1. Defining Healthcare Packages in the NHI Joe Seoloane Curator of Pro Sano Medical Scheme

3. A Perspective on NHI
NHI should be approached with soberness and objectivity based on principles of human dignity, need and cost.
Both the public and private sector to collaborate.
Stakeholders to have the opportunity participate and to influence the NHI implementation.
Rational and responsible phasing of the NHI is a critical success factor.
Genuine and objective inputs should be provided in the midst of scepticism.
We should also guard against unrealistic optimism that the NHI will be the panacea for all healthcare problems.
There will be continued lobbying to discredit whatever NHI package is ultimately developed in favour of the status quo.

4. National Stats Relevant to NHI
Total population: million Employment rate: 17.5 million Life expectancy estimated at: 53.5 years males & females Sweden 77.9 males & 82.4 females Infant mortality: 45.7 per 1000 live births Sweden 3% Living with HIV: estimated 5.2 million Adults 15-49: 17% of population is HIV positive On ART: 1.5 million older than 15 years / children TB Endemic: with a growing number of MDR TB Currently largely treated in public sector

5. The South African Envisaged Model of NHI
Mandatory Enrolment
For all citizens
No financial or other barriers - equal access to all health care services
Single Payer Payment System
NHI will be the only legitimate insurer of NHI benefits
Contracted service providers paid on a negotiated reference price list
National Administration of the Fund
Administered by a government agency/agencies - under direct supervision of the DOH
Contribution into the NHI fund
Largely from taxation
Payroll related amounts based on income
Subsidy from employers and government
Benefits
Comprehensive benefits to be defined
Public and private sectors contracted service providers
Cover will be for member and dependants

6. Comprehensive Levels of Cover
Primary Care Benefits
– Basic curative care and preventative services
Diagnosis
Laboratory tests
Prescription drugs (appropriate schedule for GP’s and nurses)
Consumables
Minor operations
Maternity services
Basic dental & optical care
Chronic medication
Secondary Care Benefits
As per above - at a referral level
Specialized care with subspecialties
Mental health care
Blood transfusions
Emergency care
Basic general & gynecological surgery
Tertiary Benefits-Highly Specialized Care
Oncology, transplants and clinical appropriate reconstructive surgery
Advanced radiology & laboratory tests

7. Basis for Level of Care
Services will be treated at appropriate level of care.
Current public sector structure is a good basis
Referral protocols and disincentives for non-compliance.
Clearly defined treatment protocols and dispensing of medicine.
NHI will cover conditions as specified in the treatment protocols.
Clear policies of patient pathways and guaranteed access
Private sector may offer supplementary cover for the services excluded from NHI.
Exclusions can be privately insured or paid out-of-pocket.

8. Experiences from Private Sector Basic Packages
Benefit
Benefit Rules
Comprehensive hospital cover
Unlimited for services delivered at appropriate level for care.
GP consultations and medication
Unlimited to network providers: (including consultation, procedures, medication, pathology and radiology).
Max of R 600 per event
2 out of network visits per family
Out of hospital specialist consultations
5 consultations per family
– max R2000 pa
3 consultations per beneficiary
– max R1600 pa
2 Maternity consultations
From network doctors
Optical benefits
Examination, frame and lens (uni & bifocal)
Basic dentistry benefits
As per protocol
Unlimited chronic medication
As per formulary

9. Top Ten GP Visits Acute upper respiratory infection, unspecified
Examples of What Primary Benefits Should Cater For:
Acute upper respiratory infection, unspecified
Acute bronchitis, unspecified
Influenza with other respiratory manifestation virus not identified
Acute sinusitis, unspecified
Essential (primary) hypertension
Acute pharyngitis, unspecified
General medical examination
Diarrhoea and gastroenteritis of presumed infectious origin
Urinary tract infection, site not specified
Influenza with other manifestations, virus not identified

10. Top Ten Dental Services
Infection control / barrier techniques
Oral examination
Local anaesthetic – per visit
Sterilized instrumentation
Intraoral radiograph – periapical
Prophylaxis – complete dentition
Limited oral examination
Examples of What Primary Dental Benefits Should Include:

11. Top Ten Specialist Referrals
General Indication of Specialist Expertise Required at Secondary Care Level
Gynaecology – Obstetrics
Orthopaedics
Surgery
Otorhinolaryngology- ENT
Ophthalmology
Paediatrics
Physicians
Urology
Dermatology
Cardiology

12. TOP 10 Hospital Admissions by Cost
Gastritis, unspecified
Bronchitis. Not specified as acute or chronic
Retention of urine
Lumb and other intrvertebral disc disorders with radiculopathy
Pneumonia, unspecified
Angina pectoris, unspecified
Diaphragmatic hernia without obstruction or gangrene
Malignant neoplasm of kidney, except renal pelvis
Respiratory syncytial virus pneumonia
Calculus of gallbladder with other cholecystitis
General Indication of Services to be Catered for at Secondary Care Level

13. Tertiary Care General Indication of Services at Tertiary Care Level
Highly Specialized and Costly Services
Oncology
Transplants
Plastic and reconstructive surgery
Complicated cases
Other specialized procedures

14. Lessons from the NHI in Taiwan
National Health Insurance Act of 1994 as amended on May 18, 2005 and Regulations for NHI Medical Care as amended on 22 April 2009

15. Framework of the Taiwanese NHI
NHI is the insurer
Operations overseen by Supervisory Body----
of Premium revenue
- Admin fee = 3,5% of annual claims payment
Beneficiaries: Clearly categorized
Pay income related premium
Professional
Government workers
Self employed / business
Farm worker etc ( 6%)
Group Insurance Applicants
Collectors of premiums
Professional body
Specific departments
Enterprises / employers
Farmers Association
Negotiation Committee vs. DSPs, specialists etc
Dispute settlement Board
Clearly specified co-payments
20% Out patient /emergency
30% Out patient DH without referral
40% Out patient RH without referral
50% Out patient RH without referral
Admissions Acute | Chronic
1st 30 days % %
% %
>60 days % %
Medical care Institutions (DSPs)
Collection of co-payments
Contracted Hospitals / outpatient
Pharmacies and medical labs
Check eligibility of beneficiaries
Summary of referral Medical history
Exclusions: Immunizations-borne by Government, drug addiction, cosmetic surgery, artificial reproduction, sex conversion surgery, dentures, OTCs of scheduled drugs etc.

16. Pertinent Principles of the Taiwanese NHI
Equal treatment for same illness
User fees
No co-payments for:
major illness | injury | maternity | low income | preventative health care | rural communities
Penalties for Payment of inappropriate treatment
(e.g. for pathology or medication) is borne by contracted medical care institution if found to be inappropriate (itemised billing)
Peer review process
For service providers
Incentives for preventive care for employers and unions.

17. Examples of Contributions Subsidy in Taiwan
Category
Member
Employer / Government departments
GOVT.
% contributions
Low Income
Social welfare 35 65
Military servicemen
100
Veterans
only
Veterans affairs commission
dependants 30 70
other 60 40
Civil servants
Private schools
SOE/POE
Employer 10
Farmers
General workers
Professionals/Technicians
SMME

18. Maintaining Discipline in the System
Transgression
Consequence
Fraud and abuse
Criminal offence
Treatment of non-members
Fine = 2 times the benefit paid
Medical care institutions (DSPs) charging more
Fine = 5 times overcharged fee
Contracted hospitals not keeping ward allocated ratios
FINE = thousand New Taiwan Dollars
Falsified classification of category
Fine = 3-15 thousand New Taiwan Dollars
Employer deducting less premiums
Fine = 2-4 times shortfall amount
Defaulting premium payment by employer
Fine = 2 times outstanding payment

20. Conclusion The role of the private health care sector:
Risk management tools
Membership management
Skills in healthcare funding and Technology
Suggested Cost parameters:
Comprehensive less than 5% of gross income subject to actuarial modeling
NHI administration 3.5%-5% of claims payment
Our NHI has to be a products of private sector, public sector and international experience.
A healthy constructive engagement is critical.

21. Conclusion Cont…
These engagements will assist us to put more detail to our NHI framework – such as what form the benefits and contributions are likely to be and guaranteed maximum waiting time to receive care.
The sheer numbers of contributors to NHI will increase the total pool into a formidable stable fund that should reduce contracted prices & contributions
Discipline as enshrined in some international models and local experiences is essential to maintain sustainability of an NHI dispensation(PMB’s & CDL)
We need strict discipline in the execution of our NHI to mitigate and control factors like our burden of disease, health care consumption patterns and spiraling healthcare inflation

22. Thank you

23. References: 1.Stats SA: Midyear estimates 2009
2 Taiwan-National Health Insurance Act no.4505 of 1994 and Regulations for NHI Medical Care of 1995 as amended
3. Glenngard AH, Hjalte F, Svensson M, Anell A, Bankauskaite V.
Health Systems in Transition: Sweden. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005.
4. National Policy Analysis no. 555: Sweden’s single-payer Health System Provides a warning to Other Nations by Hogberg D. A publication of the National Centre for Public Policy Research
5. Universal Health Care Systems , from Wikipedia, the free encyclopedia.
6. Pro Sano Medical Scheme, clinical data.