national health insurance - uhc 29 september 2014 anban pillay deputy director general national...
TRANSCRIPT
National Health Insurance - UHC
29 SEPTEMBER 2014
Anban PillayDeputy Director General
National Department of HealthSouth Africa
Designing and Managing Medicines Benefits
Outline of presentation• Why NHI for South Africa• Designing the benefit• Selection of the medicine• Procurement design• Market Intelligence• Cost estimates• Drug supply management• Reimbursement of dispensers• Copayments
WHY NATIONAL HEALTH INSURANCE FOR SOUTH AFRICA
LIST OF GINI-COEFFIECIENTS FOR DIFFERENCT COUNTRIES, LATEST WORLD BANK DATABASE
2000 to 2009
South Africa South Africa (2006) 67 2006
Seychelles Seychelles (2007) 66 2007
Comoros Islands Comoros (2004) 64 2004
Micronesia, Fed. Sts. Micronesia, Fed. Sts. (2000) 61 2000
Haiti Haiti (2001) 60 2001
Angola Angola (2000) 59 2000
Honduras Honduras (2007) 58 2007
Colombia Colombia (2006) 58 2006
Bolivia Bolivia (2007) 57 2007
Central African Republic Central African Republic (2008) 56 2008
Guatemala Guatemala (2006) 54 2006
Brazil Brazil (2009) 54 2009
Rwanda Rwanda (2005) 53 2005
Lesotho Lesotho (2003) 53 2003
Nicaragua Nicaragua (2005) 52 2005
Mexico Mexico (2008) 52 2008
Chile Chile (2009) 52 2009
Panama Panama (2009) 52 2009
5
Health Status of South Africans
Distribution of health care resources between public and private sectors
ItemPrivate
sectorPublic
sector
Population per general doctor (243) 588* 4,193
Population per specialist 470 10,811
Population per nurse 102 616
Population per pharmacist (765) 1,852* 22,879
Population per hospital bed 194 399
Results – strong preference for medicines
9
Flow of NHI Funds
National Treasury
SARS
Designing the benefit• Defined list of conditions funded through UHC
if positive list. • Standard treatment guidelines for defined list
of conditions/ common conditions.• Guidelines should define disease severity and
the levels at which this should be managed.• Medicines should be linked to this clinical
guideline - formulary• Clear eligibility criteria for access to restricted
medicines
Selection of Medicines
• Burden of Disease
• Effectiveness
• Safety
• Quality
• Appropriateness
Strategy for medicines not on formulary
• Establish a central fund that manages access to restricted medicines. These may be high cost medicines or restricted use in public health interest.
• Clear criteria for access to such medicines through a transparent evaluation process.
Procurement design
• Options – tender process vs prequalified list of products.
• There are pros and cons to both approaches.• Tenders –
– Pros: likely to achieve a much lower price than pre qual given price vol arrangement.
– Cons: lock out other competitors for a period which may be detrimental to competition, where a supplier is unable to deliver then no alternative supplier immediately available – supply interruptions
Procurement design
• Prequalification list– pros: greater likelihood of maintaining
competition between suppliers; greater patient choice – usually more than 1 item per category.
– Cons: prices are usually higher since no exclusivity; risk of lower priced medicine being dispensed and higher priced item billed to fund
Market Intelligence• How many suppliers are registered to sell a
medicine in the market?• Where are they sourcing the product from?
Same source of base chemicals, API, formulation?
• What is the production capacity of the supplier?
• Importers – T/Cs of agreement with supplier.
Cost estimates
• Estimate likely medicine consumption over the period.
• Explore price volume arrangements with suppliers in the face of volume uncertainty
• Manage the risk of currency fluctuation and changes in the input costs that may affect suppliers
Drug supply management• Drug availability at facility level is as important as
procurement. Procurement strategy must appreciate the risk of stockouts and mitigate against this risk.
• An early warning system regarding medicine non availability should be linked to the procurement system.
• Integration between supplier procurement agreement and dispensing agreement.
• Rebates and discounts to wholesalers and dispensers may lead to inappropriate dispensing and higher costs.
Reimbursement of dispensers Options available: FFS, case based
reimbursement or capitationFFS- risk of overservicing, no incentive not to
dispense medicine, rewards process rather than outcomes
Case based – less incentive to overservice, no incentive not to dispense, some opportunity to reward outcomes.
Capitation – no incentive to overservice, risk of under servicing, can reward outcomes rather than process
Copayments• Difference in cost between reimbursed price vs.
product price. Reimbursed price is usually a maximum.• Reimbursed price must be related to lowest prices in
the market. • Why should manufacturer price be lower than the
maximum reimbursed price?• Where the patient elects to take the originator when a
lower priced generic exists – does the patient pay a copay for the orginator? What is the impact of this on the generic?
THANK YOU
Designing and Managing Medicines Benefits