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

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 Throughputs Enablers of Care - Access to care - Economics of care Regulators - Healthcare technologies Outcomes & of Care Productivity - Policy & regulatory framework - … Outputs Inputs Feedback into the Delivery System

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

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)

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’

Results: GP Visits Average Visits / Member Capitation FFS * GP Visits: Surgery & In-Hospital 4.34 3.87 Specialist Visits - Radiology 4.7 5.1 - Pathology 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)

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

Results: Medication Integrated FFS Care Model -20% Cost of chronic disease & condition management These savings are achieved through a) central purchasing, b) central logistical supply and c) distribution of medicines via the Wellness centre

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%

Results: Population-Care Risk Curve A next phase of implementation of the risk-transfer approach is the member management for: - High utilization patients - High risk patients (clinical) - High cost patients

Results: Member Satisfaction 3-Year Period Resignations 0,36 % Member recourse (employee forums) 0,0 % Member dissatisfaction with providers 0,01 % (doctor change requests) <1 % Employers and employees opting out

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

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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