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
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
(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
(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
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,
(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.
(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
(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