Knut response on humiliation of teachers by AON Minet

HUMILIATION FACED BY TEACHERS COVERED UNDER AON MINET KENYA MEDICAL INSURANCE SCHEME

I     acknowledge  receipt  of  your   letter  referenced  as above  and  bearing reference number SEN/SCE/CORR/2020/40 (02) and hereby respond as requested.

I   take this opportunity to thank you for the interest you have shown in the welfare of the teachers and our medical scheme. I  am proud to report that as stakeholders in this scheme, we have seen tremendous improvement in the health  outcomes  of  our   teachers  and   their  families  since  the  medical insurance cover was  introduced.  

We collectively agreed to work  together for the good of our members and therefore each party  is continuously appraised of with the happenings with joint responsibility of ensuring its success.

1. Issue 1: Very low  capitation on  outpatient services, with some capped as low  as  KShs.900/=  inclusive  of  doctors consultation, tests and drugs

Response

From the onset of the scheme, we developed a mutually agreed mechanism of identifying parameters for capitation to service providers.  

The basis of this is that we needed  to bring on-board as many service providers as possible, but cognizant of the fact that they have different service levels.

Based on a model recognised world over, the capitation fee is a pre-negotiated amount  with  service  providers  per  visit  per   person   and   ranges  between Kshs.900/=  and  Kshs.3,000/=  depending  on facility  level,  services  available  and the hospital’s average  cost per visit.

This is  derived  from  cost analysis based on past trends, scope of service, the level  of hospital  and economies of scale due to the  significant  number  of  lives  under  the scheme.  

For example, the  rates of capitation will be different for a service provider  who only has consultation and pharmacy  compared  to one who  has this plus say  laboratory and  radiology services.  

Even  where the  laboratory  and  radiology  services  are available,  rates will vary depending  on the level of procedures carried.

Please,  note that when  mutual  agreement  is  reached,  the  hospital  signs the contract and  is  required  to offer  all the contracted services under the agreed rates at no additional  fee from  our members, and does not serve as a financial limit to the cost of services that are to be offered.

Within the scheme, any  hospital found  culpable  of going  against contractual terms  is  singled  out  and  appropriate  measures  as  guided  by the  contract  are taken to  ensure eradication  of non-compliance  and  ensure our members  get their due benefits.

Please, be informed that this model has been in use world  over and has helped in reducing the turnaround time of clients receiving services by eliminating the need for preauthorization and curb fraud  resulting from  inflation  of bills.

We  have  also  initiated  a  process  with  Minet  to  review  the  current  rates to ensure come 2021-2022 cover year, the effects of the economic hardships  being globally  and locally experienced due to the  impact  of COVID-19  and the  surge in  cases  is   captured  in  the  capitation.  

This  is   to  ensure that  not  only  our members continue enjoying  services seamlessly,  but also service  providers are economically  empowered  so  that we all  grow  together  health wise,  physically and economically.

It  is  noteworthy  to  mention  that our  scheme  is   competitively  priced.    For example,  compared  to the  National  Police cove for  130,000  members  at  a premium    of  Kshs.5.5   billion,   our   teachers’   scheme   for   350,000  principle members is  Kshs.9 billion.  

Obviously, our scheme is  cheaper  by half with more benefits, portability, dedicated  ICT systems, Call centre and mobile based technologies which are continuously being introduced and  improved  to ensure that seeking services for our members is not a treacherous exercise for already ill-health stressed members or their dependants.

After witnessing  the  benefits  of the scheme, our members  have requested  that we   allow   them   to  have   additional   dependants   enlisted   in   the   scheme. Specifically, of interest to them  is  inclusion  of more children including those over 21 years who are not in school but are jobless and thus depend on their parents, second families in cases where  polygamy  is  allowed  by  law and  their elderly parents  and  dependant  siblings.  

We have  let  them  understand  that this,  if  it were to be allowed, would  be at a fee to them  and they are aware and willing as  long  as  it  is  affordable.  

We are now seeking  for best  ways to bring them  on board  through a subsidized rate/services for teachers.  Our aim  is  to make this cover to be as comprehensive as possible and take care of all medical financial needs for all members and their families.

Besides  this   scheme,   all   our   members   contribute   the   mandatory   NHIF deductions. Unfortunately, we understand from service providers that the universal benefits all contributors are entitled to are being rejected by NHIF at hospitals  where  our  members  seek  services.  

If  this  was  happening   as  it  is supposed  to,  the  scheme  would  be even more affordable as they  would  have two  streams  of  payments.  We would  like this  issue  addressed  and  we  have agreed that TSC addresses this without further  delay.

I bring  to  you  this issue  because it is  something that we  believe needs to be addressed so that if NHIF is  not willing to provide  services, then through policy, remedial actions can be done.

2. Issue 2: Restrictions  on the  hospitals  teachers are allowed to visit for treatment,  some   of  which   are  ill   equipped  and lack qualified personnel

Response

(a)     On Restrictions

From the onset of the medical scheme, through consultation amongst the stake holders, it was agreed that there would  be at least 200 service providers  across  the  country  where  our  members  would  access  services.

Another  condition  that we agreed was  that there  would  be portability and  our  members  would  not  be confined  to any  one service  provider against  their  choice but  were  free  to  access  any  of  the  empanelled providers within the set out scheme rules.

Over the  course  of the  scheme,  consultatively  based  on feedback from our members, through the regional offices of the  key  stakeholders, the scheme administrator has continued to increase the service providers that are now  at about 500  providers  across  the  country.  This  is  way  above what was  required  of the  Consortium in the  tender  request  to have at least   200  accredited   medical   service   providers/specialist   across   the country.

We continue consulting on the panel, and depending  on issues of concern, we have created a mechanism and criteria of adding  or removing service providers from the list.

(b)      On ill Equipped Facilities

Using the expertise amongst the stakeholders, we ensure that before a service  provider  is   empanelled  it  is  always verified  to be that which  is approved  and registered by the Medical Board. This is  because the Board undertakes  a  rigorous  exercise  of  assessment  before  it  approves  any facility  for  registration.  Part  of the  assessment  is  the  equipment  quality and type. This is how they categorise facilities. It means then that different facilities  will  have different equipment and this also  determines the  level of services expected.

When our member  goes to a clinic, for example that has only basic  levels of services  and  they  need  other  higher  level  of  intervention, they  are referred to such  level of facility for that service.  Some regions do not have high  level  providers and  have  only  primary  care facilities,  and  from  a member comparing  it to another higher level facility, they may be misconstrued to be ill equipped.

We have also ensured that both planned and impromptu visits are made to the various service providers to ensure that they are honouring  their commitment to treat our members accordingly.

(c)      On Lack of Qualified Personnel

This  would  be a grieveous  act, if such  things  are happening.   Sometimes people are judged  wrongly based on preferences.  

For example, someone would  assume that a young (or young looking)  person  is not qualified  to be a medical  doctor  because  of age.  To be fair  to the  service  providers and their  personnel,  we request  that we are given  specifics  so  that our representatives  on the  ground  can follow  up  and  provide  a  feedback within a fortnight.

3. lssue 3: Delay in approvals which  sometimes can take up to one month putting the life of a teacher  at risk

Response

(a) This   issue   has   been   raised   previously   in   some   regions  during our stakeholders’   meetings   and   in   some   instances   it   was   resolved.

For example,  in July  2020  in a stakeholders’  meeting  in  Nyeri, the  issue  of preauthorization for Dental and Optical services was discussed and after considerations   of  the   factors  that  led   to  importance   of   the   preauthorization were weighed against the pros of the same, we agreed that this  would   be  done  away   with.  

It  was  also  agreed  that the  scheme administrator would  work on an online mechanism  for preauthorization of  referral to other hospitals in  order  to reduce  the time for  accessing services.  

As  we speak  right  now, this will be rolled out  by mid this  month and we expect to see a great  reduction  in the turnaround times for preauthorization of referrals and other services.

(b)     The  previous  one  required  an  email  to  be  sent  to the  administrator, followed  by a telephonic conversation but this has now been automated.

4. Issue 4: The   teachers   suffer  due  to  challenges  that some  service providers face while  lodging claims with Aon Minet

Response

Denial  of services  to our  members  is  a  breach  of  contractual  agreements  by empanelled  service providers and we do not take this kindly.

(a)      We have had cases reported  and on investigation we found that some of the  service  providers  were  doing  this  to sabotage  the  scheme  with  the hope that they  would  be given more capitation  amount like the  bigger hospitals.

The remedial  actions required  of the providers were carried out and thus our members continue enjoying the services.

(b)     There   has   been   instances   where   instead   of  the   service   providers responding  to  queries  of  bills,  they  have  ignored  and  stopped  service deliery.  

Stern  action  has  been taken  when  all  the  levels  of  seeking remedy  has  been  ignored  or  not  borne  fruit,  including   dropping   the service provider  from the panel and seeking an alternative facility.

(c)      It  is  noteworthy  to  inform  the  Committee  that we  have  had  two  (2) facilities  suspended.  The  cases  involved   in  one  facility  was  fraud   and wrong  reconciliation  in another.  

In  both  instances  the  affected  members are informed through sms to ensure they were aware  so they could seek alternative facilities for their medical needs.

(d)     We are also  aware  that there  was  some  delay  in disbursement  of funds from the government which trickled don to the service providers not getting  their  funds  on time.   

After Consultative  meetings  it  was agreed that this was detrimental to the smooth service delivery that would cause our members vulnerable especially because late payment to service providers  means  delayed  payments  to  their  suppliers.  The  underlying issue  was  resolved  and  we  believe  that  this  will   be  maintained  for efficiency.

5. Issue 5: There  is limited access due to rigid  operating hours in some health facilities,

Response

(a)     Together with the scheme administrator, as pointed  out earlier,  we have put in great effort to bring on board as many  service providers as possible in all the regions with at least 2 facilities that offer 24-hour services.

(b)     We agreed and enacted that where the Capitator does not have 24-hour clinics, there are  other providers who  carry  out 24-hour services. As we progress, we continue to bring as many providers as is possible on board.

(c)      At this  juncture,  I    wish  to bring  to your  attention  that in  some  remote regions, it has not been economically viable for service providers to run on 24-hour basis due to the  limited populations not just of teachers but also of the communities in the region.

In such cases, we are seeking ways of encouraging service providers to run for longer hours. This includes considering what  Rind of incentives can be provided  to the communities through  county  offices  to  encourage  consolidating  resources  to  have mutual  inter-region  facilities.  

I can use  this  platform  to launch  the  idea for discussion as policy makers, which I will gladly  take to the rest of the stakeholders.

(d)      Please,  note  that Accreditation  of service  providers  is  also  dependent  on availability of credible facilities within any given location.

6. Issue 6: On dental services only tooth extraction is catered for  by AON Minet.

Response

(a)      In  reference  to the  dental  services  to the  provided   under  this  medical scheme the tender documents explicitly indicated the following  would be availed to the members:

•   Dental Consultation and Anaesthetist’s fees;

•   Dental X-rays and Root canal treatment;

•   Tooth Extraction;

•     Scaling necessitated by a prevailing  medical conditions and prescribed by a dentist;

•   Dentures necessitated by an accident/ injury;

•   Deformation surgery

(b)     On querying  claim, we were informed that there have been no reported cases of  members being  denied  deserving  interventions and  that there have  been  various  members who  have  received  other services  besides tooth extraction.

7. Issue 7: Other Issues raised in the Hansard Extract

Response

(a)     On behalf of the  stabeholders,  I   tabe this opportunity to appreciate that the  honourable  members  recognise  the  great  and  unmatched  role that our teachers play in shaping the destiny of our society, right from a young age.  

It  is true that we are all products of an encounter with  a teacher at one time in a growth journey.

(b)      It  is  important  to appreciate  that since  the  medical  scheme,  which  has been running  for  about 6  years  now, was introduced, we  have  seen  a great  improvement  in school  attendance  of our members.  

The lifting  of the  medical  bill  burden  from  the  teachers  has  been  a  very  welcome move.  The  number   of  fundraising  cards  amongst  our  members  has reduced  greatly.  

Even  where an admitted  member  or their  dependant has exhausted their limits the excess of loss has been very welcome by the teaching  fraternity.  The  last  expense cover  has  helped  many  families cater  for  the  funeral   expenses  and  now  people  can  bury  their  own decently without having to struggle to raise the funds.

(c)      The fight  for better terms  for the  teachers  has  not  been in vain  even as we endeavor  to see  more  happen  for  them.  We are  not  ignorant as stakeholders of the developments in the health industry both locally and globally.  

We  have  had  an  opportunity  to  compare  various  medical schemes for other organisations  and we can proudly  and confidently say that our members have a uniquely good scheme which has continued to improve   and   impact  the  them  positively.  

The  medical   scheme  has created  better  and  deeper  ties  between  us  and  our  members  as  we engage  more  on issues  health  and  also  get  to know  from  the  various forums what their needs are.

We are aware that many  schemes are now seeking  to  replicate  what we  have  for  our  members  and  for  this  we appreciate  because  such  developments  are  helping  the  country  draw closer towards universal healthcare as we fulfil the Big 4 Agenda.

Conclusion and Recommendations

1.    Our  Teachers  Medical  Scheme  serves  over  a  million  lives  and  has  been very instrumental in availing  access to the much sought-after medical care.

Over the years  in administration  of the scheme there has  been significant  impact among the population preventing members out of pocket expenditure which would  in extreme  circumstances  lead  to “Harambees”  and  loans  to  settle  medical  bills. This has become a thing  of the  past as teachers and  their dependants have access to medical insurance services.

2.  There is also an established scheme governance model at County and National level. This involves holding regular meetings of administrators and Rey stakeholders  within  each county  including  teachers’  representatives  to address any emerging issues affecting  teachers and coming up with local solutions and resolutions at the grassroots level.

3.  All of us together shall make our teachers proud and happy  in their service. This will translate to better learning/teaching environment and thus better society.

4.   We shall continue encouraging our members to launch their complaints as soon as is  possible, preferably  when it occurs to the medical administrator or to our regional  offices  with  accurate  details  of  the  issue  for  easier  tracking  and resolution.

5.   We  are   currently   working   with   the   scheme   administrators   and   towards removing  preauthorization of referrals for all treatments for our members. We believe this shall be effective from this month.

6.   We  are  committed   to  continuously   improve   the   medical   scheme   for  our members and shall continue holding stakeholders’ meetings on a monthly basis until  we achieve our goal  of having  one of the  best  medical  schemes  globally with potential for being replicated for attainment of universal health care.

7.   We are glad that the teaching fraternity has found partners that they can walk with,  reason  together  and  willing  to compromise  some  of  their  benefits and   privileges  for   the  greater  good.  

We  continue  to  hold   meetings  as stakeholders to deliberate on ho to  keep the scheme  running and benefitting all the  members  without  harming  the  service  providers.  We believe in coming up  with  solutions  that would  preserve  the  baby  instead  of throwing  it  away with the birth water.

8.   Whereas  it  is   good  that  the  issue   was  brought  to  the  Senate  for  further ventilation,  it  begs  the  question  whether  the  complainants  used  the  right channels and if so at what extent did it become unresolvable?

As a politician  as well as a union member, I   would  hate to see our institutions  being undermined or being used to settle scores. Based on the information you have sent to me, an invitation to respond, besides the Hansard, there is  no other information that would  show that the  issues raised  were beyond resolving  by the stakeholders of the medical scheme before coming to the Senate.

In  my  own  capacity and  on behalf of the  members and  stakeholder’s  I    wish to confirm  my  availability to attend the  zoom  meeting  scheduled  for  Wednesday November  4th  2020  at 9:30  a.m.  with  a  willingness  to respond  to  any  of your queries if any, to the best of my ability and knowledge.

HON. WILSON SOSSION
SECRETARY GENERAL
KNUT