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Competition in the south african health system

Prof Alex van den Heever Wits School of Governance Alex.vandenhever@wits.ac.za. Competition in the south african health system. Source for Content. The contents of this presentation reflect a high level summary of the analysis in a report provided to the Competition Commission in 2012

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Competition in the south african health system

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  1. Prof Alex van den Heever Wits School of Governance Alex.vandenhever@wits.ac.za Competition in the south african health system

  2. Source for Content The contents of this presentation reflect a high level summary of the analysis in a report provided to the Competition Commission in 2012 http://www.compcom.co.za/assets/Healthcare-Inquiry/Review-of-Competition-in-the-South-African-Health-System.pdf

  3. What makes markets work? • Basis for exchange • Individuals produce products and are able to exchange them for other products • Consumers • Understand the product (price/quality) • Have a choice of alternatives • Able to exercise choice

  4. When do markets fail? • Basis for exchange • Individuals produce products and are unable to exchange them for other products (absence of efficient systems of exchange – money) • Consumers • Do not understand the product (price/quality) • Have limited or no choice of alternatives • Unable to exercise choice

  5. How do consumers lose control of demand? • Product complexity • Price and quality comparisons not possible in real time • Market problems possible despite competition • Market concentration • Structural reduction in products choice • National or geographic markets

  6. Market manipulation • Collusion to exclude competition from the market • Agreements between market participants, including the sharing of information (e.g. prices/costs) • Punishment for non-compliance • Payment of kickbacks to intermediaries able to determine demand (agents) • Market segmentation • Forcing consumers into market segments on the basis of their ability to pay

  7. Correcting dysfunctional/failing markets • Ensure an efficient basis for exchange • Put consumers rather than product suppliers in control of demand • Effective market signalling • Price • Quality • Product simplicity – remove need for advice Correcting markets is more than just about price

  8. What about efficiency? • Allocative efficiency - static • Technical efficiency - static • Dynamic efficiency - innovation

  9. Analysis of the south african market

  10. Two key “products” • Insurance • Healthcare • What about consumers? • Don’t understand what they’re buying • Don’t understand the pricing • Have no idea about product quality • Key strategic product purchases are channelled through conflicted intermediaries

  11. Health insurance - unregulated Financing and Risk Pooling Brokers Health insurance - regulated 3rd Party Managed Care 3rd Party Administration Holding companies Information asymmetry Diagnostic Specialists Hospital-based and substitute services Consumer General Practitioner Surgical Specialists Information asymmetry Medicines and other medical products and services Health goods and services

  12. Health insurance - unregulated Financing and Risk Pooling Brokers Health insurance - regulated 3rd Party Managed Care 3rd Party Administration Financial sector holding companies Information asymmetry Diagnostic Specialists Hospital-based and substitute services Consumer General Practitioner Surgical Specialists Information asymmetry Gate keeper Consumer agents Possible conflicts of interest Moral hazard Anti-selection Risk-selection Commercial relationships Medicines and other medical products and services Health goods and services

  13. What’s in the contract today

  14. Systemic Market-related Issues Regulated Insurance Unregulated Insurance Regulated Insurance Unregulated Insurance Markets only compete on factors/signals that are transparent to relevant decision-makers

  15. Internalised into Insurance contract – medical schemes • Risk Medium • Price Medium • Quality of coverage Medium • Quality of health care services Medium/Weak • Quality of healthcare products Medium/Weak • Regulations prevent some risks from being transferred arbitrarily back to consumers

  16. Insurance contract – other • Risk Weak • Price Weak • Quality of coverage Very weak • Quality of health care services Very weak • Quality of healthcare products Very weak

  17. Internalised into insurance contract with HC service providers • Derived from the contract between consumers and insurers • Risk Weak • Price Very weak • Quality of coverage n/a • Quality of health care services Weak • Quality of healthcare products Weak

  18. Market outcomes

  19. Real per capita changes in medical scheme expenditure and GCI (2012 prices) Source: Council for Medical Schemes data from scheme audited financial statements 1990 – 2012 (adjusted for CPI)

  20. Changes in the structure of medical schemes expenditure on benefits (1981-2012) Source: Council for Medical Schemes data from scheme audited financial statements 1981 - 2012

  21. Hospital claims (real pbpa) compared to beds per 1,000 and market concentration (HHI) (for private beds) Point at which beds per 1,000 is roughly equal to the US and UK (noting that they have vastly older populations)

  22. Changes in total beds in South Africa 1976 to 2010: public and private sector

  23. Return on Capital Employed (Mediclinic and Netcare) Source: Anthony Felet, Duncan Lishman and Fatima Fiandeiro, “Do hospital mergers lead to healthy profits?”, 2012, p.11

  24. Return on Capital Employed (Mediclinic and Netcare) – 1997 - 2011 Source: Anthony Felet, Duncan Lishman and Fatima Fiandeiro, “Do hospital mergers lead to healthy profits?”, 2012, p.11

  25. Average age of Medical Schemes 2000 -2013 Sources: CMS Annual Reports 2003-4, 2004-5, 2005-6, 2007-8, 2009-10, 2010-11, 2012-13

  26. Real hospital cost (pbpa) changes from 2001 to 2006 (percentage) (includes medicines) Other causes

  27. Non-health expenditure trends from 1974-2010: percentage of Gross Contribution Income (GCI) Major deregulation Source: Council for Medical Schemes data from scheme audited financial statements 1974 - 2010

  28. Concluding remarks

  29. Ensure that health insurers have the incentive to purchase efficiently • Remove conflicts of interest in markets for advice • Simplify and standardise products • Market transparency on key indicators central to consumer choice • Internalising price and quality into the contract • Deal with regulatory arbitrage • Ensure governance arrangements correctly locate the commercial imperative in the scheme

  30. Ensure that insurer incentives cannot be undermined by anti-competitive structures and conduct on the supply side • Market transparency (price/cost/quality) • Conflicts of interest • Separate doctors from other products • Accumulation and abuse of market power • Market diversification • Penalise abuse • Collusion

  31. THANK YOU

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