1 / 19

Improving the affordability of medical schemes

ANBAN PILLAY. Improving the affordability of medical schemes. Ability to pay. Premiums are increasing at a rate higher than salary increases Benefits are decreasing at the same time Consequently members are buying lower options

flavio
Download Presentation

Improving the affordability of medical schemes

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. ANBAN PILLAY Improving the affordability of medical schemes

  2. Ability to pay • Premiums are increasing at a rate higher than salary increases • Benefits are decreasing at the same time • Consequently members are buying lower options • Providers are increasing their fees resulting in patients paying higher co-payments.

  3. What is driving the cost of care There are two main factors that drive costs: • price of healthcare services • Utilisation of services

  4. What are the factors that can be used to address efficiency • Regulation of price • Referral system to access care • Primary care based model that is preventative in nature • Encourage a team approach to care at primary care level • Reform of the reimbursement model from the current fee for service model.

  5. What are the factors that can be used to address efficiency • Standardisation of treatment guidelines • Pay for performance model • Partnerships with the public healthcare sector.

  6. Regulation of price • Absence of a forum for funders and providers to negotiate tariffs in a manner that is based on transparency and reasonableness • Providers are free to charge whatever fee they choose. Difficult to determine whether these fees are reasonable. • Smaller schemes are unable to access lower tariffs

  7. Referral system to access care • Currently direct access to high cost specialist services – inefficient • Access to care should be based on severity and complexity of disease not ability to pay • Primary care providers should be responsible for selecting patients for higher level care

  8. Encourage a team approach to care at primary care level • Current model is based on individual providers delivering a service with reimbursement on a fee for service basis. • Team approach within a health centre will improve efficiency: • Primary care nurse manages minor ailments • GP manages more complex cases • Dentist/Therapist manage dental care similarly • Pharmacist • Physiotherapist • Optometrist

  9. Reform of the reimbursement model • Currently using a fee for service model for reimbursement which encourages providers to over service patients. • No responsibility on provider to manage disease. • Alternate reimbursement models such as DRGs and capitation more efficient in producing outcomes.

  10. Standardisation of treatment guidelines • Lack of standardisation across the industry in the management of disease. • Each scheme has adopted its own guidelines and formulary. • Lack of standardisation results in market fragmentation – higher prices. • Evidence of efficacy, safety and cost effectiveness does not differ by scheme.

  11. Pay for performance model • Quality of healthcare outcomes is not the basis of funding decisions. • Little incentive to provide high quality care. • Introduce a pay for performance reimbursement model. • Identify complex high risk patients, set health indicator targets and pay based on their achievement.

  12. What are the possible opportunities for partnerships • Utilisation of public hospitals for selected cases • Access to primary healthcare medicines • Harmonisation of treatment guidelines for disease management • Harmonisation of coding systems. • Improving revenue collection in public facilities

  13. Alignment of PMBs to NHI • PMBs are intended to cover members against high cost diseases – catastrophic cover • Assumption is that members could fund primary care through savings since the cost is relatively low. • There is no incentive to provide primary care benefits given that hospital benefits have no limits.

  14. Alignment of PMBs to NHI • Effective PHC could reduce the extent of hospital utilisation – improved efficiency • Introducing the PHC benefits may affect premiums. If PHC benefits are accessed as intended then the extent of hospital utilisation should reduce. This may be a zero sum game? • The alternative is that the schemes partner with government to deliver the PMBs.

  15. Alignment of PMBs to NHI • The NHI framework is developed on an effective primary care model. Nevertheless the NHI will not exclude catastrophic diseases. • Care will be accessed based on need. • NHI financing is not be based on an insurance model ie benefits are not linked to an option chosen or the amount contributed.

  16. Alignment of PMBs to NHI • The NHI will emphasise both primary and secondary prevention. • Primary prevention includes screening for prevalent conditions that are easily prevented with early intervention • Secondary prevention through lifestyle changes particularly to high risk individuals

  17. Implication of Demarcation on medical scheme environment • Insurance products will most likely have to transform into medical scheme products • new members in the low income category hence affordable premiums will be a challenge • Council for medical schemes is considering various options to accommodate new members

  18. Conclusions • There are a number of interventions that could be implemented that would help reduce the cost pressures of medical schemes. • Primary care benefits should be aligned to the national health insurance design. • The demarcation process is likely to result in new members entering the medical scheme environment in search of affordable benefits.

  19. THANK YOU

More Related