national-health-insuranceHere is a proposal for the NHI Fund to contract their administration to competitively-contracted medical scheme administrators per province to then 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 the NHI fund and then be removed from the remit of the DOH as they meet NHI accreditation standards. GPs and NGOs should be encouraged to join the NHI PHC network. The Community Practice contract will start with a panel of 2000 (minimum) to 10000 (maximum) people per Accountable Doctor.

Clinics should be supported to manage their funds for  their 10 000 panel with a District Management Support Team (similar to the District Clinical Specialist Team), as part of the Administrator contract. A minimum of 2000 is not sustainable for South Africa as 30 000 primary care doctors will be required to cover ±60m people. There were 10 000 primary care doctors in SA (9000 in private and 1000 in public) as at 2018. 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 as they join and allow them to plan expansion on a firmer basis by reaching 6000 over eight years (500/year). The maximum of 10 000 can be reviewed downwards as coverage across the country becomes universally saturated with more than 6000 standardised Community Practices (each having an Accountable Doctor) for 60 million people. A larger than global panel size of 6000 per doctor/team could be South Africa’s equilibrium model, until we attract more doctors to primary health care and family medicine and bring it further down. Brazil, the current global largest, has 3500 persons per doctor. South Africa has plenty of experience with team-based care to work at these levels until more doctors are produced.

Community Practices should be expected to competitively enroll patients from within a Health District (aligned with Districts/Metros), validating NHI beneficiary cards and then formally enrolling them into the Community Practice for payment to start. There 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 should 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 with service defined by the standard personnel mix. For acute and chronic care, including mental health and palliative care the Community Practice can assume a visit rate of 4 visits per person per year (based on private sector capitation experience). A Community Practice of 10000 people will see 160 patients per day. A community-oriented primary care (COPC) approach can drive costs down as prevention keeps people healthier and happier at home with a visit rate of 1 visits per person per year or 40 patients per day (based on Chiawelo Community Practice experience). A Community Practice is also expected to do a Comprehensive Health Check on every enrolled person once in five years as part of prevention. This means a total of ±165 patients a day of this variety (acute, chronic, some preventive work and health checks) in the Community Practice for a panel of 10000 (or 45 patients a day with COPC). These free visits will be covered by a monthly prepaid Capitation Payment (per validated enrollee) that is 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 and should constitute ±70% of income.

The Accountable Doctor and team will also 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 by NHI administrators, covering ±20% of income. 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 ±40 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.

A Community Practice is expected to progressively implement an electronic health record (EHR) related to outcomes performance management, (with a 10% allocation) and between 0% and 20% performance payment paid per quarter retrospectively, in addition to the prepaid monthly capitation and fee-for-service payments. The Accountable Doctor is expected (for now) to refer to a designated network in the public service in each Health District 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 others in the private sector. Whilst private allieds, specialists and hospitals will be progressively contracted, using fee-for-service and diagnostic related groups, alternative reimbursement models could 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.

A 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. COPC practice includes publicly-available annual open days / priority-setting workshops with the panel population and meetings 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. This will create a cascade of learning and quality in Community Practices across the country.

This summary is based on actual work done for National Treasury and National Department of Health of South Africa in 2018. See below.

NHI PHC Administration Agreement v1.2 – Draft 1

NHI PHC Contract Operational Manual v1.2 – Draft 1

NHI PHC Contract v1.2 – Draft 1 Annexures

NHI PHC Contract v1.2 – Draft 1