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Table 1 Synopsis of definitions related to “optimal-resource-use” domains by the providers

From: Performance evaluation of a health insurance in Nigeria using optimal resource use: health care providers perspectives

Domain name Variable used Definition (provided in the interview manual)
Administrative efficiency Prompt arrival of insurance funds Regular monthly reimbursement of capitation payment made by the Hmos* to the health facilities or hospitals, and fee-for-service payment in case of referral.
Promptness of the referral system Efficient and rapid (24 hours) response of the Hmos* to the health care provider, when patients are to be referred for secondary or tertiary care in the insurance scheme.
Active monitoring mechanism Claims review (as a proxy) Monthly cross-checking that enrolees received all necessary treatments and diagnostic tests covered by the health insurance and all prescribed drugs that are included in the NHIS* drug list.
Provider payment mechanism Capitation payment method Total monthly amount of money (fixed per enrolee) received by the health provider or hospital from the Hmos*. This total fixed sum excludes payments for referrals and 10% of total cost of drugs paid already by the patient during hospital visit.
Fee-for-service payment method This is termed an amount of money reimbursed by the Hmos to the health provider facility or hospital per episode of specialty, secondary or tertiary care administered to the enrolee. This amount of money excludes payments for capitation and 10% of total cost of drugs paid already by the patient during hospital visit.
Benefit package Benefit package inclusion Includes all treatments and diagnostic tests covered by the health insurance plus all drugs prescribed by doctors or nurses as included in the NHIS* drug list. This benefit package includes out-patient care, in-patient care, specialized care (eye and dental care), and prescribed medications and consumables. However there are exclusions such as dialysis, cancer treatment, mental disorders, branded medications and ostentatious consumables (as specified by the regulatory agency).
  1. *Abbreviations: Hmos health management organizations, NHIS national health insurance scheme.
  2. Sources: NHIS [2]; NHIS [3, 4]; Carrin and James [68].