the scheme to keep up with its financial obligations.
To this end, Mr Otoo said, they were looking at ways to diversify and increase its sources of funding and was, therefore, exploring options such as linking up with telecommunication companies as well as banks who used NHIS database for verifications to generate further resources to support the scheme.