PRESS RELEASE: On the submission to the Green Paper on NHI
by The Board of Healthcare Funders of Southern Africa (BHF)
The BHF fully supports the implementation of a system of universal healthcare to all South African citizens to appropriate, efficient and quality health services in South Africa. The need to reform and improve service provision is paramount to promote equity and efficiency. BHF acknowledges that the current two-tier system should be reviewed in order to bring about greater efficiencies in healthcare.
South Africa already spends 8.5% of its GDP on health and still has poor health outcomes when compared to similar middle-income countries. It is evident that South Africa needs to more efficiently use the money it already spends on healthcare.
In its submission, BHF stresses that the private funding sector is a national asset, rich in expertise and experience in governing and administering healthcare systems, which could be made available to government as it implements NHI. BHF believes that, once fully implemented, the model could be similar to the ‘Gautrain’ model where the private sector was contracted by government to fulfil a function of building the entire system, and the establishment of the Gautrain Management Agency, under the Provincial Government, manages the running of Gautrain. This model creates flexibility and establishes an appropriate platform to attract , retain, contract and remunerate the required skills and expertise adequately. To have a well functioning NHI system will certainly require such a model.
Included in the submission is an offering from the sector to provide expertise in a number of areas necessary for the successful development and implementation of a NHI. Many of these areas relate directly to the NDoH 10 point plan for health., as once these have been achieved, universal access to health will have been realised.
These areas are:
Designing and costing of the NHI package of benefits - BHF has structured an Essential Benefit Package in line with National Health Policy, WHO recommendations and the stated objectives contained in the Green Paper on NHI
Development of coding structures for reimbursing healthcare providers - Clinical coding is important and its use allows for the improvement of efficiency of healthcare service delivery through appropriate and standardised recording of diagnosis, analyses of patient care information, research, quality assessment, use of performance improvement tools (profiling), healthcare planning and facility management. It also enables the development of fair reimbursement for healthcare services provided. The systematic collection of morbidity and mortality data assists with the identification of health needs and therefore the content of benefits to be provided.
Development of healthcare tariffs, payment and provider reimbursement models – BHF believes that the prevailing Fee for Service (FFS) model is problematic, further exacerbated by the third party payment system. The private funding industry has extensive experience in contracting with private practice providers, and BHF could play an important facilitation role in rolling out alternative reimbursement models in preparation for NHI.
Measurement of healthcare quality and other outcomes - Measurement of clinical quality indicators from the outset is recommended to enable the proper and appropriate measurement of clinical outcomes. Much expertise exists within the the private funding sector in developing quality measurement standards in clinical quality codes, utilization statistics, morbidity and mortality figures, as well as quality standards within the practice settings, and hospital and clinic environments.
Fraud management interventions – Due to the high level of fraud within the private sector, sophisticated fraud management interventions have been developed., which could be utilised in a NHI environment. Already BHF coordinates and manages the Healthcare Forensic Management Unit (HFMU), with the support and participation of the majority of industry players.
Accreditation of providers/facilities and provider contracting - The BHF believes that healthcare providers should have the option to participate in the NHI on an ‘able and willing’ basis, and that the system of accreditation should be as inclusive as possible. The private healthcare system, including managed care organizations and administrators, have experience in contracting with providers, and such healthcare providers could easily assist the NHI initiative to put in place the required service agreements.
Communication and education – to the general population and providers of service - The BHF submission stressed the need for effective communication to all constituencies affected by NHI, both during the build up to NHI and during implementation. BHF and its members offer communications expertise and established communications channels that can fulfil the required communication and education needs.
Provider Network Management - Managed care organizations and provider groups have organized themselves into risk-bearing entities with the ability to take capitation risk, and with the ability to perform the required network management functions to ensure the proper functioning of provider services within a national framework. Such organizations could be invaluable with the requirement of providing services under a NHI model, and ensure that administration functions required in terms of provider network management and recruitment of additional providers within selected areas are performed. BHF with the support of it members can facilitate utilisation of these networks in a way that will service NHI.
Peer Review and Profiling - BHF have a long and successful history of working with the IPAs and academics in the development of peer review and provider profiling systems. These systems can be adapted and extended for use within the NHI contracting environment.
Administration, Claims and Information Systems and Managed Care Services - In order for NHI to be effective administration services and customer support services will be essential. Current administrator and managed care organisations have an infrastructure, systems and the experience to provide a valuable service under a NHI dispensation. These include: Collection of key health data to monitor health system performance; the provision of accredited managed healthcare services based on identified needs including disease management for priority health problems; provision of switching house services to the NHI Agency; and, management of the provider contracting arrangements.
Call Centre Support Services - The importance of call centres to support members and providers is essential to provide a quality service. These services should be easily accessible with the correct level of skills, service levels and capacity to deal with queries and questions. The current medical aid industry provides a highly competent call centre environment which could easily be extended to be utilized via the current
The BHF submission stresses the urgent need for reform of the private sector in the build-up to NHI, in order to align this sector with current and future national health policy and to ensure a seamless integration of the 8.2 million medical scheme members into the NHI.
The reform must include the following areas:
The Prescribed Minimum Benefits (PMB) - These are hospi-centric and curative focused and are a major contributor to the high cost of private sector costs. The benefits package underlying the PMBs must be restructured to focus on essential healthcare, which would bring them in line with national health policy and what is stated in the Green Paper on NHI. The legislation must be reviewed in order to alter the focus to primary and preventative care. This would enable resources to be directed to primary and preventative healthcare.
The establishment of the proposed Pricing Commission - This will act as the precursor to the single purchaser function which is a cornerstone of the NHI and would bring an end to the runaway costs experienced by consumers in the private sector and enable medical schemes to further the social solidarity objectives under which they are governed. The proposed NHI single-purchaser model will inevitably include regulated prices for the NHI benefit package. Therefore, in order to prepare both the providers and the funders for NHI, we urge the Minister of Health to introduce the proposed pricing negotiating commission
Regulatory and Professional Bodies - Reform of the current regulatory and professional statutory bodies will be required to bring these bodies in line with the requirements of a NHI model.
The services to be delivered should be identified, together with the service providers responsible for the delivery of the services – Healthcare services should be distinguished in terms of the level of expertise required and type of discipline required, including differentiation between primary care, secondary care, tertiary care and quaternary care or academic hospital environment. Access to specialist care should be following consultation with a primary care provider, with appropriate referral procedures in place.
The submission applauds the Minister of Health and his team for providing a framework for consultation and emphasises the importance for South Africa of the successful implementation of a NHI system.
ENDS
The Board of Healthcare Funders of Southern Africa (BHF) is the representative body for the majority of medical schemes throughout South Africa, Lesotho, Namibia, Botswana and Zimbabwe.
For further information and comment, please contact Heidi Kruger, Head of Corporate Communications on 011 5370237; 0829051161; or, heidik@bhfglobal.com
