MEDICAL SCHEMES ACT OF SOUTH AFRICA AMENDMENT BILL, 2018

Transcription

1 MEDICAL SCHEMES ACT OF SOUTH AFRICA AMENDMENT BILL, 2018

2 Purpose The Medical Schemes Amendment Bill 2017 ( the Bill ) seeks to improve The legislative oversight of the medical schemes industry, To align the regulatory environment with changes in the sector, To improve the protection of medical scheme beneficiaries and. It further seeks to promote alignment with the NHI Fund bill.

3 Challenges Affordability of medical scheme premiums. Unregulated contracts which is not accessible for regulatory scrutiny. Lack of transparent in pricing and allocation of contributions. Current legislative framework provides for the appointment of brokers as opposed to the member. Bureaucratic appeal processes and volumes of disputes. Absence of enabling provisions relating to costs orders. Lack of a definitive database with information of beneficiary movement. Current legislation does not provide for adequate exceptions

4 Draft MSA Amendment Bill Exclude the application of the Consumer Protection Act; Application of the Public Finance Management Act, applicable to the Council; Establish, maintain and administer a Central Beneficiary Register, and to include information about the prices, utilisation and costs of relevant health services; Addresses the relationship between the Council and the National Health Insurance Fund; Empowers the Council to require certain information from the medical schemes; 4

5 Draft MSA Amendment Bill Empower the Registrar to direct the medical schemes in writing to amend their rules; Waiting periods for beneficiaries Discontinuation/cancellation of membership Contributions Table Discount for DSP arrangements Introduction of comprehensive service benefits Establish health care providers register; 5

6 Draft MSA Amendment Bill A medical scheme is prohibited to offer, market or provide any benefit option unless such benefit option has been approved by the Registrar on application made by the medical scheme; empower the Registrar to request medical schemes to produce information as requested by the Registrar; Empower the Registrar to publish guidelines about the content and application of the dispute resolution mechanisms that have to be included in the rules of a medical scheme; Appeals against the decision of the Registrar; Establish the Appeal Board; 6

7 Draft MSA Amendment Bill Governance of medical schemes; accreditation as an administrator, suspension or withdrawal of such accreditation; Role of Brokers Future role of medical schemes 7

8 PRESENTATION ON NHI BILL

9 WHAT IS NHI? NHI is a health financing system that pools funds to provide access to quality health services for all South Africans based on their health needs and irrespective of their socio-economic status. NHI is intended to ensure that the use of health services does not result in financial hardships for individuals and their families. NHI represents a substantial policy shift that will necessitate a massive reorganisation of the current health system, both public and private and also derives its mandate from the National Development Plan (NDP) of the country. This is the only way to guarantee Universal Health Coverage (UHC) as adopted in September 2015 as one of the United Nations Sustainable Development Goals, NDP, African Claims (1943), Gluckman Commission (1944), Freedom Charter (1955) 9

10 UN Sustainable Development Goals (SDGs) Goal 3.8 Achieve Universal Health Coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines, and vaccines for all. 10

11 Global Structural Problems of Health Care Systems Dr Margaret Chan Director-General (WHO) That is (i) rising health care costs yet poor access to essential medicines, especially affordable generic products; (ii) an emphasis on cure that leaves prevention by the wayside; (iii) costly private care for the privileged few, but secondrate care for everybody else; (iv) grossly inadequate numbers of staff, or the wrong mix of staff; (v) weak or inappropriate information systems; (vi) weak regulatory control; and (vii) schemes for financing care that punish the poor. 11

12 South Africa is an outlier: world s largest share of spending from VHI 12 Source: WHO estimates for 2012, countries with population > 600,000

13 The Country s Plan - The NDP Chapter 10: Promoting Health - Targets for 2030, Under Universal Health Coverage: Everyone has access to an equal standard of care regardless of their income; A common fund enables equitable access regardless of what people can afford to pay or how frequently they need to make use of health services 13

14 WHAT PROBLEM ARE WE SOLVING IN SOUTH AFRICA TO ACHIEVE UINVERSAL HEALTH COVERAGE? DEEPLY ENTRENCHED INEQUITIES The World Health Organisation recommends that countries should spend 5% of GDP on health. South Africa currently spends 8.7% of GDP on health (2018) The private sector spends 4.5% of GDP on health but only provides care to 16% of the population. The public sector spends 4.2% of GDP on health but only provides care to 84% of the population 2015 (Bn) 2018 (Bn) % Change GEMS % Civil Servants not on GEMS % SOEs % TOTAL GOVT AS AN EMPLOYER % MEDICAL TAX CREDITS AND REBATES % TOTAL STATE SUBSIDY %

15 THE WHITE PAPER ON NHI 15

16 FEATURES OF NHI Universal access Mandatory prepayment of health care Comprehensive Services Financial risk protection Single fund Strategic purchaser Single-payer 2018/07/06 16

17 Stewardship of financing and provision (governance, regulation, information) Provision of services Health care Allocation mechanisms (provider payment) Purchasing of services Allocation mechanisms Pooling of funds Allocation mechanisms Economies of scale and efficiencies Single Payor / purchaser Social solidarity and cross-subsidisation Single Pool for Income and Risk COVERED POPULATION Collection of funds Prepayment Taxes/ Contributions 17 17

18 The NHI Bill This cannot be achieved without creating a single common fund, which in itself will directly contribute towards: a unified health system by improving equity in financing, reducing fragmentation in funding pools across both the public and private sectors, and making health care delivery more affordable and accessible for the population The NHI Bill is a crucial step in creating the common Fund. 18

19 Parts of the NHI Bill Establishment of the NHI Fund Right to health care The Board of the Fund The CEO Ministerial Committees General provisions applicable to operation of Fund Complaints and appeals Financial matters Miscellaneous 19

20 Key Features of the Bill (not exhaustive) Beneficiaries Covered (Section 7) Rights of users (Section 9 (a)) Purchaser-Provider Split (Section 35(1)) Mandatory Prepayment (Section 3(4)) Fighting Corruption (Section 6 (1) (I)(vi), Section 6(1)(L)) Single Purchaser (Payer) (Section 3(3)) No co-payments, free at point of service (Section 9 (a)) Strategic Purchasing (no more tenders for health services) (Section 35(1) Comprehensive Health Service Benefits (Section 11 (1) & 11 (2)) Registration of users (Section 8) Public and Private Providers (Section 5(1)(d)) Affordability (Section 9) 20

21 Key Features of the Bill (contd.) Entry point to health care system PHC (clinics, GPs and other PHC providers) (Section 11(2)(a)) Sources of Funding - Minister of Health and Finance to jointly determine (Section 46 (1), (2), (3)) Ministerial Committees (Section 25, 26, 27, 28) Referral Pathways Section 11 (2)(b) Procurement through Chief Procurement Officer (National Treasury) Appeals and Complaints (Section 40) When are Services not covered Section 12 (2) Method of Payment capitation, DRGs, Global fees (Section 35 (2), (3), (5) Schedule of Amendments (Annexure) 21

22 Benefits Advisory Committee NHI Committee Health Benefits Pricing Committee Stakeholder Advisory Committee Technical committees 22

23 Consolidation of Financing Streams Presently, according to STATSSA, this is how the SA population is divided in terms of income, employment and hence, indirectly medical scheme coverage In reorganising the population, cognisance will be taken of these various categories, i.e. when we implement NHI, we have to start with those who are not covered Interim Insitutional Structure Civil servants and their dependants (incl. SoEs) Formal Sector Employed and their dependants (large business) Formal Sector Employed and their dependants (SMMEs) Informal sector and their dependants Individuals in households with no income or are not employed 5.5m 12m 6m 8m 24m Government Employees State Owned Enterprises Public Entities Only 8.8m of these people have access to health services via medical schemes Domestic Workers Hawkers Taxi industry Casual labourers The elderly with no income Children School kids (12m) Unemployed Unemployable The central philosophy of Implementation of NHI is to bring into fold those people who are not insured (specifically those who are unable to afford medical scheme cover). 23

24 Transitional Arrangements Described in section 54 of the bill. Specifies the structures, and process of implementation Phase 1 was from 2012 to Phase 2 will be for a period of five years from 2017 to 2022 and will i. continue with the implementation health system strengthening initiatives, including the alignment of human resources with that which will be required under the Fund; ii. iii. iv. include the development of National Health Insurance legislation and amendments to other legislation; include the undertaking of Initiatives which are aimed at establishing institutions that will be the foundation for a fully functional Fund; and will include the interim purchasing of personal healthcare services for vulnerable groups such as children, women, people with mental health disorders, people with disability and the elderly. 24

25 Transitional Arrangements Phase 3 will be for a period of four years from 2022 to 2026 and will include i. the continuation of Health systems strengthening activities on an ongoing basis; ii. the mobilisation of additional resources as approved by Cabinet; and iii. the selective contracting of healthcare services from private providers. 25

26 NHI Grant Framework 2018/19 Non- personal services CCMDD Capitation model Ideal Clinic Information Systems (HPRS, Pharma systems) Personal Services Health Professional current contracting model GP capitation contracting out Community mental Health Services School Health Services High Risk Pregnancies, Cancer,

27 THANK YOU 27