Healthcare sector should adopt improved provider reimbursement models, says BHF


Recent calls by the Health Professions Council of SA (HPCSA) to its members not to enter into agreements with medical schemes, specifically on Global Fees and similar arrangements, have raised an important discourse across the healthcare funding industry, says the Board of Healthcare Funders of Southern African (BHF).

The body supports the NHI policy direction and refers to the green and white papers that emphase the adoption of alternative reimbursement models. In this context, global fees are important tools in the achievement of accountable and affordable healthcare, and the establishment of guidelines for the implementation of such alternative reimbursement models is vital, explains the BHF.

“When you consider the private sector will play an important role in National Health Insurance (NHI) delivery and can help SA’s NHI leapfrog many of the challenges experienced in other geographies, the need for new models of reimbursement that drive quality outcomes and not utilisation is crucial,” according to the BHF.

The implementation and adoption of alternative models of provider reimbursement are crucial to the sustainability of the healthcare sector, the BHF stresses. “South African consumers have faced unavoidable medical scheme tariff increases far beyond inflation and as a result, an erosion of benefits for the past decade.

“Relevant healthcare stakeholders need to find common ground and collaborate through mature leadership on the issues of spiraling benefit utilisation and costs, finding agreeable ways to reimburse providers that are premised on quality outcomes for patients, transparency and accountability for patient outcomes by providers,” says Dr Ali Hamdulay, chairperson of BHF.

Alternative models 

Alternative reimbursement models such as global fee models provide a single payment to a healthcare team to cover all the tests, procedures, drugs, devices and rehabilitation needed for a patient’s condition and are premised on accountability for the quality of care provided by each team member— a vastly different approach to the current fee-for-service model.

The BHF has emphasised it’s not about imposing models on healthcare providers, and that it’s essential that funders and healthcare providers work collaboratively to find the right reimbursement models that work towards better managing risks and costs, serve the interests of the patient and the health professional’s ability to act in the best interests of the patient.

“The alternative reimbursement models also stimulate the creation of centres of excellence by increasing competition and accountability between healthcare providers – teams with consistently better healthcare outcomes are likely to receive more patient referrals from schemes based on quality outcomes.  This will also have the effect of driving more competition between healthcare providers, which in turn drives better outcomes, and which will have the effect of improving pricing as well. All of this ultimately equates to the best care and outcome for the patient and medical scheme member,” explains Hamdulay.

The BHF adds that the concerns raised by healthcare providers that global fee models will create an environment of “under-servicing”, which compromises patients are moot. “Within such a model, there is little room to under-service since the focus is on outcomes and most crucially, an increased demand for accountability by the healthcare provider for such outcomes.  Essentially a global fees arrangement paves the way for schemes to contract with specific suppliers because they offer the best quality, transparency and outcome, and not the lowest fee,” explains Hamdulay.

Ultimately, how the reimbursement models of the future are built is important, and this must be done collaboratively, he explains. “We have strong leadership in the healthcare sector, but what we need is stronger leadership that is pulling towards what should be our shared objectives – patient care and quality healthcare outcomes. If we can collaboratively solve these challenges with funders, specialists, and patient advocacy groups, we can work towards creating models that represent fair outcomes for all parties and solve some very real and fundamental challenges in the private healthcare industry.”

The interconnected nature of the healthcare supply chain emphasises the need for a strategic approach that involves all role players to find a way to standardise benefits in a manner in which we can measure the quality and cost of care, and in turn use the outcomes data to better define the future healthcare model for the country and all South Africans, Hamdulay explains.