Dr. Kalada Richard is Managing Director of Mediplan Healthcare Limited. In this exclusive interview with Loveth Ezeugwu, Daniel Abraham and John Ameh, he talks on the issue of healthcare financing and the operations of Health Maintenance Organizations (HMOs) in Nigeria. Among others, he gives a fresh insight into medical quackery and what health insurance can do to reduce or completely eradicate it; alternative healthcare and the need for Nigerians to imbibe the culture of health insurance .He equally gave an insight on how they manage the issue of medical emergency situation in a case of referring their clients to a specialist. He talks also on the body that regulates the activates of HMOs in Nigeria.
1. What is Mediplan HMO all about?
MEDIPLAN Healthcare Limited is a Health Maintenance Organization incorporated in May 2000 in Nigeria to carry on the business of providing healthcare services to corporate organizations and members of the public, under a prepaid arrangement, utilizing a network of primary, secondary and specialist healthcare providers nationwide.
MEDIPLAN Healthcare Ltd is a GIANT in managed medical care delivery, and is duly accredited by the National Health Insurance Scheme (NHIS) as a National Health Maintenance Organization to participate in the National Health Insurance Scheme. Apart from the numerous corporate clients and individual policy holders, Mediplan provides health cover for the staff and their dependants of Federal Ministries.
Our goal is to elevate the quality of healthcare services to the highest level in the country at an affordable cost. It is in furtherance of this that our Company was established to fully participate in the provision of healthcare services in the country using Managed Care.
This is a system of delivering a set of healthcare services to defined voluntarily enrolled clients through a network of Healthcare Providers (HCP) i.e. hospitals, clinics, pharmacies, etc. This system ensures improved health outcomes at very reasonable cost. It is a prepaid scheme, in which payment for healthcare coverage is in the form of insurance premium, which is calculated as a fixed amount per person per annum.
2. In how many states are you operational?
Mediplan Health Ltd is a nationally accredited organization, we cover the 36 states of the federation including the FCT. We have regional and branch offices in Abuja, Kaduna and Gombe. Abuja is a zonal office in the north whereas the ones in Kaduna and Gombe are branch offices; they have their head office in Lagos and a Lagos zonal office also in Lagos. They also have Ibadan zonal office and Akure and Osogbo as branch offices in the South West. In port-Harcourt and Enugu the company also has zonal offices; all these offices are operating very well in those states.
3. What is your relationship with your health providers?
First of all, I will say our relationship with our healthcare providers is mutually beneficial, cordial and of course dynamic. In other words, we have our medical doctors, zonal medical managers who go to our providers for medical treat, utilization review, credentialing and they even interact with our providers to ensure there are no issues and where they are issues, we also respond accordingly
4. Who regulate the activities of HMO(s) in Nigeria?
The regulator of health insurance in Nigeria is the National Health Insurance scheme which is a federal parastatal but however, states are also allowed to have their state health insurance scheme that simply means they should operate in consonant with the national law but it simply means that if I have a federal enrollee or if I am running a federal programme as of today for example, we cover federal commerce sector also university students. It means that I will have to obey the rules, regulation and guidance that are being stipulated that runs the federal scheme. So if I have a state government that I am covering its enrollees and it has its own scheme and law which will not run contrary to the national law. I am also expected to also abide by its law. But overall, the regulator is the national health insurance scheme; it regulate both the public and the private sector.
5. In a case of physician negligence on the patient, who is to be held responsible?
The doctor is to be held responsible. That is why we do what we call credentialing. We do not just throw any provider into our network. Before we bring in any provider into our network, we must have gone through what we call a credentialing process. And also, no hospital came into existence just by will of I want to establish a hospital. There is FERMA; Hospital regulatory board in Lagos. Every state has its own. So if you look at it, everything is in place. Any hospital we want to work with must have that certification from the regulatory board and we also want to look at the doctors that are working there. Do they have the credentials they say they have? If yes, Do they have current license from Medical and Dental council to operate as a medical Doctor? .Also we look at the facilities. Do they have the right equipment and settings in and out? And if you have looked at all those things in our structure: process and of course the outcome. If you have checked all these things and they are in place, then we can be said to have done due diligence in our part. And as a medical doctor, I can tell you that sometimes things go wrong not because the person who attended to the patient is not capable, sometimes when you look at this, was it really a case of negligence? or is it something that could happen? If for example, the HMO has not done due diligence, then the HMO(s) itself cannot be absorbed because it means that it has not done due diligence to ensure that the patients or enrollees are safe guided, taking the right treatment in the right settings, given by the right person. So if you have not done that, then you cannot be absorbed totally. But if that has been done, definitely the provider is supposed to be held responsible. That is why there is what we call malpractice insurance. Every doctor is supposed to have malpractice insurance as an individual and if you are running a hospital, it also beholds on you to take malpractice insurance for the staff working with you because the owner of the hospital cannot be absorbed if something goes wrong. He too has to show that he has done what he is supposed to do to ensure that the right person is working there. If you do not have your malpractice insurance, it means you have to pay from your pocket which could be colossal and we do not pray for that.
6. Is mediplan involved in community health instance or any other specialized / specific health insurance?
Last year, we had to re-arrange our market strategy where we now look at breaking our prospects into categories; we looked at the public sector, Ops, market association, that is where community base insurance comes in, we equally look at schools and other institutions
In case of medical emergency situation, does the patient need a referral from the PC in order to see a specialist?
No, even though we require that secondary, tertiary care like admission, surgical cases, and specialized consultation should be referred, in other cases, they need referral authorization to refer the patient, but when it’s an emergency, we do not require that. We don’t even insist you take them to the hospitals that are under our network because when you are talking about medical emergency, you are about life or death.
7. What is medical emergency?
A medical emergency is any medical condition occurring which if not taken care of timel, can lead to death or permanent disability. And so you want to avoid those two. So in the case of emergency, we say rush that patient to the nearest hospital in that vicinity. It does not matter whether it is our network or not and we will take care because we have to save live first, it is an emergency. So within 24 to 48 hours, we are to be notified so we can come in and move the patient to the hospital but whatever has been incurred at the primary healthcare, we have to take care of.
8. Do you agree with suggestions that health insurance is one way to check medical quack in Nigeria and to what extent?
I totally agree with that 100%, .in fact that is part of the reason why I came to the health industry among other things; it has this property or ability to be able to in other words change the health seeking behaviour of our populace. You will agree with me that the average Nigerian when he is sick does not go to the hospital as a first point of call. First of all, she goes to the friend and says I have headache or my sister, my tommy is turning me. Then the friend will ask, are you having your menses? She says no. The other time, my stomach was turning me and went to the hospital, the drugs they gave me is still remaining. So we try self medication, friends or relation consultation. If that fails, then we move to drug peddlers and then rise to the level of the chemist. A lot of time, it is when things are going wrong, and then we run to the hospital and expect the doctor who is a human being to perform miracle but it is only God that does miracle.
So but in health insurance, what happens is different when somebody is covered under a health insurance policy. The question we need to ask ourselves is that why is that people don’t go to the hospital is that they are not well advised? No! It is what we call financial barrier, it is pocket matter, and the money is not there. Yesterday I took a patient to the hospital and they told us to pay N100, 000 admission deposit. Now the question is how many people can pay that just at the twinkle of an eye? Not many. And so people look at it and say this is expensive, let me see what I can do for myself. I probably do not need to go the hospital. And of course, that is a wrong choice because you are applying treatment without thorough examination. What you think is just a simple stomach ache can actually be a ruptured appendix which means it’s a surgical emergency that needs to be treated now or operated upon and then you are just there wasting time. So the problem is finance and so health insurance makes access to quality healthcare affordable and because people now know that it has been paid for or they have bought an insurance, so the issue of quackery does not come in again because it means they will not go to the quack isn’t it? In fact, when we talk about moral hazard that people have consumer moral hazard, that people have insurance because they know they are covered for any little thing, they run to the hospital. So you see now that they are not going to the quacks. So they are going to the right setting to receive the right treatment given by the right person, so health insurance 100% I agree is a solution to quackery
9. How would you rate the success of the scheme so far?
Generally speaking, it can be better. So right now, we have about 5% enrolments or thereabout. It can be better and so things are being put in place. The government has given a mandate to NHIS so we believe that before the end of next year, enrolment will rise from 5% to 30%.
But there are other things, there are other crises;/ when you talk about scaling-up, for example, if we have 30% enrolment, do we have capacity that can handle that?, are our providers ready to handle that kind of influx?.