The National Health Insurance Fund (NHIF) will allow members to directly access consultant doctors and private pharmacies in a move aimed at widening treatment options and keeping a lid on costs.
NHIF chief executive Peter Kamunyo said the board is currently finalising roll-out of the model that will offer members more options in accessing healthcare and reduce amounts spent on payment for claims.
Presently, NHIF pays for services through accredited hospitals, locking out consultants operating in private clinics and pharmacies.
This has forced its members to meet the cost of buying medicines and tapping consulting doctors outside qualified hospitals.
“Right now, we can only reimburse hospitals and that has been a problem. Why don’t we have consultants who charge less, we can negotiate with them because the Act was that we could only reimburse hospitals,” Dr Kamunyo said on Monday.
“Now we will be more creative in cost containment, adding quality and value to our members. The [NHIF] team is working very hard to ensure we get there because this is one of the big-ticket items [needed] to achieve quality and cost containment.”
The shift is riding on changes to the NHIF (Amendment) Act, 2022 that now allow the State insurer to directly contract individual healthcare professionals to provide consultancy, preventive care and other services.
The previous law restricted the NHIF to public, private and faith-based hospitals for inpatient and outpatient services.
Now, the NHIF will negotiate the payment rates with private clinics and pharmacies as it races to adopt the business model pursued by insurance firms.
The fund did not provide details of how its members will access the planned service.
Official data shows that Kenya had 13, 376 registered doctors and 4,285 registered pharmacists as at December last year.
The NHIF is betting on its wide membership of 13.8 million to negotiate fees lower than the market rates.
The State-backed insurer spent Sh54 billion on claims in the year ended June 2021, representing 91 percent of the Sh62 billion it collected as premiums.
“Currently, the drivers of costs in the health sector are medication and diagnostics,” the NHIF says in a brief.
It estimates that drugs account for between 30-70 percent of the treatment costs, underlining the need to seek discounted prices and fees from consulting doctors.
Dr Kamunyo added that the deals with chemists and drug manufacturers will be an enhanced version of a contract that the NHIF signed with Janssen Kenya – a company owned by American pharmaceutical giant, Johnson & Johnson.
The NHIF’s deal with Janssen Kenya allows prostate cancer patients to get 10 packs of Abiraterone acetate — a prescription drug — at Sh600,000 which is half the market price of Sh1.2 million.
“We have negotiated with key pharmaceutical companies and we are going on and this will be more enhanced when we start a pharmacy benefits management,” Dr Kamunyo said.
The State-backed insurer is keen to contain costs and protect cash reserves given its role of spearheading affordable and quality healthcare to all Kenyans under universal health coverage (UHC).
The NHIF is at the centre of the government’s ambitious UHC where all membership is compulsory to all Kenyans aged 18 years and above. The State insurer is also battling high rates of fictitious claims and adverse selection that bleed it up to Sh16.5 billion annually, piling pressure on its finances given that it spends over 90 percent of its premiums to settle claims.
The scheme has also increased reimbursement rates to contracted health facilities by 12 percent, more than doubled the number of surgical procedures it covers and expanded oncology benefits for cancer patients, bringing to fore the importance of containing costs.