The National Health Insurance Fund will not take the accumulated reserves of medical schemes because these belong to the members and not the schemes, according to a factsheet published by the government.
The factsheet – answers to frequently asked questions about NHI – was published this month on the South African Government News Agency website, a service of the Government Communication and Information System.
The factsheet largely summarises, in layperson’s terms, what is contained in the NHI Bill and what the Minister of Health and the officials in his department have already said about NHI.
The FAQs in factsheet include how NHI will be funded, the accreditation of healthcare providers, the role of the private healthcare sector, the future of medical schemes, how NHI will be funded, and measures to prevent corruption.
Read: Treasury hasn’t done any new work on the cost of NHI – report
The factsheet also perpetuates questionable narratives about the healthcare system. One of the most prevalent is that the poor performance of the public healthcare sector is solely a result of financial constraints. This overlooks that all the provinces are allocated a health budget using the same formula, yet the performance of the public healthcare sector in the Western Cape is far better than that of the other provinces, according to the Health Ombud.
Infant and maternal mortality rates are substantially lower in the Western Cape compared to other provinces.
By 2020/21, the provincial departments of health had incurred medical malpractice liability claims of R120 billion, of which the Western Cape’s share was 0.0005%.
The health department’s Office of Health Standards Compliance assesses public healthcare facilities based on 13 broad metrics. Overall, these facilities have the lowest scores for “leadership and governance” and “operational management”.
Reduced role for medical schemes
The NHI Fund will be implemented in phases and “over many years”, the factsheet says. Regulations will be published to address the phased implementation of the NHI Fund and benefits as money is moved to the fund. Medical schemes will be given notice of the type of services they will no longer be able to cover.
Medical schemes will remain a voluntary arrangement for those who choose to contribute to them, but they will only cover you for any additional benefits for which the NHI Fund does not pay.
The factsheet says the reduction in the benefits covered by schemes should result in members paying lower contributions. Some schemes will be too small to survive, so they will have to merge with others to maintain a viable risk pool for the benefits they may still cover.
Out-of-pocket payments, such as co-payments and user fees, will not be used to generate funding for NHI.
Private providers will be paid on a capitation basis
The factsheet says that “contrary to some public narrative”, NHI will not abolish or do away with the private healthcare sector, and private providers will continue to operate under NHI.
Private health providers will not be forced to contract with the NHI Fund, it says.
Healthcare providers will not be permitted to set their own fees for NHI-funded benefits. The NHI Fund will set the fees it will pay to private doctors, hospitals, and others on users’ behalf.
Primary healthcare providers will be assigned a designated population that will be under their care. They will be paid by the NHI Fund on a capitation basis. “The details are being developed and will include a performance-based portion.”
Private healthcare providers “will benefit from the opportunity to contract with NHI” to provide health services to the broader public, rather than the small proportion for which they currently provide services. “They will be able to provide services to patients throughout the year”, without having to worry that patients have depleted their funds.
Private hospitals will see patients referred by primary healthcare providers in the public and private sectors, and the NHI Fund will settle their bills at the prescribed rates.
Patients who consult with providers who are not contracted with NHI will pay cash for these providers’ services.
Suppliers of health products will remain private companies, the factsheet says. The NHI Fund will determine the range of products that are required to deliver the benefits for which the fund is paying and will set prices for those products that any contracted provider will pay to the suppliers. “The large volumes create certainty for suppliers and help to reduce prices.”
