Outcomes measurement and reporting (OMR) have the potential to address many failings in the South African health system. However, despite agreement among most stakeholders that this is the way to go, nothing much has happened to start implementing a system aimed at improving the quality and accessibility of healthcare and maximising the value for patients by achieving the best outcomes for the lowest costs.

The Health Market Inquiry’s 2019 report that found the absence of appropriate information on the quality of health services in South Africa to be a major constraint to moving towards value-based purchasing of healthcare services.

To discuss the many challenges and “potholes” obstructing and delaying the adoption of an effective OMR system and finding solutions to address the current fragmented system, poor patient outcomes and high costs, local and international experts gathered in the beginning of September for the first virtual Outcome Measurement and Reporting Conference (OMRC).

One of the main messages coming out of the conference was that there was no time to waste in setting up an OMR system, encompassing both the private and public sector and involving all role-players in the delivery of health services including government, regulators, healthcare providers, medical schemes and academia.

Opening the conference, organiser, Dr Andrew Good from Lifechoice stressed that HMI recommended that OMR should not be subject to political interference or commercial influence and should be practitioner driven.  He stressed the need to create a forum to debate outcomes and practical considerations that will inform the journey to the establishment of a value-based system that will benefit all patients and the providers that serve them.

“We should agree that the road we take must service everyone in the country, that it must be a single road interlinking the private and public sector and that we must all work together to make the road the best we can,” Dr Good said.

OMR: What is needed

In her presentation, HMI panellist Prof Sharon Fonn reiterated the lack of standardised measures of quality and outcomes in the current healthcare market.

“Consumers are uninformed and cannot compare the services they pay for, practitioners cannot benchmark themselves against each other or refer their patients based on quality and funders cannot contract based on quality. No one in this market knows what they are purchasing or what they are selling,“ Prof Fonn said. She reiterated that the public sector had a responsibility to demonstrate the value it was delivering to patients.

Outcomes measures, she added, are not process measures as done by the Office of Health Standards Compliance (OHSC) or satisfaction surveys conducted by private hospitals but should determine if treatment and clinical interventions result in improving patients’ health and quality of life.

According to Prof Fonn, the establishment of an independent body funded by multiple income streams such as the Outcomes Measurement Reporting Organisation (OMRO) recommended by the HMI is key to ensuring that quality measurement and the reporting of outcomes are done in a transparent, effective, and credible way without any vested interests.

“It should be outside government, the private sector and clinician societies because each of them has vested interests,” she explained.

Getting academia on board

A starting point, she proposed, is getting universities and the College of Medicine involved in setting up the system as they have the expertise, capacity and independence to research and determine what quality outcomes should be and publish the results.

“Academia should be leading it by setting it up, measuring the results and write about it. They should also be involved in training the range of providers required to make it possible, including clinicians, other health professionals, data scientists and statisticians,” Prof Fonn elaborated.

Presenting his views, HMI panellist, Dr Ntuthuko Bhengu reiterated the Inquiry’s findings that outcomes measurement is the most desirable measure of quality that stakeholders should aim for to address the lack of information that is available in the South African health system.

OMR must be practitioner-driven

Dr Bhengu stressed that the system should be practitioner-driven, and that OMRO should collaborate with existing condition-specific registries and stimulate new initiatives. He said while questions are being asked about why it is necessary to establish a new body, the HMI found that given their current functions, bodies such as the Office of Health Standards Compliance, the CMS and the HPCSA won’t be suitable options.

Referring to the pricing of services, Dr Bhengu made it clear that it should be value-based and not based on the FFS model, which he described as the biggest driver of high costs and overutilization.

“Outcomes are what ultimately matter to patients and are objective measures to assess the effectiveness of care. When combined with cost data, they enable the measurement of value, which is an essential indicator for comparing providers. The lack of outcomes information seriously impairs competition between providers, limits consumer choice and prevents value-based contracting with funders,” Dr Bhengu concluded.

Structural changes in contracting

Pointing out the many problems and inefficiencies relating to quality and the cost of healthcare services in the private and public sector, Prof Alex van den Heever stressed the need for structural changes to the way contracting occurs. In the private sector, he said, the changes will need to ensure that medical schemes purchase health services and contract with providers based on the quality and value of the services rendered, he emphasised.

Stating that FFS is a major impediment in achieving these structural changes, Van den Heever said the three key factors that need to be integrated in value-purchasing were the quality of the product, the price and the demand for services.

“Currently, medical schemes separate these factors, making it impossible for consumers to determine the quality of the services they buy and if the options they choose are appropriate for their needs,” Van den Heever said.

Funders’ role

The Board of Healthcare Funders’ Head of Health System Strengthening, Dr Rajesh Patel, told delegates that the BHF is currently piloting an initiative based on the Effective Coverage model that is being used in several countries. Essentially a reporting and assessment tool, it allows medical schemes to score how they are doing in terms of addressing the needs of the at-risk population, the interventions they are getting, members’ access to these interventions and the outcomes that are achieved.

“It combines the quality and outcomes component and then measure the impact the interventions have in improving outcomes in key areas such as maternal health, infections, non-communicable diseases and cancers,” Dr Patel explained.

He stressed that there is a need for the funding industry to measure outcomes and protect, promote, maintain and improve the health of beneficiaries, and most importantly that the results achieved should be shared and published to all stakeholders. This should be done on a continuous basis to establish where interventions are needed, which interventions achieve the best results, where improvements are needed, and the data shared with both healthcare providers and members.

“The results should not be disclosed for the sake of disclosing but should be engaged on with all stakeholders to ensure there is continuous quality improvement,” Dr Patel added.

Most importantly, he suggested is that it should be a centralised, standardised, open-source measuring and scoring system that will enable the dissecting of the results to determine how they can be improved upon.

Family practitioners’ role

Discussing the central role family practitioners should play in an OMR system, Dr Good highlighted the findings from the HMI about the cost-drivers of care that have put the delivery of private healthcare and the future of medical schemes on an unsustainable trajectory. These include high utilisation, lack of price transparency, overservicing driven by the fee-for-service model, the disintermediation of scheme members and the lack of coordinated care management.

“Currently, there is no price transparency, no oversight on the treatment path or outcome information. The cost of treatment is rarely discussed with patients. They are often not informed about issues such as the rate the specialist they are referred to charge, the entire cost of the treatment that is recommended, the portion the medical scheme is likely to fund or given an option to see a specialist who charges less,” Dr Good noted.

There is also a lack of checks in the system to verify conditions patients are treated for, the prices that are being charged and most importantly the outcomes that are achieved.

Noting that it is universally accepted that health systems function best if care is coordinated and referral structured, Dr Good says this is still not happening in South Africa, leading to high utilisation and costs.

“High utilisation confirms the need for multidisciplinary practice and family practitioners’ involvement in multi-disciplinary decision-making. Family practitioners (FPs) should be involved in collecting the information relating to the success of conservative treatment and confirming when conservative management options have been exhausted. They should ensure that the treating team takes joint or full responsibility for the cycle of care and that a single person such as a case manager oversees every patient’s care,” Dr Good emphasised.

“Furthermore, FPs as primary care practitioners should be involved in reviewing adherence to clinical pathways, documenting disease status, independently overseeing results, measuring the results of non-specialised or non-surgical treatment options, and verifying the accurate documentation of conditions.”

No time to waste

In her closing remarks, the CEO of the OHSC, Siphiwe Mdanweni said it is imperative that investments be made to develop health outcome measurement capability through the strengthening of information infrastructure that will ensure the improvement of patient health and care.

“We don’t need to wait for policy development around this. We all have a role in starting with the steps to develop an OMR system. The ultimate measure of success will be the involvement of all clinicians, health system managers in both the private and public sector, regulators and policymakers in creating a country-specific framework to advance the overall goals of the health system to ensure quality, effective, evidence-based care to the benefit of every patient in the country,” Dr Mdanweni concluded.

Closing the conference, Dr Good urged all interested parties to come together to discuss possible projects that can produce value-based care models aimed at contributing to the establishment of an independent OMR system.

“The door is open for clinical practitioners to take charge and drive this process. There is no doubt that we should progress, that we need multi-disciplinary approaches and be honest and transparent in our dealings, share information and improve price transparency and most importantly collaborate to make it possible,” Dr Good concluded.