On the way to NHI Re­or­gan­i­sa­tion of SA’s en­tire health­care in­dus­try

Finweek English Edition - - News -

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.”

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