Defining Healthcare Packages in the NHI

Joe SeoloaneCurator of Pro Sano Medical Scheme

A Perspective on NHI • NHI should be approached with soberness and objectivity based on

principles of human dignity, need and cost.

• Both the public and private sector to collaborate.

• Stakeholders to have the opportunity participate and to influence the NHI implementation.

• Rational and responsible phasing of the NHI is a critical success factor.

• Genuine and objective inputs should be provided in the midst of scepticism.

• We should also guard against unrealistic optimism that the NHI will be the panacea for all healthcare problems.

• There will be continued lobbying to discredit whatever NHI package is ultimately developed in favour of the status quo.

National Stats Relevant to NHI

Total population: 49.32 million

Employment rate: 17.5 million

Life expectancy estimated at: 53.5 years males & 57. 2 females

Sweden 77.9 males & 82.4

females

Infant mortality: 45.7 per 1000 live births Sweden 3%

Living with HIV: estimated 5.2 million

Adults 15-49: 17% of population is HIV positive

On ART: 1.5 million older than 15 years /106 000 children

TB Endemic: with a growing number of MDR TB

Currently largely treated in public sector

The South African Envisaged Model of NHI• Mandatory Enrolment

For all citizensNo financial or other barriers - equal access to all health care services

• Single Payer Payment System NHI will be the only legitimate insurer of NHI benefitsContracted service providers paid on a negotiated reference price list

• National Administration of the FundAdministered by a government agency/agencies - under direct supervision of the DOH

• Contribution into the NHI fund Largely from taxationPayroll related amounts based on income Subsidy from employers and government

• Benefits Comprehensive benefits to be defined

Public and private sectors contracted service providersCover will be for member and dependants

Primary Care Benefits – Basic curative care and preventative services• Diagnosis• Laboratory tests• Prescription drugs (appropriate schedule for GP’s and nurses) • Consumables• Minor operations• Maternity services • Basic dental & optical care• Chronic medication

Secondary Care Benefits• As per above - at a referral level•Specialized care with subspecialties•Mental health care• Blood transfusions• Emergency care• Basic general & gynecological surgery

Tertiary Benefits-Highly Specialized Care• Oncology, transplants and clinical appropriate reconstructive surgery• Advanced radiology & laboratory tests

Comprehensive Levels of Cover

Basis for Level of Care • Services will be treated at appropriate level of care.

•Current public sector structure is a good basis

• Referral protocols and disincentives for non-compliance.

• Clearly defined treatment protocols and dispensing of medicine.

• NHI will cover conditions as specified in the treatment protocols.

• Clear policies of patient pathways and guaranteed access

• Private sector may offer supplementary cover for the services

excluded from NHI.

• Exclusions can be privately insured or paid out-of-pocket.

Experiences from Private Sector Basic Packages

Benefit Benefit Rules

Comprehensive hospital cover Unlimited for services delivered at appropriate level for care.

GP consultations and medication Unlimited to network providers: (including consultation, procedures, medication, pathology and radiology).Max of R 600 per event 2 out of network visits per family

Out of hospital specialist consultations

5 consultations per family – max R2000 pa3 consultations per beneficiary – max R1600 pa

2 Maternity consultations From network doctors

Optical benefits Examination, frame and lens (uni & bifocal)

Basic dentistry benefits As per protocol

Unlimited chronic medication As per formulary

Top Ten GP Visits

Acute upper respiratory infection, unspecified

Acute bronchitis, unspecified

Influenza with other respiratory manifestation virus not identified

Acute sinusitis, unspecified

Essential (primary) hypertension

Acute pharyngitis, unspecified

General medical examination

Diarrhoea and gastroenteritis of presumed infectious origin

Urinary tract infection, site not specified

Influenza with other manifestations, virus not identified

Examples of What Primary Benefits Should Cater For:

Top Ten Dental Services

Infection control / barrier techniques

Oral examination

Local anaesthetic – per visit

Sterilized instrumentation

Intraoral radiograph – periapical

Infection control / barrier techniques

Prophylaxis – complete dentition

Local anaesthetic – per visit

Sterilized instrumentation

Limited oral examination

Examples of What Primary Dental Benefits Should Include:

Top Ten Specialist Referrals

Gynaecology – Obstetrics

Orthopaedics

Surgery

Otorhinolaryngology- ENT

Ophthalmology

Paediatrics

Physicians

Urology

Dermatology

Cardiology

General Indication of Specialist Expertise Required at Secondary Care Level

TOP 10 Hospital Admissions by Cost

Gastritis, unspecified

Bronchitis. Not specified as acute or chronic

Retention of urine

Lumb and other intrvertebral disc disorders with radiculopathy

Pneumonia, unspecified

Angina pectoris, unspecified

Diaphragmatic hernia without obstruction or gangrene

Malignant neoplasm of kidney, except renal pelvis

Respiratory syncytial virus pneumonia

Calculus of gallbladder with other cholecystitis

General Indication of Services to be Catered for at Secondary Care Level

Tertiary Care

Highly Specialized and Costly Services

Oncology

Transplants

Plastic and reconstructive surgery

Complicated cases

Other specialized procedures

General Indication of Services at Tertiary Care Level

Lessons from the NHI in Taiwan

National Health Insurance Act of 1994 as amended on May 18, 2005 and Regulations for NHI Medical Care as amended on 22 April 2009

Framework of the Taiwanese NHI NHI is the insurer

Operations overseen by Supervisory Body----Reserve @5% of Premium revenue - Admin fee = 3,5% of annual claims payment

Dispute sett

lement Board

Beneficiaries: Clearly categorizedPay income related premium

•Professional •Government workers•Self employed / business•Farm worker etc ( 6%)

Group Insurance ApplicantsCollectors of premiums

•Professional body•Specific departments•Enterprises / employers•Farmers Association

Clearly specified co-payments20% Out patient /emergency30% Out patient DH without referral40% Out patient RH without referral50% Out patient RH without referralAdmissions Acute | Chronic 1st 30 days 10% 5% 30-60 20% 10% >60 days 30% 20%

Medical care Institutions (DSPs)Collection of co-payments

Contracted Hospitals / outpatientPharmacies and medical labs

Check eligibility of beneficiariesSummary of referral Medical history

Exclusions: Immunizations-borne by Government, drug addiction, cosmetic surgery, artificial reproduction, sex conversion surgery, dentures, OTCs of scheduled drugs etc.

Negotiation Com

mitt

ee vs. DSPs, specialists etc

Pertinent Principles of the Taiwanese NHI

• Equal treatment for same illness

• User fees

• No co-payments for:

– major illness | injury | maternity | low income | preventative

health care | rural communities

• Penalties for Payment of inappropriate treatment

– (e.g. for pathology or medication) is borne by contracted medical

care institution if found to be inappropriate (itemised billing)

• Peer review process

– For service providers

• Incentives for preventive care for employers and unions.

Examples of Contributions Subsidy in Taiwan

Category Member Employer / Government departments

GOVT.

% contributions

Low Income 0 Social welfare 35 65

Military servicemen 0 100

Veterans only 0 Veterans affairs commission

100

dependants 30 Veterans affairs commission

70

other 60 Veterans affairs commission

40

Civil servants 30 70

30 Private schools 35 35

SOE/POE 30 Employer 60 10

Farmers 30 70

General workers 60 40

Professionals/TechniciansSMME

100 0

Maintaining Discipline in the System

Transgression Consequence

Fraud and abuse Criminal offence

Treatment of non-members Fine = 2 times the benefit paid

Medical care institutions (DSPs) charging more

Fine = 5 times overcharged fee

Contracted hospitals not keeping ward allocated ratios

FINE = 20 -100 000 thousand New Taiwan Dollars

Falsified classification of category Fine = 3-15 thousand New Taiwan Dollars

Employer deducting less premiums

Fine = 2-4 times shortfall amount

Defaulting premium payment by employer

Fine = 2 times outstanding payment

Conclusion

• The role of the private health care sector:

– Risk management tools

– Membership management

– Skills in healthcare funding and Technology

• Suggested Cost parameters:

– Comprehensive cover @ less than 5% of gross income subject to actuarial modeling

– NHI administration cost @ 3.5%-5% of claims payment

• Our NHI has to be a products of private sector, public sector and international experience.

– A healthy constructive engagement is critical.

Conclusion Cont…• These engagements will assist us to put more detail to our NHI

framework – such as what form the benefits and contributions are likely to be and guaranteed maximum waiting time to receive care.

• The sheer numbers of contributors to NHI will increase the total pool into a formidable stable fund that should reduce contracted prices & contributions

• Discipline as enshrined in some international models and local experiences is essential to maintain sustainability of an NHI dispensation(PMB’s & CDL)

• We need strict discipline in the execution of our NHI to mitigate and control factors like our burden of disease, health care consumption patterns and spiraling healthcare inflation

Thank you

References:

1.Stats SA: Midyear estimates 20092 Taiwan-National Health Insurance Act no.4505 of 1994 and

Regulations for NHI Medical Care of 1995 as amended3. Glenngard AH, Hjalte F, Svensson M, Anell A, Bankauskaite V.

Health Systems in Transition: Sweden. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005.

4. National Policy Analysis no. 555: Sweden’s single-payer Health System Provides a warning to Other Nations by Hogberg D. A publication of the National Centre for Public Policy Research

5. Universal Health Care Systems , from Wikipedia, the free encyclopedia.

6. Pro Sano Medical Scheme, clinical data.