Challenges Facing Health Care Providers and Health Insurance

Published Date: 22 Nov 2017

Topic: challenges facing Health care providers while dealing with Health insurances: a case study of a private hospital in Nairobi Kenya

Introduction

Define health financing (who,2000)world health report ‘

A health system is the sum total of all the organizations, ititutions and resources whoseprimary intent is to promote, restore or maintain health (WHO, 2000).Effectiveness, efficiency andequity of health financing system is determined by interaction of the three health financing functions namely collection of revenues, the pooling of pre-paid revenues and purchasing.Purchasig means the process by which interventions are selected and services are paid for or providers are paid. Healthcare providers are part of health system and re key component of health system strengthening and they play a significant role in determining whether the goals of a health system can be achieved.It is important that the buyers of services align provider payment methods with organizationalarrangements for service providers and other incentives for efficient service provision

In Kenya most of the private health insurances operate on a purchaser provider split model with the insurances being directly responsible for entering into purchase agreements with providers and reimbursing them. Most of the provider payment is fee for service with a few health management organizations trying out the capitation mode of payment on outpatient services.Before the claims are approved for payments they have to undergo through the schemes claims process for eligibility purposes. According to S. Sodzi-Tetteyet al (2012) the purchasing function of health financing has been beset with problems of delay in provider payments. A study by Ministry of Health, Ghana, (2009) showed that in 2008 health facilities nationwide were owed a total of USD 32.6M most of it in unpaid claims while health providers themselves reported a 2-6 month delaying having their bills settled.

Health insurance schemes are being used as an alternatives funding for health sector (Baltussen et al 2000).Insurance authorities are established to secure improvements in the health of the population by assessing health needs of the population ,determining the most cost effective mean of meeting these needs and contracting with providers to supply the required services.

They are different types of health insurance models and one of them is the purchaser /provider splint models .they are many advantages to this arrangement according to Zurn&Adams (2004) among them compiling of services providers to offer quality care however this model can also lead to major problems which according to Sakyi et al (2012)could be enormous among them being late reimbursement thus increasing the financial volatility of health providers which may in turn affect service delivery due to lack of finances to buy drugs ,to improve health facilities, to pay health workers to buy commodities among other things .witter&Garshong ,(2009) says that providers who depend heavily on subsidies from the insurances could offer poor quality care when they are under billed or a large portion of their claims are rejected.

The study will explore the challenges experienced by health care providers dealing with private health insurances especially the claim processing.

Problem statements

Health providers are offering health services to health insurances clients yet the insurances are not honoring their pledges to pay. There so many rejected bills after clients are discharged; many providers have unsettled bills by the patients because after services were offered the insurances give decline letters or covered bills up to a certain limit.

A lot of time and money ,human resource is used in reconciliation of the accounts and in most cases the claims are not paid and as sakyi et al (2012) says this increases financial volatility of the health care providers which may in turn affect service delivery due to lack of finances to buy commodities and pay workers.witter &Garshong (2009)continue to say that providers wo depend heavily on subsidies form the insurances could offer poor quality care when they are under billed or a large portion of their claims are rejected.

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Research Objectives

The study seeks to explore the challenges facing healthcare providers while dealing health insurance companies.

The specific objectives of the study will be:

1. To establish the administrative challenges facing health providers in executing operational guidance of health insurances.
2. To establish the challenges healthproviders face from the health insurance during service delivery to their clients.
3. To establish the challenges health providers face from the health insurance after the delivery of service to their client
4. To come up with recommendation’s that would be used by the health providers and health insurance to ensure a workable purchaser –provider splint system

Research Questions

The study will answer the following research questions:

1. What are the administrative challenges facing health providers in executing operational guidance of health insurances(admission process, scheduled cases ,emergency cases )
2. What are challenges health providers face during service delivery to health insurance clients(declines,exclusion ,limited covers ,clients not knowing their limits )
3. What are the challenges health providers face from the health insurance after the delivery of service to their clients.(rejections of claims ,late reimbursements What are the political challenges facing healthcare financing towards universal coverage by NHIF?
4. What are the recommendation’s to health providers and health insurance to ensure a workable purchaser –provider splint system

Theoretical framework

1. Health insurance theory
2. Utility theory
3. Behavioral model of utilization
4. Event model of studying health services utilization med care 1998.

Conceptual framework

Dependent variable-

• Challenges faced by health providers

Independent variable-

• Operational guidelines (preauthorization process-preadmission process).
• service provision(admission
• post service provision (claim and reimbursement process)

Significance of the Study

Health providers are key in health system strengthening and key stakeholders in attainment of universal health coverage (delloitte ,2012)hence the importance to find out ways of ensuring both the private and public insurance work harmoniously with providers.

Help policy makers in making decision like proper ttraining their enrolessabout their benefits ,providers to hve mechanism to carry out operational guidelines,

Policy makers need access to knowledge on purchaser –provider splint system dynamics and the appropriate responses. Therefore, the study provides guidance and recommendations instrumental in designing appropriate policies that regulate the healthcare sector and what need to be done to ensure workable /effective and efficient system. The study will also be a reference material to the healthcare insurance firms, healthcare providers/institutions and other stakeholders.

Relevant data that could allow for recommendations that could be implemented to strengthen the role of private health insurance players or providers or to strengthen provider and purchaser reltionship

Methodology of the Study

It will be an exploratory study .Qualitative andquantitative approaches will be used for primary datacollection using interview guides and checklists.

References

WHO,the world Health report 2000:Health systemsimproving performance ,Geneva ,World Health Organisation,2000