Is health insurance hampering quality care?

The introduction of capitation as a provider payment mechanism may well reduce reimbursement costs for primary healthcare services, but will it also improve quality care as claimed by the National Health Insurance Authority (NHIA)?

At the recent national stakeholders’ forum at GIMPA, Dr Cheryl Cashin, a health economist of international repute, said: “Capitation can play an important part in cost containment for the NHIS,” and called on stakeholders in Ghana’s health service delivery system “to make it work.” 

Capitation is a provider payment method in which providers in the payment system are paid, typically, in advance a pre-determined fixed rate to provide a defined set of services for the individual enrolled for a fixed period of time. It has been piloted in the Ashanti region and is due to be scaled up in the Volta, Upper East and Upper West regions this year. 

Speaking to a district medical practitioner, there is obviously real concern that inadequate and delayed reimbursements may further worsen the prospects for providing quality  care, even under capitation. 

Sounding frustrated, the doctor lamented how despite submitting January 2014 claims as far back as February 14, 2014, the hospital had still not been reimbursed for services rendered in September 2013. 

In the event, while some suppliers had stopped offering services, others had threatened to sue the hospital, while other suppliers hung on fairly “certain that the money will eventually come.” 

On capitation specifically, this same doctor reflected on how “At least, according to the information we have been given, every month, the primary care services will be catered for, hopefully without delay. 

My only real fear is that once some advance payment is made to us, the NHIA will go to sleep and even take longer than the current six months to reimburse us for the rest of the services which we would have rendered for in-patient care. 

As you know, these costs are significant and may impair our ability to comprehensively provide services. I also hear the reimbursement is itself inadequate. At the end of the day, it is really important to pay promptly as enshrined in the legislative instrument as a lot of health institutions are really suffering.” 

Overall, the NHIA’s past behaviour regarding significant delays in reimbursing claims, coupled with explicit decisions on clinical matters, have left a sour taste in the mouths of some providers who have in turn slammed the NHIA for encroaching on the professional space of health workers and allegedly compromising patient care in the process.

Health professionals cite several instances where the NHIS purportedly took decisions to strengthen the claims process but ended up with the perhaps unintended consequence of dictating how doctors should care for their patients.  

Speaking to a doctor with over 30 years of clinical experience, he queried instances where doctors had prescribed antibiotics to treat eye infections acquired by babies during the delivery process only to have the NHIA refuse to reimburse same because “it is not part of the delivery process.” In its aftermath, doctors have prescribed the required medication for the patient to purchase directly–(resulting in co-funding) which the NHIA frowns upon. In some cases, hospitals have simply supplied the drugs and absorbed the costs or where the patient was unable to afford the prescribed medication, treatment had been forfeited altogether.  

In other instances, the NHIA allegedly refused to reimburse for patients diagnosed with gastritis and treated with antacids (used to reduce the effect of stomach acid secretion) on the basis that “dyspepsia” instead had not been diagnosed.

 As it turns out, gastritis or inflammation or irritation of the stomach lining and dyspepsia as a more general term describing pain or discomfort in the upper part of the gastrointestinal tract may both have antacids being correctly and legitimately used to cause relief for the patient. 

The fact that on the scheme side such decisions on “technical clinical” matters are left to be enforced by “non-technical” claims, officers appear to have created a strain between some prescribers and claims officials. Additionally, health professionals have certainly raised concerns about the processes used by the NHIA in arriving at these decisions bordering on clinical care, describing same as largely non consultative. Explanations provided by scheme authorities that doctors are often consulted, coupled with the significant representation of the Ghana Health Service within the NHIA, have proved far from convincing to some of the health professionals.   

Citing the case where the NHIA allegedly only acknowledges black water fever and cerebral malaria as complicated cases of malaria and pays for them as such, some doctors wondered how a diagnosis of a case of malaria with severe anaemia could be considered as anything but complicated. With the NHIA not fully reimbursing for the resources used in managing such cases, the hospital was put in a position of having to offer the full range of care at a loss, pursue copayment or to offer only the level of care that the NHIA was willing and able to pay for thus raising quality concerns. In theory, therefore, if the NHIA pays an unrealistic fee, the healthcare provider may then be put into the position of determining whether or not to conduct a laboratory test to confirm suspected malaria or to simply proceed with treatment on the basis of clinical suspicion only. If conducting a laboratory test will escalate costs beyond the rates reimbursed by the NHIA, then your guess is as good as mine as to who will suffer – between the NHIA, the provider and the patient! 

 In all cases, a medical superintendent’s concern was that by reimbursing facilities for far less than the resources used in treating the patient, while simultaneously frowning on copayment, the NHIA was creating an untenable situation which had ultimately created a system of compromised quality care. 

Other services that in providers’ view the NHIA did not pay for, although it claimed that it was part of bundled services, included “giving set, gloves, oxygen, suturing materials etc.,” adding; “they claim it is bundled but we spend far more resources than anything they reimburse us.”

The NHIA has in times past expressed great frustration at what it views as the unfairness of being held responsible for all the major challenges of the health system, including those outside its mandate. Typically, while health professionals have queried why the NHIA does not reimburse for blood transfusion services although post-partum hemorrhage is a leading cause of maternal deaths, the NHIA has replied that the mandate for ensuring reliable supply of blood lies within the National Blood Transfusion Services.

Explaining the fate of a woman who needs blood, a district doctor in the Volta region explained that the hospitals secured blood from the Korle Bu Teaching Hospital where it pays for “handling charges” which are then passed onto the patient. In other instances, the hospital organises blood donation campaigns where voluntary donors from schools etc. are relied upon in addition to patients’ relying on “community blood contractors” when both measures above fail. 

In conclusion, the NHIA may have to carefully consider whatever processes it currently uses to arrive at decisions, with a bearing on clinical professional practices in order to deal with the perception that it is meddling with quality care. Secondly, the planned exercise aimed at providing an evidence base for determining realistic costs as reported by the Ghana Health Service is a step in the right direction. 

Thirdly, the Ministry of Finance has to do a much better job of swiftly transferring national health insurance levies to the NHIA for prompt payment to the providers for services rendered.

On all those borderline instances where the use of professional discretion may lead to quality care being compromised, service agencies of the Ministry of Health and professional associations may have to reassert their mandate of upholding sound professional practices among their own members in the best interest of the patient while active monitoring is instituted at all levels. 

Finally, all the big players – NHIA, National Blood Transfusion Services, National Ambulance Service etc. – need to create a coordinated platform where they, together with patient groups, will engage in affirmatively disruptive conversations that place the patient at the centre of all their considerations in order not to create a system where compromised quality care would simply become a matter of course. 

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