dr. stan moloabi gems coo · dr. stan moloabi gems coo . the gems. mandate. contents. additional...
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SAMA CONFERENCE 2018Alternative Remuneration Models and
Patient Centered CareDr. Stan Moloabi
GEMS COO
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The GEMSMandate
Contents
Additional Considerations
Patient Centred Care as part of
Care Coordination
1 2 3
ARMs are part of Sustainable
HealthcareFunding
5
2
The Way Forward
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The GEMS Mandate
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“Excellence, Integrity, Member Value, Innovation, Collaboration”
“To provide all members with equitable access to affordable and comprehensive healthcare, promoting member well-being.”
“An excellent, sustainable and effective medical scheme that drives transformation in the healthcare industry, aligned with the principles of universal health coverage.”
Values
Mission
Vision
To ensure that there is adequate provisioning of healthcare coverage to public service employees that is efficient, cost-effective and equitable; and to provide further options for those who wish to purchase more extensive cover.
Mandate
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Additional Considerations - Healthcare Market Inquiry
“Overall, the market is characterized by high and rising costs of healthcare and medical scheme cover, highly concentrated funders’ and facilities’ markets, disempowered and uninformed consumers, a general absence of value-based purchasing, ineffective constraints on rising volumes of care, practitioners that are subject to little regulation and failures of accountability at many levels”
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Additional Considerations - Healthcare Market Inquiry
“Practitioners are usually the point of entry into the health care market. Due to their superior health care knowledge, they act as agents for consumers. Practitioners are able to influence healthcare expenditure in two ways: through their own activities, such as diagnoses and treatment, and through the services and treatments they recommend, which include referral for further investigation, treatment, and hospitalization. Overall, medical practitioners drive much of the health care expenditure in the sector. ”
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Additional Considerations - Healthcare Market Inquiry
“Fee-for-Service (FFS) models of remuneration are known to stimulate oversupply which results in wasteful expenditure and incentivises practitioners to provide more services than needed. This incentive is intensified by the current unregulated pricing environment. ”
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Additional Considerations - Healthcare Market Inquiry
“The ethical rules of the Health Professions Council of South Africa (HPCSA) are cited as the reason for lack of innovation in models of care and development of alternative reimbursement models. It is our view that the HPCSA is not sensitive to the benefits of competition in creating incentives for affordable and quality care”.
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Patient Centred Care as part of Care Coordination
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Patient Centred Care as part of Care Coordination
54%30%
12% 4% 1%
1 GP 2 GPs 3 GPs 4 GPs 5+ GPs
In the absence of substantive interventions, care coordination is poor and hence the need for care coordination to be enforced across schemes and options
Nearly one in two beneficiaries consult with multiple general practitioners
Beneficiaries who consult with multiple general practitioner generate higher costs
-3%-1% -1%
1%
6%9%
1 2 3 4 5+
Specialists only
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Patient Centred Care as part of Care Coordination
GEMS established the Emerald Value Option (EVO) in 2017 which is underpinned by care coordination. The option demonstrates the benefits of care coordination.
-12%-14%
-21%
21%
Admission rate Specialist visit rate Cost per admission GP visit rate (relativeto specialists)
Impa
ct o
f car
e co
ordi
natio
n Fewer admissions, fewer specialist visits
and more GP visits
EVO
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Patient Centred Care as part of Care Coordination
“Applied across the medical schemes industry, it is estimated that EVO like care coordination principles could save up to R20 billion per annum”
Minister Ayanda Dlodlo, Public Services and Administration Budget Vote
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Alternative Remuneration(Reimbursement) Models are already part of Care Coordination within the GEMS environment
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Hospital ARMs
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Alternative Reimbursement Models – Implemented
Procedures Clinix JMH LHCMedi-Clinic Netcare NHN
Caesarean Delivery
Cataract Procedures
Knee Replacement
Laparoscopic Cholecystectomy
Vaginal Delivery
ImplementedNot implementedPricing to be agreed on
Procedures Clinix JMH LHCMedi-Clinic Netcare NHN
Colonoscopy
Circumcision
Cystoscopy
Gastroscopy
Hip Replacement
Tranche 1 Tranche 2
The highlight for Q2 is that GEMS reached and arrangement with NHN to implement both tranches with effect from July 1st
2018
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ARMs with DoH
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Objective is to partner with Tertiary Hospitals and be part of leveraging these Centres of Excellence(COE’s)
The COE initiative aims to:1. Partner with public hospitals to build medical expertise;2. Ensure the delivery of affordable, quality health care;
• Not only to GEMS members
3. Manage costs and payment of services through alternative reimbursement models (ARMs)• Proposed ARMs based on UPFS + %
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ARMs with DoH
Hospital Procedure Status
SBAH GP Cataract surgery Scheduling follow-up meeting
CHBAH GP Cochlear implants Agreement on TAVI and CI
CM-JAH GP Breast Cancer surgery Account recon complete, Schedule follow-up meeting
Frere/CMH EC Arthroplasty Rescheduling meeting
HJAH GP Arthroplasty Rescheduling meeting
Ink. Albert Luthuli KZN Cochlear Implants
Initial engagementClaims challenges raised –awaiting schedule of unpaid claims for recon
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Bariatric
surgeryTAVIArthro-
plasty
Cochlear
implants
Liposuction for
lipodystrophy
Breast patholo
gy & reductio
n
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Global Fee as ARMs – GEMS Initiatives Underway
GF-ARM PPI1 UPFS+
Structure Global-Fee Global-Fee Global-Fee
Pricing Profit based Cost based Cost based + Profitability incentive
Risk coverProspectiveStop lossCarve out
RetrospectiveAnnual recon
RetrospectiveQuarterly recon
Incentive Financial Risk transferImproved efficiency
Reducedadministrative burden
Reduced admin burdenImproved efficiency
1PPI - Provider Payment Initiative
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% of Total GEMS claims paid as ARMS
92.6
0%
91.4
0%
90.2
0%
7.40
%
8.60
%
9.80
%
JANUARY FEBRUARY MARCHFee for Service ARMS
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FP Filler Project
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GP Filler: Background
Less than ideal Specialist coverageApprox. 30% members travel distances of > 30Km
Specialists (and most other professionals) based mainly in 3 provinces:
Gauteng, Western Cape, KZN Invited FPs with post-basic qualifications:
Diploma in Child Health - DCH(SA)Diploma in Gynaecology and Obstetrics - Dip Obst(SA)Diploma in Ophthalmology - Dip Ophth(SA)Diploma in Mental Health - DMH(SA)Diploma in Anaesthetics - DA(SA
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GP Filler: Responses
Qualification No of responses
Diploma in Child Health - DCH(SA) 44
Diploma in Gynaecology and Obstetrics - Dip Obst(SA) 38
Diploma in Ophthalmology - Dip Ophth(SA) 0
Diploma in Mental Health - DMH(SA) 6
Diploma in Anaesthetics - DA(SA 84
Total 172
Master of Medicine in Family Medicine(MMED Family Medicine) or FCFP(SA) Fellow of the College of Family Physicians 49
Other qualifications 74
Total respondents 295
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PROVINCE DCH Dip Obst DMH DA TOTAL % TOTAL
Gauteng 15 7 0 29 51 30%
Western Cape 16 11 0 20 47 27%
KwaZulu-Natal 5 5 0 17 27 16%
Eastern Cape 5 4 4 9 22 13%
Free State 0 1 0 4 5 3%
North West 0 2 1 1 4 2%
Mpumalanga 2 4 1 2 9 5%
Limpopo 1 2 0 1 4 2%
Northern Cape 0 2 0 1 3 2%
TOTAL 44 38 6 84 172 100%
GP Filler: Provincial distribution
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GP Filler: Conclusions
Urban concentration of skills similar to Specialist patternsDCH, Dip Obst, DCH, DMH:
No indication of “specialisation” in respective fields (from claims analysis)No advantage in creating a “filler” network
DA:FP network will bolster existing Specialist networkConditions for participation – min 80% Anaesthetic workWill have a financial cost impact
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Progress made on GEMS FP Networks ARMs
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Determining FP ARMs using Profiling tool
Profiling tool is good at analysing claim but not at identifying a subset of provider types Currently being reviewed
We have engaged with various FP societies and are reassessing what is achievable Aim is to finalise the review by September 2018
Principles:Universally acceptable to all role players SimplerTracks quality and cost outcomes Identifies high-value FPsEnables self-assessmentEncourages improving performance (cost and quality outcomes) Enables effective peer managementUltimate Objective is to move towards Value Based Reimbursement of FPs
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FP ARMs
Undergoing review (parallel with the profiling tool)
Considerations:Incentivise and reward better outcomes
High value FPsDifferential network ratesRecognition of post-basic skills, e.g. opening up of certain restricted codes, etc.
Review to be finalised September 2018
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Sustainable Healthcare Funding
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Sustainable Funding is possible
Over R40 billion per annum can be liberated by making the healthcare system more efficient
Care Coordination (R20 billion*)
Fraud, waste and abuse
(R10 billion*)Review of
regulation 8 (R4 billion*)
Risk based capital(R6 billion*)
29Note: *Values are estimates
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Sustainable Funding of Health Priorities facing the country
MoH Budget
Cancer
Cancer program
Diabetes
Chronic medicines program
Hypertension
Chronic medicines program
HIV
ARV Surgery
TB Maternal Health
Complicated pregnancies
Mental Health
Mental health program
R40 billion could significantly contribute towards the funding of the health priorities put forward by the Minister of Health
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The Way Forward
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The Way Forward
Family Practitioners and Healthcare Funders need to work together more closely to ensure
the sustainability of healthcare funding and lay a foundation for UHC
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The Way Forward
A “CODESA” is needed whereby all stakeholders agree on a new healthcare dispensation which improves access
A process of grand tradeoffs whereby all concerns of all addressed in the long term interests of the country
Affordable pricing of healthcare
services needed
Further challenges to overcome include
Healthcare Funding must become more
sustainable
ARMs must become the dominant FP
Remuneration
Provider driven peer review is
essential
Care coordination as part of Value Based
Remuneration results in better outcomes 33
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Conclusion
All South Africans need to work tirelessly towards advancing universal healthcare irrespective of the challenges and ARMs
are an integral part of the work that is required 34
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Conclusion
“As we enter a new era, we are determined to confront the challenges that we face and to accelerate progress in building a more prosperous and equitable society …The time has now finally arrived to implement universal health coverage”
President Cyril Ramaphosa, SONA 2018
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Thank You!