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SAMA INSIDER The Competition Commission's market inquiry into private healthcare [health market inquiry (HMI)] in SA is taking much longer than expected to reach its conclusion. The HMI began in January 2014, with the overall objective of establishing whether there were barriers to competition in the private healthcare sector. Originally, a final report was anticipated in November 2016. However, the complexity of engaging with the private sector, and the multiple issues the inquiry has faced, have resulted in several delays. The latest delay occurred when the inquiry ran out of funds towards the end of the last financial year, and activities planned for early 2019 had to be delayed. The Competition Commission announced in February that the inquiry is set to start up again in the 2019 2020 financial year, and will be completed by November 2019. The HMI's provisional report was published last July, inviting comments by the end of October. This was at more or less the same time as the revised National Health Insurance (NHI) white paper and the Medical Schemes Amendment Bill were published for comment. Many readers might have attended one of the workshops that SAMA organised in August in order for membership to interrogate and contribute comments to all of these important policy documents. SAMA's comments on the HMI report were submitted in September 2018, and we are continuing to engage with the HMI processes to make sure that interpretation and concerns about the provisional report are adequately considered. HMI findings relevant to practitioners The HMI panel, composed in the main of health economists and public health specialists, identified many issues in private healthcare that they believe are distorting pricing to the users and negatively affecting the services provided and the clinical outcomes achieved. The provisional report has criticisms to level at all participants in private healthcare, from patients to practitioners to medical schemes, and the regulatory bodies themselves. Of most concern from SAMA's point of view are the findings about practitioners, and the recommendations to potentially address these. The HMI found that medical practitioners drive much of the healthcare expenditure in the private sector, and that societies and associations aim to ensure that practitioners are well remunerated, in addition to other activities. The main problem identified by the HMI in this regard is "supply induced demand', a phenomenon whereby the supply of services creates demand for these services. These findings were supported by a number of analyses of claims data that showed unexplained increases in claims and claims expenditure between 2010 and 2014. The HMI also found that specialists "sometimes operate collectively to resist joining provider networks, and introduce or adapt codes that push up prices without commensurate improvement in quality of care or value." The HMI panel determined that fee-for-service models of remuneration stimulate oversupply of services, which results in wasteful expenditure and incentivises practitioners to provide more services than needed. The panel also found that a weakness in the private sector is lack of accountability on the part of practitioners, with little emphasis on interventions such as case review, peer review and morbidity and mortality meetings. In addition, they declared that academia has also shown little leadership in driving evidence based practice in the private sector. Increased admission to hospital, increased length of patient stay, higher levels of care and greater intensity of care have all manifested, and seemingly cannot be explained by the disease burden in the population. The HPCSA also came under scrutiny, and the HMI found that the regulator is cited as the reason that innovative models of care and alternative reimbursement models have been difficult to implement in the private sector. The HMI concluded that the HPCSA is not sensitive to the benefits of competition in creating incentives for affordable and quality care. SAMA's submission to the HMI SAMA has been a committed participant in the Competition Commission processes from the start of the inquiry, and we have responded to multiple calls for comment and participated in a number of seminars and stakeholder sessions called by the HMI to address specific aspects of competition in the private health sector. SAMA believes that the findings of the inquiry, the first to truly try to interrogate the situation in private healthcare, will be key to the future of the whole health system in the country, including considerations around the implementation of NHI and the proposed single payer monopoly which has been proposed for this purpose. Actually demonstrating market distortion within patterns provided by claims data has proven difficult. In response to the provisional report, SAMA was concerned that the HMI had used the technical services of data analytics firms who serve the medical schemes environment, and whose client base is predominantly medical schemes and medical scheme administrators. We believe that this may unfortunately have introduced an element of bias into the analyses produced by the HMI. SAMA was also able to identify a number of faults in the way the data was analysed and interpreted. The models used fail to adequately consider changes in disease burden and developments in technology, and models for specific disciplines generally lack an understanding of the environment, epidemiology, dynamics and developments in the fields assessed. Where comparisons were made indicating patterns of higher hospital admission rates in the SA private sector than in other countries, we feel these were conducted without consideration of such key factors as local disease burden, patient waiting times, facility availability and balance of funding public and private in other jurisdictions. SAMA is concerned that the analyses that have supposedly proven the existence of overservicing, supply-induced demand and unsubstantiated increases in care intensity have not been conducted with due attention to detail on the local issues, new technology, available and burden of disease. Full stakeholder comments submitted in response to the HMI report were made public in December 2018, and after son significant reading, we have found sever areas where our concerns regarding the HMI analyses are shared by specialist societi and several actuarial analyses. When the HMI commences again this month, SAMA hopes that attention will fall on some of the challenges in the provisional report, and that some reviews may be triggered so that the findings and recommendations are based on a solid set of data analyses. Shelley McGee, health policy researcher, SAMA Knowledge Management and Research Department
Created at 2019/04/16 08:51 AM by Mediclinic
Last modified at 2019/04/16 08:51 AM by Mediclinic