HMO AND THE SHORT-CHANGING OF NIGERIA’S PRIVATE DENTAL PRACTITIONERS

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The relationship between HEALTH MAINTENANCE ORGANIZATIONS, HMOs and Private Dental Practitioners in Nigeria, is more of a “monkey dey work, baboon dey chop” (as they say in local parlance) scenario presently.

Things used to be rosier for these group of dentists way back when the HMO’s hadn’t made much inroads into Nigeria. Most of them were located in urban areas, while government was left to cater for the dental needs of the people in the villages and countryside. Setting up a dental practice could be quite expensive hence the reason behind the setting up of such practices in choice locations in cities, or heavily populated areas in suburbs, such that premium fees could be charged in the highbrow areas for fewer patients, and competitive fees in the latter because of a high turnout. Back then, visiting the dentist was considered elitist. For notable names in the sector, cornering RETAINERSHIPS from the conglomerates and other well established companies wasn’t difficult, their revenue guaranteed them the lives they had dreamt of.

When the HMO’s came on board, a little over a decade ago, many of those dentists who flourished under retainerships felt that they won’t be touched, and that the phenomenon would soon die off, as many other policies of government set up in the past to increase access of citizens to healthcare had. Unfortunately, for them, it didn’t happen as they planned, and some of the practices that failed to envisage and accept the change that came with HMO’s fell, while others were left with no choice than to join the moving train.

Retainerships simply evaporated into the thin air of the HMO world (except for a few who continued to keep faith with the dentists after seeing the shenanigans of the HMOs), as the conglomerates and companies that fed dentists soon received offers they couldn’t resist, which amongst others, included a reduction in their budget for medical. On the flip side, dentists were made offers of increased patient turnout with the caveat of a reduction in tariff.

Even dentists whose practice weren’t in the highbrow areas had cause to smile as they could also enjoy the patient flow with tariffs as competitive as those charged by their counterparts in choice locations. With companies joining up to HMO’s, as it now cost them much less, the field soon became saturated and an all comers game, and everyone (it seemed at the time) was the happier for it. Like the undertaker with business that had no season, the HMOs and dentists smiled to the bank, until the bubble burst.

This is because, somewhere along the line, the owners of these HMOs felt there was a need to diversify their investments with these funds in their care, since not all insured eventually got “dentally” ill (in this case, toothache and the likes in dental health challenges) and needed dental care. So they pushed some of the funds into the then growing stock market in Nigeria that was Bullish at the time, others plunged theirs into the Real Estate sector, and began defaulting in settling their debts to dentists, who continued to offer their services to the enrollees of these indebted HMOs. At this point, their medical counterparts were largely shielded from the effects of the shenanigans of the HMOs as they got their CAPITATION upfront.

By the time the bubble burst, not a few private dental practitioners aligned with HMOs came out of the situation unscathed, not because of a direct action of theirs, but because of the financial indiscretion on the part of the handlers of some of the HMOs, especially those who saw the opportunity it provided as the Goose that laid golden eggs. The dentists couldn’t, like their medical counterparts (who could easily tell patients that their HMO hadn’t paid capitation and hence could not be seen, unless they desired to make payments out of pocket), send their patients back since the HMOs kept promising to pay the mounting debts, in the face of dwindling revenue as a result of a reduction in number of cash paying patients, who in their large numbers continued to enroll with more HMOs by the day.

In the end, some of these HMOs never recovered, and some dental practices and dentists never got paid. Some got some percentage of the totals due them paid after some negotiations, or following the use of STRONG ARM tactics with the help of DEBT RECOVERY AGENTS, which of course resulted in the termination of relationships with the HMOs in question. It was a bad time for dentists who reaped very little for all of their hardwork, while the owners of some of those HMOs simply walked away with what was left of their assets to invest in other businesses, with no one holding them responsible for, in some cases, personally bankrupting their HMO business.

Out of this chaos arose some certain changes amongst the HMOs which survived the avalanche, and the new ones that appeared intent not to make the mistakes of the past. These, though promised their enrollees “heaven and earth”, in terms of their ability to enable them procure the best in terms of dental care, within and outside of Nigeria but on the other hand provided many of those treatments as EXCLUSIONS in the list they made available to the dentists, even with the highest class of health insurance cover they managed to convince some enrollees to buy, leading to situations where conflicts erupt between dentists and such patients when the latter appear to procure such treatments, especially those considered as cosmetic, and hence not covered by the HMO.

Even the bit covered are heavily scrutinized and vetted mostly by the staff of these HMOs who aren’t dentists and couldn’t understand the ramifications of the bills presented to them to verify and approve payments for, with auditors visiting the dentists routinely to look through patient files to see if the treatments offered were the same ones paid for by the HMOs. Their activity has managed to turn the HIPPOCRATES OATH on its head, and many dentists have had to improvise in order to help their patients, and not run foul of the rules of the HMOs (many of which are random shifting of the goalpost in the middle of the game), just so they can get paid and run their practices profitably. Unfortunately many a time, these HMOs simply slash the dentists’ due for no just cause, in flagrant breach of the agreements they reached with the practices and dentists, and of trust, even after payment had been delayed beyond the period stipulated in the agreement both sides reached at the onset.

While the dentists suffer and wallow in poverty, and the patients are shortchanged (in quality of treatment sometimes), the only profiteers are the executives of the HMOs, who allocate to themselves the largest percentage of what the clients and their companies pay in premiums, changing offices, cars and issuing their employees huge payouts in emoluments, benefits and bonuses.

It is in this unfortunate reality that many PRIVATE DENTAL PRACTITIONERS traverse to eke out a living for themselves in the harsh economic atmosphere that currently envelopes Nigeria, which if not turned around in favour of dentists can lead to scenarios that will hardly benefit the patients, and enrollees of these HMOs in that some dentists, especially the best of them, may decline managing HMO enrollees, leaving the space for less skilled dentists to manage them for the meagre fees the HMOs will pay, or alternatively give to the patients the dental care commensurate with such fees; a lose-lose situation for the patients at the end of the day.

It has become trite that the HMOs listen to the yearnings of these private dental practitioners that are the pivot of their health schemes, with the view to addressing their grievances, atleast to reach a compromise with a deal acceptable to all parties involved for the good of the patients, and their enrollees, so that all concerned can sleep peacefully at night.

‘kovich

PICTURE CREDIT: http://www.heroesofnigeriahealthsectorawards.com

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