Outlining how the NHI will work
Dr Anban Pillay, the Deputy Director General of the National Health Insurance (NHI), explains the differences between the NHI benefits and the current medical scheme benefits
IN MY previous article, I provided an outline of the legislative process for the NHI Bill. The Bill provides a legislative framework on which the NHI system will be developed.
Details relating to services that will be reimbursed or which medicines will be paid for etc will not be found in the Bill. Such details are not drafted in the Act but rather in regulations and other policy documents which will be developed after the Act has been finalised.
There is a tendency to want to compare the current medical scheme benefits with benefits that would become available through the NHI. The NHI benefits structure will be different to the current medical scheme benefits. A medical scheme benefit is structured as an insurance product with each benefit category having limits usually based on a fixed monetary value or number of consultations.
For example, a medical scheme would limit GP visits to only 10 visits per year for a family. In that year, if the family needed healthcare more regularly than these 10 visits, then they would have to pay cash for such visits.
The NHI will not have such limits since it is inappropriate to restrict the healthcare needs of a person. The obvious question that usually arises is “where will the money come from?” since this approach may result in excessive costs.
One of the major changes that the NHI will introduce is the manner in which health providers (doctors, dentists, physiotherapists, optometrists and other allied health professionals) are reimbursed.
Health care providers will be reimbursed on a capitation basis. Capitation based reimbursement involves paying a provider an agreed fixed monthly payment for accepting to treat a cohort of patients registered with the provider.
In a capitation based system, the provider accepts responsibility for the health of those registered with him/ her and will not levy any additional charges on the patient. In this model of payment, the provider manages how often the patient should return for follow up visits.
The capitation system is different from the current fee for service system where the fee for service system incentivises the provider to maximise services and goods to a patient in order to increase their own income. So, South Africans will be able to access the system when it is being implemented? Yes, all South Africans will be eligible to access the system after registration. When the registration system commences, then all citizens will be required to register at designated registration facilities.
The registration will involve the selection of primary care providers like general practitioners, dentists, pharmacists, physiotherapists and optometrists amongst others.
During the registration, demographic information such as age, gender, address and known medical conditions must be provided. This information will assist with the adjustment of the capitation rate based on the disease burden of the cohort registered with the GP.
Register
It is important to note that patients must register where they prefer their primary care. This primary care provider will then be contracted to deliver services. There are circumstances where a patient will have to access care from a different service provider (for example, when you on holiday or an emergency) and this will also be reimbursed.
Central to the implementation of the NHI is a reliable health information system that includes, amongst others, an electronic health record. The electronic health record should be able to store all the health information centrally in a manner that allows for easy access when a patient has to access services. This prevents the risk of lost records or the need for records to be physically transferred between providers.
Implementation of this system has commenced with the initial phase involving electronic registration of patients visiting public health clinics. The system will expand in phases to include relevant health records. At full implementation, it is planned that the treating health professional will be able to access all relevant health records of the patient electronically. The electronic health record will facilitate care amongst multiple health professionals at primary care level.
The NHI policy, as well as the NHI Bill, highlights the importance of multidisciplinary teams at primary care level. There is overwhelming evidence that multi-disciplinary teams at primary care level provide better quality care and there is improved patient satisfaction with this model of care. Currently, in South Africa, the model of care is mainly an individual provider based model which has been shown to be inefficient.
A multi-disciplinary team would involve various health professionals working as a team to improve the health outcomes of the patients they manage.
Consider a diabetic patient that regularly visits his or her general practitioner, who must manage multiple aspects of the disease such as blood glucose levels, medication titration, diet, exercise, eye care, foot care etc.
It would be much more efficient to have various health professionals managing specific aspects of the disease. This benefit is compounded if the multidisciplinary teams can deliver the service under one roof, instead of the patient having to travel between providers.
There are few examples of multidisciplinary teams in South Africa. However, this needs to be expanded, so that we can provide patients with good quality healthcare.