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Towards a Unified No-Balance Billing Payment System: Insights and Models for Healthcare

This document discusses the move toward a single no-balance billing payment system in healthcare, emphasizing affordability and quality of care. It covers historical context, regulatory frameworks, and models from South Africa, Belgium, and Australia. The text highlights issues like remuneration, the unbundling of RAMS, and statutory provisions for fee negotiations. It outlines the advantages and disadvantages of various models, examining their implications for healthcare accessibility, efficiency, and budgeting in the industry. It also addresses potential challenges and future considerations in implementing such a system.

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Towards a Unified No-Balance Billing Payment System: Insights and Models for Healthcare

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  1. Towards a single “no balance billing” payment system Rajesh Patel Jhb June 2007

  2. BHF board mandate • Affordability • Quality of care • …

  3. Benefit History • 2001 • Regulated minimum benefit entitlement • At cost • No co-pay….

  4. Remunerations • Unbundling of RAMS • Competition Commissioner actions • HPCSA ethical fees • Surgicom; Spesnet and its actions • Cost escalations • Funders as price takers

  5. Regulated SOB Negotiated SOB Reference price ???? SAMA; SADA rate HPCSA ethical fees Tariff history

  6. Regulated Negotiated RAP Reference

  7. Considerations • Statutory provision for a no balance billing fee • Schemes can negotiate a lower fee

  8. Remuneration determination Models • SA model • Belgium model • Australian model • Hybrid model

  9. Advantages of statutory maximum fee • Affordability • Expansion of minimum mandatory benefit • Rationalisation of plans • Can include assessment of healthcare needs

  10. Belgium model • Bargaining council model • If no agreement, Minister decides • 7 year – no Minister’s intervention • Advantage • Agreed fee by all parties • Disadvantage • Inefficiency may be entrenched

  11. Australian model Coding centre Federal Government MBS fees Fees centre Disadvantage: coding development for National Health benefits

  12. Hybrid model Sufficiently representative provider group No Certification criteria met? Yes Centralised bargaining process Consideration for Certification by MOH Ministerial determination Publication in Gazette of no balance-billing tariffs Yes Sufficiently representative funder group Appeal process (limited to subsequent process) Agreement? ICU No

  13. Certification criteria and statutory powers • Statutory “TOR” • Include budget impact, Inflation… • Representivity • Powers of the Minister • …

  14. Timelines • Code structure settlement • Price settlement • Ministerial determination • Consider • Technology assessment • REF time lines

  15. Questions?

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