In response to a worsening affordability
crisis in medical aid in South Africa, a clinician-owned company in Alberton,
Gauteng, has been transforming the way private medical care is practiced and paid
for by medical schemes. The team is made up of medical specialists, general
practitioners and nurses, with allied healthcare worker associates. Supported
by healthcare management company PPO Serve, they develop individual care plans
for each patient – meeting regularly around a table to discuss complex cases
and plan for the optimal care and best possible outcomes for their clients.

“Schemes should support these innovations
in the way medical care is delivered. Community-level accountable care models,
which reduce cost and promote team work, are the way to make medical aid
premiums affordable for working South Africans,” says health systems expert and
PPO Serve co-founder, Dr Brian Ruff.

Medical schemes, whose memberships are
stagnant or shrinking, are struggling to keep premiums down while continuing to
cover treatment costs. For many years, annual increases have exceeded
inflation, resulting in members buying down or forgoing medical aid entirely. Current
benefit schedules are generally strong for hospital based services but scant
for community-level care, resulting in schemes paying out heavily for expensive
in-hospital treatment and specialist care.

At the Alberton Pioneer Integrated Clinical
Consortium (ICC), nurses are the care co-ordinators. They conduct home visits
and assessments of physical and mental health, living conditions, family
environments and access to healthcare services. They work daily with each of
the doctors concerning the care of specific patients and the team meets
regularly to expand patients’ diagnosis and design care plans together. “Care
for complex patients has become well-coordinated and is far more holistic than
is usually the case in the private sector. A collaborative team culture now
exists in the Alberton team,” says Ruff.

In contrast to the status quo in South
Africa, in which schemes attempt to manage care and spend through restricted
benefits and pre-authorisation, the accountable care model gives local
multidisciplinary teams considerable freedom to manage the needs of their
community. Clinician-owned teams contract with funders in ways that ensure accountability
for outcomes, while promoting the delivery of needed care in a cost-effective
manner. Much care takes place within the home and at local facilities, avoiding
unnecessary hospitalisations. The Alberton consortium has built partnerships
with available medical and psychiatric facilities in the area they service, as
well as non-profits such as hospice.

The strength of this team-based and
community-level model is in managing complex medical conditions as well as the direct
impact of social, psychological and financial circumstances on patients’ illnesses
and treatment. “Despite their best efforts, lone clinicians cannot deliver this
level of holistic care or the health outcomes of such a collaborative treatment
model,” says Ruff.

Ruff says PPO Serve is working on many
other population medicine models like that at Alberton; “As these projects
mature, and as is already the case at Alberton, they will demonstrate their
value by improved scores on measures of both the quality of healthcare delivered,
as well as reduction in spend.”

“Holistic and preventative care, delivered by
a multi-disciplinary teams is the sustainable solution to the crisis of rising
premiums and shrinking memberships – this is the way forward,” says Ruff.