The First Steps in implementation on NHI
The Medical Schemes Amendment Bill
The NHI Bill
The transition to NHI and it’s implementation began in earnest with the tabling of 2 bills in Parliament this month.
- The Medical Schemes Amendment bill and
- The National Health Insurance bill
Both bills are on the CPC/Qualicare website, www.docweb.co.za for your immediate attention and comment to us at [email protected] within the next 45 days, to allow us time to correlate your responses into an official response from Qualicare to the Dept of Health which is due no later than 21 September 2018.
You will recall that CPC/Qualicare has been at the forefront of reporting back to our shareholders and members on the progress on the road to NHI, and shaping professions position on NHI, since our first articles on the subject in 2009. After carefully reading and discussing the elements of Dr Motsoaledi’s press conference on the 21 June 2018, I have summarised the salient points from the Hon. Minister’s press release and have addressed the most important elements proposed in both of these bills, for your ease of reading and repsonse.
The changes suggested to the Medical Schemes Amendment bill are easier to grasp, than the NHI bill, as they refer to an already existing Act, it’s infrastructure and operations, most of which form your day to day business of medicine.
THE NHI BILL
This bill is mostly conceptual in nature, and certain of the clauses are not immediately of interest to the Family Practitioners as they deal with the legal’ez behind putting the entire process into being.
The following paragraphs form ESSENTIAL READING in the new bill when you ask: “What can we do to get our practice ready for NHI?”
The essential elements in paragraphs 8, 10, 11, 12, 34, 35, 36, 37, 38 must be read and studied and commented upon to me with all urgency.
There is still a huge amount of work to be done by the State and therefore NHI will be rolled out in stages and not via a Big Bang approach.
The initial patient mix will be the unemployed, the indigent, the poor, maternal and child health, and the elderly, and there is a push to have this portion of the NHI implemented by 2022.
NHI patients will be entitled to receive healthcare at no fee from registered providers. They may however access services not reimbursed by NHI through the private healthcare system, or pay out of pocket.
NHI patients will however not be permitted to access practitioners to whom they have not been allocated, nor go directly to specialists except in emergencies.
All providers must be certified and accredited to see NHI patients.
A National Health Repository and Data system will be established to ensure portability and accessibility/continuity of healthcare.
Payment for services to FPs will be via risk adjusted capitation related to the size of the population you receive to care for and the services required to be performed.
FPs will need to be organized into horizontal networks of practitioners (e.g. Qualicare), with specified geographic areas, and must assist the Contracting Units for PHC (CUPS) in the manner described in para 37.
Accreditation of service providers is described in detail in paragraph 38 of the NHI Bill.
Complete (or if you have already done so, update) the practice self-accreditation form appearing on Docweb.co.za and send it to [email protected], urgently. Do it today!
Qualicare already has accepted and endorsed the self-accreditation form from the IPA Foundation and we have a list of fully self-accredited doctors on a database, ready for NHI contracting when it arrives. Should you want to be included, there is no barrier to entry to anyone!!
In the interim, you should diligently look into the running costs of your practice and keep it lean and mean whilst remaining highly cost and patient efficient. You will then be in a strong position to know if capitation fee offered to you will be realistic or not.
- Group practices
- Multidisciplinary practices
- Employ a nurse, a technician etc qualified to perform ECGs, sonars, LFTs, Point of service pathology, venisections
- Offer a one stop shop
When considering new legislation, always remember that the devil is in the detail, and that both the MSA Amendments Bill and the NHI Bill, are BILLS and not Acts, so they are open to public commentary and will accommodate certain Public requests, hence the period of commentary for 90 days. The Minister explained that the implementation of NHI was not a once off event, but rather will be introduced in a phased process over 10 to 15 years.
The Medical Schemes Amendment Bill:
The Medical Schemes Act, as we currently know it, and the resultant medical aid system, will slowly be phased out, as NHI takes over. In the interim, the Minister appears to be desirous of amending the Act to become more congruent with the thinking behind the National Health Insurance White paper, and National Health Insurance Bill. He further felt it necessary to provide immediate relief to current beneficiaries of Medical Schemes, to protect them against certain serious challenges threatening the current status quo of private medical scheme insurance, and their members as he is of the opinion that more and more people can no longer afford Medical aid subs. Importantly also is the Market Inquiry into the cost of Private Health Care, due to be released on 28 June 2018. We expect that this will address Private Healthcare cost aberrations in more detail as well, and we will summarise this for you as soon as possible. You will however notice that, in the MSA amendment bill, the emphasis is on making changes to traditional pillars of the Act, which are widely thought to weaken the financial sustainability of the Funders. Whether or not this will affect the current status quo in a positive or negative way, is what we would like to hear from you. I do not want to give my comments, which may or may not shape your thinking, so here your urgent input is needed. Schemes approached to date however intimate that this will interfere with the financial soundness of the current Medical Schemes environment.
Abolition of Co-Payments:
Medical schemes will be obliged to pay in full what is charged to the patients, and NOT burden the patient with any co-pays.
The justification of this suggestion is that there is R60, 000,000,000.00 in reserves in the funders’ coffers, which is in excess of the statutory 25% of reserves, by approx. a further 33%. The Minister attributes this excess to unnecessarily high premiums, as well as the use of unnecessarily resorting to patient liable co-payments.
He further explains that the CMS is reviewing the minimum solvency requirements for a scheme, possibly downwards, to provide beneficiaries with further relief in the form of lower subs and no co-payments.
It is unclear if all co-payments will be abolished, and if so, when?
Will schemes be obliged to pay for all services at Invoice face value?
Or will it only be limited to PMBs or to their new replacement, the newly named “Comprehensive Service Benefits (CSBs)?”
Abolition of Brokers
Brokers cost the beneficiaries R 2, 2000,000,000.00 per annum. The Minister is of the opinion that many members do not know why or what they are paying this for, and at the rate of R 90.00 per principle member, per month. He goes further to state that most of the work done by brokers is in any event done by the Council of Medical schemes and explains that this money could go into paying claims instead.
Again it is not immediately clear if these services will be abolished, or merely be made patient-liable if the members actively choose to opt in to their services, which may need to offer more value added services to remain in business.
Introduction of Comprehensive Service Benefits to replace PMBs
The Hospicentrically focussed PMBs will be removed although no time limit is offered, and replaced by a list of Comprehensive Service Benefits, which will include PRIMARY HEALTH CARE with elements of Family planning, Vaccination, Wellness screening and wellness services.
When this amendment finally occurs, it will be a huge boost to the Primary Health Care Providers like Family Practitioners, who will once again be placed into the central position of coordinating their patient’s health, and wellness. Specialist referrals will be via FPs. Direct referrals to specialists in an NHI setting will not be permitted.
Removal of unfair and unequal benefit options
The Minister intends to remove “unfair and unequal” benefit options which present a wide variety of plan rules and restrictions on benefits to unwitting members who do not understand the option which they have bought.
This clause is once again an indictment of brokers, who are free to sell these plans to poorly informed members of the public, buying what they can afford, and not necessarily what their needs require.
It also speaks to certain unscrupulous funders who devise bottom of the range health plans and allow them to be sold to unsuspecting members without a full financial needs analysis having been conducted.
In future all benefit options will have to be approved by the CMS, who will examine these only in the light of the benefit to the patient.
Carrying on of the business of a medical scheme
It will become an offence to conduct the business of a medical scheme by organisations which sell health products like medical schemes, but which are not registered with the CMS and which are not registered as a medical scheme.
This amendment is designed to curtail “cash back” plans, and businesses which sell “Medical aid lookalike” products to defray the cost of health expenditure but which are not registered with the CMS. Certain of these are currently registered with the Financial Services Board (now called the Financial Sector Conduct Authority) but this organisation has amended it’s rules to exclude such entities from registering with them.
Creation of Central beneficiary and provider registry
The reasoning behind this requirement is to provide the Registrar of the CMS with data on Trends of behaviour in the public’s selection of medical scheme offerings, age, disease profiles, health seeker behaviour, and geographic distribution. These will assist in the planning of services needed for the implementation of a future NHI.
The Minister alleges that the Private Funders are not forthcoming with this type of information which he may need for NHI. Certainly CPC/Qualicare would look at providing profiling and peer review information, devoid of patient of doctor particulars to the Dept for demographic studies.
Cross subsidisation and social solidarity model
Currently medical aids charge the same amount to all income earners irrespective of the quantum earned. The Minister feels that this ignores the principle of Cross subsidisation.
Cross subsidisation will therefore be introduced through differential premiums based on income earned.
I find it strange that we have, for years, suggested that a Risk Equalisation Fund, and Compulsory membership of a medical aid by all employed South Africans, has not been honoured with the same sense of urgency as it deserves, alongside need for Social Solidarity.
Financial rewards for cost saving behaviour
Patients who use DSPs, and whose behaviour includes abiding by formularies, algorithms etc, will save the schemes money and those savings will hence forth find their way back into premium reductions for members who comply.
This recommendation is more of a wish, than a command, as the mechanisms for this need to be studied and the implementation of same will be a statistical minefield.
Abolition of Waiting periods between joining and accessing benefits
NHI will not permit waiting periods or late joiner penalties, nor will it discriminate against surviving spouses or members after retirement. These will also be eliminated from the current medical aid model rules in preparation for the eventual implementation of NHI.
Social Solidarity again comes to the fore here, however , the current medical aids will still need to be around for the next 10 to 20 years whilst NHI goes through its various iterations and formative years, and I fear that this clause could lead to massive anti-selection against schemes.
Minimum educational requirement for Trustees on Boards of Medical aids and for CEOs of Medical schemes
These minimum requirements include training and qualification as a doctor, an accountant, a lawyer, a member holding a tertiary qualification in business management. I am certain that the Unions will not accept this in it’s current format, despite it being a sound idea.
Qualicare requests your input over the next 30 to 45 days, to allow us to compile your ideas and our thoughts and recommendations into a single response to the bills, which we will ensure shall reach them before the deadline of 90 days after release.
For a more comprehensive overview, I have included in this edition, 4 previous newsletters on NHI from 2009, 2011, 2016 and 2017 featuring important landmarks and attitudes prevailing at the time of each previous publication. As you peruse the articles, you will notice the changes in emphasis and nuances with the evolution of time as well as certain non-negotiables which Government has insisted upon since day 1.
CPC/Qualicare provides you with this initial overview of the changes in the MSA, and will, in further articles, dissect the specifics of both draft bills finer points, and provide them to you well in time for you to study, digest and then submit your in depth suggestions to our head office at 18 Lower Burg St, Cape Town, to emma[email protected] in time for their compilation into our combined submission to the Minister of Health.
In closing, I need to add that the release of these 2 Bills by the Minister could cause massive expectations in the eyes of the patients and confusion in the ranks of doctors, who may expect, as a result of the saturation newspaper coverage, that these Amendments are of immediate force and effect.
I want to therefore caution that a long and protracted period of negotiations can be expected, and that these new amendments are bound to be refined and change with time.
Only once the Regulations are written to control and implement the final Acts, will we be able to assess the nett effect on the citizens of RSA and the on the Medical Profession.
CPC /Qualicare hopes to run facilitated workshops shortly to explore the NHI in deeper detail.
I look forward to receiving your comments, suggestions, criticism and comment urgently
Tony Behrman and the Qualicare Team