PRIVATE HEALTHCARE MARKET INQUIRY REPORT: IMPLICATIONS FOR NHI

This article was published on 4 October 2019 in the Law Society of SA Legalbrief Weekly, an initiative of the Law Society of South Africa & Juta Law

Recommendations in the recently released Competition Commission’s health market inquiry report were made with the aim of providing a better-functioning environment for national health insurance (NHI). According to the report’s executive summary, this is noting that NHI implementation ‘is some years away’ and that the fund proposed in the 2019 NHI Bill is ‘scheduled to be operational by 2026 at the earliest’. The six-year inquiry found the private healthcare sector to be ‘neither efficient nor competitive’ and characterised by low levels of ‘value-based purchasing’, poorly regulated practitioners and accountability ‘failures’ at many levels. In the panel’s view, this has left consumers ‘disempowered and uninformed’ – especially in the prevailing ‘highly concentrated’ funder and facilities markets. The Department of Health is partly to blame, not having used its ‘existing legislated powers’ to conduct the ‘regular reviews … required by law’ and hold regulators ‘sufficiently accountable’.

Key recommendations include establishing a supply-side regulator (among other things to formulate a ‘needs-based system of licensing’); making a standardised, single benefit package a mandatory medical scheme option; introducing a risk adjustment mechanism (among other things involving income cross-subsidisation and disincentivising risk-based competition between medical schemes); and putting in place a ‘reliable outcomes measurement system’ (allowing consumers to compare and select healthcare providers, and funders to contact those offering value for money). In addition, the report calls for changes in the ‘ethical rules’ of the Health Professions Council of SA (to promote ‘innovation in models of care’ that allow for ‘multidisciplinary group practices and alternative care models’, ending the dominance of the fee-for-service payment mechanism); the development of guidelines for health professional associations (‘to ensure that they are not at risk of potentially anti-competitive behaviour’); and compulsory training for undergraduate and postgraduate students on the cost implications of healthcare technology and the impact of health system financing models on patients’ healthcare choices.

While President Cyril Ramaphosa’s remarks at the health sector anti-corruption forum launch this week tended to point to a focus on the plethora of illegal practices bedevilling state-run healthcare institutions, he nevertheless noted the importance of curbing ‘false invoicing, collusion and price fixing’ by private service providers. Also speaking at the launch, Justice & Correctional Services Deputy Minister John Jeffery said the Council for Medical Schemes has estimated that private healthcare system fraud amounts to ‘approximately R22bn annually’. According to Health Minister Zweli Mkhize, ‘over-servicing’ consumers and ‘over-pricing’ products in some markets are the ‘big issues’ requiring attention as his department rolls out NHI (Engineering News).

Meanwhile, the National Assembly’s Health Committee has extended the deadline for written submissions on the NHI Bill by seven weeks – to 29 November. This will allow ‘important’ healthcare delivery stakeholders two weeks more than they requested to prepare input in anticipation of parliamentary hearings likely to be held next year – although no dates have been announced. The decision may have been influenced by recommendations in the Competition Commission report, which committee chair Sibongiseni Dhlomo believes point to the need for government intervention. Public hearings in all nine provinces are scheduled to begin on 25 October in Mpumalanga, followed by the Northern Cape on 1 November.

NHI BILL: PUBLIC PARTICIPATION PROCESS

The thinking behind Parliament’s decision to hold provincial public hearings this year on the National Health Insurance (NHI) Bill has not been clearly communiciated in the mainstream media. A Parliamentary Monitoring Group (PMG) sound recording of the meeting at which National Assembly Health Committee chair Sibongiseni Dhlomo announced what is envisaged confirmed that several stakeholders have already approached the committee for more time to prepare detailed written submissions and, subsequently, to present their views during parliamentary hearings. Given the importance of allowing committee members enough time to study these submissions and others already received, according to Dhlomo it seems likely that parliamentary hearings will only take place next year – possibly also allowing more preparation time for those requiring it.

Meanwhile, members of the general public will air their views during provincial hearings scheduled to begin on 25 October in Mpumalanga . Hearings in the Northern Cape province will follow on 1 November. Although dates for the remaining provinces have yet to be announced, four days have been allocated to each province thus far. According to the PMG recording, Dhlomo believes it is important that committee members have an opportunity to hear first-hand the perspectives, concerns and expectations of ordinary South Africans before considering those of stakeholders with the resources to make more detailed written submissions and travel to Parliament to present them in person.

A presidential health accord signed in July maps out what needs to be accomplished during the next five years if NHI is ever to get off the ground. Among other things, the compact entails ‘engaging the private sector’ on improving healthcare service access, coverage and quality.

NHI NEWS FLASH:

During a meeting of the National Assembly’s Health Committee on 29 August, Department of Health DG Precious Matsoso told members that work has already begun on drafting amendments to Acts likely to be affected when the National Health Insurance Bill becomes law. They are listed in a schedule to the Bill and include the 2003 National Health Act. Last week, in a written reply to questions from the DA’s Mbulelo Bara, Health Minister Zweli Mkhize provided some insights into ‘direct powers’ likely to be ‘allocated’ to provincial governments in amendments to this Act.

Readers are encouraged to bear in mind that:

  1. Any proposed amendments to the Act will need to be released as a draft Bill for public comment;
  2. Once finalised, that Bill will then need to be tabled in Parliament for processing; and
  3. Public hearings will then need to be held in the National Assembly and, as the Bill proceeds through Parliament, also in the NCOP and provincial legislatures.

This is just one example of the extent to which NHI implementation is likely to be postponed until other legislation affected by the NHI Bill has been synchronised with it. Realistically, that cannot be done until the Bill has been finalised and passed by Parliament.

The same will apply to any proposed amendments to the 1998 Medical Schemes Act. Although a draft Medical Schemes Amendment Bill was released in June 2018 for comment, its proposals appear not to be in line with the NHI Bill – tending to imply that it is being reworked and will therefore need to be released again for public input. It will then need to be tabled in Parliament and undergo the same process as any other Bill.

Against that backdrop, the NHI Bill’s passage through Parliament is likely to be long, arduous and fraught. It could take many years, begging the question: Has this has ever been explained to grassroots ANC members and supporters? If the party’s 2019 election manifesto is any indication, probably not.

HOW ‘TRANSPARENT’ WILL THE NHI BILL’S PARLIAMENTARY PROCESS BE?

This article appeared in the 30 August edition of Legalbrief Today, under Policy Watch

An opinion document on the constitutionality of the National Health Insurance (NHI) Bill presented orally to members of the National Assembly’s Health Committee before a briefing from Health Minister Zweli Mkhize was withheld from journalists – despite reportedly having been made available for copying and public circulation well before the meeting. Prepared by the Office of the State Law Adviser and read verbatim to the committee by acting head Ayesha Johaar in the presence of media representatives and health sector stakeholders, the document was only distributed to committee members after lunch, by which time Johaar had left. Her presence at the meeting was apparently requested at surprisingly short notice. When the morning session ended and committee chair Sibongiseni Dhlomo was approached for permission to make copies available to members of the public, he declined – claiming not to have seen or read the document.

Image result for TRANSPARENCY PARLIAMENT SOUTH AFRICA

Why Dhlomo adopted this stance is not clear. Underpinned by provisions in sections 27 and 146(2) of the Constitution, as well as sections 3 and 25 of the 2003 National Health Act, Johaar’s opinion is that the Bill is ‘constitutionally sound’. Section 27(1)(a) of the Constitution makes access to health care services a universal right. Section 146(2) spells out the conditions in which national legislation uniformly applicable ‘to the country as a whole’ prevails over provincial legislation. Section 3 of the Act deals with the responsibilities of the Minister, the national department, provincial departments and local authorities in providing healthcare services. Section 25 sets out the general functions of provincial departments in that context.

A committee media statement issued two days before the briefing – refuting allegations that the Bill had been ‘suspended’ because of concerns about its constitutionality – also noted that, having met ‘one of the state law advisers’ to discuss the matter, Dhlomo was ‘comfortable’ with the advice he received. Johaar is the adviser to whom he was referring. However, widely publicised reservations by some stakeholders about government’s capacity to fund NHI, manage it financially and deliver quality services – not to mention speculation about the future role of medical schemes – may explain Dhlomo’s obvious distrust of media representatives. This is especially given the extent to which some journalists tend to sensationalise issues without scrutinising the documents on which they report. The indignant tone of DA Evelyn Wilson’s input during the meeting probably did little to smooth already ruffled feathers. She has much to learn from party colleagues Siviwe Gwarube and Haseena Ismail, whose equally candid approach was noticeably more deferential.

Against that backdrop, the Minister, his deputy Joe Phaahla, Health Department DG Precious Matsoso, deputy DG Anban Pillay, presidential adviser Olive Shisana, NHI office head Nicholas Crisp and other departmental officials fielded an avalanche of questions about the Bill and NHI in general from the DA, FF Plus MP Philippus van Staden and the EFF’s Naledi Chirwa – but did little to assuage their fears. Neither the model to be used in implementing NHI nor the mix of options available to fund it are cast in stone. However, conceding that government ‘will need to invest strongly’ in improving the standard of public healthcare services and facilities, Mkhize said that, where there is evidence of ‘neglect’ it ‘must be corrected’. ‘We are at such a low level of quality that we will have to fight hard to improve it,’ he told the committee, referring to NHI as a ‘vision’ and an opportunity to ‘up the game’. According to Pillay, the need for ‘robust’ monitoring and evaluation was simply confirmed by the pilot phase.

In the Deputy Minister’s view, while NHI promises to be a ‘disruptive intervention’ – especially for the 15% of citizens able to afford private healthcare – ‘fear of the unknown’ cannot be allowed to prevent government from moving forward with plans to honour not only its constitutional obligations but also binding international commitments. While Phaahla did not elaborate on the role of medical schemes under the NHI system and little was said on the issue, Pillay confirmed that it will be spelled out in regulations. References by Shisana to presidential health compact partnerships and by Crisp to the introduction of NHI as ‘a journey, not an event’ were vague – tending to point to a long road ahead, albeit with ample opportunities for public consultation. Funding proposals will be the focus of a separate draft money Bill.

NHI BILL CONFIRMS LIMITS TO ‘UNIVERSAL’ QUALITY CARE

This article is is based on two that appeared in the 12 and 15 August editions of Legalbrief Today, under Policy Watch

Once in force, the National Health Insurance Bill tabled last week in Parliament is expected to facilitate universal access to ‘needed health care that is of sufficient quality to be effective’ – and ‘financial protection’ from its costs. This is according to a memorandum on the Bill’s objects. However, in expanding on this, clauses 4, 5 and 7 of the Bill (respectively dealing with population coverage, user registration and health care services coverage) point to distinct limitations. Together, sub-clauses 4(4), 5(1) and 7(2)(e) make it very clear that only public and private health care facilities accredited over time by the fund will be available to registered fund users. Registration will not be compulsory. In addition, sub-clause 7(2)(e) requires the fund to ‘enter into contracts with accredited health care service providers and health establishments at primary health care and hospital level based on the health needs of users and in accordance with referral pathways’. This tends to suggest that private health care practitioners and facilities will be able to choose whether to contract in or out of the NHI system – at least at this stage of the process.

Image result for nhi south africa

Regarding the role of medical schemes, clause 33 implies that – in the context of sub-clauses 4(4), 5(1) and 7(2)(e) – ‘once NHI has been fully implemented’ registered fund users who are also members of medical schemes will only be eligible for ‘complementary cover’ for ‘services not reimbursable by the fund’. Furthermore, sub-clause 39(1) clearly states that health care service providers and health establishments accredited by the fund will be required to deliver ‘services at the appropriate level of care to users who are in need and entitled to health care service benefits that have been purchased by the fund on their behalf’. This is noting that, according to sub-clause 57(1)(b), NHI ‘must be gradually phased in using a progressive and programmatic approach based on financial resource availability’.

According to the memorandum on the Bill’s objects, ‘in a favourable economic environment’, ‘new taxation options’ for the fund will be considered. In this regard, the Bill’s clause 49(2) refers to the ‘reallocation of funding for medical scheme tax credits’, ‘employer and employee’ payroll tax and a ‘surcharge on personal income tax’. An assumption on the part of some commentators that all listed options will automatically be factored into the mix could well be misplaced. Writing for Moneyweb, Bowmans tax partner Aneria Bouwer appears to agree. Like the 2015 NHI White Paper, the Bill tends to suggest that specific elements of the combined revenue source are still up for discussion. Meanwhile, the fund will depend on ‘some’ conditional grants being shifted from the Department of Health – as well as ‘some or all’ monies for ‘personal health care services’ traditionally factored into the provincial equitable share formula (clause 49). In this regard, reference is made to moving the national tertiary services grant and the HIV/AIDS and TB grant from the Department of Health into the fund. In appropriating money from the fiscus, Parliament will be guided by the principle of ‘social solidarity’ – which is defined as ‘financial risk pooling to enable cross-subsidisation between … young and … old, rich and … poor, … healthy and sick’.

National Assembly Health Committee chair Sibongiseni Dhlomo has confirmed that work on the Bill will begin with a briefing on its constitutionality from the Office of the State Law Adviser. This is expected to allay concerns expressed by DA leader Mmusi Maimane. The parliamentary process will include public hearings to be conducted separately by the National Assembly, the NCOP and the provincial legislatures.

NEW BILL CONFIRMS NHI VULNERABILITY

This article was published on the Legalbrief website on 8 August, when the Bill was tabled in Parliament. It was not included in that morning ’s edition of Legalbrief Today, which was posted before the Bill became available. A more detailed breakdown of the Bill ’s key provisions will follow next week.

Image result for national health insurance bill

The National Health Insurance (NHI) Bill tabled in Parliament today seeks to provide South Africans with ‘access to needed health care that is of sufficient quality to be effective’, as well as ‘financial protection’ from its costs. According to a memorandum on the Bill’s objects, this is the aim of universal health coverage – as spelled out in the 2015 NHI White Paper. To that end, the Bill provides for the establishment of an NHI fund, setting out its powers, functions and governance structures.

The Bill proposes that – using ‘some’ conditional grants shifted from the Department of Health to the fund as well as ‘some or all’ monies for ‘personal health care services’ traditionally factored into the provincial equitable share formula – the fund will purchase health care services for all registered users. Reference is made specifically to moving the national tertiary services grant and the HIV/AIDS and TB grant from the Department of Health into the fund.

In addition, the fund’s executive authority ‘will bid for funds through the main budget as part of the budget process’. This is noting that, ‘in a favourable economic environment’, ‘new taxation options for the fund’ will be considered and could include either ‘a surcharge on income tax’ or ‘a small payroll tax’. Against that backdrop, it is envisaged that, over time, the fund will ‘expand coverage using certified and accredited public and private sector health facilities’.

In this regard, the memorandum refers to implementing ‘reforms’ in six phases, the first of which is apparently already a work in progress. Its focus is to improve ‘the quality of the health system by … certifying … health facilities to ensure (that) they meet the requirements of the Office of Health Standards Compliance’. The final phase will focus on expanding coverage to accommodate ‘maximum projected utilisation rates’ – and ‘gradually increasing the range of services to which there is a benefit entitlement’.

While the memorandum notes ‘legitimate’ concerns about ‘the affordability and sustainability of NHI’, it offers the assurance that ‘the nature of the proposed system’ and ‘the checks and balances that will be put in place’ will ‘limit unnecessary expenditure increases for supply-side as well as demand-side management’. The success or failure of NHI will be determined largely by the extent to which ‘high quality primary health care services’ ensure that ‘the majority of health problems’ are ‘diagnosed and treated at this level’.

NATIONAL HEALTH INSURANCE: THE BUILDING BLOCKS

This article appeared in the 17 July edition of Legalbrief Today, under Policy Watch

While the yet-to-be-tabled National Health Insurance (NHI) Bill is being processed in Parliament, ‘the structure of the national Department of Health will be reorganised’ and a dedicated NHI implementation unit established. The official version of Health Minister Zweli Mkhize’s recent budget vote speech describes the unit as an ‘embryo’ NHI fund and staff capacity-building platform. Unfortunately, the speech was only published on the department’s website several days after being delivered, which may explain why the mainstream media overlooked so much valuable information provided by the Minister on government plans for preparing public health facilities to implement the long-awaited system. As has been widely reported, Mkhize provided no information on the primary source of revenue for NHI. However, he did refer to a ‘social compact’ on building a health system fit for its implementation. It was one of the outcomes of last October’s presidential health summit.

Mkhize also confirmed that, as the ‘backbone’ of a national electronic health patient record system, a registration system has been developed on which the details of ‘all South Africans’ are expected to have been captured by the end of the 2019/20 financial year. According to the Minister, nearly 43m users have already been registered. With the aim of improving management and governance, within the ‘next six months’ the organograms of all state-run health facilities are expected to have been reviewed and the system of delegating responsibility ‘adjusted to ensure appropriate levels of authority for effective decision making’. In addition, EU funding and bilateral agreements with Japan, the UK and France will be used to ‘build the capacity of managers to implement NHI’. In this regard, Mkhize mentioned ‘twinning arrangements’ also involving ‘academic institutions’.

Conceding that ‘it will be impossible to convince the public about the virtues of NHI unless the health infrastructure is rebuilt as a matter of urgent priority’, the Minister said a ‘team of experts in finance and health … infrastructure’ has been established ‘to seek creative financing mechanisms’ and ‘alternative’ delivery models. According to Mkhize, the team’s ‘clear directive’ is to ‘accelerate the refurbishment of all old hospitals and clinics and deliver new ones within five-to-seven years’. While a ‘significant amount’ has been budgeted for this, in the Minister’s view it is ‘grossly inadequate’. Nevertheless, the ‘entire’ infrastructure build programme has been costed – informed by an audit of all public health facilities. ‘Preliminary indications are that … (it) is feasible,’ the Minister said.

Writing for the Daily Maverick (and drawing from the department’s 2019/20 annual performance plan) the Bhekisisa Centre for Health Journalism’s Laura Gonzalez reported that, initially, it is envisaged that, from 2021, the fund itself will be used to purchase a ‘basic package of services’ from both private and public healthcare providers. Over time, a ‘comprehensive package of services’ will be made available from regional and tertiary hospitals ‘in selected districts’. According to Gonzalez, these services could form the building blocks of ‘a basic medical aid option’ along the lines of one apparently being considered by the Competition Commission ‘as part of its four-year investigation into the private healthcare sector’.