Healthcare Access. As the Health Portfolio Committee in Parliament finalises the National Health Insurance (NHI) Bill, many questions remain about how the system will work in practice. These spans questions around claiming of benefits, referral pathways and payment arrangements. Questions abound about how NHI will affect the healthcare experience of citizens. In this guide, we'll explore some of the key aspects of NHI and how they are likely to work based on policy proposals made in the NHI White Paper and the NHI Bill.
Healthcare Access
To claim benefits, patients will need to register with NHI
and select a primary health care (PHC) provider. They will then be able to
access services from this provider or be referred to other providers within the
NHI network if necessary.
How will referrals from Primary Health Care to Hospitals take place?
Under NHI, PHC providers such as clinics and participating
General Practitioners will act as gatekeepers to secondary and tertiary care within
the network of providers contracted to the NHI Fund. This means that patients
will need a referral from their PHC provider in order to access specialised
care. This referral will include information about the patient's medical
history and the services they require.
The pathways will be designed to ensure that patients
receive appropriate care in a timely and efficient manner, thus reducing the
burden on hospitals and specialists. It will also help to ensure that patients
do not receive unnecessary or inappropriate care, which can drive up costs. The
NHI White Paper incorporates private healthcare facilities in the referral
pathways, if they contract with the NHI Fund.
How will patients contribute to the NHI Fund?
The NHI Fund will be financed through a combination of
general taxes, payroll taxes, and contributions from individuals and employers.
The exact payment arrangements are still being discussed, but it is likely that
all employed individuals will be required to proportionately make contributions
to the NHI Fund through payroll taxes, based on income.
This means existing contributions to private medical schemes
will cease, including subsidies and tax rebates that are currently in force. It
is expected that the contributions to the NHI Fund will be much less, in the
long-term, than contributions to private medical schemes which are 6x higher than in OECD countries.
Low-income individuals and those who are unable to work will
be exempt from paying these taxes, and the government will provide subsidies to
cover their contributions. The NHI Fund will pool these funds and use them to
purchase healthcare services for all citizens.
How will health care providers be reimbursed?
Under NHI, payments for healthcare services will be made by
the NHI Fund, rather than by individuals or medical schemes. The NHI Fund will
pay for all healthcare services that are covered under the NHI benefit package,
including PHC, hospital services, and specialist services.
The exact payment arrangements are still being discussed,
but it is likely that healthcare providers will be paid based on some form of a
capitation (or modified) model. This means that healthcare providers will be
paid based on the number of services they provide.
Pooling funds and conducting purchasing functions
The NHI Fund will be responsible for pooling funds and
conducting purchasing functions on behalf of the entire population. This means
that the NHI Fund will negotiate prices and contracts with healthcare
providers, and will be responsible for ensuring that the healthcare system
operates efficiently and effectively.
The NHI Fund will also be responsible for implementing a
system of quality assurance, which will help to ensure that all healthcare
providers meet certain standards of care. This will help to improve the quality
of care provided to patients, and will help to ensure that the healthcare
system is sustainable over the long term.
Role of the Benefits Advisory Committee
The NHI Benefits Advisory Committee (BAC) is an important
body in the implementation of the NHI. Its primary role will be to advise the
Minister of Health on the package of health services and benefits that will be
offered under the NHI. The BAC will be made up of healthcare professionals,
health economists, patient representatives, community representatives, and
other experts in the field.
The BAC will determine the standard treatment guidelines,
type of tests required and other clinical protocols to ensure all patients
receive consistent, high-quality care regardless of their socio-economic status.
The BAC will also review new technologies and treatments to ensure that they
are safe, effective, and affordable before they are included in the NHI benefits
package.
Furthermore, the BAC will play a crucial role in managing
the costs of the NHI system by ensuring that resources are allocated based on
clinical need, cost-effectiveness, and public health priorities. This may include
incentives for healthcare providers who demonstrate innovativeness and
efficiencies in resource and patient management The BAC will also work with the
NHI Fund to ensure that the benefits package is financially sustainable and
does not exceed the available budget.
Importantly, the BAC will be an independent body that is
free from political interference. This is to ensure that the benefits package
is determined by clinical evidence and patient needs rather than political
expediency. However, knowing the history of our country, a strong civil society
is necessary to enforce transparency and accountability. Public education will
also be important to ensure citizens understand their rights and are empowered
to report any malfeasance.
Role of Private Medical Schemes
The private medical schemes will still exist within the
realm of NHI, but their role will be significantly reduced. They will only be
allowed to offer complementary services that are not covered under the NHI
benefit package.
This means that private medical schemes will no longer be
able to offer cover for hospital and specialist services, as these services
will be covered under the NHI benefit package. Private medical schemes will
also not be allowed to offer cover for PHC services since these will be
accessible free of charge at the point of care. It is important, however, to
note that this remains a hotly contested policy matter in parliament.
Conclusion
The implementation of the NHI is a complex and challenging
process, but it has the potential to transform South Africa's healthcare system
and improve the lives of millions of people. By ensuring that all South
Africans have access to quality healthcare, the NHI can help to reduce
inequality, improve productivity, and promote economic growth.
The NHI will require significant policy changes and
investments in infrastructure to improve the quality of all facilities, and serves
as a long-term solution to introduce efficiencies that will ultimately save
money by reducing the burden of disease and improving overall health outcomes.
While critics lament that the NHI is not affordable, in
truth, all the NHI proposes is the consolidation of the same pool of funds that
already exists in the healthcare system — albeit, unevenly distributed. The successful
implementation of this system will require collaboration between the government,
healthcare professionals, civil society, patients, and all other stakeholders.
However, if done correctly, the NHI will be a shining example of how a
well-designed and well-implemented universal healthcare system has the capacity
to benefit everyone, regardless of class, gender, race or socio-economic status.
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