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Globally, there is a trend towards planning for healthcare in a predictable manner through prepayment and participation in health insurance pools with managed care as the mode of healthcare delivery.

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping

This is done through one of the best HMOs in Nigeria called United Healthcare International Ltd. commonly employed to:

i. Provide affordable and efficient health services
ii. Improve quality of healthcare
iii. Increase access to healthcare, and finally
iv. Advance the health of enrolled populations, employee groups, communities, states and countries.

This adoption of managed care mechanisms, techniques, tools and use of ensuring entities like HMOs goes with the trend toward decentralization of the health financing function of the health system. Many countries are abandoning centralized, government financed, government-owned health delivery systems and instead opting for a Public Private Partnership as the financing agent and the delivery system. The National Health Insurance Scheme is a public-private partnership solution. It is private sector is driven and public sector regulated; an ideal model for PPP.

Managing Cost is done in three ways:

a. Managing Insurance Risk: There is a package in Health Insurance which details services that will be covered, who will be covered and under what terms and conditions such that pooled funds from a prepaid scheme can cover this. This helps in spreading of risks across larger population groups from healthy to sick. There will also be a detailed list of exclusions. The NHIS is a special social security arrangement based on the concept of solidarity and equity to provide financial protection to participants against ill-health through the payment of contributions and pooling of resources.

b. Managing Contracted Providers: The scheme also makes use of a network of both public and private providers. The scheme has adopted capitation and fee-for-service as payment mechanisms. Primary care is paid by capitation while secondary and tertiary care services are paid through fee-for-service tariffs. Providers with a good track record with enrollees tend to get higher enrolment with a consequent increase in their capitation. The WHO and Federal Government recommend the use of Generic Drugs Generic drugs are adapted to control the cost of healthcare.

c. Managing Utilization of Services: Healthcare providers are health facilities at Primary, Secondary and Tertiary levels that provide services at respective levels in the healthcare delivery system.

  1. Entry into the health system is to be at the primary level where each beneficiary is expected to be registered. Enrollees are to pick providers nearest to their homes or offices which can be private or public clinic and will act as their primary provider
  2. Subsequent access to other levels is only by referral. This technique of prior authorization of services is a global practice which ensures appropriate utilization of resources at all levels. It also helps in concurrent review and availability of the second opinion. The referral levels allow equitable patronage of all three levels of healthcare.

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