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growing stronger & healthier STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE SCHEME APRIL 2012 HEALTH SUMMIT National Health Insurance Authority 1 APRIL 2012 HEALTH SUMMIT

STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

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Page 1: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

STRATEGIES TO SUSTAIN THE NATIONAL

HEALTH INSURANCE SCHEME

APRIL 2012 HEALTH SUMMIT

National Health Insurance Authority

1 APRIL 2012 HEALTH SUMMIT

Page 2: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

OUTLINE OF PRESENTATION

Membership Distribution by Category

NHIS Income and Expenditure Trend

Fund Management

Consolidated Premium Account

Cost Containment Measures

Call Centre

Way Forward

2 APRIL 2012 HEALTH SUMMIT

Page 3: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

MEMBERSHIP BY CATEGORY 2010

APRIL 2012 HEALTH SUMMIT 3

Under 18 years 3,894,782

70 years & above 439,349

Indigents 117,295

SSNIT contributors

386,249

SSNIT pensioners

32,136

Pregnant women 701,015

Informal sector 2,592,888

Page 4: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

MEMBERSHIP BY CATEGORY 2011 (provisional)

APRIL 2012 HEALTH SUMMIT 4

Children (under 18), 3,959,802

Informal, 2,638,585

Aged (over 70), 446,684

Pregnant women, 712,718

SSNIT contributors,

392,697

SSNIT pensioners,

32,672

Indigents, 219,555

Page 5: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

Page 6: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

Page 7: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

(200.00)

(100.00)

0.00

100.00

200.00

300.00

400.00

500.00

600.00

700.00

800.00

2007 2008 2009 2010 2011

Income Expenditure Surplus/Deficit

Am

ou

nt

(GH

¢ M

illio

n)

TREND OF NHIS INCOME & EXPENDITURE 2007 –2011)

7 APRIL 2012 HEALTH SUMMIT

Page 8: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

FUND INVESTMENT VALUE

337.41 322.45

258.87 253.91 245.01

291.41

318.42

247.71

163.38

0

50

100

150

200

250

300

350

400

AS AT31/12/1999

1STQUARTER

2010

2NDQUARTER

2010

3RDQUARTER

2010

4THQUARTER

2010

1STQUARTER

2011

2NDQUARTER

2011

3RDQUARTER

2011

4THQUARTER

2011

Am

ou

nt

(GH

¢’m

)

Page 9: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

INVESTMENT PORTFOLIO RETURNS

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

2011 2010

13.63% 21.01%

8.73%

10.75% 4.50%

9.27%

Ra

te

Nominal Return Average Inflation Rate Real Rate of Return

Fisher's Formula: Real Rate of Return = [(1+Nominal Return)/(1+Average Inflation Rate)-1]

Page 10: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

Consolidated Premium Account

It is a centralized bank account into which premiums collected by the Schemes across the country are deposited

It was implemented in January 1, 2011

To ensure that premiums collected are:

– Properly accounted for

– Comprehensively Reported

– Adequately monitored & Controlled

– Reduce abuse/leakage

– Efficient use of premium income

APRIL 2012 HEALTH SUMMIT 10

Page 11: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

COST CONTAINMENT MEASURES

CAPITATION

LINKING DIAGNOSES TO TREATMENT

ELECTRONIC CLAIMS PROCESSING

CLINICAL AUDIT

APRIL 2012 HEALTH SUMMIT 11

Page 12: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

CAPITATION

Capitation is defined as a pre-determined fixed rate paid to Providers to offer a defined set of services for each individual enrolled with the provider for a fixed period of time.

Capitation is being piloted for basic walk-in outpatient services only. Outpatient specialty services and inpatient services will be reimbursed under the G-DRG.

APRIL 2012 HEALTH SUMMIT 12

Page 13: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

OBJECTIVES OF CAPITATION

Improve financial efficiency

Share risks among schemes, providers and subscribers

Improve efficiency and effectiveness of health services through more rational resource use

Correct some imbalances created by the G-DRG (e.g. OPD supplier-induced demand); supply-side and demand-side moral hazard

Simplify claims processing

Address difficulties in forecasting and budgeting

13 APRIL 2012 HEALTH SUMMIT

Page 14: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

ENROLMENT OF ACTIVE SUBSCRIBERS TO PREFERRED PRIMARY PROVIDER (PPP)

Active members as of 30th March 2012 1,614,731

Active members enrolled 987,485

% enrolled (active) to total active

members 61.2%

Active members not enrolled and

distributed as “blanks” 627,246

14 APRIL 2012 HEALTH SUMMIT

Page 15: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

IMPLEMENTATION CHALLENGES

Inclusion of medicines in the capitation basket would disadvantage community practice pharmacies

Lack of enforcement of separation of services by prescriber and dispenser could affect quality of care

Complaints about low per capita rates

Region has not achieved initial target of 80% PPP enrollment

Inclusion of maternal care (antenatal, delivery, postnatal)

Education has been inadequate, especially in the sub-metros of Kumasi

Co-payment for services and medicines

15 APRIL 2012 HEALTH SUMMIT

Page 16: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

ACTIONS TAKEN ON IMPLEMENTATION CHALLENGES

Per capita rate revised upwards

Maternal services removed from capitation basket

Medicines removed from capitation basket

Enhanced engagement of Stakeholders

Intensified media campaign and community durbars

Setting up enrollment teams and enrollment points and effectively advertising them

Enrollment officers located at community level (going directly to households)

16 APRIL 2012 HEALTH SUMMIT

Page 17: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

LINKING DIAGNOSES TO TREATMENT JUSTIFICATION

– Non compliance to national Standard Treatment Guidelines (STGs) and NHIS Medicine list

– Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines

– Some providers are prescribing medicines simply because they are on the NHIS Medicines List.

OBJECTIVES

– Improve efficiency in claims processing

– To make claims vetting easier and simple

– Improve quality of care

17 APRIL 2012 HEALTH SUMMIT

Page 18: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

ELECTRONIC CLAIMS PROCESSING JUSTIFICATION

– To inject speed and accuracy into claims processing

– Easy access to claims data for analysis

ACTION

– Implementation of the e-claims solution to begin by end of August 2012

18 APRIL 2012 HEALTH SUMMIT

Page 19: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

REASONS FOR CLINICAL AUDIT

Improves the quality of service being offered to subscribers

Identifies and promotes good practice

Provides information on cost-effectiveness

Ensures efficient use of resources

CLINICAL AUDIT - BACKGROUND

Page 20: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

KEY FINDINGS

• Using wrong accreditation status to bill

• Up-coding of tariffs

• Wrong tariff, bundled & unbundled

• Providing services above accreditation level

• Non-adherence to NHIS Benefit Package

Services

• Insertion/substitution of medicines

• Inflation of quantities of medicines

• Irrational prescribing

• Over billing of medicines

• Billing outside the medicines list

Medicines

• Co-payment

• No record of attendance

• Inadequate record-keeping

• Inadequate human resource Others

Page 21: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

KEY FINDINGS Total Cost Retrieval according to Regions

-

50,000,000.00

100,000,000.00

150,000,000.00

200,000,000.00

250,000,000.00

195,087,963.52

18,950,098.65

COST RETRIEVAL( 2010 & 2011) - AUDITED FACILITIES

CLAIMS PAID CAD DEDUCTION

214,038,062.17

9.71% leakages

21 APRIL 2012 HEALTH SUMMIT

Page 22: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

OBJECTIVES

Increase cost containment and Quality of Care measures and Decrease Fraud and Abuse – Greater the Sustainability of NHIS and Providers

Cost Containment

Measures

Cost Effectiveness

Decreasing Fraud and

Abuse

Quality of Care

Sustainability of NHIS and

Providers

Page 23: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

CALL CENTRE - OBJECTIVES

Build stronger relationships with stakeholders

Provide quick solutions to subscribers’ needs

Respond to stakeholder queries

Ensure proper handling of complaints

Solicit feedback for strategy development

Opportunity for reporting abuse (co-payment, provider shopping, etc.)

23 APRIL 2012 HEALTH SUMMIT

Page 24: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

CALL CENTRE NUMBERS

The number for all subscribers to call is 054 444 6447.

MTN and Vodafone subscribers can also access the call centre via short code 6447 (NHIS)

24 APRIL 2012 HEALTH SUMMIT

Page 25: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

THE WAY FORWARD –Financial Management

Continuous dialogue with MOFEP for timely releases and additional inflows.

Intensification of prudent investment portfolio management for optimal returns.

Page 26: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

WAY FORWARD - CAPITATION

Continue engagement with stakeholders

Increase PPP enrolment to 80%

Intensify public education

Strengthen M&E

Scale up nation-wide education on PPP enrolment

Scale up nation-wide enrollment to PPP by end of year 2012 as a platform for a national rollout in January 2013

26 APRIL 2012 HEALTH SUMMIT

Page 27: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

WAY FORWARD – COST CONTAINMENT

Complete CPC Implementation

Set up of second CPC

Improve ICT infrastructure & membership management

Nation-wide PPP enrolment

Enforce Gatekeeper/Prescribing Levels

Implement the new MOH prescription form

Intensify Clinical Audit

Enhance administrative efficiency

Sustain stakeholder engagement

APRIL 2012 HEALTH SUMMIT 27

Page 28: STRATEGIES TO SUSTAIN THE NATIONAL HEALTH INSURANCE … · –Evidence of irrational prescribing and poly-pharmacy. 53% of claims cost due to medicines –Some providers are prescribing

growing stronger & healthier

Thank You

28 APRIL 2012 HEALTH SUMMIT