Amalgamation of the 3 IPAs in RSA into an NPC

Organisation and leadership : Who is IPAF?

FOR PROVIDERS AND PATIENTS

BY THE PROVIDERS

Dedicated to• The Profession especially the FPs • Our Patients Health and Well being• Maintaining the best elements from a

flawed system of PHCD

Voluntary registration by over 5,000 GP/FPsInclusivity, “all willing providers”

Credible, responsible thought leaders with established relationships across the Industry

Familiar with the Medical Industry (Private and State)

Committed to sustainable, scalable primary health care

Patient and Person centric approach

Voluntary provider membership whether in or out of IPAF

Organised regionally

Level 4 BBEEE accreditation

Organisation and leadership : Who is IPAF?

FOR PROVIDERS AND PATIENTS

BY THE PROVIDERS

• Cost of healthcare is too high• Huge Wastage and duplication in system• Costs skewed to specialist , hospitals and

emergency care• Cost variations based on Geographic

parameters• Lack of accreditation• Lack of clinical guidelines• Uncoordinated wasteful Health Care

initiatives

Why IPAF?

FOR PROVIDERS AND PATIENTS BY THE PROVIDERS

• Non-restrictive participation, all willing-provider basis.

• Transparency , trust and integrity.

• Accommodate the independent status of the constituent IPAs within the IPA Foundation.

• Patient and Person centricity

• To develop standardised clinical protocols and formularies which are acceptable to the contracted provider and which will result in cost-efficiencies for the patients.

• Utilise evidence-based clinical algorithms.

GOAL

S AND

OBJ

ECTI

VES

• Best Practice initiatives• Enhancement of Quality and

Value and reduction of Cost• Improving the Safety within

practices• Responsible pathology and

radiology requests from FPs• Responsible antibiotic use• Uniformity and responsibility in

investigating ,prescribing and referring

Value= Quality

Cost

“Value can be defined as the health outcomes achieved per dollar spent”

Michael Porter: Economist and Competitions expert Harvard Business school

We all want more value

While Family Practitioners ( GPs) typically represent 6% of scheme claims, approx. 35% of costs downstream costs could be controlled by utilising the FP as care Coordinator

Historically the relationship between “open” schemes, managed care companies and PHC providers has been negative due to their failure to curtail patient access to specialists and hospitals

IPAF fosters a more Direct relationship between scheme and the providers by utilising our network management to develop a partnership to achieve value in primary health care

IPAF: a key stakeholder

Mature GP networks open to all willing providers

A form of PHC driven self-regulation to improve the contractual relationships between funder and provider

Shared accountability A means to improve Quality and Value of care (there

is also value to funder and provider and patient) and address Cost containment

Usually linked to a profiling tool

Peer review and Profiling of GPs , done by IPAF trained GPs has demonstrated improved outcomes and reproducible savings whilst enhancing Quality

Value for funder:• reduced downstream costs • Improved network compliance and • more predictable fees• reduced risk of poor outcomes

Value to the provider :• increased rewards for Quality outcomes and management of resources • improved patient outcomes through PHC

Value to patients:• Preservation of their medical plan benefits• Quality assurance of attending doctor• Reduced wastage• Reduced unnecessary specialist referrals and hospitalisation and EMUs • Better coordination of care

How to Unlock Value though Network Management

1. FP Networks2. FP nomination3. Controlled Specialist referral4. FP benchmarking5. Peer Review6. Enabling benefit design 7. Alternative Reimbursement Models8. Future close cooperation with NHI pilots

Toward a sustainable Primary Health Care system

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Ethos of Peer Review• Fundamental tool to achieve “Best Practice

Initiatives”.• Focused on the Best care to our patients.• We need to promote value healthcare:

Value (V) = Quality / outcomescost

• The approach is “Patient centric”• Aligned to professionalism• The entire review must be:

– Ethical– Scientifically sound– Best Evidence supported approach

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What necessitated the need for Peer Review

• Important Observations– Marked variation between practitioners and between

regions for the same conditions.– Cost of care vary (for the same risk adjusted

conditions).– Quality varies and often not achieved, in spite of the

high spend on healthcare.– Financial reforms were on the horizon.– There was a need to pay for value and not just for

interventions.– The Fee for Service reimbursement was not really

promoting value-based outcomes but rather volume-based outcomes.

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• The work of Wennberg (USA) and others showing very wide variations in practice patterns must call into question the appropriateness and evidence base for much of what many doctors do.

• Large amounts of inappropriate hospitalization and surgery.

• Price controls and negotiated price reductions on doctors and hospitals alone, without addressing the actual practice patterns, won’t come close to solving the problems of expenditure growth.

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• Peer Review is a voluntary, collaborative activity led by Health Practitioners that is regularly used to monitor, maintain and improve the quality of their patient care.

• The review of professional practice by a Peer is an important part of the maintenance and enhancement of a Health practitioner’s clinical and professional skills.

• Overall objective of the Peer Review process is to improve patient safety and health outcomes.

Purpose of Peer Review

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Principles of Effective Peer Review

• Peer Review should produce valid and reliable information:– The utility of Peer Review depends on the quality of its

processes and the perceived value of the information it generates for health practitioners and the Health system.

• Processes for peer review must be Transparent, fair and equitable, and legally and ethically robust.

• The outcomes of Peer Review should be applied ultimately to improve patient care.

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The events that lead to Peer Review of medical Professionals

• Practice claim patterns are captured by the Actuaries.

• These are converted to a statistic – which is risk adjusted for:– Patient demographics (age / gender)– Health status (prior diagnosis, current illness, severity)– Co-morbidities– Previous hospitalization– Environmental exposure– Cost– Other Externalities

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• These statistics are then arranged into a report.• There is a scatter around a mean distribution for that

population of patients. • At the review itself the reviewer will correlate the

clinical burden to the statistics produced.• The process is mainly a mentoring process to assist

doctors to become more efficient and to deliver “Quality” care within a cost framework that the patient can afford.

• The practice may then be flagged and reviewed at the next appropriate review period to ascertain a change in practice outcomes.

• Peer Review by Peers is not aligned with forensic audits schemes conduct.

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What follows a Peer Review?

• Some healthcare trends are observed and reported on:– Costs– Overuse of antibiotics– Excessive laboratory and radiology use– Increased referral for secondary and tertiary care

(hospitalization)

• The evaluation is based on the appropriateness of clinical decisions.

• The Health practitioners are informed and we also distribute evidence-based literature that looks at similar International and National trends.

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Our focus for the future• Person-based Healthcare and population health• Increased emphasis on skills to decrease the

asymmetry of information between the patient and health professional

• The new emphasis to improve compliance:The conversation we have with our patients:

• The content and appropriateness• Understanding the health issue, its complexity and a

commitment to shared management

The use of the narrative theory and methodology• Shared decision making.

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• We conduct an annual Peer Review masterclass.

• This updates reviewers, helps them understand the statistical emphasis and also how to interpret costs against clinical burden and new clinical guidelines.

ConclusionWe consider peer review as an essential tool to:

– Promote Quality outcomes– Enhance safety– Manage costs and appropriate use of resources.– Production of information that will help improve

healthcare.

Ongoing upskilling of Peer Reviewers

Medical Schemes /

Administrators

Engagement structure

Individual

DoctorsData

Facilitated discussion on cost drivers; Development of policies and measurements

Reports, analysis and practice benchmarks generated independently

Clinical

Input

Measurement basis

Direct costs

Costs directly in the FP’s control

Indirect costs

Costs outside of the FP’s direct control but can be traced back to an FP treatment episode

Benchmarks are risk adjusted using demographic and clinical

data

Cost metrics – per patient per month Quality metrics

6 primary care focused screening and preventative metrics

3 disease management process measures

3 disease management outcomes measures

Cost and quality scores are combined on a 50/50 basis to

produce an overall score

Operational process

1

Data obtained from participating medical schemes

2

Benchmark reports are distributed to doctors

3

Outlier doctors are earmarked for peer review

4

Peer reviewers interact with identified doctors and report back

5

Reports are distributed to the scheme(s) and IPAF

6

Ongoing analysis of trends, cost drivers, quality markers is discussed with schemes and IPAF to design interventions and improvement programs.

Quality metrics for chronic patients managed by

network FPs are better than those managed by non

network FPs Network Family Practitioners cost medical schemes less than non-

network Family Practitioners

Example outcomes

Cost Category

Costs per life per month for patients

allocated to Network vs. Non-

network FPsFamily

Practitioner 6.9%Acute

medication -5.0%Chronic

medication 14.0%Pathology -29.4%Radiology -21.1%Specialist -31.5%

Flu va

ccine

HIV test

HPV vacci

ne

Mammogram

Pap smear

PSA te

st0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%

Network Non-network

Vacc

ine/

test

rate

Cardiac conditions

Diabetes Respiratory conditions

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0%18.0%

Network Non-network

% o

f pati

ents

adm

itted

Restricted medical scheme data, 2015