PROVIDER-MANAGED ALTERNATIVE REIMBURSEMENT MODEL PROMOTING UHC - - PowerPoint PPT Presentation

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PROVIDER-MANAGED ALTERNATIVE REIMBURSEMENT MODEL PROMOTING UHC - - PowerPoint PPT Presentation

Jul 04, 2023 385 likes •531 views

PROVIDER-MANAGED ALTERNATIVE REIMBURSEMENT MODEL PROMOTING UHC Rossouw Louis (Dr), De Villiers Martin (Dr), Singh Santosh (Dr), Vawda Bob (Dr) Drivers , Enablers and Regulators of Care Drivers of Care Patient Acceptance Providers of Care

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SLIDE 1

PROVIDER-MANAGED ALTERNATIVE REIMBURSEMENT MODEL PROMOTING UHC

Rossouw Louis (Dr), De Villiers Martin (Dr), Singh Santosh (Dr), Vawda Bob (Dr)

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SLIDE 2

Drivers, Enablers and Regulators of Care

Providers of Care

  • Access to care
  • Economics of care
  • Healthcare technologies
  • Policy & regulatory framework
  • …

Patient Acceptance Outcomes & Productivity Drivers of Care Enablers of Care Regulators

  • f Care

Inputs Throughputs Outputs Feedback into the Delivery System

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SLIDE 3

History & Background

  • South Africa: Fee-for-Service (FFS) has predominated provider reimbursements

for the past 50 years For the past 22 Years: Local Primary Care Provider Network in the Nelson Mandela Metropolitan region has grown a “home-grown” and locally developed:

  • Alternative Reimbursement Model (capitation)

with

  • Risk-transfer to providers
  • Integrated delivery of care
  • Primary care (physician) management
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SLIDE 4

Study, Materials & Methods

Refer to ABSTRACT for study framework & Materials & Methods

– In essence, the study was a 3-Year Cross-Sectional Analysis of:

  • Economic data (costs)
  • Production data (services delivery)
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SLIDE 5

Basics of Reimbursement & Risk-Transfer

For Provider-Managed Capitation*

  • GP’s & primary care providers: Does not limit patient consultations
  • Specialists: Certain specialities: Referrals & consultations on capitation
  • Integration of care processes with risk-transfer
  • Authorization processes are actively managed between MCO & Providers
  • Facility-based care (hospitals etc.) are actively case-managed

* There are several types & applications of “capitation”. The most effective capitation is ‘provider-managed capitation’

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SLIDE 6

Results: GP Visits

Average Visits / Member Capitation FFS * GP Visits: Surgery & In-Hospital 4.34 3.87 Specialist Visits

  • Radiology
  • Pathology

4.7 5.1 Physiotherapy Visits 0.5 2.5 9.54 11.47 Average Cost / Consultation -8.5%

* FFS data reported is the national consolidated data as reported by Council for Medical Schemes (Annual Reports)

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SLIDE 7

Results: Outcomes – Hospital Care

Admissions* LOS** 2009 205 3.2 2013 176 3.1 2016 164 3.6 **** 2017 156 3.7 Benchmark Industry *** 200 4.06 Total Hospital Cost / Admission -10 %

* = Admissions / 1,000 Scheme Members. ** = LOS: Length of Stay *** = Data were weighted for Schemes Options

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SLIDE 8

Results: Medication

Cost of chronic disease & condition management Integrated Care Model FFS

  • 20%

These savings are achieved through a) central purchasing, b) central logistical supply and c) distribution of medicines via the Wellness centre

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SLIDE 9

Results: Economics - Reimbursement

Category FFS Capitation Category

GP 5 % 21 % Primary Care (GP, Dental, Optometry + Other) Dental (Primary + Specialists) 2.5 % 1 % Dental Specialists Supplementary & Allied Professions 6 % 3 % Supplementary & Allied Professions Chronic / Medications 14 % 11 % Chronic / Medications Specialists 20 % 13 % Specialists (excluding Pathology & Radiology) Other Out-of-Hospital Services 5.5 % 4 % Other Out-of-Hospital Services Hospital & Facilities 32 % 25% Hospital & Facilities Administration 15 % 15 % Administration 100 % 93%

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SLIDE 10

Results: Population-Care Risk Curve

A next phase of implementation

  • f the risk-transfer approach is

the member management for:

  • High utilization patients
  • High risk patients (clinical)
  • High cost patients
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SLIDE 11

Results: Member Satisfaction

Resignations 3-Year Period

0,36 %

Member recourse (employee forums)

0,0 %

Member dissatisfaction with providers (doctor change requests)

0,01 %

Employers and employees opting out

<1 %

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SLIDE 12

Conclusions

  • In support of the international trend:
  • FSS reimbursement outdated
  • FFS do not incentivize risk-transfer arrangements
  • Need ongoing benchmarking measurements for

care outcomes to support objective decision-making

  • Objective data help strategic-decision & policy-making

to steer clear of opinions & ideological argumentation

  • a South African, home-grown solution for

alternative reimbursement, risk transfer services exists

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SLIDE 13

Strategic Directions

  • This alternative reimbursement model (capitation) with risk-transfer is

provider-managed, provider-lead and provider-owned

  • The reimbursement model was made possible only through collaboration

and alignment between the participating Funder (Medical Scheme) and the Provider Network (Primary Care Physicians & Specialists)

  • InteliHealth Africa (provider-managed, provider-lead & provider-owned

network) is in strategic partnership with IPAF (Independent Practitioners’ Association of South Africa)

  • The findings of this study support the expansion of

UHC to employees in the low income bracket of ZAR 6,000 to ZAR 15,000 per month

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SLIDE 14

THANK YOU

IHA (Admin Office) <admin-office@intelihealthafrica.com> IHA (web site) <www.intelihealthafrica.com>