A provider driven strategy that will fix healthcare –
A South African model case study
Grant Newton in association with:
Dr. Bob Vawda
Dr. Louis Rossouw
Dr. Martin De Villiers
Dr. Santy Singh
Dr. Logan Naidoo
Introduction
Consider why we have market
failure…
• No disruptive changes to the market since the MSA.
• Control of the care continuum sits with the Third
Party administrators and Managed Care
organizations.
• GP’s/ care coordinators have been disenfranchised.
• The balance necessary to keep the eco system of
accountable care healthy, has collapsed preventing
the ability to have good patient outcomes at
affordable costs.
• The specialists and hospitals have taken
control over the patient…
Current status of the inter Specialist/GP
professional & economic relationship.
Hospitals &
Specialists
Care
coordinator
Changes to Regulation 8 ?
Locus of control has shifted tearing the
professional relationship between
GP & Specialist
Introducing Uitenhage and Dispatch
IPA “UDIPA” …
What is UDIPA?
•
•
•
•
•
IPA and ‘real Managed Care Organization’
Between +- 60 primary care physicians, specialists, other
healthcare providers
Nelson Mandela Metropolis
(1+ M population)
Capitation services – managing options profitably for
over 20 years
Coexist competitively with other IPA’s in the region
Run a GP/Care coordinator centric model
An integrated health management
system …
•
Capitation model:
•
&
•
•
•
•
•
Primary care (physician and nursing)
out of hospital specialist services
Primary dental care
Primary optometry
Ancillary
Specialist Diagnostics:
•
•
•
•
•
Radiology
Pathology
Chronic care (wellness solutions)and chronic medications
Currently constructing its own sub-acute facility
Full control ‘on costs’ to specialist and hospitals
What's necessary to scale?
• Engage/create a national network who have
‘gotten over’ the following:
•
•
Writing off the fact that “UDIPA only works due
to the parochial nature of the geographic and
socio demographic of Uitenhage”.
Forgets the ‘historic ‘idiosyncratic’ nature of the
Uitenhage stakeholders including the doctors,
members & employers and learn from 18 years of
trial and error.
GP’s searching to truly restructure ecosystem in the interests of the patient
Can this model scale?
And construct the recipe of national expansion by?
UDIPA
• Absolutely necessary to move to a fully fledged
Managed Care platform
• Populating the platform with the IP of 18
successful years & local Doctor designed protocols
and treatment plans
• Adding tried and tested referral mechanisms that
maintains the control over the patient care whilst
retaining the professional relationship with the
specialists and other care givers.
The diagnosis cycles always lead back and are
controlled by the GP…
Can this model scale?
And:
• Adding GP owned central chronic meds
dispensaries, sub acute & diagnostic centers
• Balancing the equation of ‘data power’ between
the TPA’s and the provider group creating an
equitable negotiating fee and outcome measured
environment.
• Forge a relationship not only between the doctor
and the administrator but between the provider
/IPA and the funder and NB the member
Evidence (one of many):
Care Comparison Hospital Admissions
An example of many…
Percentage of Beneficiaries with
Hospital Admissions
Average LOS
(Length of Stay)
Hospital Days / 1000
Beneficiaries
*CMS reports 2012 to 2014
Capitation
FFS*
1,8 %
4,1 %
3,2
3,1
57,6
127,1
Strives toward the Porter model
Source: Prof Michael Porter Harvard Business School
Preventative care
Solutions
Force the
point
of diagnosis
back
to arrest
future costs
Achieve
Better
outcomes
Post - diagnosis
Diagnosis
New point of diagnosis
Pre- diagnosis
Legacy
Managed
Care
providers
Identify failures from a Care coordinators perspective…
Care coordinators (the GP’s) have been
disenfranchised through the current
Managed Care economic model that is
killing the industry…
Aware of the Current Managed Care companies
Economic Model
Number of members under Managed care contract - R pmpm
Increase wellness patients under management
Profits
Profits
Chronic wellness patients under management
To solve the current crises…
“Give the GP who
owns the pen the
power to be a family
physician so that they
can again coordinate
the health care
continuum.”
“Lets bring the care by the GP back into healthcare”
THANK YOU