As part of a process of improving provider payment systems under the National Health Insurance Scheme (NHIS), work is ongoing to design, pilot and evaluate a per capita (capitation) provider payment system. The pilot will take place in the Ashanti region. The per capita payment method 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 using the already existing Ghana Diagnostic Related Groups (G-DRG) with the fee for service and medicines payment method.

A forum on the capitation proposals for major stakeholders in the National Health Insurance Scheme (NHIS) organized by the National Health Insurance Authority (NHIA) 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 are finalized, piloted and evaluated.

Professor Irene Agyepong, chair of the provider payment systems reform committee, outlined the reform objectives and explained the merits of the proposals to the delegates. Capitation, (per capita payments 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 utilization rates and costs projected over a period of time and subject to periodic reviews and adjustments. The use of per capita payments for primary care under the National Health Insurance Scheme 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, each National Health Insurance subscriber would indicate their 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.

Delegates sought clarifications about portability e.g. what happens when a subscriber relocates to another district. Concerns were also expressed about provider shopping (involving subscribers switching rapidly from one service provider to another) which interrupts continuity of care. Other questions were on perceived ambiguities in accreditation procedures and processes; the role of pharmacists and midwives under capitation and whether tariffs for services and medicines will be combined in a single merged payment. There were also issues raised about cumbersome modalities that hinder doctors from engaging in office practice and the need to fit office practice into the system.

In response, it was explained that portability would still be practiced but with clear regulations, guidelines and procedures. Subscribers can change their preferred primary-care provider (PPP) if they want to e.g. if they are not satisfied with the services provided, or if they have moved and want a PPP nearer to them. However such routine changes of PPP can only be done every six months. The administrative burden of more frequent changes of PPP on a routine basis will be unmanageable. However, in special /exceptional cases, such as a subscriber moving permanently to a totally different district or region, arrangements can 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.

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. This is a waste of resources and of the time of healthcare personnel. It renders disjointed care and also puts the client at risk from the dangers of multiple medications.

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 team together as a PPP was discussed 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. Reassurance was provided to fears expressed about the possible misapplication of funds by service providers in an advance payment system. It was explained that there will be a rigorous monitoring regime in place to ensure that funds are not diverted from primary healthcare purposes.

It was also emphasized that the DRG has not failed as suggested by a participant. The G-DRG with fee for service for medicines system is considered as still useful and would be combined with capitation. However, it will be limited to payments for specialist out-patient (OPD) care and for in-patient care. Moreover, the NHIA is in the process of reviewing the experience with the G-DRG method over the last two years to inform its continuous improvement.

In response to a question raised about basic medicines to be dispensed under capitation, Professor Agyepong said that the list of medicines will derive from the National Standard Treatment Guidelines.

It was emphasized that the committee remains open to new ideas and suggestions that would help to improve the proposals. The delegates’ concerns, questions and suggestions would be taken into account to improve the proposals. More consultations are envisaged in preparation for the start of the pilot scheduled for early 2011.

Nii Anang Adjetey
Communications Manager,
Strategy and Corporate Affairs Directorate
National Health Insurance Authority