Opinionista Shabir Moosa 1 September 2019

What primary healthcare may look like under NHI – a proposal

Many South Africans have difficulty imagining what the National Health Insurance will look when implemented. There has been work done in South Africa to explore what primary healthcare might look like under NHI.

What follows is a proposal for primary healthcare, as the first step in National Health Insurance (NHI) implementation.

The proposal is that NHI contracts with medical scheme administrators in each province to manage NHI funds, much as medical schemes are managed now. It is one of the constructive suggestions I have made elsewhere. These NHI administrators should then contract with accredited publicly owned clinics, private general practitioners (GPs), and any non-government organisation or academic institution able to employ healthcare workers under the rules of the Health Professions Council of South Africa.

The contract should be for a panel of people as a basic primary healthcare building block to the NHI. I suggest the panel per accountable doctor be termed a community practice. The community practice contract should be for a panel of 2,000 people (minimum) to 10,000 people (maximum).

The idea in starting with a panel minimum of 2,000 people (about 32 patients a day at an expected visit rate of four visits per person per year) is to allow the mostly solo GPs in South Africa to get used to the new system and allow them to plan expansion on a firmer basis. However, a minimum of 2,000 is not sustainable to continue for South Africa as it will require 30,000 primary care doctors to cover approximately 60 million people in South Africa.

There are only 10,000 primary care doctors in SA (9,000 in private and 1,000 in public practice). This beginning minimum of 2,000 needs to be raised to 6,000 over eight years to ensure wider coverage of the population, otherwise many parts of the population, especially in rural areas, will suffer poorer care.

With good engagement, GPs should see the opportunity to grow their community practices to the maximum of 10,000 with a stronger team approach. South Africa needs 6,000 doctors to cover approximately 60 million people in practices of 10,000.

The Department of Health (DoH) should progressively reorganise and strengthen clinics and community health centres and then move accredited facilities from district health services into a district trust with an independent board appointed by the district health authority, that is able to contract with the NHI. This district trust could start as a district-level organisation and evolve towards sub-district units if there is a need for greater agility and capacity.

Each accredited clinic and clinics and community health centres should be organised into community practices with an accountable doctor for 10,000 people at most, that are clearly enrolled with the team. The 10,000 maximum is to ensure public providers add doctors to the team at the clinic. The contract payment at higher levels from the NHI should cater to employing the doctor.

Many may contest that 10,000 is too large a panel per doctor. Brazil has unusually large panels by global standards, with 3,000-4,500 per doctor because it includes a nurse in the team. South Africa has nurses and clinical associates who are very skilled clinically and can work effectively with task-shifting under the clinical leadership of an accountable doctor.

Each community practice should include a minimum number of nurses, clinical associates, and community health workers to ensure appropriate team-based approaches to care. As coverage is achieved across the country (including rural areas), more doctors are produced (including adding the Cuban-trained doctors) and more doctors are attracted to primary healthcare, this maximum of 10,000 per panel can be reviewed and decreased. Where the panel range eventually settles will depend on how well the government prioritises primary healthcare.

Certification and accreditation need not be problems. Providers can submit a self-assessment checklist (amended from the Ideal Clinic Manual) but know that they may have a random unannounced accreditation visit on average 1.25 times in five years. This can be partly outsourced by the Office of Health Standards Compliance to scale the inclusion of all providers.

Enrolment can be a challenge. The NHI should have campaigns to register every eligible person in the country, supported by the Department of Home Affairs and Independent Electoral Commission of South Africa. There is plenty of experience with this. This can scale quickly but will plateau, with some populations taking more time to reach.

As people are registered with validated documents, they should be loaded onto a central beneficiary database accessible to NHI scheme administrators, with all beneficiaries having an NHI card. The NHI should then provide all beneficiaries in a district with a list of all accredited and contracted providers (including publicly owned clinics, GPs and NGOs) as community practices with accountable doctors that they can enrol with. There can be some administrative enrolment support from the NHI Fund and Department of Health (in their coordination and programmatic support role) in local campaigns, especially to enrol poorly informed and marginalised communities.

All registered beneficiaries should formally visit and enrol with their provider of choice, within a health district as the catchment area, for prepaid monthly capitation payments to start from the NHI to their provider. Community practices should competitively enrol patients and do much the same as they do with current medical schemes in checking against the NHI beneficiary database. Challenges at district boundary areas and risk selection in enrolment should be managed. Gaps may show with progress and will require specific plans by the Department of Health.

Those beneficiaries enrolled in the community practice should have full access to the doctor-led team in the community practice’s accredited facility for service. The service package can be defined broadly as office-based primary healthcare elements of current national guidelines (including specialist associations).

For acute and chronic care, including mental health and palliative care, the community practice could assume a visit rate of four visits per person per year, based on current private capitation plans. This means a community practice of 6,000 people should see about 96 patients per day.

The community practice should also do a comprehensive health check on every enrolled person once in five years. One can assume a visit rate of 0.2 visits per person per year for this. This means the community practice should see about five such health checks per person per day. This means a total of about 100 patients a day of this variety (acute, chronic, some preventive work and health checks) in the community practice for a panel of 6,000.

There should be a monthly prepaid capitation payment (per validated enrollee) that is initially adjusted for age, gender, social deprivation and rurality. Morbidity adjustments can be added in year two once valid data is collected in year one. Capitation payments should cover the cost of consultations and minor office tests, eg. urine, pregnancy etc. All coded consultations should be transmitted via current practice management software/electronic data interchange and include the details of the healthcare worker seeing the patient. This should help the NHI understand the nature of teamwork being implemented.

The accountable doctor and team should dispense medicines (or send to a contracted pharmacy), send for laboratory tests and/or x-rays and do a shortlist of procedures (eg cautery, ECG, lung function etc) for which the community practice (or contracted providers) will be paid a fee-for-service. Each community practice should also provide preventive services such as family planning and immunisation on a fee-for-service basis (or sub-contract this service).

One can assume a visit rate of one visit per person per year. This means the community practice should see about 24 patients per day for these preventive services. The community practice should be paid a fee-for-service separately for these preventive visits, medicines dispensed (including dispensing fee) and tests done, as per defined lists and per claim submitted electronically using payment management systems/electronic data interchange. This should be paid as is usual with medical scheme claims currently.

Retrospective quarterly performance payments should start in year one with a few very simple measures, including fully enrolling the panel that has been contracted. Payment levels should be up to 20% of the prepaid monthly capitation payment to be of consequence. The measures should progressively include the practice of implementing an accredited electronic health record (EHR) related to the outcomes the government prioritises. The performance indicator sets should be laid out in a five- to 10-year plan that allows the software market to respond to EHR needs. There has to be a balance between performance management and delivery of quality care.

The community practice should profile all members of the panel population with community health workers using mobile data collection tools linked to the community practice’s EHR and related to the health checks. Care by community health workers in the community should be closely linked to care at the facility. The community practice should have an annual open day/priority-setting workshop with the panel population and then meet monthly with elected leaders to consult and plan the community practice’s targeted health promotion efforts for the community practice’s panel in the community. There should be empowering partnerships with the enrolled community and related stakeholders that advocate addressing social determinants of health.

Community practices need to provide 40 hours of services per week, with patients having a complaints hotline to the NHI for poor service overall. There should also be after-hours services provided up to 9pm that can be arranged as a group of community practices.

The accountable doctor should be able to refer patients to a designated network of the public service for any other service needed (specialist, hospital and allied health care,) using a free software available – Vula. This system, besides facilitating good referrals both ways, should allow important cost data to be collected. This can develop the base for contracting to progressively include the private sector.

While private specialist, hospital and allied healthcare should 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 community-oriented and focused on prevention/case management. This is a need for a major paradigm shift to a population approach and is the reason the model is called “community” practice. It is intended to reduce specialist, hospital and allied healthcare costs using a stronger integrated model of primary healthcare and to allow community practices to later “buy” these additional services or collaborate to provide them in a more efficient manner using alternative reimbursement models currently being tested in South Africa.

The community practice should send a representative to the district health management office monthly to coordinate priority programmes/health promotion activities, reduce fragmentation and ensure alignment with district health management office planning and priorities.

The accountable doctor should ensure that all referrals from the community practice team are vetted. S/he should provide clinical governance for the team in the community practice. S/he should meet monthly with a group of peers and referral specialists, led by a family physician from the NHI Fund. They should review utilisation of referrals, procedures, drugs and tests.

The accountable doctor should also 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 weekly visits by the family physician from the NHI Fund.

Infrastructure costs will need strong consideration as the current spend in the public service, as shown in the District Health Barometer 2017-2018, does not account for this. Most GPs will need to expand their facilities or move to new facilities to take on the larger panels and patient burden. This can be addressed by supporting providers with infrastructural grants of up to 50% for the development of facilities, with additional support for rural community practices. This can include EHRs. This means social infrastructure at half the cost one-off and without continued maintenance costs for the public purse.

This model of primary healthcare can be very effective to deliver high quality and cost-effective care. It can reduce the other levels of care with both strong referral management and community-oriented approaches to case management and prevention. Considering that the District Health Barometer 2017-2018 shows public primary healthcare all-inclusive costs at R1,155 per person per year this may get GPs seriously considering such a contract.

One does have to factor a number of issues into adjustments to this price – infrastructure costs, VAT, high utilisation rates and previous poor care in the public service. All GP leaders in South Africa have already indicated their support for this proposal.

Let us hope NHI policymakers look at this proposal. DM

Professor Shabir Moosa is a family physician and professor at the Department of Family Medicine and Primary Care, University of Witwatersrand and president of the African region of WONCA, World Organisation of Family Doctors.

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