Healthcare Financing Flashcards
Health
A state of complete physical, mental and social well-being.
Not just the absence of disease.
Department of Health’s “Ten Point Plan”
- Providing strategic leadership and the creation of a social compact for better health outcomes
- Implementing National Health Insurance (NHI)
- Improving quality of health services
- Overhauling the health care system and improving its management
- Improving human resource planning, development and management
- Revitalising infrastructure
- Accelerating the implementation of the HIV/AIDS and STI National strategic plan
- Implementing mass mobilisation for better health among the population
- Reviewing the Drug Policy
- Strengthening research and development.
Two major classes of health products on offer in SA
- Medical schemes
- Health insurance
Medical schemes
Indemnity business. Medical schemes reimburse their members for actual expenditure on health. Run on a not-for-profit basis and are essentially mutual societies, owned by their members.
Health Insurance
Provided by short-term insurances and life offices.
The products were controversial and many designs have become illegal.
It now covers insurance products such as long term sickness, critical illness and disability cover.
Healthcare expenditure spread in SA
Currently estimated at R108 billion, equivalent to 7,7% of GDP.
- 60% flows to private intermediaries
- 40% flows through the public sector
Healthcare delivery in SA
- About 16-17% of the population are served by medical schemes.
- About 20% of the population are not covered by medical schemes but prefer to use private primary care doctors and pharmacies on an out-of-pocket basis. They are almost entirely dependent on the public sector for specialist and hospital care.
- The remaining 64% are dependent on the public sector.
A Medical Scheme according to the Medical Schemes Act of 1998
The business of undertaking liability in return for a premium or contribution in order to:
- Make provision for obtaining any “relevant service”
- Or in order to grant assistance in defraying expenditure on a health service
- Or to render a relevant health service, directly or by agreement with the medical scheme.
Define “relevant health service” under the medical scheme definition
- Examination, diagnosis, treatment, prevention or advice
- Prescription or supply of medicine, appliance or apparatus
- Ambulance service, accommodation in hospital, maternity or nursing home
- For a physical or mental defect, illness, deficiency or pregnancy.
Minimum amount of members for a med. scheme
6000 members
Explain how a medical scheme is a “not-for-profit” fund
The fund is built up from contributions by the members. The money in the fund belongs to the members. In addition to payments directly relating to the provision of healthcare for members, medical schemes will also have to pay an administrator.
Medical scheme administrator
Responsible for the daily running of the scheme, processing claims and making payments to healthcare providers.
3 forms of Medical scheme management
- Board of trustees
- Council for Medical Schemes
- Registrar of Medical Schemes
Board of Trustees
Each medical scheme is managed by a board of trustees, of which at least 50% are fund members.
The board must ensure that the interests of beneficiaries are protected at all times.
Council for Medical Schemes
Appointed by the Minister of Health.
- Oversees the activities of medical schemes
- Aims to protect the interests of beneficiaries and controls/co-ordinates the activities of schemes accordingly.
- Measures quality, collects information on private healthcare and advises the Minister.
The Registrar of Medical Schemes
The Chief Executive Officer of the Council for Medical Schemes and is also appointed by the Minister.
The Registrar has the power to specify steps to ensure the financial soundness of medical schemes and can direct schemes to ammend their rules or in sever cases put the scheme under curatorship.
Restricted membership schemes
Medical schemes, which are allowed to restrict who may be come a member.
Definitions of restricted membership
- Employment in profession, trade, industry or calling
- Employment or former employment by particular employer, class of employers
- Membership or former membership of profession, professional association or union.