PROVIDER REFORM REQUIRES A ‘POPULATION VALUE-BASED’ PURCHASING SYSTEM

Dr Brian RuffPPO ServeSouth African ProfessionalProvider Organisation Services

Current….

Managing the healthcare sector of SA

System Result: Costly, fractious system• Unhappy confused

patients• clinical outcomes??• Inappropriate

resources consumed

Supply side result:• Isolated, insecure,

frustrated clinician practices

• Clinical autonomy compromised

• Huge administration load

Demand side access management:

• Restricted Benefits• Managed Care

protocols• FFS with profiles and

outlier management

Individuals Premiums in

Risk pool

Healthcare System

System Outcomes

Preferred…

Managing the healthcare sector of SA

Individuals Premiums in

Risk pool

Healthcare System

System Outcomes

System Result: Higher quality, lower

costs, enhanced access• Satisfied patients • Continually improving

outcomes• Reduced waste

Supply side governance:• Patient centred,

integrated support structure

• Clinical autonomy restored

• Happy clinicians in teams

Demand side ‘value’ purchaser:

• Contracts support optimal clinician/patient interactions

• Measures; reward effectiveness

• Appropriate Benefits

Imagine a healthcare system…• That is organised around you and your family's medical and social problems

with a tailored care plan which reflects your preferences and leads to routine monitoring and reach out

• Where all healthcare professionals, including doctors, work together in local teams organised around you, focused on coordination and the quality of your medical care, with no gaps or waste. The team has a shared understanding of your complete care plan so interactions with you & family are straightforward

• Your Medical Scheme backs the clinical team to make the right decisions in a contract that measures and rewards quality care. Your benefits are comprehensive and affordable

Building blocks of Healthcare system reformPopulation medicine and the healthcare system: • Planned: capacity = local population needs • Patient & Community centered • Accountable for production / outcomes

Integrated local healthcare systems:• Collaborative Teams • Multidisciplinary, proactive patient centered approach

• Autonomous – owned & managed by working clinicians • Well supported – management, support staff; Health IT

Value contract – funds from ‘shared value’ with Medical Schemes:• Individual/FFS replaced by monthly Population Risk team fees +

Upside ‘Value’ rewards – quality/prudence measures• Competition is between coherent systems ~ via Schemes

How to achieve Population Medicine / Integrated Care / Value Contract?

6

Integrated Clinical ConsortiaTM

Service Lines Primary Care General Specialist care Hospital/ Other care

General Integrated Care Plans

Social interventions

Maternity and Confinement

Early Childhood

ENT & Respiratory Care

General Practitioner

Allied Healthcare professionals incl Midwife, OT, Social Worker

Mid level workers incl clinical associates, nurse coordinators

Paediatrician

Physician

O&G

Psychiatrist

General & ENT Surgeon

General hospitalSub-acute facility

Hospice Home nurse agency

Gastroenterologist, Cardiologists; Endocrinologist etc

Community organisations

Integrated Clinical Consortium Sub-contract

• ICCTMis a commercial entity and the working clinicians are its shareholders. • Well supported multidisciplinary teams matched to local population needs• Earnings are jointly determined by Value Contracts with Schemes • Care is supported through a Clinical Care IT support system

• Enables proactive management of the clinical and social circumstances of every patient.

Local; integrated care delivery to stable, defined populations

Hospital and other specialists

Home Nurse agency; Step down hospital

Rad/ Path

General Practitioner; Allied Healthcare Professionals; Mid level workers

Paediaticians; Physicians; Geriatricians; Psychiatrists; Gynaecologists; ENT, Urologists

Integrated Clinical ConsortiumSupported by PPO Serve

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

6 GPs; Allieds; mid level workers

0.5 Physici

an

0.3 Paeds

0.2 Psych

0.1 ENT, Uro

0.2 Gynae

Complex; multi morbidity 2%

Chronic illness

8%

At risk25%

Healthy 65%

DiabetesPVD

IHD isolation

MyelomaEarly dementia

obesity

Hyper-tension

Care plans by need segments

15

60

203 2

Contract basis:

Baseline structure, process, patient satisfaction &outcome scores

ICC Contract; Care Plans & Coordinators; MDT meetings; EMR deployed

Social support; conservative Ortho; Palliative Care; better PES; less ER/readmit, surgery/ICU

Best Patient Experience; multiple new quality initiatives; highest prudencePopulation

based projections

Tiered Value targets:

PPO Serve

Clinical Consortiu

Clinical Consortiu

Clinical Consortia

5

40

5

0

3

35

12

Supply side reengineered Managed care projects

Adoption: • Clinical team works in the same integrated system: regardless of patients Scheme = embraced change

• ++ Scheme projects => contradictory, silo, uncertain remuneration = resistance to change

Performance: Savings and Measured Quality

30-40%:• Scale, focus => full clinical care management system• Investment & experience => mature, evolving

competence • ‘Hub’ PPO Serve => rapid dispersal of good practice

3-4%:• tentative, parallel silos; ongoing

fragmentation

Effective Governance:

• ‘Value contract’ Schemes => governance is back to clinicians => invest in management, tools, infrastructure => autonomy, efficacy, clinical excellence => Better outcomes

• Restricted benefits, Protocols, Disease Management = disparate efforts, low effect => poor system performance

Integrated Care system reform: More effective for Schemes and members

Integrated Clinical Consortia: Patients Value PropositionPatients:• personalised care (plan) from an complete local

system• healthcare services are patient centered,

coordinated, accountable • Rare interactions with Schemes Consumers:• local health systems are branded, known entities

with sound reputations for the quality of their integrated care

Peninsula ICCTM - Effective Care • Schemes that contract with them share their

reputation and sell their story

Integrated Clinical Consortia: Individual Clinicians Value Proposition• Income is generous links to patient complexity, clinical practice experience &

merit• Gratifying work - proactive population care; top of scope practice & team

work matching each individual patient needs

• Clinical autonomy regained in a collaborative, commercial entity which they own & govern. Elected clinical leaders promote healthcare quality and prudence:• Peer mentoring • Strategic performance and planning• Promotes consortiums brand /

reputation for integrated quality careConsortium as a local empowering nexus: balancing the strength of Schemes & network hospitals

THANK YOU