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  1. 1. Defining Healthcare Packages in the NHI Joe Seoloane Curator of Pro Sano Medical Scheme
  2. 3. A Perspective on NHI <ul><li>NHI should be approached with soberness and objectivity based on principles of human dignity, need and cost. </li></ul><ul><li>Both the public and private sector to collaborate. </li></ul><ul><li>Stakeholders to have the opportunity participate and to influence the NHI implementation. </li></ul><ul><li>Rational and responsible phasing of the NHI is a critical success factor. </li></ul><ul><li>Genuine and objective inputs should be provided in the midst of scepticism. </li></ul><ul><li>We should also guard against unrealistic optimism that the NHI will be the panacea for all healthcare problems. </li></ul><ul><li>There will be continued lobbying to discredit whatever NHI package is ultimately developed in favour of the status quo. </li></ul>
  3. 4. <ul><li>Total population: 49.32 million </li></ul><ul><li>Employment rate: 17.5 million </li></ul><ul><li>Life expectancy estimated at : 53.5 years males & 57. 2 females </li></ul><ul><li>Sweden 77.9 males & 82.4 females </li></ul><ul><li>Infant mortality: 45.7 per 1000 live births Sweden 3% </li></ul><ul><li>Living with HIV: estimated 5.2 million </li></ul><ul><li>Adults 15-49: 17% of population is HIV positive </li></ul><ul><li>On ART: 1.5 million older than 15 years /106 000 children </li></ul><ul><li>TB Endemic: with a growing number of MDR TB </li></ul><ul><ul><li>Currently largely treated in public sector </li></ul></ul>National Stats Relevant to NHI
  4. 5. The South African Envisaged Model of NHI <ul><li>Mandatory Enrolment </li></ul><ul><ul><li>For all citizens </li></ul></ul><ul><ul><li>No financial or other barriers - equal access to all health care services </li></ul></ul><ul><li>Single Payer Payment System </li></ul><ul><ul><li>NHI will be the only legitimate insurer of NHI benefits </li></ul></ul><ul><ul><li>Contracted service providers paid on a negotiated reference price list </li></ul></ul><ul><li>National Administration of the Fund </li></ul><ul><ul><li>Administered by a government agency/agencies - under direct supervision of the DOH </li></ul></ul><ul><li>Contribution into the NHI fund </li></ul><ul><ul><li>Largely from taxation </li></ul></ul><ul><ul><ul><li>Payroll related amounts based on income </li></ul></ul></ul><ul><ul><ul><li>Subsidy from employers and government </li></ul></ul></ul><ul><li>Benefits </li></ul><ul><li>Comprehensive benefits to be defined </li></ul><ul><ul><li>Public and private sectors contracted service providers </li></ul></ul><ul><ul><li>Cover will be for member and dependants </li></ul></ul>
  5. 6. Comprehensive Levels of Cover <ul><li>Primary Care Benefits </li></ul><ul><li>– Basic curative care and preventative services </li></ul><ul><li>Diagnosis </li></ul><ul><li>Laboratory tests </li></ul><ul><li>Prescription drugs (appropriate schedule for GP’s and nurses) </li></ul><ul><li>Consumables </li></ul><ul><li>Minor operations </li></ul><ul><li>Maternity services </li></ul><ul><li>Basic dental & optical care </li></ul><ul><li>Chronic medication </li></ul><ul><li>Secondary Care Benefits </li></ul><ul><li>As per above - at a referral level </li></ul><ul><li>Specialized care with subspecialties </li></ul><ul><li>Mental health care </li></ul><ul><li>Blood transfusions </li></ul><ul><li>Emergency care </li></ul><ul><li>Basic general & gynecological surgery </li></ul><ul><li>Tertiary Benefits-Highly Specialized Care </li></ul><ul><li>Oncology, transplants and clinical appropriate reconstructive surgery </li></ul><ul><li>Advanced radiology & laboratory tests </li></ul>
  6. 7. Basis for Level of Care <ul><li>Services will be treated at appropriate level of care. </li></ul><ul><ul><li>Current public sector structure is a good basis </li></ul></ul><ul><li>Referral protocols and disincentives for non-compliance. </li></ul><ul><li>Clearly defined treatment protocols and dispensing of medicine. </li></ul><ul><li>NHI will cover conditions as specified in the treatment protocols. </li></ul><ul><li>Clear policies of patient pathways and guaranteed access </li></ul><ul><li>Private sector may offer supplementary cover for the services excluded from NHI. </li></ul><ul><li>Exclusions can be privately insured or paid out-of-pocket. </li></ul>
  7. 8. 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 pa 3 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
  8. 9. Top Ten GP Visits Examples of What Primary Benefits Should Cater For: 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
  9. 10. Top Ten Dental Services Examples of What Primary Dental Benefits Should Include: 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
  10. 11. Top Ten Specialist Referrals General Indication of Specialist Expertise Required at Secondary Care Level Gynaecology – Obstetrics Orthopaedics Surgery Otorhinolaryngology- ENT Ophthalmology Paediatrics Physicians Urology Dermatology Cardiology
  11. 12. TOP 10 Hospital Admissions by Cost General Indication of Services to be Catered for at Secondary Care Level 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
  12. 13. Tertiary Care General Indication of Services at Tertiary Care Level Highly Specialized and Costly Services Oncology Transplants Plastic and reconstructive surgery Complicated cases Other specialized procedures
  13. 14. 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
  14. 15. 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 settlement Board <ul><li>Beneficiaries: Clearly categorized </li></ul><ul><li>Pay income related premium </li></ul><ul><li>Professional </li></ul><ul><li>Government workers </li></ul><ul><li>Self employed / business </li></ul><ul><li>Farm worker etc ( 6%) </li></ul><ul><li>Group Insurance Applicants </li></ul><ul><li>Collectors of premiums </li></ul><ul><li>Professional body </li></ul><ul><li>Specific departments </li></ul><ul><li>Enterprises / employers </li></ul><ul><li>Farmers Association </li></ul>Clearly specified co-payments 20% Out patient /emergency 30% Out patient DH without referral 40% Out patient RH without referral 50% Out patient RH without referral Admissions Acute | Chronic 1 st 30 days 10% 5% 30-60 20% 10% >60 days 30% 20% Medical care Institutions (DSPs ) Collection of co-payments Contracted Hospitals / outpatient Pharmacies and medical labs Check eligibility of beneficiaries Summary 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 Committee vs. DSPs, specialists etc
  15. 16. Pertinent Principles of the Taiwanese NHI <ul><li>Equal treatment for same illness </li></ul><ul><li>User fees </li></ul><ul><li>No co-payments for: </li></ul><ul><ul><li>major illness | injury | maternity | low income | preventative health care | rural communities </li></ul></ul><ul><li>Penalties for Payment of inappropriate treatment </li></ul><ul><ul><li>(e.g. for pathology or medication) is borne by contracted medical care institution if found to be inappropriate (itemised billing) </li></ul></ul><ul><li>Peer review process </li></ul><ul><ul><li>For service providers </li></ul></ul><ul><li>Incentives for preventive care for employers and unions. </li></ul>
  16. 17. 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/Technicians SMME 100 0
  17. 18. 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
  18. 20. Conclusion <ul><li>The role of the private health care sector: </li></ul><ul><ul><li>Risk management tools </li></ul></ul><ul><ul><li>Membership management </li></ul></ul><ul><ul><li>Skills in healthcare funding and Technology </li></ul></ul><ul><li>Suggested Cost parameters: </li></ul><ul><ul><li>Comprehensive cover @ less than 5% of gross income subject to actuarial modeling </li></ul></ul><ul><ul><li>NHI administration cost @ 3.5%-5% of claims payment </li></ul></ul><ul><li>Our NHI has to be a products of private sector, public sector and international experience. </li></ul><ul><ul><li>A healthy constructive engagement is critical. </li></ul></ul>
  19. 21. Conclusion Cont… <ul><li>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. </li></ul><ul><li>The sheer numbers of contributors to NHI will increase the total pool into a formidable stable fund that should reduce contracted prices & contributions </li></ul><ul><li>Discipline as enshrined in some international models and local experiences is essential to maintain sustainability of an NHI dispensation(PMB’s & CDL) </li></ul><ul><li>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 </li></ul>
  20. 22. Thank you
  21. 23. References: 1.Stats SA: Midyear estimates 2009 2 Taiwan-National Health Insurance Act no.4505 of 1994 and Regulations for NHI Medical Care of 1995 as amended 3. 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.

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