Introduction

In healthcare, there are growing concerns with accountability because of considerable dissatisfaction with health system performance due to lack of basic services, inadequate access, poor quality, abuses of power, high cost of services and lack of responsiveness.

In addition, poor accountability causes significant efficiency loss, discourage access to health services, cause poor quality of service and cause poor health outcomes.

There is also strong correlation between accountability and health outcomes measures because of its impact on patients’ experience.

Nowadays, accountability is seen as a new frontier and tool for improving health system performance and achieving greater health impact, and many governments are facing pressure to provide health services effectively, efficiently and equitably through approaches which often converge in emphasizing accountability.

What Does Provider Accountability in Healthcare Mean?

Accountability means being answerable to someone for decisions and actions.

Healthcare delivery is premised on unwritten agreement between service provider and health consumer.

Accountability describes a relationship between a duty holder and a person or organization to whom a duty is owed. It describes the capacity to demand that a person or organization give reasons to justify their behavior and the capacity to impose a sanction if they fail to give reasons, or if their performance is poor.

Provider accountability is about a health professional being answerable to health consumer for his/her decisions and actions.

It is about delivering on a commitment in service delivery. It is responsibility to an outcome, not just a set of tasks and not simply taking the blame when something goes wrong in healthcare delivery.

Types of Abuses and Frauds in Healthcare

Insufficient Accountability fuels abuses, non-compliance with ethics, standards and procedures and several other illegal and unethical acts and behaviors which undermine health care delivery and result is poor performance. It also impedes confidence, trust, reputation, and reliance causing considerable damage in patients experience.

They are frequently described to occur under the following categories:

1. Health & Medical Service Delivery: Common examples under this category include:

1. Absenteeism: Absence of providers at duty post can severely limit patient access to services, reduce quality and patient’s satisfaction.
2. Conflict of Interest: Spending official government time in private practice and diversion of patients etc.
3. Self-referral: referring the patients to a clinic, diagnostic service, hospital etc. with which the referring physician has a financial relationship.
4. Unofficial payment: Informal charging by providers often have serious equity implications.
5. Providing unnecessary care or maximizing care: more healthcare is provided than was needed to heal the patient. Sometimes certificates are falsified to show the medical necessity of certain actions in order to justify payments.
6. Prescription of specific brands of medicine that yields a bonus from the pharmaceutical company. Physicians themselves can fraudulently write prescriptions for money.
7. Off -label promotion of drugs: this involves the marketing of drugs for uses which are not approved by NAFDAC.
8. Diversion of operational vehicles - ambulances for unofficial use.
9. Wastage of Drugs and Commodities: Procurement of near expiration (short-shelf-life) pharmaceutical products.
10. Lack of Basic Equipment: Basic Equipment required for routine service delivery such as BP machine, stethoscope and weighing scales are often lacking.

2. Irregularities in Provider Payment Schemes under the national and private health insurance agencies:

This category of cases arises from infractions and infringements against health consumers by provider institutions and the health maintenance organizations (HMOs).  Examples include: 

1. Identity theft: - an uninsured individual assumes the identity of a person with insurance coverages to obtain services.
2. Waiving co-payments: Insurance plans can require co-payments for certain services to encourage patients to make appropriate cost minded decisions in their health care. This violates agreement with the insurer.
3. Lying about eligibility: Patients can lie and misrepresent information about their dependents to get insurance coverage such as declaring an ineligible person as underaged so he/she can access healthcare.
4. Improper coding (upcoding): Billing for a more expensive service or procedure than the one performed. It could be a malicious attempt to increase revenue.
5. Unbundling: Unbundling means creating separate claims for services that should be grouped together.
6. Submission of double bills: care providers can try to submit the same claim multiple times, in order to get paid two times for performing one action.
7. False claims - billing for services that have not been provided or for medicines or medical devices that have not been delivered to the patient.
8. Billing for services rendered by unquailed personnel: provider is unqualified or uncertified - does not have the credentials or license to actually perform the kind of care provided.
9. Doctor shopping: a drug-seeking patient visiting multiple doctors to obtain desired prescriptions.

Strategies that can be used to increase the provider’s accountability to the client/patient.

1. Display of Patient’s Charter (Patient’s Bill of Rights) in strategic places in healthcare facilities.
2. Provision of channels of enquires and complaints: dedicated officers to handle complaints/grievances.
3. Set up Complaints Management System such as complain boxes, dedicated helpline, and electronic platform.
4. Putting in place transparent and responsive administrative procedures for handling complaints and petitions through SERVICOM desks.
5. Putting in place Health Consumers Forum at facility and community level can increase citizens/user participation and transform them from passive recipients of services to active.
6. Conducting focus groups and client satisfaction surveys can be used to obtain the views of service users on accountability.
7. Possible contacts with CSOs to enable access to professional regulators and legal system where patients can pursue malpractice suits to hold health providers accountable.

We care about your experience in healthcare.

To share your healthcare experience, visit our Health Consumers Forum.

To channel your complaints or grievances, visit https://voiceit.ihatresources.org/

Watch out for next blog on the role of different actors in health provider accountability.

Are you passionate for, and interested in promoting provider accountability in healthcare?

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