A new data analysis report has shown that full digitization of NHIS claims is the most important strategic policy measure for the NHIS’s future.

According to the study, a strategic action would be an efficient cost-containment measure for operational efficiency and strategic management decision-making as a data-driven insurer.

A team from the NHIA, the PharmAccess Foundation, and the University of Ghana’s Economics Department collaborated to work on that study; data analytics of three years of NHIS electronic claims.

The largest single claims payments, according to the data, were for pregnancy, with delivery accounting for 16.1% of total claims cost and treatment of hypertension and diabetes accounting for 14.6 percent, with the two accounting for more than 30% of all claims during the time under consideration. During the same period, the analysis revealed that diagnoses of hypertension and diabetes in patients over the ages of 18 increased dramatically.

“About 48 per cent of patients first diagnosed with hypertension or diabetes in 2019 did not have follow-up visits for the same diagnoses. The high ‘loss to follow-up’ could be due to many factors, including misdiagnosis at first visits, follow-up visits to NHIS service providers that submit manual claims, follow-up visits to non-NHIS service providers or seeking of alternative therapies.
Data report

“Medicines constituted nearly 34 per cent of average claims cost. The medicines cost was as high as 70 per cent for some CHPS facilities, which could be due to cover prescription or over-billing for medicines. However, high under-prescription of medicines was observed for specific urban-located facilities, compared to peer facilities (ownership and level) with a similar urban location.”
Data report

The report recommended to the NHIS to put in place a system that allows for the tracking and linking of prescriptions to submitted claims in order to locate and control unethical provider behavior and NHIS member provider shopping, both of which have led to a higher claim cost.

“Cost-wise, it was revealed that multiple diagnoses per claim have high implications on claims costs, as average cost per claim increased by over 400 per cent from GHc40 per claim with single diagnosis to GHc166 per claim with five diagnoses.”
Data report

Lower Average Cost of Claims in 2019

The analysis equally demonstrated that despite three consecutive annual increases of about 20% in NHIS service and medicines tariffs, the average cost of claims was lower in December 2019 (GHc43.30) than in January 2017(GHc44.80). It showed that electronic claims management was more effective than manual claims management at controlling the average cost of claims, even during consecutive increases in tariffs.

Dr Maxwell Antwi, Ghana’s Director of PharmAccess Foundation, speaking at the NHIA Data Day as part of the NHIS Week celebrations, averred that the best way to keep costs down was to continue digitizing by making claims filing purely electronic.

“When it comes to female genital cancers in low middle-income countries, cervical cancer is number one; the cases are being seen, but most of them are financed out of private pockets and that is because there are challenges with the NHIS costing structure and the guidelines.”
Dr Maxwell Antwi

As part of its benefits package, the Country Director added that the NHIA was taking steps to improve the costing structure and treatment recommendations for cervical cancer management.

Dr. Antwi further explained that the data analytics were significant because they were intended to turn the NHIA into a data-driven insurer that could make the most of its own data.