national-health-insuranceIt is proposed that the NHI Fund (NDOH in the interim) contracts with competitively-contracted medical scheme administrators per province to contract with GPs, NGOs and government clinics for a basic building block: A Community Practice, as the first step in NHI implementation. The current Department of Health (DOH) should progressively reorganize CHCs/Clinics into competent decentralized subdistrict (or smaller) units with independent boards that are able to contract with NHI and then removed from the remit of the DOH as they meet NHI accreditation standards. The Community Practice contract will be for a panel of 2000 (minimum) to 10000 (maximum) people per Accountable Doctor, with the minimum of 2000 raised to 6000 over eight years and the maximum of 10 000 being reviewed as coverage across the country is saturated with 6000 Accountable Doctors.

The idea in starting with a panel minimum of 2000 people (±40 patients a day) is to allow GPs to get used to the system and allow them to plan expansion on a firmer basis. The minimum of 2000 is not sustainable for South Africa as 10 000 primary care doctors will be required to cover ±60m people using 6000. There are currently 10 000 primary care doctors in SA (9000 in private and 1000 in public).

Community Practices are expected to competitively enroll patients from within a Health District, using the Health Patient Registry System (HPRS) to validate beneficiaries and to formally enroll for payment to start. The should be some administrative enrolment support from the NHI Fund and Department of Health in the Health District (funded progressively just for coordination and programmatic support). Each Community Practice should have a team led by an Accountable Doctor and must include a minimum number of nurses, clinical associates, and community health workers to ensure appropriate team-based approaches to care.

Those community members enrolled in Community Practice will have full access to the team in the Community Practice’s accredited facility for service. The service package can be defined broadly as office-based PHC elements of current national guidelines. For acute and chronic care, including mental health and palliative care the Community Practice could assume a visit rate of 4 visits per person per year. This means a Community Practice of 6000 people will see ±96 patients per day. The Community Practice is also expected to do a Comprehensive Health Check on every enrolled person once in five years. Assume a visit rate of 0.2 visits per person per year. This means that the Community Practice will have to see ±5 such Comprehensive Health Checks per person per day. This means a total of ±105 patients a day of this variety (acute, chronic, some preventive work and health checks) in the Community Practice for a panel of 6000. There will be a monthly prepaid Capitation Payment (per validated enrollee) that is initially adjusted for age, gender, social deprivation and rurality. Morbidity adjustments will be added in year two once valid data is collected with payment management data systems available in South Africa. Capitation payments will cater to consultations and very minor office tests e.g. urines etc.

The Accountable Doctor and team will dispense medicines (or send to a contracted pharmacy), send for lab tests and/or x-rays and do a short list of procedures (e.g. cautery, ECG, lung function etc.) for which the Community Practice (or contracted providers) will be paid a fee-for-service. Each Community Practice will also have to provide preventive services like family planning, immunization on a fee-for-service basis. Assume a visit rate of 1 visit per person per year. This means the Community Practice will see ±24 patients per day for these preventive services. The Community Practice will be paid separately for these visits, medicines dispensed (including dispensing fee) and tests done, as per defined lists and per claim submitted electronically using payment management data systems and paid as is usual with medical scheme claims currently.

The Community Practice is expected to progressively implement an electronic health record (EHR) related to outcomes performance management, with up to 20% performance payment paid per quarter retrospectively, in addition to the prepaid monthly capitation payment. The Accountable Doctor is expected (for now) to refer to a designated network in the public service for any other service needed (allieds, specialist and hospital) using a free software available – Vula. This system, besides facilitating good referral both ways, will allow important cost data to be collected and will allow contracting to be progressively expanded to include the private sector. Whilst private allieds, specialists and hospitals will be progressively contracted, using fee-for-service and diagnostic related groups, alternative re-imbursement models should be explored, especially given the expectation that Community Practices have to be very community-oriented and focused on prevention / case management. This is a major paradigm shift to a population approach and is why the model is called “Community” practice. It is intended to reduce allied, specialist and hospital costs using a stronger integrated model of Primary Health Care and allow Community Practices to later ‘buy’ these additional services or provide them in a more efficient manner using alternative reimbursement models currently being tested in South Africa.

The Community Practice is expected to profile all members of the panel population using mobile data collection tools linked to their EHRs and related to the Comprehensive Health Checks. The practice is expected to have an annual open day / priority-setting workshop with the panel population and then meet with elected leaders monthly to consult and plan the practices targeted health promotion efforts for the Community Practice panel in the community. The Community Practice is expected to send a representative to the Health District monthly to coordinate priority programme / health promotion activities, reduce fragmentation and ensure alignment with Health District planning and priorities.

The Accountable Doctor is expected to ensure all referrals are vetted, to provide clinical governance in the Community Practice and to meet monthly with a group of peers and referral specialists, led by a family physician from the NHI Fund, reviewing utilization of referrals, procedures, drugs and tests. The Accountable Doctor is also expected to do a practice-based part-time mostly online two-year Diploma in Family Medicine (if s/he has less than 15 years of experience in primary care) to ensure that s/he embraces the new model of Community Practice in a successful and sustainable manner. This should be supported by the family physician from the NHI Fund.