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Recent developments in the implementation of the National Health Insurance Scheme (NHIS) |
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Written by Administrator
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Sunday, 28 December 2008 |
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The NHIS in recent times has opted for a health insurance scheme in which capitation payments made to physicians will cover not only their direct services, but cost of drugs and other indirect services such as X-ray diagnosis (see annexure A). By this arrangement, the physician will be expected to stock most drugs and only send out prescriptions to approved pharmacies for the few drugs he does not carry. The physician will then be responsible for reimbursing the private pharmacy for such few prescriptions filled.
| Recent developments in the implementation of the National Health Insurance Scheme (NHIS) | by
Pharm. (Dr.) U. N. O. Uwaga, FPSN, FPC Pharm
The NHIS in recent times has opted for a health insurance scheme in which capitation payments made to physicians will cover not only their direct services, but cost of drugs and other indirect services such as X-ray diagnosis (see annexure A). By this arrangement, the physician will be expected to stock most drugs and only send out prescriptions to approved pharmacies for the few drugs he does not carry. The physician will then be responsible for reimbursing the private pharmacy for such few prescriptions filled.
It is not realistic to expect private pharmacies and indeed other health professionals including specialists to individually work out reimbursement for services and credit supplies with doctor’s practices.
This system which puts money in the hands of the physician and leaves him to determine what drugs to stock and when to refer his patients for specialist care (for which he is expected to pay) is bound to compromise the quality of health service to the insured. With due respect to our physician colleagues, the decision to prescribe appropriate drugs and make referrals from bulk capitation paid in advance will be very dependent on the cash flow position of the practice. This system cannot guarantee that capitation (which is expected to be quite heavy) will not be diverted into other projects outside the scheme and in the personal interest of the physician
Pharmacists have been keen promoters of the team concept in Healthcare Delivery for the Scheme. To achieve this in the NHIS there should be a direct relationship with the National Health Insurance Scheme by members of the health team and they must be duly recognized as healthcare providers by the act of parliament Act 35 of 1999) establishing the Scheme. Capitation payment to physicians as primary providers should exclude provision of drugs and other consumables, X-ray, Laboratory, Specialist and other services. Payment for these services should be on fee-for-service basis as already entrenched in the relevant statutes and guidelines.
Prescribing and dispensing of drugs in the NHIS
In the current discourse many physicians expect that approved practices will carry their own stock of drugs and only send prescriptions out to pharmacies for those few drugs not in stock. The implication of this position is that prescribers will also be dispensers in the Scheme. This new development is very much in tandem with the dangerous manures of NMA to frustrate inspection of professionally inclined facilities in hospitals. (Annexure C). Pharmacists find this most unacceptable and have made special representations to the Federal Ministry of Health and the National Health Insurance Scheme. Reasons adduced for rejecting the position that physicians stock drugs and only send prescriptions to Pharmacies for the few not in stock are summarized thus:-
1. Prescribing and dispensing of drugs by the same person is inherently not in the best interest of the patient and may be exploitative. Such unethical acts encourage prescribing of only drugs currently stocked by the perescriber. The patient is therefore not always guaranteed the best drug for his ailment as less effective alternatives are prescribed thereby reducing quality of healthcare. The physician should be encouraged to prescribe what he considers best for the patient at all times.
2. Ethically, the prescriber of any medicine should not gain or lose financially from the supply of such medicine. Similarly, the person who dispenses should not liaise with a prescriber in order to deliver only drugs available in stock. One of the problems in healthcare today is that doctor carry drug stocks albeit illegally, thus eliminating checks and balances in prescription of drugs.
3. The persons who profit from the supply of medicines should also not decide directly or indirectly on medicines prescribed.
4. As a focus on healthcare delivery, dispensing should not be seen as purely commercial activity (annexure B). It is in fact a professional service of which the dispensed medicine is only a part. The Pharmacist’s training enables him to have a broad knowledge of the properties of drugs, their adverse effects and interactions with other drugs or food substances. The Pharmacist is therefore the best placed to offer patient counselling optimising adherence with physician’s prescription in a properly organized scheme. The Pharmacist reads and validates the prescription, checks that the dosage is safe and appropriate, looks for interaction between medicines, contra-indications and other factors which might render the medicines ineffective or harmful, advises the prescriber on possible misuse by checking Pharmacy records, keeps patient records as required, makes up special formulations, obtains medicines in a cost-effective manner, packs the medicines in a safe and suitable container, and labels the medicine with the physician’s directions and warnings or instructions that the pharmacist fees are necessary. The Pharmacist’s training and expertise, positions him to identify fake and substandard drugs, spurious, counterfeit and expired drugs which are a reality in our drug distribution system.
5. Where the physician prescribes and dispenses, the patient will surely lose the benefit of having the pharmacist check on drug-drug interactions drugs food, drug disease and dosage problems and errors in prescriptions which sometime occur with serious and irreparable consequences.
6. That physicians should carry their own stock of drugs contravenes the spirit of the provisions of the Poisons and Pharmacy Act of the Federal Republic of Nigeria which regulates the dispensing, compounding, mixing and sale or delivery of drugs and poisons in the country. Specifically, the provisions of Part III Section 7 and part 4 Sections 32 (i) & (2) of PPA Cap 535LFN 1990 are unambiguous about this.
7. For the improvement of quality of life of the citizenry of this country, there is a great need for statistical data on drugs and medical supplies. The pharmacist is indeed better placed to collect and make available such information, even if only for the appraisal of the National Health Insurance Scheme.
In full recognition of the ethics of their professions, physicians and pharmacists must jealously protect the patient from explorative practices which the Health Insurance Scheme seems to encourage.
Availability of drugs and approved pharmacies
It would be advisable for the National Health Insurance Scheme to have a critical appraisal on the issue of availability of drugs for the Scheme. To ensure optimum benefit from the investment of insured persons, employers and government, a need arises to reckon with the below listed factors.
Responsibility for ensuring that drugs are effectively managed within the Scheme should rest with pharmacist. The scheme should be supplied with drugs by approved manufacturers and importers at negotiated prices from whom approved pharmacies should obtain stocks fro dispensing to insured persons. The Petroleum (Special Trust Fund) once adopted this concept and it worked very well.
Criteria to be fulfilled by suppliers and pharmacies are listed for reasons already stated, physicians should prescribe and pharmacists dispense. The already reflected positions in Act 35 of 1999 and the operational guidelines is recommended for working out how approved pharmacies will be reimbursed directly by the Scheme.
A drug formulary should be drawn from the National Essential Drug List. This formulary would of be updated periodically by a working party comprising pharmacists and other care-providers.
Conclusion
For the avoidance of doubt, pharmacists firmly support the concept of a Health Insurance Scheme as a viable option to financing better healthcare services in Nigeria. They are however, not comfortable with modalities put in place at this point in time for the implementation of the proposed health insurance scheme.
Pharmacists believe that a Scheme which already has an enabling Act to back it, the NHIS must continue to do anything possible to carry along principal actors in the field of healthcare. For example, if the top echelon of the Pharmaceutical Society of Nigeria is not convinced on the National Health Insurance Scheme, then it is unlikely to encourage the membership to embrace the Scheme.
The Federal Ministry of Health and NHIS must package a Health Insurance Scheme that is workable will be acceptable to all stakeholders or else the whole exercise would have been in vain
Pharmacists and indeed all members of the health team cannot afford to have such a laudable scheme collapse as a result of inadequate planning of selfish interest of any professional group. It would take so many years to regain the confidence of the populace into experimenting with any such scheme again.
Pharmacists continue to solicit the support of all health professions for proper implementation of the scheme. The major contentions on capitation payment to physicians to cover prescribing and dispensing of drugs abound to create problems with other members of the health team which could frustrate the scheme. It is in the long term interest of the insured patient that the separation of roles for all categories of professionals must be guaranteed.
If all selfish considerations are relegated to the background and these contentious issues are appropriately addressed, then may be we can begin to look forward to health for all. Health that is available, affordable and acceptable. |
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Last Updated ( Thursday, 26 February 2009 )
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