On the way to NHI Reorganisation of SA’s entire healthcare industry
FOLLOWING THE ANC’S watershed Polokwane conference in December last year a national health insurance (NHI) system is again topping the ruling party’s healthcare agenda. In fact, all the legislation currently under scrutiny – particularly the National Health Act and the Medical Schemes Amendment Bill – is clearly aimed at creating a facilitating environment for its implementation.
Back in 1994 the ANC stated the case for NHI, with a social health insurance (SHI) system as a possible intermediary step. (In the case of SHI, working people benefit equally and Government takes care of the rest, while in NHI the working people contribute to tax and everybody benefits equally.)
“The policy direction from an ANC viewpoint is quite clear: it’s not a matter of ‘if’ but ‘when’. However, I expect the ANC will keep mum until the election next year. Once that’s over details should be coming through about the costing, benefits, etc,” predicts Board of Healthcare Funders (BHF) corporate communications head Heidi Kruger. “As NHI is essentially a reorganisation of SA’s entire healthcare sector – both private and public – the industry is abuzz with NHI talk. Much of BHF’s energy is going into this, as it’s bound to have a major effect on medical schemes.
“The benefit package is the most important concern, coupled with what’s actually affordable. To ascertain that, you have to take into consideration what Treasury is currently giving to health, what members of medical schemes are currently paying in as well as the current tax expenditure subsidy and see where the shortfalls are,” says Kruger.
The other important issue in terms of the NHI is the vehicle that’s going to provide the services, which raises a number of questions.
“Is it going to be the public sector? Will it be through public/private partnerships? Do medical schemes need to think about putting money into the public sector to upgrade it? How can providers of service be incen- tivised to stay in the country and to go back into the public sector? Much work needs to go into ensuring there are sufficient human resources in the public sector.” Then there’s the whole funding issue. And more questions. How many medical schemes will there be? What role will medical schemes play in a NHI environment?
Also (still) under discussion is the issue of prescribed minimum benefits (PMBs) and last month a draft PMB review discussion document was released. “In our view it needs to be looked at in the light of the NHI and other policy and legislative changes under way, because an NHI is all about the package that will be offered under that system,” says Kruger.
As the umbrella body for the medical schemes industry, BHF proposed far-reaching changes to the existing PMB framework. “Our stance for some time has been that PMBs are too focused on hospital and referred care – the expensive interventions. We therefore proposed PMBs include primary and preventative care, especially when you consider the burden of disease and the causes of death in the entire population and not only for the 7m insured lives.”
Says Kruger: “Suppose you’ve been bitten by a rat and have to go for a tetanus shot. PMBs don’t cover a tetanus shot but they do cover you when you’re really sick and have to go into hospital due to the tetanus. We maintain it would be more efficient to put a primary and preventative care component into PMBs so that you spend less money on the high cost interventions.
“At the primary care level we proposed PMBs shouldn’t be diagnosis based but rather consultation based. So that you could, for example, have15 consultations a year at a primary care giver such as a GP and that would cover you for any chronic disease you might have. Currently, if you don’t have any of those chronic conditions on PMB chronic disease lists, you may not be covered by your scheme.”
The national health reference price list (NHRPL) is another bone of contention. It currently makes provision for an 8,7% increase for all schedules, which is contested by some role-players who argue it’s not even inflation related but also way out of kilter for the services offered by medical specialists, for example.
“However, it’s encouraging that 11 of the 36 disciplines submitted proper audited input to the Department of Health (DoH). Those inputs will be scrutinised by the DoH. According to the DoH the remaining 26 submissions weren’t acceptable because, for example, they didn’t use the correct representative sample or didn’t use the correct costing or coding methodology,” Kruger says.
“The ultimate goal regarding the NHRPL is that we reach a stage where it’s fair and based on real costs incurred by health providers. Whatever happens under the NHI, the NHRPL process is going to be very important because it will – for the first time – provide the industry with the real costs of providing a healthcare service. We’ve never really known how much things cost; nor has there been this kind of transparency and work done on the various codes.”