HEALTH FINANCING PRACTICES�

GROUP A1

MODERATORS: PROF. DANKYAU/ DR. OLOWU

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C

GROUP MEMBERS

ABAH EUGENIA EJALO

ABAH THERESA ENE

ABALAKA VICTORY MOSES

ABAWULOR VICTOR

ABU VANESSA EKOCHE

ADEGBOYE ADEDAMOLA

ADEOYE AYOMIKUN

ADEYEYE ADESANOYE

AGADA EBENEZER

BHU/17/01/01/0019

BHU/17/01/01/0254

BHU/17/01/01/0069

BHU/17/01/01/0113

BHU/17/01/01/0094

BHU/17/01/01/0135

BHU/17/01/01/0044

BHU/17/01/01/0261

BHU/17/01/01/0132

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GROUP MEMBERS

AGBO CATHERINE

AJIBOSO MOBERE

AJIMOKO FERANMI

AKALI ALEXANDER

ALHASSAN EMMANUEL

ANDREW CHRISTIANA

ANDREW EMMANUEL

ANTHONY ADEGOKE

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BHU/17/01/01/0056

BHU/17/01/01/0043

BHU/17/01/01/0074

BHU/17/01/01/0024

BHU/17/01/01/0092

BHU/17/01/01/0179

BHU/17/01/01/0183

BHU/17/01/01/0297

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OUTLINE

• INTRODUCTION
• TYPES OF HEALTH FINANCING
• COST OF MEDICAL CARE TO THE FAMILY
• IMPORTANCE OF HEALTH FINANCING
• HEALTH INSURANCE AND TYPES
• NHIS AND ITS OPPERATIONS
• SERVICE PRICING
• CHALLENGES IN HEALTH FINANCING
• CONCLUSION
• REFERENCES

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INTRODUCTION

• Health financing is a critical aspect of healthcare systems globally, influencing the accessibility, affordability, and quality of healthcare services which encompasses the mechanisms through which money is collected, pooled, and allocated to pay for healthcare services.

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• Effective health financing practices are essential for ensuring equitable access to quality healthcare, achieving universal health coverage (UHC), and improving health outcomes.

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TYPES OF HEALTH FINANCING

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TYPES OF HEALTH FINANCING

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COST OF MEDICAL CARE TO THE FAMILY

• The cost of medical care to families is influenced by various factors, including health financing practices, health insurance coverage, and out-of-pocket expenses.
• HEALTH INSURANCE PREMIUMS: Families enrolled in health insurance plans pay premiums. Health insurance premiums are regular payments made by families to maintain coverage under a health insurance plan. The cost of premiums varies depending on the type of insurance, coverage level, and the number of family members covered.

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COST OF MEDICAL CARE TO THE FAMILY

• OUT-OF-POCKET EXPENSES: Even with health insurance, families may incur out-of-pocket expenses such as deductibles, copayments, and coinsurance for certain services or treatments not fully covered by their insurance plans.
• Deductible is the amount of money that the insured person must pay before their insurance policy starts paying for covered expenses.
• A copay is a fixed out-of-pocket amount paid by an insured for covered services.
• Coinsurance is the amount you pay for covered health care after you meet your deductible. This amount is a percentage of the total cost of care
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COST OF MEDICAL CARE TO THE FAMILY

• UNINSURED FAMILIES: Families without health insurance often bear the full cost of medical care out-of-pocket. This can lead to financial hardship, medical debt, and limited access to healthcare services, particularly for low-income families.
•  MEDICAL EXPENSES: Medical expenses include costs associated with healthcare services, such as doctor visits, hospital stays, medications, diagnostic tests, surgeries, and medical procedures. These expenses can quickly add up, particularly for families facing chronic or acute health conditions.

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COST OF MEDICAL CARE TO THE FAMILY

• EMERGENCY AND UNEXPECTED MEDICAL EXPENSES: Emergency medical expenses, such as visits to the emergency room or urgent care, can arise unexpectedly and place a sudden financial burden on families. These expenses may not be fully covered by insurance, leading to out-of-pocket costs for families.
• LONG-TERM CARE AND CHRONIC CONDITIONS: Families caring for members with chronic health conditions or disabilities may incur long-term care expenses, including home healthcare, assisted living facilities, medical equipment, and specialized therapies. These costs can be substantial and may require families to make financial sacrifices to ensure their loved ones receive the care they need.

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COST OF MEDICAL CARE TO THE FAMILY

• PRESCRIPTION MEDICATIONS: The cost of prescription medications can be a significant expense for families, particularly for those with chronic health conditions that require ongoing medication management. Rising drug prices and lack of insurance coverage for certain medications can make it challenging for families to afford essential drugs
• EMOTIONAL AND PSYCHOLOGICAL IMPACt: The financial stress associated with the cost of medical care can take a toll on families' emotional and psychological well-being, leading to feelings of anxiety, depression, and uncertainty about the future. Families may experience guilt, shame, or fear related to their inability to afford necessary medical care for themselves or their lo
• IMPACT ON FINANCIAL STABILITY: The high cost of medical care can have long-term implications for family financial stability, including increased debt, depletion of savings, and inability to afford other essential expenses such as housing, food, and education. Medical debt can also have a negative impact on credit scores and overall financial well-being.

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IMPORTANCE OF HEALTH FINANCING

Health financing plays a crucial role in healthcare systems for several reasons:

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1. Ensuring Financial Protection: Adequate health financing mechanisms help protect individuals and households from catastrophic health expenditures, which can push them into poverty.

2. Promoting Equity: Fair and efficient health financing practices can help reduce disparities in access to healthcare services among different socio-economic groups, thereby promoting equity in healthcare delivery.

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IMPORTANCE OF HEALTH FINANCING

3. Sustaining Healthcare Systems: Proper financing is essential for maintaining and improving healthcare infrastructure, staffing, and service delivery, ensuring the sustainability of healthcare systems.

4. Facilitating Innovation: Sufficient funding enables healthcare systems to invest in research, technology, and innovation, leading to the development of new treatments, interventions, and approaches to healthcare delivery.

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HEALTH INSURANCE

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Health insurance is essential for ensuring access to quality healthcare while managing financial risks associated with medical expenses.

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HEALTH INSURANCE PLANS

• Health Maintenance Organization (HMO): HMO plans typically require members to choose a primary care physician (PCP) who coordinates their care and provides referrals to specialists when needed. Members must generally receive care from healthcare providers within the plan's network to be covered, except in emergencies. HMOs often have lower premiums and out-of-pocket costs compared to other types of plans but may offer less flexibility in choosing providers.

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• Preferred Provider Organization (PPO): PPO plans offer more flexibility in choosing healthcare providers, allowing members to visit both in-network and out-of-network providers. Members do not need a referral to see a specialist, and they can typically receive partial coverage for out-of-network care. PPO plans often have higher premiums and out-of-pocket costs compared to HMOs but provide greater provider choice and flexibility.

HEALTH INSURANCE PLANS

• Exclusive Provider Organization (EPO): EPO plans combine elements of HMOs and PPOs, offering coverage for in-network care only. Members do not need to choose a PCP or obtain referrals to see specialists within the network. EPO plans may have lower premiums and out-of-pocket costs compared to PPOs but offer less flexibility in provider choice.

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• Point of Service (POS): POS plans combine features of HMOs and PPOs, allowing members to choose between in-network and out-of-network care. Members typically choose a primary care physician and require referrals for specialist care within the network. POS plans may have lower premiums than PPOs but higher out-of-pocket costs for out-of-network care.

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HEALTH INSURANCE PLANS

• High-Deductible Health Plan (HDHP) with Health Savings Account (HSA): HDHPs have higher deductibles and lower premiums compared to traditional plans. Members must meet the deductible before the plan starts covering medical expenses, except for preventive care, which is often covered at no cost. HSAs allow members to contribute pre-tax dollars to a savings account to pay for qualified medical expenses, providing tax advantages and potential savings for future healthcare needs.

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• Short-Term Health Insurance: Short-term health insurance provides temporary coverage for individuals in transition periods, such as between jobs or after aging out of parental insurance. Plans offer limited benefits and may not cover pre-existing conditions or preventive care. Short-term plans are generally less expensive than long-term health insurance but provide temporary coverage for unforeseen medical needs.

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HEALTH INSURANCE PLANS

• Catastrophic Health Insurance: Catastrophic plans offer coverage for major medical expenses incurred due to severe illnesses or injuries.
• Available to individuals under 30 or those with a hardship exemption, catastrophic plans have low premiums but high deductibles.
• Designed to protect against financial ruin in the event of a medical emergency, catastrophic plans provide coverage for essential health benefits after the deductible is met.

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TYPES OF HEALTH INSURANCE

• Private Health Insurance: Private health insurance plans are offered by private insurance companies and can be purchased by individuals, families, or through employers.

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• These plans offer a range of coverage options, including medical services, hospitalization, prescription drugs, and preventive care. Private health insurance plans often provide access to a network of healthcare providers, with varying levels of coverage for out-of-network services. Premiums, deductibles, copayments, and coinsurance amounts vary depending on the specific plan and coverage options chosen.

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TYPES OF HEALTH INSURANCE

• Employer-Sponsored Health Insurance: Many employers offer health insurance benefits to their employees as part of their compensation package.

Employer-sponsored health insurance plans may include options such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), or High-Deductible Health Plans (HDHPs) with Health Savings Accounts (HSAs).

Employers typically cover a portion of the premium costs, with employees responsible for the remainder through payroll deductions.

These plans often provide comprehensive coverage and may offer additional benefits such as wellness programs or health savings incentives.

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TYPES OF HEALTH INSURANCE

• Government-Sponsored Health Insurance: Government-sponsored health insurance programs are funded and administered by federal or state governments to provide coverage to specific populations. Examples include Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) in the United States.

Medicare provides health insurance for individuals aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions.

Medicaid offers coverage to low-income individuals and families, including pregnant women, children, elderly adults, and people with disabilities.

CHIP provides health coverage to uninsured children in families with incomes too high to qualify for Medicaid but too low to afford private insurance.

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TYPES OF HEALTH INSURANCE

• Social Health Insurance: Social health insurance systems are funded through mandatory contributions from individuals, employers, and/or the government to provide coverage to the entire population. Examples include the National Health Service (NHS) in the United Kingdom and statutory health insurance systems in countries like Germany and Japan. Social health insurance typically offers comprehensive coverage for medical services, hospitalization, and prescription drugs, with contributions based on income and other factors.

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• Community-Based Health Insurance (CBHI): CBHI schemes are operated by communities or local organizations to provide health coverage to their members, often in low-income or rural areas. Members pay premiums, which are used to cover healthcare costs within the community. CBHI schemes vary widely in terms of coverage, benefits, and administration, depending on the specific needs and resources of the community.

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NATIONAL HEALTH INSURANCE SCHEME (NHIS)

• NHIS is a body set up by Decree 35, of 1999 now Act 35, operating as public private partnership and directed at providing accessible, affordable and qualitative healthcare for all Nigerians.
• 1. The Scheme shall be responsible for issuing appropriate guidelines to maintain the viability of the Scheme [section 6(b)]
• 2. The Scheme shall be responsible for advising on the continuous improvement of quality of services provided under the Scheme through guidelines issued by the Standard Committee established under section 45 of this Act [section 6(g)]
• 3. The council shall have the power to set guidelines for effective co-operation with other organizations to promote the objectives of the Scheme [section 7(f)]
• On May 24th, 2022, it was officially gazetted by the Federal Government of Nigeria as the National Health Insurance Authority(NHIA)
• On the 19th of May, 2022 The NHIA ACT was ENACTED by the National Assembly of the Federal Republic of Nigeria

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NHIS AT THE PRIMARY HEALTHCARE LEVEL�

• Primary health care is a people-centred rather than disease-centred service that addresses the majority of a person’s health needs throughout their lifetime including physical, mental and social well-being.
• It is generally the first level of care that patients receive when they have medical concerns or needs and takes a whole-of-society approach that includes health promotion, disease prevention, treatment, rehabilitation and palliative care^.

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NHIS AT THE PRIMARY HEALTHCARE LEVEL�

NHIS at the primary health care level covers the following;

1. Out-patient care services such as

• Proper history taking
• Physical Examination
• Routine laboratory investigations to help reach a diagnosis.

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NHIS AT THE PRIMARY HEALTHCARE LEVEL�

Laboratory investigations includes:

• Malaria parasite and Blood film for microfilaria
• Hematocrit or Packed cell volume
• Urinalysis, stool and urine microscopy
• Erythrocyte sedimentation rate
• White Blood Cell differentials
• Pregnancy test (urine)
• Blood grouping
• Blood Sugar
• Widal test

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NHIS AT THE PRIMARY HEALTHCARE LEVEL�

2. Immunization against childhood killer diseases; The vaccines includes

• BCG
• Oral Polio
• DPT
• Measles
• Hepatitis B
• HPV
• Vitamin A supplementation

Other vaccines that maybe included in the National programme on immunization from time to time

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NHIS AT THE PRIMARY HEALTHCARE LEVEL�

3. Surgical procedures;

• Drainage of simple abscess (I&D)
• Minor wound debridement
• Surgical repairs of simple lacerations
• Drainage of paronychia
• Circumcision of male infants
• Passage of urethral catheter

Other services as may be listed from time to time by the NHIS

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

Secondary Health Care is the specialist treatment and support provided by doctors and other health professionals for patients who have been referred to them for specific expert care.

• SURGICAL PROCEDURES
• All other procedures that cannot be handled at the primary level of care can be undertaken at the Secondary level, depending on the complexity and the competence of the facility and its personnel, except those conditions requiring tertiary care or on the exclusion list.
• Note: Hospital stay in orthopedic cases is allowed for 6 cumulative weeks and does not in any way foreclose post hospitalization management. The primary healthcare facility of enrollee shall pay per diem for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 27 cumulative days per year.

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

INTERNAL MEDICINE:

Screening as determined by NHIS. All other cases that cannot be treated at the Primary level must be promptly referred to a Secondary level except those condition requiring tertiary care or on the exclusion list.

HIV/AIDS:

• HIV Screening and Confirmation
• Management of opportunistic infections
• Provision of ART

PAEDIATRICS:

All medical and surgical paediatric cases that cannot be handled at the Primary level except those requiring tertiary care or on the exclusion list

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

OBSTETRICS AND GYNAECOLOGY

• Specialist consultation
• Multiple gestation/High risk pregnancies
• Caesarian sections
• All emergency gynaecological procedures
• All Primigravida and Grand multipara shall be managed at the secondary levels of care

Other procedures that are not on the exclusion list

• OPHTHALMOLOGY
• • Refraction, incuding provision of low priced spectacles and excluding contact lenses
• All ophthalmological cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

• EAR NOSE AND THROAT (ENT):
• All E.N.T cases that cannot be handled at the primary level of care except those requiring careor on the exclusion list.
• DENTAL HEALTH:
• Dental check
• Scaling and polishing
• Minor oral surgeries
• Maximum of two root canal treatment
• Replacement of maximum of four dentures

All dental cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

• PHYSIOTHERAPHY:
• All procedures except those on the exclusion list. Hospital stay in Cerebrovascular accident is allowed for 12 cumulative weeks and does not foreclose post hospitalization therapy.
• Note: the primary healthcare facility of the enrollee shall pay for bed stay for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 69 cumulative days.
• RADIOLOGY/ULTRA-SONOGRAPHY:
• All investigation except those on the exclusion list.
• Note: All radiological imaging must be accompanied with its detailed report.

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NHIS AT THE SECONDARY HEALTHCARE LEVEL�

NHIS ANTENATAL POLICY:

• Services to be provided at Antenatal care should include at least the following
• INVESTIGATION:
• Packed cell volume/Hemoglobin estimation
• Urinalysis
• Blood grouping
• HIV screening
• Blood genotype
• Hepatitis B surface antigen
• Ultrasonography(at least twice)
• Fasting blood sugar/ Random blood sugar.

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NHIS AT THE TERTIARY HEALTHCARE LEVEL�

• Tertiary care is a level above secondary health care, that has been defined as highly specialized medical care, usually provided over an extended period of time, that involves advanced and complex diagnostics, procedures and treatments performed by medical specialists in state-of-the-art facilities. As such Consultants in tertiary care centres have access to more specialized equipment and expertise
• SURGICAL PROCEDURES
• All procedures that cannot be handled at the primary and secondary levels of except those conditions on the exclusion list.
• Note: Hospital stay in orthopedic cases is allowed for 6 cumulative weeks and does not in any way foreclose post hospitalization management. The primary healthcare facility of enrollee shall pay per diem for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 27 cumulative days per year.

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NHIS AT THE TERTIARY HEALTHCARE LEVEL�

• INTERNAL MEDICINE
• Screening as determined by NHIS. All other cases that cannot be treated at the Primary and secondary levels of care except those conditions on the exclusion list.
• HIV/AIDS
• • Management of complications of HIV/AIDS
• PAEDIATRICS
• All medical and surgical paediatric cases that cannot be handled at the Primary level and secondary levels of care except those conditions on the exclusion list
• OBSTETRICS AND GYNAECOLOGY
• All Obstetric and Gynaecological cases that cannot be handled at the primary and secondary levels of care except those conditions on the exclusion list

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NHIS AT THE TERTIARY HEALTHCARE LEVEL�

OPHTHALMOLOGY

All ophthalmological cases that cannot be handled at the primary and secondary levels of care except those on the exclusion list.

EAR NOSE AND THROAT (ENT)

• All E.N.T cases that cannot be handled at the primary and secondary levels of care except those on the exclusion list.

RADIOLOGY/ULTRA-SONOGRAPHY

• All radiological procedures/investigations cases that cannot be handled at the secondary level of care except those conditions on the exclusion list

NOTE: AIl radiological imaging must be accompanied with its detailed report.

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SERVICE PRICING

• Service pricing in health financing practices refers to the process of determining the costs associated with healthcare services provided by healthcare providers and facilities. It involves setting prices for medical procedures, treatments, consultations, diagnostic tests, medications, and other healthcare-related services. The pricing of healthcare services is influenced by various factors and plays a crucial role in shaping healthcare delivery, access, affordability, and quality
• Service pricing in healthcare is complex and can vary widely depending on factors such as provider type, geographic location, treatment complexity, and payer negotiations.

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SERVICE PRICING

Factors Influencing Service Pricing:

• Cost of Providing Services: The cost of providing healthcare services, including overhead costs, labor costs, equipment costs, facility maintenance expenses, and administrative expenses, influences service pricing. Providers need to cover their costs while maintaining profitability.
• Market Forces: Market dynamics, including supply and demand, competition among healthcare providers, geographic location, and payer mix (e.g., private insurance, government programs, self-pay patients), can impact service pricing. Providers may adjust their prices based on market conditions and payer preferences.

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SERVICE PRICING

Factors Influencing Service Pricing:

• Technology and Innovation: Advances in medical technology, diagnostic tools, treatments, and pharmaceuticals may contribute to higher costs for certain healthcare services. Providers may pass these costs onto patients through higher prices for innovative treatments and technologies.
• Regulatory Requirements: Regulatory requirements, including government regulations, reimbursement policies, billing codes, and healthcare laws, influence how healthcare services are priced. Providers must comply with regulatory standards while setting prices for their services.

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SERVICE PRICING

Methods of Service Pricing:

• Fee-for-Service (FFS): In a fee-for-service model, healthcare providers charge a fee for each individual service or procedure rendered, regardless of the outcome or value of the service. This model incentivizes volume of services provided rather than quality or outcomes.
• Value-Based Pricing: Value-based pricing focuses on the quality, outcomes, and value of healthcare services rather than the volume of services provided. Providers may be reimbursed based on performance metrics, patient outcomes, and adherence to quality standards
• Diagnosis-Related Groups (DRGs): DRGs are a payment system used primarily for inpatient hospital services, where patients with similar diagnoses and treatments are grouped together, and providers are reimbursed a fixed amount based on the assigned DRG.

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SERVICE PRICING

Methods of Service Pricing:

• Bundled Payments: Bundled payments involve grouping together multiple services or procedures related to a specific condition or episode of care and charging a single, fixed payment for the entire bundle of services. This model encourages care coordination, efficiency, and cost savings.
• Capitation: In a capitation model, healthcare providers receive a fixed payment per patient enrolled in a healthcare plan, regardless of the volume or complexity of services provided. Providers assume financial risk for managing the health of their patient population.

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SERVICE PRICING

Transparency and Consumer Engagement:

• Transparency in service pricing is essential for empowering consumers to make informed decisions about their healthcare choices. Providers, insurers, and healthcare organizations are increasingly adopting price transparency initiatives to provide patients with information about the cost of healthcare services upfront.
• Consumer engagement strategies, such as cost estimators, price comparison tools, and patient education materials, can help patients navigate service pricing, understand their financial responsibilities, and make cost-effective healthcare decisions.

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SERVICE PRICING

• Challenges and Considerations:
• Cost Variation: There is often significant variation in the cost of healthcare services across providers, regions, and payer types. Understanding and addressing cost variation is essential for promoting healthcare affordability and transparency.
• Affordability and Access: High healthcare costs can pose barriers to access for individuals with limited financial resources or inadequate insurance coverage. Addressing affordability concerns and ensuring equitable access to healthcare services are critical considerations in service pricing.
• Healthcare Equity: Service pricing practices should consider the impact on healthcare equity and disparities in access to care. Pricing policies should strive to minimize disparities and ensure equitable access to quality healthcare services for all individuals, regardless of socioeconomic status or other factors.

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CHALLENGES OF HEALTH FINANCING

• Despite its importance, health financing faces several challenges that hinder its effectiveness:

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1. Insufficient Funding: Many healthcare systems suffer from inadequate funding, limiting their ability to provide essential services, invest in infrastructure, and respond to emerging health challenges.

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2. Inequitable Distribution of Resources: Resource allocation within healthcare systems may be skewed, leading to disparities in access to services between urban and rural areas or among different population groups.

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CHALLENGES OF HEALTH FINANCING

3. Fragmentation and Duplication: Fragmentation in health financing, such as multiple insurance schemes or funding streams, can lead to inefficiencies, administrative complexities, and gaps in coverage.

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4. Financial Sustainability: Ensuring the long-term financial sustainability of healthcare systems is a persistent challenge, particularly in the face of rising healthcare costs, demographic changes, and economic uncertainties.

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5. Healthcare Cost Inflation: Healthcare cost inflation, driven by factors such as technological advancements, pharmaceutical prices, and provider payment mechanisms, poses a significant financial burden on healthcare systems.

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CONCLUSION

• Health financing practices play a pivotal role in shaping healthcare systems and impacting the accessibility, affordability, and quality of healthcare services. Effective health financing mechanisms, including diverse health insurance schemes like NHIS, are essential for achieving universal health coverage and ensuring financial protection for individuals and families. However, challenges such as rising healthcare costs, inequities in access, and inefficiencies in service delivery persist and require ongoing attention and reform efforts

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REFERENCES

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