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Di McIntyre's presentation at the Department of Science and Technology (DST) international seminar on a National Health Insurance (NHI) from 6 – 7 December 2012 at the CSIR Conference Centre, Pretoria.
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Possible provider payment mechanisms for South Africa
Di McIntyre Health Economics Unit University of Cape Town
DST 2012 NHI seminar December 2012, Pretoria
Overview
• Provider payment is part of purchasing: – Transferring funds from pool to health care providers
– AcHve purchasing – idenHfy populaHon needs and align services to needs and monitor performance
• Current payment context • Likely future purchasing context • Provider payment mechanisms proposed • Associated issues
Current payment context
• Public sector: – Line-‐item budgets (linked to inputs) for faciliHes – Salaries for individual providers
• Private sector: – Largely fee-‐for-‐service (fees not fixed) – CapitaHon for a few GPs – Limited case-‐based payment by some schemes to some hospitals
Future purchasing context
• Purchaser-‐provider split: – Requires greater management authority in public hospitals and at districts
• Public enHty to pool funds and be single ac#ve purchaser for universal service enHtlements
• Purchase from public and private providers (on same terms)
• Tax funding: – General revenue allocaHons & dedicated taxes – Budget limit – PPM must control expenditure
Interna?onal lessons
• Fee-‐for-‐service and line-‐item budgets: – Least desirable – Avoid as main provider payment mechanism
• Mix of provider payment mechanisms (to achieve an appropriate balance of incenHves)
• Refine over Hme (based on provider responses to incenHves)
PHC services
• PHC context: – Integrated, comprehensive PHC services – Provided by mulH-‐disciplinary teams – At community and facility level
• ObjecHves of provider payment: – Equity in allocaHon of resources for PHC services – Encourage prevenHve & promoHve intervenHons – Efficiency and quality
PHC services
• PotenHal provider payment mechanism: – Global budget to district based on risk-‐adjusted capitaHon
– PotenHally move to risk-‐adjusted capitaHon to individual faciliHes/groups, for comprehensive services, including community-‐based teams
• Need informaHon on: – Cost of comprehensive PHC services – Demographic composiHon of populaHon in districts and epidemiological profile (chronic condiHons)
• Fixed allowance for infrastructure & equipment
PHC services
• P4P (pay-‐for-‐performance) – some FFS: – Very weak evidence on impact – Where directed at specific services (e.g. immunisaHons) – services not part of P4P are given lower priority; gaming and false reporHng
– Some countries reward low referrals and diagnosHc tests – can lead to under-‐servicing, but could base on adherence to standard treatment guidelines (referrals, diagnosHc tests, prescribing)
– Possibly use FFS for providing services to those not from district (or facility/group)
Hospital services
• ObjecHves of provider payment: – Efficient provision of quality care – Not funding faciliHes but services for paHents in need
– Facilitate purchasing from public and private providers on same terms
• Case-‐based payments (e.g. DRGs): – IniHally as guide to determine global budget – Based on average cost per case in average hospital (category of hospital)
Other payments
• In addiHon to main payment mechanisms, can be a range of other provider payment arrangements, e.g. : – Sessional appointments (pro-‐rata of full package) – Price and volume contracts (specified quanHty of parHcular services – e.g. high tech diagnosHcs, specific surgical procedures)
Associated issues
• Preparatory steps to level the playing field between public and private providers
• Greater management authority in public faciliHes
• InformaHon systems (urgent): – Demographics; diagnosHc & procedure codes
• Monitoring (quality of care) • Accountability in terms of performance
Key issues
• PreparaHon – informaHon, management authority
• Mix of payment mechanisms and refine over Hme
• Phase in (of main payment mechanisms) – global budgets to capitaHon for PHC and case-‐based for hospitals
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© Health Economics Unit, University of Cape Town, 2012