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WHO 2006 Brazil Chile Mexico Netherlands South Africa
Argentina Brazil Chile Mexico Netherlands South Africa GDP per capita (US $, 2003) 305 212 282 372 3088 295 Life expectancy at birth male (years): 71 67 74 72 77 47 Life expectancy at birth female (years): 78 81 49 Child mortality male (per male 1000): 20 38 10 31 6 Child mortality female (per 1000): 16 9 25 5 62 The BHF Southern African Conference July’07 Sun City
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MALALIGNMENT Funders:
Regulatory reforms on funder side – social benefit (seen as commodity from supplier side) Community rating Voluntary enrolment FFS environment PMBs - regulated - referred and hospital based care - paid in full The BHF Southern African Conference July’07 Sun City
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MALALIGNMENT Competition Commissioner ruling - Costs increased
- Collective guidelines on new technology - Collective blacklisting of fraudulent provider - Collective trade practices e.g. marketing standards The BHF Southern African Conference July’07 Sun City
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MALALIGNMENT Cost spike in certain disciplines
- Uncertainty around NHRPL - Ethical tariff - Members at liberty to go directly to specialists – bypassing gatekeeper - PMB’s - regulated but in the absence of regulated pricing and delivery vehicle for benefits The BHF Southern African Conference July’07 Sun City
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MALALIGNMENT Bad habits creating wastage
- preliminary analysis undertaken by FMU shows that this environment incentivises fraud (e.g. top 10 Neurology claimers = 41% of total neurology spend. (90 Neurologists in total) Some codes used solely by one Neurologist) The BHF Southern African Conference July’07 Sun City
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Code Top 10 vs Rest (Volume) Top 10 97.80% 93.30% 94.30% 61.70% 74.20%
717 ELECTRICAL EXAMINATION OF SINGLE NERVE OR MUSCLE 97.80% As % of all consultations 2802 PERIPHERAL NERVE BLOCK 93.30% 2703 SEP SGL NERVE EXAM 94.30% 2682 VISUAL EVOKED POTENTIALS - BILATERAL 61.70% 713 ELECTROMYOGRAPHY 74.20% 2692 SHORT LATENCY BRIANSTEM EVOKED POTENTIALS: BILATERAL 84.00% 2800 PLEXUS NERVE BLOCK 97.60% 733 MOTOR NERVE CONDUCTION STUDIES SINGLE NERVE 53.10% 730 LIMB-BRAIN SOMATOSENSORY STUDIES/PER LIMB 72.80% 2711 ELECTRO-ENCEPHALOGRAPHY 33.40% 2712 ELECTRO-ENCEPHALOGRAPHY - INTERPRETATION 32.60% (2712 a function of 2711 ) As % of all consultations The BHF Southern African Conference July’07 Sun City
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THE ETHICAL TARIFF AND NHRPL
Most closed schemes have based their 2007 rates on the 2006 NHRPL rate plus 4.9% 8 386 NHRPL codes covers the majority of disciplines/specialities The “SCHEME TARIFF” may be: 100% NHRPL higher than NHRPL e.g. 150% on consultations higher than NHRPL if procedure done in-hospital e.g. 300% NHRPL lower than NHRPL e.g. physiotherapy at 80% of NHRPL The BHF Southern African Conference July’07 Sun City
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NHRPL IMPASSE Increasing trend of schemes adopting their own rates due to NHRPL uncertainty and lack of a standardised price list Multiple scheme rates will substantially increase the complexity of administration: Keeping codes are kept in sync Modifiers attached to codes Verification of exceptions Switches/hubs Practice management software The BHF Southern African Conference July’07 Sun City
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Ideal Structure Tariff Code
Speciality Speciality Tariff Code Speciality Speciality Speciality Speciality The BHF Southern African Conference July’07 Sun City
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Tariff Code The BHF Southern African Conference 22-25 July’07 Sun City
Speciality Scheme Rate Speciality Scheme Rate Speciality Scheme Rate Tariff Code Speciality Scheme Rate Speciality Scheme Rate The BHF Southern African Conference July’07 Sun City
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NHRPL IMPASSE Increased queries to schemes and administrators
Lack of transparency so members cannot use price to assist in making choices “….for a practitioner to charge at the HPCSA upper ethical tariff, they would have to obtain consent, otherwise, this will be viewed as over-charging the patient” CEO of HPCSA, 13 October 2006 Healthcare professionals turn to cash practices At what rate to pay PMB’s? The BHF Southern African Conference July’07 Sun City
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NHRPL IMPASSE State intervention and price regulation?
A standardised price list Need to enhance consumer awareness Public access to cost and quality? The BHF Southern African Conference July’07 Sun City
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CLAIMS TRENDS CLOSED SCHEMES
Benefits paid pmpm Ave Cost per Claim 2006 Inc/Dec 2007 Inc/Dec Auxillary 24% 7% 20% Dental 9% 10% 6% GP 14% 16% 12% Hospital 11% 3% 5% Medical Specialists 19% 22% Acute medicine 1% Chronic medicine 2% Other medicine 36% 27% -7% -16% Optical -4% 44% 8% Pathology Radiology Special Benefits 15% 0% -5% Total 4% The BHF Southern African Conference July’07 Sun City
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CLAIMS TRENDS CLOSED SCHEMES
Distribution of Claims 2005 2006 2007 Auxillary 4.9% 5.4% 5.2% Dental 6.1% 6.0% 5.7% GP 7.6% 7.7% Hospital 35.4% 35.2% 33.5% Medical Specialists 9.6% 10.2% 10.1% Acute medicine 10.9% 10.3% Chronic medicine 7.2% 7.1% Other medicine 1.5% 1.8% Optical 5.3% 4.5% 6.8% Pathology 4.8% Radiology Special Benefits 0.7% 0.6% The BHF Southern African Conference July’07 Sun City
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