Dr Brian Ruff
PPO Serve
South African Professional
Provider Organisation Services
PROVIDER REFORM REQUIRES A ‘POPULATION
VALUE-BASED’ PURCHASING SYSTEM
Managing the healthcare sector of SA
Current….
•
•
•
Demand side access
management:
Restricted Benefits
Managed Care
protocols
FFS with profiles and
outlier management
System Result:
Costly, fractious system
• Unhappy confused
patients
• clinical outcomes??
• Inappropriate
resources consumed
Individuals
Premiums in
Risk pool
Healthcare
System
System
Outcomes
Supply side result:
• Isolated, insecure,
frustrated clinician
practices
• Clinical autonomy
compromised
• Huge administration load
Managing the healthcare sector of SA
•
•
•
Demand side ‘value’
purchaser:
Contracts support
optimal clinician/patient
interactions
Measures; reward
effectiveness
Appropriate Benefits
System Result:
Higher quality, lower
costs, enhanced access
• Satisfied patients
• Continually improving
outcomes
• Reduced waste
Individuals
Premiums in
Risk pool
Healthcare
System
System
Outcomes
Preferred…
Supply side governance:
• Patient centred,
integrated support
structure
• Clinical autonomy
restored
• Happy clinicians in teams
Imagine a healthcare system…
• That is organised around you and your family's medical and social problems
with a tailored care plan which reflects your preferences and leads to routine
monitoring and reach out
• Where all healthcare professionals, including doctors, work together in local
teams organised around you, focused on coordination and the quality of your
medical care, with no gaps or waste. The team has a shared understanding of
your complete care plan so interactions with you & family are straightforward
• Your Medical Scheme backs the clinical team to make the right decisions in a
contract that measures and rewards quality care. Your benefits are
comprehensive and affordable
Building blocks of Healthcare system reform
Population medicine and the healthcare system:
• Planned: capacity = local population needs
• Patient & Community centered
• Accountable for production / outcomes
Integrated local healthcare systems:
• Collaborative Teams
• Multidisciplinary, proactive patient centered approach
• Autonomous – owned & managed by working clinicians
• Well supported – management, support staff; Health IT
Value contract – funds from ‘shared value’ with Medical Schemes:
• Individual/FFS replaced by monthly Population Risk team fees +
Upside ‘Value’ rewards – quality/prudence measures
• Competition is between coherent systems ~ via Schemes
How to achieve Population Medicine /
Integrated Care / Value Contract?
6
Integrated Clinical ConsortiaTM
• ICCTMis a commercial entity and the working clinicians are its shareholders.
• Well supported multidisciplinary teams matched to local population needs
• Earnings are jointly determined by Value Contracts with Schemes
• Care is supported through a Clinical Care IT support system
• Enables proactive management of the clinical and social circumstances of every patient.
Service Lines
General Integrated Care
Plans
Social interventions
Maternity and Confinement
Early Childhood
ENT & Respiratory Care
Primary Care
General Specialist care
Hospital/ Other care
Paediatrician
General hospital
Sub-acute facility
Hospice
Home nurse agency
General Practitioner
Physician
Allied Healthcare professionals
incl Midwife, OT, Social Worker
Mid level workers incl clinical
associates, nurse coordinators
O&G
Psychiatrist
Gastroenterologist, Cardiologists;
Endocrinologist etc
General & ENT Surgeon
Community organisations
Integrated Clinical Consortium
Sub-contract
Local; integrated care delivery to
stable, defined populations
0.5
Physici
an
0.1
ENT,
Uro
Hospital and other specialists
Diabetes
6 GPs; Allieds;
mid level workers
0.2
Psych
0.1
ENT,
Uro
0.3
Paeds
6 GPs; Allieds;
mid level workers
0.2
Psych
Home Nurse agency; Step down
hospital
0.2
Gynae
0.2
Gynae
0.5
Physici
an
0.1
ENT,
Uro
0.3
Paeds
IHD
6 GPs; Allieds;
mid level workers
2%
0.2
Psych
isolation
0.2
Gynae
0.5
Physici
an
0.5
Physici
an
0.1
ENT,
Uro
0.1
ENT,
Uro
0.3
Paeds
6 GPs; Allieds;
0.3
Paeds
mid level workers
0.2
Psych
0.5
Physici
an
Early
dementia
Chronic
illness
mid level workers
6 GPs; Allieds;
Rad/ Path
PVD
0.3
Paeds
Com
plex;
multi
morb
idity
0.5
Physici
an
0.2
Psych
0.2
Gynae
0.2
Gynae
Myeloma
0.1
ENT,
Uro
0.3
Paeds
6 GPs; Allieds;
mid level workers
8%
0.2
Psych
0.2
Gynae
Care plans by need segments
0.5
Physici
an
0.1
ENT,
Uro
0.3
Paeds
6 GPs; Allieds;
Integrated Clinical Consortium
Supported by PPO Serve
0.1
ENT,
Uro
0.3
Paeds
mid level workers
obesity
0.2
Gynae
0.1
ENT,
Uro
0.3
Paeds
25%
6 GPs; Allieds;
0.2
Gynae
6 GPs; Allieds;
mid level workers
0.2
Psych
0.5
Physici
an
0.1
ENT,
Uro
0.3
Paeds
6 GPs; Allieds;
mid level workers
0.2
Psych
Paediaticians; Physicians;
Geriatricians; Psychiatrists;
Gynaecologists; ENT, Urologists
0.5
Physici
an
At risk
0.2
Psych
0.2
Psych
General Practitioner; Allied
Healthcare Professionals; Mid
level workers
mid level workers
0.5
Physici
an
0.2
Gynae
Healthy
65%
0.2
Gynae
Hypertension
Contract basis:
Population
based
projections
ICC Contract; Care
Plans &
Coordinators; MDT
meetings; EMR
deployed
Social support;
conservative Ortho;
Palliative Care;
better PES; less
ER/readmit,
surgery/ICU
20
3 2
Best Patient
Experience;
multiple new
quality initiatives;
highest prudence
15
60
Baseline structure,
process, patient
satisfaction
&outcome scores
PPO
Serve
5
12
Tiered Value targets:
40
35
5
3
0
Clinical
Consortia
Clinical
Consortiu
Clinical
Consortiu
Integrated Care system reform:
More effective for Schemes and members
Supply side reengineered
Managed care projects
Adoption:
•
•
Performance:
Savings and
Measured Quality
30-40%:
• Scale, focus => full clinical care management system
• Investment & experience => mature, evolving
competence
• ‘Hub’ PPO Serve => rapid dispersal of good practice
3-4%:
• tentative, parallel silos; ongoing
fragmentation
Effective
Governance:
•
•
Clinical team works in the same integrated system:
regardless of patients Scheme = embraced change
‘Value contract’ Schemes => governance is back to
clinicians => invest in management, tools,
infrastructure => autonomy, efficacy, clinical
excellence => Better outcomes
++ Scheme projects =>
contradictory, silo, uncertain
remuneration = resistance to
change
Restricted benefits, Protocols,
Disease Management = disparate
efforts, low effect => poor system
performance
Integrated Clinical Consortia:
Patients Value Proposition
Patients:
• personalised care (plan) from an complete local
system
• healthcare services are patient centered,
coordinated, accountable
• Rare interactions with Schemes
Effective Care is a new healthcare system made up of locally organised care for communities.
Effective Care has a clear and regular connection to every person enrolled with the service,
from pregnant young women and children with blocked ears and winter chest infections to
the adult with chronic illness like hypertension and diabetes.
Past medical problems are carefully noted and protected over many years, and the
combined story leads to a well-thought-out care plan for every person. This plan is
embedded in an Electronic Medical Record and leads to ongoing care that is planned and
effective, with no gaps or waste
Consumers:
• local health systems are branded, known entities
with sound reputations for the quality of their
integrated care
Peninsula ICCTM - Effective Care
• Schemes that contract with them share their
reputation and sell their story
Effective Care is delivered by professionals working in teams, made up of doctors (both
general practitioners and specialists) and other health care workers. They work together,
with shared support staff and a locally connected electronic Clinical Care system, and they
also follow patients to Effective Care wards (including labour wards) in co-operating
hospitals. They are organised so that the patients’ medical problem gets the right attention
at the right time. The Effective Care team knows that effective and good quality makes
patients happy and is affordable.
Your Medical Scheme backs the Amber Care clinical team to make the right decisions in a
contract that measures and rewards quality care.
So calls to the Scheme for authorisation and to enquire about claim payment just aren’t
needed.
Access to the Effective Care network is via your Med ical Scheme. There is no additional cost to you 1.
The sooner you join, and the longer you’re a memb er, the more the team knows about your issues and
your preferences, leading to higher quality care and care satisfaction.
To find out more, contact XXX on 0800 000 000 or your medical scheme
TM
Effective Care network is a project of regionally based and independent Integrated Clinical Consortia
supported by PPO Serve – better health, lower costs, inspired clinicians
1
The Rules that Schemes apply may differ. Your family doctor may have joined the network. If not, the
Effective Care network will get your past clinical history from your doctor and your Medical Scheme.
Integrated Clinical Consortia:
Individual Clinicians Value Proposition
• Income is generous links to patient complexity, clinical practice experience &
merit
• Gratifying work - proactive population care; top of scope practice & team
work matching each individual patient needs
• Clinical autonomy regained in a collaborative, commercial entity which
they own & govern. Elected clinical leaders
promote healthcare quality and prudence:
•
•
•
Peer mentoring
Strategic performance and planning
Promotes consortiums brand /
reputation for integrated quality care
Consortium as a local empowering nexus: balancing the
strength of Schemes & network hospitals
Reliable Earnings
Remunerated for
population care, not
through each patient
interaction
Caring for the health of
the whole population
Practice population
medicine looking after the
best interests of each
patient and the local
community
Teamwork
Integrated Care in a team allows for
flexible working hours and involvement
leading to happier, inspired clinicians
Helping get the inspiration back…
Be er Health. Lower Costs. Inspired Clinicians
PPO Serve assists and suppor ts clinicians to build r egionally based
and independent Integrated Clinical ConsortiaTM.
Be Inspired. Change the way you pr actice. Call us on XXX
THANK YOU