Di McIntyre's presentation at the Department of Science and Technology (DST) international seminar on a National Health Insurance (NHI) from 6 – 7 December 2012 at the CSIR Conference Centre, Pretoria.

1. Possible
provider
payment
mechanisms
for
South
Africa
Di
McIntyre
Health
Economics
Unit
University
of
Cape
Town
DST
2012
NHI
seminar
December
2012,
Pretoria

2. Overview
• Provider
payment
is
part
of
purchasing:
– Transferring
funds
from
pool
to
health
care
providers
– AcHve
purchasing
–
idenHfy
populaHon
needs
and
align
services
to
needs
and
monitor
performance
• Current
payment
context
• Likely
future
purchasing
context
• Provider
payment
mechanisms
proposed
• Associated
issues

3. Current
payment
context
• Public
sector:
– Line-­‐item
budgets
(linked
to
inputs)
for
faciliHes
– Salaries
for
individual
providers
• Private
sector:
– Largely
fee-­‐for-­‐service
(fees
not
fixed)
– CapitaHon
for
a
few
GPs
– Limited
case-­‐based
payment
by
some
schemes
to
some
hospitals

4. Future
purchasing
context
• Purchaser-­‐provider
split:
– Requires
greater
management
authority
in
public
hospitals
and
at
districts
• Public
enHty
to
pool
funds
and
be
single
ac#ve
purchaser
for
universal
service
enHtlements
• Purchase
from
public
and
private
providers
(on
same
terms)
• Tax
funding:
– General
revenue
allocaHons
&
dedicated
taxes
– Budget
limit
–
PPM
must
control
expenditure

5. Interna?onal
lessons
• Fee-­‐for-­‐service
and
line-­‐item
budgets:
– Least
desirable
– Avoid
as
main
provider
payment
mechanism
• Mix
of
provider
payment
mechanisms
(to
achieve
an
appropriate
balance
of
incenHves)
• Refine
over
Hme
(based
on
provider
responses
to
incenHves)

6. PHC
services
• PHC
context:
– Integrated,
comprehensive
PHC
services
– Provided
by
mulH-­‐disciplinary
teams
– At
community
and
facility
level
• ObjecHves
of
provider
payment:
– Equity
in
allocaHon
of
resources
for
PHC
services
– Encourage
prevenHve
&
promoHve
intervenHons
– Efficiency
and
quality

7. PHC
services
• PotenHal
provider
payment
mechanism:
– Global
budget
to
district
based
on
risk-­‐adjusted
capitaHon
– PotenHally
move
to
risk-­‐adjusted
capitaHon
to
individual
faciliHes/groups,
for
comprehensive
services,
including
community-­‐based
teams
• Need
informaHon
on:
– Cost
of
comprehensive
PHC
services
– Demographic
composiHon
of
populaHon
in
districts
and
epidemiological
profile
(chronic
condiHons)
• Fixed
allowance
for
infrastructure
&
equipment

8. PHC
services
• P4P
(pay-­‐for-­‐performance)
–
some
FFS:
– Very
weak
evidence
on
impact
– Where
directed
at
specific
services
(e.g.
immunisaHons)
–
services
not
part
of
P4P
are
given
lower
priority;
gaming
and
false
reporHng
– Some
countries
reward
low
referrals
and
diagnosHc
tests
–
can
lead
to
under-­‐servicing,
but
could
base
on
adherence
to
standard
treatment
guidelines
(referrals,
diagnosHc
tests,
prescribing)
– Possibly
use
FFS
for
providing
services
to
those
not
from
district
(or
facility/group)

9. Hospital
services
• ObjecHves
of
provider
payment:
– Efficient
provision
of
quality
care
– Not
funding
faciliHes
but
services
for
paHents
in
need
– Facilitate
purchasing
from
public
and
private
providers
on
same
terms
• Case-­‐based
payments
(e.g.
DRGs):
– IniHally
as
guide
to
determine
global
budget
– Based
on
average
cost
per
case
in
average
hospital
(category
of
hospital)

10. Other
payments
• In
addiHon
to
main
payment
mechanisms,
can
be
a
range
of
other
provider
payment
arrangements,
e.g.
:
– Sessional
appointments
(pro-­‐rata
of
full
package)
– Price
and
volume
contracts
(specified
quanHty
of
parHcular
services
–
e.g.
high
tech
diagnosHcs,
specific
surgical
procedures)

11. Associated
issues
• Preparatory
steps
to
level
the
playing
field
between
public
and
private
providers
• Greater
management
authority
in
public
faciliHes
• InformaHon
systems
(urgent):
– Demographics;
diagnosHc
&
procedure
codes
• Monitoring
(quality
of
care)
• Accountability
in
terms
of
performance

12. Key
issues
• PreparaHon
–
informaHon,
management
authority
• Mix
of
payment
mechanisms
and
refine
over
Hme
• Phase
in
(of
main
payment
mechanisms)
–
global
budgets
to
capitaHon
for
PHC
and
case-­‐
based
for
hospitals

13. www.heu-­‐uct.org.za
www.facebook.com/uct.heu
©
Health
Economics
Unit,
University
of
Cape
Town,
2012