possible provider payment mechanisms for south africa

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

possible provider payment mechanisms for south africa

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