Health care consultants Sanigest Internacional -- whose terms of reference include the specification of the key design features of a National Health Insurance (NHI) scheme, its benefits, costs and payment mechanisms and financing -- has given the government three options, ranging in cost and depth of coverage. Initially estimated to cost $230 million to $320 million, updated costings for NHI envision three scenarios: a vital benefits package costing $362.6 million per year assuming 85 percent of the population enrolls; a core package costing $504.8 million per year, and an expanded package costing $632.54 million per year.
Sanigest points out that the vital benefits package -- the cheapest of the three -- leaves out three key benefits components: dental care, eyeglasses and pay-for-performance.
Pay-for-performance (also called P4P) is an umbrella term for initiatives aimed at improving the quality, efficiency and overall value of health care. These arrangements provide financial incentives to hospitals, physicians and other health care providers to carry out such improvements and achieve optimal outcomes for patients.
The World Health Organization (WHO) points out that P4P is increasingly used as an innovative tool intended to improve efficiency and service quality in health systems around the world. As the WHO notes, however, evidence is limited that P4P increases value for money, boosts quality of processes in health care, or improves health outcomes.
Pay-for-performance has become popular within the United States health care system, including the Medicare and Medicaid systems. The U.S. Affordable Care Act (Obamacare) expands the use of pay-for-performance approaches in Medicare in particular and encourages experimentation to identify designs and programs that are most effective.
In theory, paying providers for achieving better outcomes for patients should improve those outcomes, but in actuality, studies of these programs have revealed that they yield mixed results. Quality measures used in pay-for-performance generally fall into four categories:
o Process measures assess the performance of activities that have been demonstrated to contribute to positive health outcomes for patients.
o Outcome measures refer to the effects that care had on patients, for example, whether or not a patient's diabetes is under control based on laboratory tests. The use of outcome measures is particularly controversial in pay-for-performance because outcomes are often affected by social and clinical factors unrelated to the treatment provided and beyond the provider's control.
o Patient experience measures assess patients' perception of the quality of care they have received and their satisfaction with the care experience.
o Structure measures relate to the facilities, personnel and equipment used in treatment.
Aaron E. Carroll, a professor of pediatrics who writes a column for the New York Times, said after reviewing the medical literature in 2014 that P4P in the U.S. and UK has brought "disappointingly mixed results". The vital benefits package also omits benefits components, including curative home care, home-based rehab, home care long-term nursing, glasses, hearing aids, medico-technical devices and interventional dentistry, and only preventive care is fully covered.
Sanigest describes the core package -- at $504.8 million, 42 percent more than the vital package -- as "the affordable core benefits package", and notes that it would offer the eyeglasses and dental care to the under-18 population, but restrict access to services like allied health and non-essential lab and pharmacy products. Home-based rehab is omitted under this scenario, and inpatient rehab, preventive care and inpatient curative care are all fully covered. The core package provides "a generous level of coverage with limited financial co-payments for the population", the consultants say in the report.
At a 78 percent cost increase over the vital package, the expanded benefits package reflects a comprehensive package with limited controls and -- as Sanigest put it -- nearly unlimited access. Preventive and inpatient curative care and inpatient rehab are fully covered by this scenario as well. Additionally, day cases of long-term nursing care and diagnostic imaging are also fully covered.
"Under this scenario, NHI administrative costs increase to eight percent and hospital and other service costs increase significantly. This scenario considers loose controls on utilization and limited control of chronic disease through active case management," the report says.
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