Private healthcare providers have been given the assurance
that government will take all costs related to the delivery of health services
into account when determining uniform tariffs and capitation models under the
soon to be implemented National Health Insurance (NHI) scheme.

Speaking to MedBrief
on the sidelines of last week’s media conference on the NHI Bill and
Medical Scheme Amendment Act, Health Minister, Dr Aaron Motsoaledi said the
tariffs will be calculated “scientifically” by members of a Pricing Committee
answerable to the NHI Fund, comprising of, among others, experts from the
private sector, academics and representatives of statutory bodies.

Asked whether government will consider the results of the
latest practice cost studies conducted in the private sector on behalf of SAMA,
the Minister was very vague, only saying that payments will be based on a
Diagnosis-related Model (DRG) that will take all costs pertaining to specific
treatments and services into account.

“For example, when paying for a C-section, all costs pertaining
to the procedure will be taken into account to establish exactly what it costs
to determine the tariffs that will be paid. We are not against remunerating
doctors according to what it cost them to deliver a service. What we are
against is charging, for instance, for whole packs of consumables such as
swabs, cotton wool or needles when only one item in that pack has been used,”
the Minister said.

According to the NHI Bill, the NHI Fund in consultation with
the Minister must determine the nature of service provider payment mechanisms
to all providers, health establishments and suppliers accredited by the Fund.

“In the case of specialist and hospital services, payments
must be all-inclusive and based on the performance of the provider,” the Bill
reads. Providers of primary healthcare services such as GPs will be paid
according to a risk-adjusted capitation basis that will take into consideration
the size of the population served and the range of services they deliver. The
NHI Fund’s Contracting Unit for Primary Health Care will be responsible for the
contracting and remuneration of these providers, the Bill states.

Criteria for accreditation include adherence to treatment
protocols and guidelines, referral networks (Patients must be referred by a GP
before they can access specialist services), and the “delivery of healthcare
services at the appropriate level of care to users who are entitled to benefits
purchased by the Fund on their behalf”.

Mandatory NHI
membership and contribution

Membership of the NHI will be mandatory to all citizens
registered with the Fund and beneficiaries will be able to access accredited
services in both the public and private sector with the full costs being
covered by the Fund. According to Motsoaledi, the Fund will be a single
purchaser of health services funded by the “consolidation of revenue” to
protect users against financial risk. However, he refrained from giving any
details on how all of this will be funded, saying it will be determined by
Treasury, Cabinet and government “and not by the Health Minister”.  He, however, indicated that all South
Africans will have to make mandatory contributions to the Fund based on their
means once the NHI becomes law.

Asked about the role of medical schemes once the NHI is
fully established, he also refrained from giving a direct answer.

“As we implement NHI, we are not going to say medical
schemes are no longer going to be there. We know that once the Fund is
established, there will be no logic for government-subsidised schemes such as
GEMS and POLMED to continue to exist. The others that are private – that is a decision
that South Africans will have to debate. What we know now is that payment to
the NHI will be mandatory and everybody by law will have to be part of it. What
people do thereafter is their choice,” Motsoaledi said.

He reiterated that NHI will need a massive reorganisation of
the current health system in both the private and public sectors, requiring the
amendment of 12 Acts. The first two Acts to be amended will be the National
Health Act of 2003 and the Mental Health Act of 2002. The amendment of Act 61
of the National Health Act will see the reimplementation of Act No 63 of the
1977 National Health Act which will provide National Government with the powers
to directly intervene in the event of health system failures rather than
provincial governments.

“We believe that if we wish to get immediate results, the
old Act is the one that will provide for that. We must bear in mind that the
old Act was promulgated when provinces were only administrative centres rather
than the political centres they are today,” the Minister said.