NHI State of Readiness Joe Seoloane 1
The South African Envisaged Model of NHI Mandatory Enrolment For all citizens and Legal Residents No financial or other barriers equal access to all health care services No co-payments or deductibles Single Payer Payment System NHI will be the only legitimate insurer of NHI benefits Contracted service providers paid on a negotiated reference price list National Administration of the Fund Administered by a government agency/agencies under direct supervision of the DOH and Compliance Authority Contribution into the NHI fund Largely from taxation Payroll related amounts based on income through SARS Subsidy from employers and government Benefits Comprehensive benefits to be definedpublic and private sectors contracted service providers Cover will be for member and dependants A Perspective on the NHI Impact All Stakeholders including the public and private sector need to collaborate on NHI. Model and phasing in of the NHI is a critical success factor. We should also guard against : lobbying to discredit the NHI in favour of the status quo. Interest groups that want to advance their economic interest at the expense of Universal health access unrealistic optimism that the NHI will be the panacea for all healthcare problems. 2
Comprehensive Levels of Cover Primary Care Benefits Diagnosis Laboratory tests Prescription drugs (appropriate schedule for nurses) Consumables Minor operations Maternity services Basic dental & optical care Chronic medication Secondary Care Benefits As per above / at a referral level Blood transfusions Emergency care Basic general & gynecological surgery Tertiary Benefits Oncology, transplants and clinical appropriate reconstructive surgery Advanced radiology & laboratory tests 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 3
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. Framework of the Taiwanese NHI Negotiation Committee vs. DSPs, specialists etc NHI is the insurer Operations overseen by Supervisory Body----Reserve @5% of Premium revenue - Admin fee = 3,5% of annual claims payment Beneficiaries: Clearly categorized Pay income related premium Professional Government workers Self employed / business Farm worker etc ( 6%) 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% Group Insurance Applicants Collectors of premiums Professional body Specific departments Enterprises / employers Farmers Association Medical care Institutions (DSPs) Collection of co-payments Contracted Hospitals / outpatient Pharmacies and medical labs Check eligibility of Exclusions: Immunizations-borne by Government, drug addiction, cosmetic beneficiaries surgery, artificial reproduction, sex conversion Summary surgery, of referral dentures, Medical OTCs of Dispute settlement Board 4
Examples of Contributions Subsidy in Taiwan Category Member Employer / Government departments % contributions GOVT. 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 Maintaining Discipline in the System Transgression Fraud and abuse Treatment of non-members Medical care institutions (DSPs) charging more Contracted hospitals not keeping ward allocated ratios Falsified classification of category Employer deducting less premiums Defaulting premium payment by employer Consequence Criminal offence Fine = 2 times the benefit paid Fine = 5 times overcharged fee FINE = 20-100 000 thousand New Taiwan Dollars Fine = 3-15 thousand New Taiwan Dollars Fine = 2-4 times shortfall amount Fine = 2 times outstanding payment 5
How ready is South Africa for NHI The announcement of Pilot sites by the Minister of Health 10 Districts plus 1 Steercom and Task teams set up Initial pilot budget provided to set up the sites Phased Business Plan approved Enhancing IT Platform System Integration Revenue Collection Human Resource Development Facilities Improvement Quality Improvement with quality measures Improve District Health System Etc. 6
Conclusion Our NHI has to be a product of private sector, public sector, civil society, labour and international experience. A healthy constructive engagement is critical. Communication and Promotion Health care service delivery Product mapping Cost Conclusion Cont The sheer numbers of contributors to NHI will increase the total pool into a formidable fund that should reduce contracted prices, contributions and administration costs. 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 Services should be treated at appropriate level of care. Implement effective Referral protocols & Treatment protocols Disincentives for non-compliance. Improve the public sector healthcare delivery Phased implementation to ensure sustainability 7
Thank you 8