NHIA holds stakeholder forum on capitation (Graphic Business)

THE National Health Insurance Authority (NHIA) is to pilot what it terms a per capita provider payment system as part of a process of improving payment systems under the National Health Insurance Scheme (NHIS).
The per capita payment method, when it begins will only be used for primary care - non specialist out-patient’s services. Specialist referral and in-patient care will continue to be paid for by using the already existing Ghana Diagnostic Related Groups (G-DRG) with the fee for service and medicines payment method.
The proposed per capita payments, which is also referred to as capitation or money per person per period, involves advance payments to primary care service providers of a calculated and agreed amount of money per client per period.
The amount transferred is calculated based on prior research into utilisation rates and costs projected over a period of time and subject to periodic reviews and adjustments.
To ensure success of the project, a forum on the capitation proposals for major stakeholders in the NHIS has taken place at the National Insurance Commission (NIC) in Accra. It was attended by delegates from the Community Practice Pharmacists Association, Private Medical and Dental Practitioners Association, and Private Midwives and Maternity Homes Association.
The forum was to provide an opportunity for the stakeholders to review, question, and provide constructive suggestions on the proposals before they were finalised, piloted and evaluated.
The Greater Accra Regional Director of Health Services, Professor Irene Agyepong, who is also chair of the Provider Payment Systems Reform Committee, outlined the reform objectives and explained the merits of the proposals to the participants.
She said the use of per capita payments for primary care under the NHIS is being proposed to address some of the observed shortcomings of the current provider payment system.
Under the current system, payment for services provided to National Health Insurance clients at all levels is done after service is provided. The payments are based on claims submitted by service providers using the G-DRG rates for services and Fee for Service (FFS) for medicines.
Capitation is expected to achieve the following:
* Improve cost containment
* Control cost escalation by sharing financial risk between schemes, providers and subscribers
* Introduce managed competition for providers and choice for patients as a way of increasing the responsiveness of the health system.
* Improve efficiency through more rational use of resources.
* Correct some imbalances created by the Ghana Drug Related Groupings (G-DRG) such as OPD supplier-induced demand where clients may be requested to make unnecessary visits because they are a condition for reimbursement under the DRG
* Simplify claims processing
* Address difficulties in forecasting and budgeting
Under the capitation proposals being developed indicated that each National Health Insurance subscriber would indicate his preferred primary-care provider (PPP). The choice of preferred primary-care provider by the subscriber will be voluntary. The preferred primary care service provider takes on the responsibility of managing the primary healthcare needs of the clients, including assisting them to adopt better lifestyles and other preventive measures to stay healthy.
On a monthly basis, an agreed amount of money would be advanced to the selected PPP on behalf of the client to provide for the agreed primary health care needs. It is expected that under capitation portability will be maintained. Every six months a subscriber could switch from one provider to another and payments will be redirected accordingly.
It came `out during the meeting that portability would still be practised but with clear regulations, guidelines and procedures. Subscribers can change their preferred primary-care provider (PPP) if they want to, for example if they were not satisfied with the services provided, or if they had moved and want a PPP nearer to them.
However, is was explained that such routine changes of PPP could only be done every six months but if not controlled, the administrative burden of more frequent changes of PPP on a routine basis will be unmanageable. However, in special or exceptional cases, such as a subscriber moving permanently to a totally different district or region, arrangements could be made to change the PPP in-between the six months period. In such non-emergency cases, the scheme will have to be notified for the subscriber to be temporarily attached to a facility. In all emergency cases, subscribers can be treated by the nearest qualified service provider and reimbursement will be done using G-DRG, and FFS for medicines.
It is clear that since capitation ties a subscriber down to one service provider for at least six months, it would eliminate the situation where a subscriber could visit three different service providers within a short period of time, sometimes as short as a day or two and obtain three different sets of medicines or services for the same condition.
Under the proposals, tariffs for services and medicines for primary care will be combined under a single capitated payment.
A model of group practice where prescribers, dispensers and laboratories work together as a PPP was discussed at the forum and providers were asked to seriously consider the possibilities under such a proposal. Being part of a group PPP would also be a viable option for physicians who want to do office practice part-time rather than provide comprehensive primary care services full-time.
The chief executive of the NHIA, Mr Sylvester Mensah, reiterated the advantages of capitation and the possibilities for using the provider competition generated by open enrolment of clients as a lever for improvements in quality of care.