Transcript Here
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