Global Trend

Globally, there is a trend towards planning for healthcare in a predictable manner through prepayment and participation in health insurance pools with managed care as the mode of healthcare delivery.
This is done through one of the best HMOs in Nigeria called United Healthcare International Ltd. commonly employed to:
1. Provide affordable and efficient health services
2. Improve quality of healthcare
3. Increase access to healthcare, and finally
4. Advance the health of enrolled populations, employee groups, communities, states and countries

This adoption of managed care mechanisms, techniques, tools and use of insuring entities like HMOs goes with the trend toward decentralization of the health financing function of the health system. Many countries are abandoning centralized, government financed, government-owned health delivery systems and instead opting for a Public Private Partnership as the financing agent and the delivery system. The National Health Insurance Scheme is a public-private partnership solution. It is private sector driven and public sector regulated; an ideal model for PPP.
Managing Cost
This is done in 3 ways viz:
1. Managing Insurance Risk: There is a Benefit Package in National Health Insurance which details services that will be covered, who will be covered and under what terms and conditions such that pooled funds from a prepaid scheme can cover this. This helps in spreading of risks across larger population groups from healthy to sick. There will also be a detailed list of exclusions. The NHIS is a special social security arrangement based on the concept of solidarity and equity to provide financial protection to participants against ill-health through the payment of contributions and pooling of resources.

2. Managing Contracted Providers: The scheme also makes use of a network of both public and private providers. The scheme has adopted capitation and fee-for-service as payment mechanisms. Primary care is paid by capitation while secondary and tertiary care services are paid through fee-for-service tariffs. Providers with good track record with enrollees tend to get higher enrolment with consequent increase in their capitation. The WHO and Federal Government recommend use of Generic Drugs Generic drugs are adopted to control cost of healthcare.

3. Managing Utilization of Services: Healthcare providers are health facilities at Primary, Secondary and Tertiary levels that provide services at respective levels in the healthcare delivery system.

1. Entry into the health system is to be at the primary level where each beneficiary is expected to be registered. Enrollees are to pick providers nearest to their homes or offices which can be private or public clinic and will act as their primary provider

2. Subsequent access to other levels is only by referral. This technique of prior authorization of services is a global practice which ensures appropriate utilization of resources at all levels. It also helps in concurrent review and availability of second opinion. The referral levels allow equitable patronage of all three levels of healthcare.

Managing Of Risks and Managing Access and Quality of Health Services;The prevailing Health Indicators for Nigeria are worrisome and unacceptable:
- One out of every 10 infants dies before age of 1 year
- One out of every 5 children dies before age of 5 years
- Maternal mortality is very high, 900-1000 per 100,000 live births

Managing Of Risks and Managing Access and Quality of Health Services:The prevailing Health Indicators for Nigeria are worrisome and unacceptable:
- One out of every 10 infants dies before age of 1 year
- One out of every 5 children dies before age of 5 years
- Maternal mortality is very high, 900-1000 per 100,000 live births
- Life expectancy is 52 years.

This health scenario has stemmed several from the unorganized delivery of care in both public and private owned experience.
The former retainership system of contracting and paying for healthcare on a wholly fee-for service basis contributed
1. Inequitable healthcare service
2. Poly-pharmacy-giving of more drugs than is needed so as to justify huge bills
3. Unnecessary admissions which will put you at risk of dangerous hospital-acquired infections
4. Frivolous Bills

United Healthcare provides you an opportunity of putting a Structured Management Layer on your healthcare delivery experience through our Health Maintenance Services which comprise:

1. Pooling of Funds and Resources

a. This ensures you are protected from the financial overhead of ill health by having your risk spread through the contributions of a larger group
b. Providers are paid upfront as well from pooled funds to ensure that they give both preventive and curative services

2. Managing access and quality involves the following activities:

a) Availability of enabling protocols as:
i. Treatment Guidelines for providers to provide quality service.
ii. General and Specific Prevention Guides to enrollees for enlightenment on developing healthy habits and corresponding lifestyle changes
iii. Management Guidelines of acute emergencies which is available to providers as a job aid and knowledge booster.
b) Case management- The scheme allows home care, rehabilitation at home and health education on life style changes of patients with chronic cases like stroke. HMOs will send utilization Nurses /Doctors as the need arises to continue to monitor the patient even after being discharged from the hospital.
c) Disease management: The scheme allows inclusion of numerous types of health professionals through the referral systems

person with Diabetes must be able to see a dietician and a neurologist.
d) Our Processes for Medical Utilization Management encompasses prospective, concurrent and retrospective activities:

a. Our Prospective Utilization Management is intended to influence favourably future demand for medical services; for example:
a) A Care Line for enrolees to access a trained Nurse 24 hrs a day will be made available.
b) Access to preventive services such as immunization and
c) Medical advice manuals for use at home.
d) For any new patient an overall assessment (health risk appraisal) will be done by making sure that once a year a routine medical examination is carried out.

b. We routinely carry out Concurrent Utilization Management in which a Registered Nurse in our operations unit will visit your staff and dependants while on admission in the hospital for the purpose of monitor the progress and process of care to ensure delivery standards are adhered to.

c. Retrospective Utilization Management provides us the opportunity to review and analyze past cases and occurrences at our providers to determine the pattern of the utilization for the purpose of:

a) Monitoring your experience at the point of care.
b) Improving the quality of healthcare on our network.
c) Evidence based peer review by other a Provider Committee.
e) To ensure Total Quality Management, a trilogy model of quality assurance is been used. This trilogy entails :
a. setting standard
b. monitoring and measuring standard processes and outcomes
c. continuous and sustained improvement in standard.

You can also visit this website for more information http://www.unitedhealthcare-ng.com