NHI debate is stuck in the weeds

Dr Brian Ruff, co-founder of PPO Serve

As the Health Market Inquiry (HMI) report makes clear, the large commercial medical schemes are resisting needed reforms that with better productivity would lead to the convergence of the two systems. In particular, they persist with an outdated tariff system that pays for services not outcomes and doesn’t support team-based delivery models. This is probably because it threatens their claim payment and ‘managed care’ role that justifies a very high income. This strategy is counterproductive for their members.

South Africa cannot move forward socially or economically without convergence. We need a high functioning universal healthcare system – which can provide high volumes of quality care at low cost. One that uses all available resources, assigns funding according to need and rewards value (the best outcomes, at the lowest costs) when it is delivered.

The challenge for all stakeholders is how best to transition to such a system – one that places patients at the centre of its model, with service by multidisciplinary teams providing continuous and proactive care. The transition must be compelling and safe for clinicians. It must be an attractive vision, have realistic milestones and pose no threat to clinician income. It must produce a system that is affordable for all South Africans.

The NHI proposition

This is what the NHI proposes to do – it has as its premise the separation of the supply of healthcare from the role of an agency purchasing it, in line with international best practice. Since 2000, medical schemes have been cast in the role of purchaser, but none have taken it beyond pursuing good prices from providers. Instead of actively commissioned new highly productive models, they have overseen rapidly rising premiums. The HMI report vividly describes how schemes have failed their members by not buying overall value for money, despite the reform road being perfectly clear.

The purchaser role put forward by the NHI is the proper one, however – with providers competing for contracts from a large purchaser, based on the value they deliver. It sets out to quickly drive vast improvements in how care is delivered to bring down the cost of comprehensive medical care. It plans for a major shift towards community-based care, instead of today’s hospital plans. It supports widespread multidisciplinary teamwork - a much more effective and cost-efficient model.

Call to action

The NHI is not a move to dismantle the commercial sector – it’s a call to action for much-needed reforms. A commercial sector that offers high value services will provide them for an NHI purchaser, which has no preference for publicly owned, commercial or not-for-profit providers. Made subject to market competition, public sector services will need to tremendously improve their delivery of care or face losing their funding.

We need to acknowledge that, as it currently stands, neither system produces good value, essentially because they are badly structured. They are built around the convenience of clinicians - bringing sick patients to multiple hospitals, clinics or private rooms for care. Doctors are paid and work as individuals, which hinders multidisciplinary input and results in reactive rather than proactive healthcare. Both systems have poor process management, which cannot manage patients with multiple problems. In different ways, both have badly misaligned incentives for the practitioners who work within them.

Healthcare stakeholders must get out of the weeds and stop resisting change by disputing unspecified details of the proposed NHI. We urge stakeholders to rather embrace the NHI as a framework, as a step in the right direction, one that will spur the sector to action, and out of its current stasis.