1. Haroon Wadee Head: Health Systems & Policy BHF Trends in Specialist Costs 2005/2006

3. Annual increases to providers Remuneration = Volume X unit price % Funder perspective Provider perspective

4. Which is the correct perspective? ¿

5. CMS 2006 report Specialist payments continue to climb Hospital payments levelling –? Dispensing fee & SEP Verifiable pattern in BHF 2006 KPI report (in press)

6. Medical specialist cost trends 3 administrators data aggregated 0 200 400 600 800 1,000 1,200 1,400 2000200120022003200420052006 Millions 1.PMB 2.8% NHRPL

7. Payment trends of some disciplines for a administrator ? ICD10 ?Spesnet Millions

8. Result of SAMA participation in NHRPL! ? Some science behind NHRPL process

9. 6.3% impact expected

10. Key issues currently exploring Policy and economic analysis of specialist cost increases in South Africa –Contextual analysis (historical, political- economy & health system landscape) –Economic analysis – agency theory & moral hazard –Preliminary stakeholder analysis

11. Funder Perspective Key issue emerging is that of allocative inefficiency in service provision. –Potential to off-set any efficiency gains from other policy interventions –Potential to undermine cost-containment overall, impacting on ability to increase access to medical aid market and in BBP context to widen the scope of benefits –Efficiency relative to GEMS – exploration of issues – large risk pool, high employer subsidy, access of previously uninsured (or shifting of current insured) –Sustainability of current schemes environment important factor – but also the future – LIMS and SHI

12. Remedies No Golden Rule Political pressure on SAMA with close engagement with NDOH, CMS and media

13. Key Messages Increases above NHRPL impact Increases above CPIX Increases above economic growth Increases above employment growth High increases – Paediatrics and O&G – undermines ability to meet UN MDGs and SAs overall health system performance and ranking Obstacle to LIMS and eventual transition towards SHI

14. Remedies No Golden Rule Political pressure on SAMA with close engagement with NDOH, CMS and media Medium-term – review experience of financing/service-delivery models that have demonstrated affordable and quality service delivery. –To inform strategy

15. Traditional financing-services flows

16. Flows (with co-payments and out-of-pocket expenditure)

17. Member (consumer) Perspective Increased rate of co-payments and/or out- of-pocket expenditure –Equity consideration – regressive nature of OOP –Relationship between consumer and scheme under spotlight with fragmentation of trust – tilting scales in favour of providers

18. Remedies Improved communication to members to address information asymmetry – ongoing Engagement with CMS

19. Force-field analysis vis-à-vis NHRPL Process

20. Key issues currently exploring Policy and economic analysis of specialist cost increases in South Africa –Contextual analysis (historical, political-economy & health system landscape) –Economic analysis – agency theory & moral hazard –Preliminary stakeholder analysis Diagnosis and procedure coding –Coding creep? –CPT4 vs ACHI vs ICHI – design and implementation impacts

21. Thank You