Patients to pay more if insurance cover stand-off persists

The Kenya Association of Private Hospitals (KPHA) has indicated that they are going to alert the private insurers that they do not have a contract with the National Health Insurance Fund (NHIF) and that should make a decision either to clear patients bills in totality or patients pays in cash.

Currently, most of the private insurance normally pay medical bills minus what NHIF ought to pay. If the stand-off continues, patients will have to foot the balance or the insurance clears the bill.

“We are going to communicate to the private insurers that we do not have a contract with the NHIF, so should a patient be treated in any facility, she/he either pay the money that the NHIF was to reimburse the facility or the private insurer to clear the total bill,” said Dr Timothy Olweny, KPHA secretary-general.

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The association has since demanded that before it begins any engagement with the insurer, the contracts have to be extended.

“We are left with only four days to the expiry of the contract that we have with NHIF and because we do not have time, we want a formal communication that they are going to extend the contracts before we begin any engagements,” Dr Olweny said.

The association had earlier indicated that the Fund had proposed to drastically slash doctors’ fees in the new contracts, which they said would hurt patient care as it is not viable to their institutions.

The hospitals have, therefore, said patients with NHIF cards will be locked out of service until further notice.

However, Dr Peter Kamunyo, NHIF chief executive officer said the standardising of contracts for all facilities are to benefit patients.

Comprehensive cover

“You know before, we negotiated contracts for individual facilities and this has since stopped. We are rationalising the rates for all the hospitals. We are not in business and all we value is the health of Kenyans,” he said.

He said doctors are blackmailing the Fund and sabotaging the enhanced scheme, adding that about 50 per cent of the facilities have signed the contracts.

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“We contract the hospitals and not the doctors. The ones making noise are the associations. The money is going to the hospitals and because the doctors’ fees have been rationalised, the complainants are the perceived losers,” Dr Kamunyo said.

He said the doctor’s interest is in their fees and not the health of Kenyans. “In the interest of attaining the Universal Health Coverage, we just had to review the contracts. At the end of the day, we will all smile,” he said

The Fund has come up with two contracts — the comprehensive and non-comprehensive cover. Facilities have the leeway to choose which one works for them.  

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“For the comprehensive cover, a patient walks to a facility, gets attended to and walks out without paying any single cent to the healthcare provider, while for the non-comprehensive, facilities charge what they want to the patients but the reimbursement is standardised across all the facilities,” said Dr Andrew Mulwa, acting Director Medical Services, Ministry of Health

“If you choose NHIF as your source of revenue, then you have to take what we are giving you and do not charge our clients, but if you want to make profits from patients then, take the non-comprehensive cover and charge what you want but we will pay our rates. The patients can pay the rest if they so wish.”

He said the government will invest money in public hospitals because that is where many Kenyans get affordable services. 

“Why should we spend a lot of money on private hospitals? We are not going to push people to make abnormal profits from people’s health. We are paying 85 per cent of NHIF money to private facilities despite only having 15 per cent of the providers,” he said.

He said before the 2017 doctors’ strike, the NHIF package was for public hospitals and private ones were only brought in to bridge the gap.

New dialysis fee

“We are taking back the 85 per cent to public hospitals and the people making noise are out to make abnormal profits from overcharging Kenyans. We have refused,” he said.

Dr Olweny had earlier indicated that in the new contract for the year 2022 to 2024, which they have not had a chance to look at, the input of private hospitals was not sought, save for a few providers and the contents of the contracts currently being circulated for execution will not work for them.

He said the charges were even lower than what was proposed by the Kenya Medical Practitioners and Dentists Council in 2016.  

“We are not going to sign the contract until they are reviewed,” Dr Olweny said.

They said that in the new contract, for instance, for appendectomy (a surgical operation to remove the appendix), the combined rate proposed by the NHIF suggests that doctors’ fees and hospital charges should not exceed Sh40,000.

However, under KMPDC guidelines, doctors’ fees range from Sh60,000 to Sh120,000, while anesthetists are allocated Sh20,000.

For haemorrhoid surgery (removal of swollen blood vessels inside or around the anus and rectum), KMPDC guidelines for doctors’ fees are from Sh70,000 to Sh150,000, but for NHIF, the services should not exceed Sh24,000.

For removal of tonsils, NHIF says the fees should not exceed Sh32,000; however, private hospital doctors have been charging between Sh60,000 and Sh120,000. The 2016 KMPDC fee guidelines are overdue for review.

The hospitals have also refused to adopt the new dialysis fee of Sh6,500, down from Sh9,500. The NHIF has indicated in the new contract that it will increase the frequency of dialysis sessions from two to three a week in line with international standards but has reduced the reimbursement by Sh3,000, meaning patients will have to pay the difference.

“We are open to any discussion to end this and agree so that we give Kenyans the best,” Dr Kaminyo said.