1. Board of Healthcare Funders of Southern Africa
Cost and Quality
Board of Healthcare Funders of Southern Africa
Conference 2007
Sun City
The BHF Southern African Conference July’07 Sun City

2. Speakers R Patel Charles Harbottle Roseanne da Silva Barry Childs
Why measure quality?
Role of health governance and management
Perversity in private healthcare
Charles Harbottle
Evaluating value of non healthcare cost
Roseanne da Silva
Evaluation of intermediary cost
Barry Childs
Collaborative risk management
The BHF Southern African Conference July’07 Sun City

3. Governance Process Health Finance
The BHF Southern African Conference July’07 Sun City

4. What Value Health status accountability R66 billion in private sector
R1 : R7 per capita (public vs private)
Health status accountability
Measure the value and achievements of health resources utilised
Vital stats
Millennium development goals
WHO Report: indicators
The BHF Southern African Conference July’07 Sun City

5. Quality in healthcare & medical audit
Appropriate
Efficacy
Effectiveness
Efficiency
Affordability
Access
Equity
The BHF Southern African Conference July’07 Sun City

6. Health measurement Demographic profile monitoring
Health status indicators
Quality /outcome indicators - HQA
Utilisation indicators
Economic indicators
The BHF Southern African Conference July’07 Sun City

7. Health status indicators
Life expectancy
Death rates
Maternal
Peri-natal, neonatal, infant
Inhospital
Disease specific
Dx Prevalence
Dx Incidence
Birth weights
Suicide rates
Teenage pregnancy
Immunisation coverage …
The BHF Southern African Conference July’07 Sun City

8. Examples of quality indicators
Hospitalisation
death rate
Readmission
Infection rate
Disease specific complication
Ambulatory
Pap & mammogram coverage
Flu vaccine coverage in >= 50years
Chronic: Diabetes
HbA1C coverage and frequency
Retina evaluation
Renal evaluation and outcomes
Hospitalisation
Acute - glucose level related
Amputation rates
The BHF Southern African Conference July’07 Sun City

9. 2005 claim data
The BHF Southern African Conference July’07 Sun City

10. 2005 Claims Data
The BHF Southern African Conference July’07 Sun City

11. Diabetes 2005
The BHF Southern African Conference July’07 Sun City

12. Others Beneficiaries visiting dentists Dental caries (2-8years)
32% (average of 1 per family)
Dental caries (2-8years)
19.1%
Optometrist visit ≤ 6years
1% (Could be low because of free screening)
The BHF Southern African Conference July’07 Sun City

13. Quality assurance: trends
The BHF Southern African Conference July’07 Sun City

14. QA: Success factors Commitment Consensus
Coding including accuracy & detail
(E)quipment ?
The BHF Southern African Conference July’07 Sun City

15. Needs Need to redefine mandatory benefits
Emphasis on spend in the right places
Need to promote access where benefit exists
Need for ongoing monitoring
Need for accountability by all stakeholders
The BHF Southern African Conference July’07 Sun City

16. HQA Health Quality Assessment Non profit entity
Committed to quality care monitoring
Independent and unbiased
Belongs to the members
Confidentiality assured
Supported by BHF
The BHF Southern African Conference July’07 Sun City

17. Legal and Policy framework
National Health Act
Office of Standards Compliance
NHIS
Health Charter
Quality, equity and access
UN: Millennium development goals
Medical Schemes Act amendment
Governance guideline
regulate by Circular
Statutory submissions
The BHF Southern African Conference July’07 Sun City

18. Proactive or Reactive? Robert Kennedy - 1967
“I’m sorry. We can do better in this country. We will--we ought to.”
The BHF Southern African Conference July’07 Sun City

19. Private Sector Perversity
The BHF Southern African Conference July’07 Sun City

20. One Lab’s fee structure
Test
Med Aid
Cash %
Difference
FBC/Platelet, ESR
121.30 59 51
HbA1c
109 78 29
U&E
Creatinine
150 94 37
HIV ab
Elisa
108.70 70 35
The BHF Southern African Conference July’07 Sun City

21. Optical costs 1 + 1 specials
Suggests price padding to Medical Aids
If optical benefit is considered “Essential” and to be included in Basic Benefit and LIMS
Prices need investigation
Benefit provided needs review
The BHF Southern African Conference July’07 Sun City

22. Private hospitals Low flow anaesthesia
Codes charged per min (code schedule)
Inappropriate since low flow & Medicine Pricing Regulation
Correct: R per millilitre used (SEP-regulated)
NDoH confirmation
Implementation:
NHRPL code description change
System and process changes
Need for settlement, THIS YEAR!
Charging error due to incorrect code description
Lo-flo in about 7 of 8 patients
15-20% gas utilisation per patient when used
Current billing:
approx. 4 X SEP
100% - 70% appropriate (Average)
2007: est >R300m (excluding Nitrous Oxide)
History: 7-10year
FSB & LOA refund arrangement
The BHF Southern African Conference July’07 Sun City

23. Governance Low flow anaesthesia: Legal implications
NDoH: current billing in contravention of the law
Duties of trustees (Medical Schemes Act)
Section 57(4)(h)
“ensure that the rules, operation and administration of the medical scheme comply with the provisions of this Act and all other applicable laws”
Failure to comply by trustees (if continue to pay)
Section 66
…be guilty of an offence, and liable on conviction to a fine or to imprisonment for a period not exceeding five years or to both a fine and imprisonment.
Possible personal liability
The BHF Southern African Conference July’07 Sun City

24. Private hospitals
Rebates, off-invoice discounts and effect of centralised buying 98
RAMS (statutory body) fee structure adjustment
Approx. 30% increase on tariff items
10% on materials (invoice):
2003/2004:
“net acquisition price” (SOB)
Invoice minus discount and rebate
Pre 98: invoice padding using in-house wholesaler
Late 90s: Start of “invoice padding” and price “fixing” at NAPPI level
Example (discussion with Vendor)
Cost of item R12
Net Sale price R15
Invoice price R80 (“insist” by hospitals)
Retail R80
Coding system use and apparent misrepresentation; apparent money laundering
Legal opinion required
The BHF Southern African Conference July’07 Sun City

25. CMS, 2007 RAMS: Regulated Unregulated
The BHF Southern African Conference July’07 Sun City

26. Early Analysis
The BHF Southern African Conference July’07 Sun City

27. Private hospitals
Rebates, off-invoice discounts and effect of centralised buying
estimate (from data presented last year)
2007: R2b+ & non Medical Aid payments
“generic” calculator
History: 7 year
…..
Excludes logistic fee secured ??????
The BHF Southern African Conference July’07 Sun City

28. Question Competition Commissioner investigates Bank charges
Would you like the NDoH, Competition Commissioner to investigate the hospital industry and vendor relationship related to invoice price (“fixing”) of the non medicinal items? No
Yes
FMU, OSEO or NPA: depending on legal opinion
The BHF Southern African Conference July’07 Sun City