FIRST PORT OF CALL: Developing an outcomes-based contract for primary care AUTHORS Victoria Barr Odwa Mazwai
PEER REVIEWER: Buddy Modi
EXECUTIVE SUMMARY There is a desperate need for standardisation of alternative reimbursement models (ARMs). In 2020, Sizwe Medical Fund embarked on a collaborative process to design a value-based contract to support its long-term vision of patient-centred primary care and preventive population health management. The contract combines a capitated fee with an outcomes-based component. The capitation mechanism encourages clinicians to deliver care cost-effectively, while the outcomes-based payment incentivises them to promote patient health and addresses the risk of under-servicing. Key contract elements to be determined included the scope of services covered, aligning benefit structure, design of the payment model, and selection and weighting of the outcomes. The Sizwe model has a tiered structure, with two levels of the capitation fee associated with different service packages. The fee level also depends on a provider’s performance across five outcome domains: general physical and mental health; prevention and management of acute episodes; characteristics of good primary care; quality of care; and financial outcomes. General agreement on the need for ARMs has not led to widespread adoption in South Africa or globally. Some of the major barriers to implementation are: the diversity of providers; absence of precedent on the measurement of outcomes and their use in contracting; lack of trust between funders and providers; and the limited use of electronic health records in GP practices. The Sizwe experience shows that these hurdles can be overcome when approached with a balance of idealism and pragmatism, and therefore helps to lay the foundation for the implementation of value-based healthcare in a national health insurance (NHI) environment. In 2020, Sizwe Medical Fund set out to redesign an existing capitated contract for primary care services provided to beneficiaries on its entry-level option. The aim was to introduce a value-based payment model, combining an outcomes-based component with the existing capitated fee. Despite widespread agreement on the need for ARMs, providers and funders have struggled to implement value-based contracts, both globally and in South Africa. This article presents key features of the Sizwe model, as well as discussion of the challenges to the implementation of value-based approaches.
20 2 0 S O UT H E R N A FR IC A N H E A LT H JO UR N A L P U B L I S H E D B Y T H E B O A R D O F H E A LT H C A R E F U N D E R S
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