Post on 15-Jan-2016
description
CMS STRATEGIC PLAN, ANNUAL PERFORMANCE PLAN AND BUDGET
Portfolio Committee on Health20 March 2013
INTRODUCTION OF THE CMS CHAIRPERSON, PROF Y VERIAVA AND DELEGATION BY THE REGISTRAR & CEO, DR MONWABISI GANTSHO
2
FEEDBACK FROM PREVIOUS INTERACTIONS WITH THE HPC
3
• In the past, we have responded to formal questions from HPC in relation to tenders , the asset register, payment of creditors, annual report costs, private hospital costs, market consolidation, non-healthcare expenditure and other policy related questions
• MoH has indicated his full support for our 2013/14 plans, and has requested the MoF to concur
• The medical aid industry in SA has experienced increase in contributions alone from R30.6bil in year 2000 to about R110bil in 2012/13.
4
Contents
• Discuss challenges to our strategic goals and present the actions we undertake to protect the goals
• Discuss the proposed budget required to ensure that we continue to discharge our mandate– Strategist will present strategic challenges and our
responses, including proposed amendments to the Act
– CFO will present the budget
5
CMS strategic goals• Goal 1
– Access to good quality medical scheme cover is maximized• Goal 2
– Medical schemes are properly governed, are responsive to the environment, and beneficiaries are informed and protected
• Goal 3– CMS is responsive to the needs of the environment by being an
effective and efficient organisation• Goal 4
– CMS provides influential strategic advice and support for the development and implementation of strategic health policy, including support to the NHI development process
6
SITUATION ANALYSIS AND STRATEGIC RESPONSE IN RELATION TO STRATEGIC GOALS
STRATEGIST
7
Access to schemes
1
Medical schemes
2
Regulator
3
Strategic review
4
CMS strategic goals
8
GOAL 1: ACCESS TO GOOD QUALITY MEDICAL SCHEME COVER IS MAXIMISED
9
…membership growth is faster than employment
growth…
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012Restrictedschemes 1,983 1,953 1,907 1,930 2,077 2,527 2,986 3,253 3,516 3,766 3,924
Openschemes 4,731 4,719 4,755 4,906 5,050 4,951 4,889 4,815 4,800 4,760 4,759
Total 6,714 6,672 6,663 6,836 7,127 7,478 7,875 8,069 8,316 8,526 8,684
0
1 000
2 000
3 000
4 000
5 000
6 000
7 000
8 000
9 000
10 000
Beneficiaries(Thousands)
10
…to benefit, access is required…
11
IncomeIncomeCostCost
Affordability
...access to medical schemes must be fair, and
non-discriminatory
Risk PoolingRisk Pooling
Mandatory coverMandatory cover
Risk adjustmentRisk adjustment
Community ratingCommunity rating
Benefit coverage
Benefit coverage
Open enrollment
Open enrollment
12
THREATS TO FAIR AND NON-DISCRIMINATORY ACCESS
13
…the difference in scheme risk profiles have worsened over the
past two years, leaving more than a million beneficiaries
vulnerable…
14
…unfettered growth in short-term, for-profit, risk rated and
restricted access insurance products undermine risk pools…
• Through risk rating, restricted enrolment, and no minimum benefits, GAP cover, and other short term insurance products erode the cross subsidisation from young & healthy to sick & old
15
…continued opposition to the “payment in full” provisions in
the PMB regulations could leave members vulnerable…
• Some schemes challenge the “payment in full provisions” in the regulations and– Cover PMBs (270 +25) only in terms of scheme
rules– Managed care interventions
16
…enrollment provisions are challenged more and
more…• Discovery has refused to accept Transmed
members, in spite of a ruling by the Registrar and Council, matter will be heard by the appeal board soon.
• GEMS has appealed the decisions by the Registrar, Council and the appeal board, and has taken the decision to the High court for revision
17
…increases in utilisation, tariffs and technology
use presents affordability challenges…• Cost: Absent health price determination
framework– Increasingly larger portion of benefits go towards
PMBs– GAP cover drives up professional fees
• Income– Tax credit system in place
18
Council’s response to access challenges (Goal 1)
• A research project is underway in order to advise the DoH on possible interventions to contain the increasingly disparate risk distribution between schemes
• Continued interaction with the DoH and Treasury to get consensus on the demarcation regulations
• Draft amendments to the PMB regulations were submitted to the MoH in March 2010
• Excited about the Competition Commission’s market enquiry
• Met with the MoH and GEMS to avoid the court action by GEMS
19
GOAL 2: MEDICAL SCHEMES ARE PROPERLY GOVERNED, ARE RESPONSIVE TO THE ENVIRONMENT, AND BENEFICIARIES ARE INFORMED AND PROTECTED
The performance of medical schemesGovernance matters in medical schemes
Functioning of the appeals committeeManaged care
ADR
20
THE PERFORMANCE OF MEDICAL SCHEMES
21
…claims costs pbpm continue to rise at rates much higher than inflation, with hospitals and specialists in the lead…
22
…non healthcare expenditure declining since 2005…
23
…increase in costs largely due to an increase in health benefits…
24
Council’s response to the performance of medical schemes
• Continued engagement with schemes on non-health costs
• Amendment to MSA required to strengthen regulatory powers
• Research the level of out-of pocket expenditure
25
GOVERNANCE MATTERS IN MEDICAL SCHEMES
26
Interaction of regulatory functions
Prospective regulation
Prospective regulation
Concurrent regulationConcurrent regulation
Retrospective regulation
Retrospective regulation
IndustryIndustry
27
…there is a large increase in retrospective workload…
28
…with many more complaints requiring a clinical opinion…
29
..the balance between retrospective and prospective
regulation is threatened..
Prospective regulation
Prospective regulation
Concurrent regulationConcurrent regulation
Retrospective regulation
Retrospective regulation
IndustryIndustry
Retrospective regulation
Retrospective regulation
Retrospective regulation
30
…governance failures, although not pervasive,
persists in some schemes…• Strong administrator influence on the affairs
of some schemes• Instances where there is not an arms-length
relationships between trustees and third party contractors
• Some boards lack in expertise and skills mix• Clear fit & proper standards not established
31
Council response
• Governance provisions in the MSA must be strengthened, a later slide on the draft MSAB will address this
• Continued enforcement of existing provisions in the MSA
• Some schemes are under curatorship
32
THE ROLE OF MANAGED CARE ORGANISATIONS
33
Council response on managed care
• Continue work to determine the exact role and the value added by managed care organisations
• Fundamental question: Do MCO’s contribute to the healthcare environment by reducing cost and improving quality?
• Develop a process, TOR, consult council, do research, and report back
• What action is required to address potential problems?
34
ALTERNATIVE DISPUTE RESOLUTION TO RESOLVE COMPLAINTS FASTER AND CHEAPER
35
…alternate dispute resolution may be more cost effective and result in a
shortened turnaround….
36
Council’s response to ADR
• Propose amendments to the MSA to require ADR at scheme level, and to allow for ADR prior to referral to a Tribunal
• Pilot the process on a voluntary basis to reduce the backlog of appeals to Council
37
GOAL 3: CMS IS RESPONSIVE TO THE NEEDS OF THE ENVIRONMENT BY BEING AN EFFECTIVE AND EFFICIENT ORGANISATION 38
…the existing office accommodation is inadequate…
• Currently occupying two separate buildings in an office park, which is filled to capacity
• Other space in the same office park are too far from existing offices
39
…matters before Council are sometimes challenged on procedural grounds…
• MSA is not clear on many of the processes to be followed in making a determination on certain matters
• No rules on appeals committee proceedings
40
Council response• A tender was awarded for new office accommodation
in Centurion, the office will start using these premises in May 2013
• Section 7 (f):“Make rules, not inconsistent with the provisions of this
Act for the purpose of the performance of its functions and the exercise of its powers”
• Council rules: Rules to govern Council process and Appeals committee proceedings are being made currently
• MSAB contains further provisions to govern Council affairs
41
GOAL 4: CMS PROVIDES INFLUENTIAL STRATEGIC ADVICE AND SUPPORT FOR THE DEVELOPMENT AND IMPLEMENTATION OF STRATEGIC HEALTH POLICY, INCLUDING SUPPORT TO THE NHI DEVELOPMENT PROCESS
42
Strategic advice – what must we do differently?
• There has been slow progress in the publication of the proposed PMB regulations
• Demarcation regulations• Statutory fees• Price determination
43
Council response• A Council delegation met with the Minister• PMB and Statutory fee regulations: Still with the
DoH’s legal unit• Demarcation regulations, the MoH supports
strong regulation to protect sicker and older members of the public
• Price determination: Collaborate with the Competition commission market enquiry
• NHI: Continue regulating the medical schemes environment
44
KEY AMENDMENTS IN PROPOSED MSAB
45
Changes with a large impact on the functioning of the office and the industry
• Improved information management– Health service provider
register– Beneficiary register– Contracts with providers– Health service utilisation
• New chapters relating to membership and contributions– Transparency– Open enrolment
• PMB’s/MMB’s• Complaints procedures
– ADR at scheme level• Appeals procedure
– Single tribunal– Alternative dispute resolution
at scheme and tribunal level
• Governance provisions– Elections
• Range of incidental changes – legislation is 15 years old
46
CMS Income budget 2013 14Funding Proposal 2013/14 2012/13 2011/12Operational expenditure A 110,130,989 98,402,778 90,483,837Capital expenditure B - 2,609,000 2,312,000Total expenditure C A + B 110,130,989 101,011,778 92,795,837Less: Depreciation and Amortisation E - 2,039,373 2,520,000Total cash requirement F C + D - E 110,130,989 98,972,405 90,275,837Surplus funds G - - 6,900,000Accreditation fees H 5,700,000 4,700,000 5,500,000Registration Fees I 370,000 400,000 400,000Interest Received J 840,000 1,200,000 900,000Total income excluding levies K G + H + I + J 6,910,000 6,300,000 13,700,000Income from levies L F - K 103,220,989 92,672,405 76,575,837Total membership M 0 3,852,956 3,800,000 3,608,727
Levy amount N L / M 26.79 24.39 21.229.85% 14.93% 16.00%
47
Legal fees 6,000,000 Total cash requirement 110,130,989 106,527,821 (3,603,168)
Performance bonus 2,192,454 Levy income 103,220,989 99,617,821 (3,603,168) Performance factor ( 1/3 *1.2) 40.0% Levy amount R 26.79 R 25.85 -R 0.94Add performance increase factor ( 30 % * 1% ) 0.3% Levy increase 9.8% 6.0% -3.8%Head: Research and monitoring 1 64%
Deputy Registrar 1New permanent positions 5 P C R Access Entities CMS Review
Accreditation: Clinical analyst 1 0 1 0 0Compliance : Senior investigator 1 0 1 0 0Snr financial analyst 1 0 1 0 0Supply chain officer 1 0 0 1 0Clinical research analyst 1 0.8 0.2 0 0
New temporary positions 3 P C R Access Entities CMS ReviewComplaints : Legal adjudication officer 1 0 1 0 0Switchboard operator 1 0 0 1 0Customer Care Intern 1 0.1 0.6 0.2 0.1
General salary increase 7.0%Inflationary increases 6.0%
Assumptions Impact Target
Budget assumptions
HR costs as % of budget
48
Access Entities CMS Review
2011/12 5.8% 44.5% 44.4% 5.4%
2012/13 5.7% 40.1% 48.5% 5.8%
2013/14 5.6% 41.0% 47.8% 5.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Budgeted expenditure by Strategic Goal
49
Prospective Concurrent Retrospective
2011/12 39.4% 21.5% 39.2%
2012/13 40.7% 22.8% 36.5%
2013/14 40.3% 22.8% 36.9%
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%
Budgeted expenditure by regulatory activity
50
CONCLUSION
51
Access to schemes
1
Medical schemes
2
Regulator
3
Strategic review
4
CMS strategic goals
52
DISCUSSION
53