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

Haroon Wadee

Head: Health Systems & Policy

BHF

Trends in Specialist Costs

2005/2006

Annual increases to providers

Remuneration = Volume X unit price

% %

Funder perspective

Provider perspective

Which is the correct perspective?

¿

CMS 2006 report

• Specialist payments continue to climb

• Hospital payments levelling– ? Dispensing fee & SEP

• Verifiable pattern in BHF 2006 KPI report (in press)

Medical specialist cost trends3 administrator’s data aggregated

0

200

400

600

800

1,000

1,200

1,400

2000 2001 2002 2003 2004 2005 2006

Mill

ion

s

1. PMB

2. 8%NHRPL

Payment trends of some disciplines for a administrator

0

20

40

60

80

100

120

2000 2001 2002 2003 2004 2005 2006

Mill

ions

GYNAECOLOGISTS

ANAESTHETIST

PHYSICIAN

ORTHOPAEDICSURGEONS

SURGEONS

PAEDIATRICIANS

? ICD10

?Spesnet

Millions

2005/2006 % Payment Increase by Administrator

14

32

19

36

23

35

20

30

05

10152025303540

Anaesthetist Psychiatrists

%Admin 1 Admin 2 Admin 3 NHRPL impact

•Result of SAMA participation in NHRPL!

•? Some science behind NHRPL process

2005/2006 % payment increase for other specialists

6

22

11 10

30

133 5

14 15 1712

31

8

19 1819

34

1813

47

1319

11

01020304050

Admin 1 Admin 2 Admin 3

6.3% impact expected

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

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

Remedies

• No Golden Rule

• Political pressure on SAMA with close engagement with NDOH, CMS and media

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 MDG’s and SA’s overall health system performance and ranking

• Obstacle to LIMS and eventual transition towards SHI

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

Traditional financing-services flows

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

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

Remedies

• Improved communication to members to address information asymmetry – ongoing

• Engagement with CMS

Force-field analysis vis-à-vis NHRPL Process

<<<<<<<<<<<< <<<<<<<<<<<< <<<< >>>> >>>>>>>>>>>> >>>>>>>>>>>> NDOH CMS HPCSA Board of Healthcare Funders Medical Aid Schemes

Private hospitals SAMA

Private providers Consumers

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

Thank You