UNRAVELLING THE BASIC BENEFIT PACKAGE

1. UNRAVELLING THE BASIC BENEFIT PACKAGE BHF Conference 11th July 2oo6

2. UNRAVELLING THE BASIC BENEFIT PACKAGE • Objectives…….. • To highlight the factors that should influence the content of a basic benefit package • To review PMB’s within the context of SA healthcare reform • To examine the implications of an explicit core package for South Africa • To suggest a way forward

3. BBP: MECHANISM TO PRIORITISE LIMITED FUNDS • Principles…… • No matter how efficient a healthcare system (i.e. optimised price for health care commodities and service delivery, application of most cost-efficient clinical protocols), community healthcare funds will never be able to provide for all necessary healthcare within a said population. • Non-prioritised care ≠ unnecessary care • Prioritising care is all about choices

4. HOW SHOULD WE CHOOSE? • Scientific evidence • Economic considerations • Efficiencies • Budget impact • Moral values/ preferences

5. PRIORITISATION: EVIDENCE-BASED MEDICINE Best • Systematic review of RCTs • At least one good quality RCT • Observational studies • Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees • Someone once told me…… • Prof. J. Volmink Worst

6. PRIORITISATION: EVIDENCE-BASED MEDICINE • The trap of generalisation….. – the example of a vaccine

7. EVIDENCE-BASED MEDICINE The statistics and data presentation trap …… Relative Risk Reduction – 20% Absolute Risk Reduction – 5% % Patients with first major vascular event % Patients free of major vascular events

8. EVIDENCE-BASED MEDICINEThe trap of ignoring common sense……

9. EVIDENCE-BASED MEDICINEThe trap of ignoring common sense……

10. PRIORITISATION: ECONOMIC EVALUATION • Purpose ……. • To ensure adherence to a budget • To guide efficiency in the allocation of health care resources • To minimise wastage (technical efficiency) • To ensure best possible outcome within a fixed budget (allocative efficiency) • Cost-utility • NB! Cost-efficiency ≠ cost-saving; cost-efficiency ≠ affordability

11. PRIORITISATION: CAN EFFICIENCY BE JUSTIFIED ETHICALLY? • Defining ‘best’ outcome ….. • Is outcome confined to health? • What is the society’s ultimate end? • Competing theories of distributive justice: utilitarianism (efficiency) versus egalitarianism (equity) versus ‘rule of rescue’ (urgency) versus libertarianism (free market)

12. PRIORITISATION: COMPETING MORAL THEORIES • Problems…….. • Utilitarianism • allows interests of minority to be over-ridden • little to offer in eradicating health inequalities • Egalitarianism • lack of definition on ‘adequate level’ of health • Rule of rescue • often promotes care that has both poor effectiveness and efficiency • Libertarianism • disregards needs of the vulnerable

13. PRIORITISATION: PREFERENCES • Other moral considerations …….. • Individual effort • Social worth • Quality-of-life versus longevity of life • Cultural beliefs and preferences • Identifiable versus non-identifiable patients • Retributive justice

14. PRIORITISATION: CONCLUSION • Would result in list that defines level of payment for each disease, at particular severity, treated with specific intervention under special circumstance …… • No technical solution to substantive aspect of decision-making! • Highly complex, value-laden process • Assumes a defined budget , a uniform delivery system and sound health care data (including population statistics)

15. PART 1: QUESTION 1 • Assuming that the following interventions would have the same impact on the budget, but a health fund only has enough budget to accommodate one, which would you choose (in the absence of legislation that would force you to choose one over the other); to pay for • treatment with an expensive medication that could dramatically improve the well-being of patients crippled with rheumatoid arthritis • treatment that somewhat reduces (but in no way takes away!) the risk of a experiencing a heart attack some time in the future

16. PART 1: QUESTION 2 • Base your decision-making on the following facts: • Smoking is the strongest modifiable risk factor to prevent premature atherosclerosis-related illness and death. • Cholesterol-lowering medication is not cost-saving to the healthcare system. • Given such facts, do you think that limited community funds should be used to pay for cholesterol-lowering medication of smokers? • Yes • No

17. PART 1: QUESTION 3 • Assuming you only have budget to pay for one of the following life-saving interventions, which would you choose? • Clipping of high-risk brain aneurysms (swelling of arteries of the brain that have a high chance of rupturing, causing disabling and/or fatal brain bleeds) for ALL patients who may benefit clinically • Treatment of aggressive breast cancer for ALL patients who may benefit clinically • Both, but in each case only for SOME of those who could benefit clinically (such patients may be chosen on various grounds – eg. they are anticipated to have a particularly good clinical outcome, they may be considered as particularly deserving, for example on the basis of social contribution such as Nelson Mandela versus convicted mass murderer or they may simply be th most demanding) • You are not prepared to choose and thus abstain from the vote.

18. PRIORITISATION IN THE REAL WORLD: BASIC BENEFIT PACKAGE • Definition…… • A Basic Benefit Package defines a • minimum level of health services • that should be available to • all members of a population • irrespective of their ability to pay and • as mandated by government .

19. PRIORITISATION IN THE REAL WORLD: BASIC BENEFIT PACKAGE IN SOUTH AFRICA • Proposed objective: To ensure equity. • Equity in health care involves ensuring equal access to equal care for equal need • The Basic Package must reflect the minimum acceptable standard of health services to be made available as the health care safety net for all. • National Health Charter

20. PRIORITISATION IN THE REAL WORLD: THE SA PMB EXPERIENCE • Objectives…… • To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilization of public hospitals • To encourage improved efficiency in the allocation of Private and Public health care resources • Medical Schemes Act 131 of 1998, • Regulations GNR 1262 of 20 October 1999

21. PRIORITISATION IN THE REAL WORLD: THE SA PMB EXPERIENCE • Emphasis on hospital-based and emergency care • Defining original PMB’s in order of priority • The extent to which another responsible party should be paying for treatment • The urgency (or discretion) required • The cost-effectiveness of treatment • Result: 271 DTP’s • And then….. • Inclusion of woman health care (HRT, infertility, screening for cervical and breast cancer) • Collation of the CDL (medication, but then also diagnosis and medical management) • Neil Söderlund, Enoch Peprah. An Essential Hospital Package for South Africa: • Selection Criteria, Costs and Affordability, May 1998

22. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilization of public hospitals • a

23. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • To encourage improved efficiency in the allocation of Private and Public health care resources • Public resources protected a • Increased use of chronic medicine formularies and protocols, i.e. more efficient use of medicines a • No efficiencies gained in use of private hospital facilities x

24. CHANGES IN USE OF FORMULARIES 2004 2003

25. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • To encourage improved efficiency in the allocation of Private and Public health care resources • Public resources protected a • Increased use of chronic medicine formularies and protocols, i.e. more efficient use of medicines a • No efficiencies gained in use of private hospital facilities x

26. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • To achieve equity • Equity in health care involves ensuring equal access to equal care for equal need x

27. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • Reasons …….. • “Equity in health care involves ensuring equal access to equal care for equal need “ • Patients with non-PMB diseases have equal or greater needs than those with non-PMB diseases, yet they are often abandoned within scheme benefit designs

28. COVER OF CHRONIC MEDICATION: CDL VERSUS NON-CDL CONDITIONS 2003 2004

29. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • Reasons …….. • “Equity in health care involves ensuring equal access to equal care for equal need “ • Assumption is that at a national level, medical scheme membership provides better access to better care. • Hence, stagnant scheme membership despite significant population growth = increasing disparity in access to quality care To what extent is the core package contributing?

31. THE SA PMB EXPERIENCE: ARE WE MEETING OBJECTIVES? • Reason ……. • VOLUNTARY scheme membership critically dependent on • Contribution levels • Insurance package • If not in line with member’s expectations, member is free to leave! (low-income earners and healthy population most likely to leave)

32. YET OPERATION PMB’S TO BBP IS CONTINUING ……. ?

33. AN EXPLICIT BASIC BENEFIT PACKAGE : IMPLICATIONS • Impractical and tedious • Abandonment of some patients • Inflexibility (i.e. non-adaptation to specific population needs) • Commercial exploitation • Lack of allowance for a queueing system and doctor-initiated rationing • Vulnerability of government

34. THE INDIVIDUAL VERSUS SOCIETAL PERSPECTIVE

35. AN EXPLICIT BASIC BENEFIT PACKAGE : IMPLICATIONS • Impractical and tedious • Abandonment of some patients • Inflexibility (i.e. non-adaptation to specific population needs) • Commercial exploitation • Lack of queueing system and effective doctor-initiated rationing • Vulnerability of government

36. PMB’ s AND BBP: THE WAY FORWARD • WWW.OPERATION_BASICBENEFITPACKAGE.COM …… • STEP 1 • SWOT analysis (strengths, weaknesses, opportunities, threats) • (Soderlund 1998: “The political feasibility of a core-package approach needs to be tested. Virtually no political debate has arisen around the core package approach. Hopefully this document helps to provide a baseline for discussion.”

37. PMB’ s AND BBP: THE WAY FORWARD • WWW.OPERATION_BASICBENEFITPACKAGE.COM …… • STEP 2 • Democratic deliberation

38. FEATURING: ADDITIONAL SPEAKERS ·Dr. Norman Daniels, Professor, Harvard School of Public Health  ·Dr. Susan Dorr Goold, Director, Bioethics Program, U of Michigan THEME:  Real World Priority Setting Streams: 1. Methods, Approaches and Knowledge Transfer in Real World Priority Setting 2. Priority Setting for New Technologies 3. Priority Setting in mixed Public and Private Systems 4. Values in Priority Setting 5. Priority Setting and the Interaction between the Micro and Meso levels

39. PMB’ s AND BBP: THE WAY FORWARD • WWW.OPERATION_BASICBENEFITPACKAGE.COM …… • STEP 3 • Accountability for reasonableness • Rationale for decision must be publicly accessible • Decisions about meeting health care needs must be contextually relevant to fair-minded people • Allowance must be made for appeals • Daniels N, Sabin J. Philosophy and Public Affairs 1997; 26 (4); 303-350

41. PART 2 : QUESTION 1 • Which statement do you agree with most? • The PMB’s are unproblematic in their current format and likely to contribute in a significant way towards achieving the overall goals of health care reform. • The current PMB’s are reasonable and if some primary care component is added are likely to contribute in a significant way towards achieving the overall goals of health care reform in South Africa. • The PMB’s should be reviewed in their entirety.

42. PART 2 : QUESTION 2 • An explicitly defined single basic benefit package for South Africa is likely to guide health care reform towards greater equity in access to quality care for all. • Do you • Agree strongly • Agree somewhat • Disagree somewhat • Disagree strongly