Towards a single no balance billing payment system Rajesh Patel Jhb June 2007

BHF board mandate Affordability Quality of care …

Benefit History 2001 –Regulated minimum benefit entitlement –At cost –No co-pay….

Remunerations Unbundling of RAMS Competition Commissioner actions HPCSA ethical fees Surgicom; Spesnet and its actions Cost escalations Funders as price takers

Tariff history Regulated SOB Negotiated SOB Reference price ???? SAMA; SADA rate HPCSA ethical fees

Negotiated RAP RegulatedReference

Considerations Statutory provision for a no balance billing fee Schemes can negotiate a lower fee

Remuneration determination Models –SA model –Belgium model –Australian model –Hybrid model

Advantages of statutory maximum fee Affordability Expansion of minimum mandatory benefit Rationalisation of plans Can include assessment of healthcare needs

Belgium model Bargaining council model If no agreement, Minister decides 7 year – no Ministers intervention Advantage –Agreed fee by all parties Disadvantage –Inefficiency may be entrenched

Australian model Coding centre Fees centre Federal Government MBS fees Disadvantage: coding development for National Health benefits

Hybrid model Sufficiently representative provider group Sufficiently representative funder group Centralised bargaining process Agreement? Consideration for Certification by MOH Certification criteria met? Ministerial determination Publication in Gazette of no balance-billing tariffs Appeal process (limited to subsequent process) Yes No Yes ICU

Certification criteria and statutory powers Statutory TOR Include budget impact, Inflation… Representivity Powers of the Minister …

Timelines Code structure settlement Price settlement Ministerial determination Consider –Technology assessment –REF time lines

Questions?