Uniqueness of TVCT:
TVCT pioneered VBC in South Africa and was the first team to offer:
- Integrated care from a TVCT Coach lead team of GPs, specialists, AHPs, Care coordinators etc funded by a VBC contract with a medical scheme
- Patient management from the Intelligent Care System (ICS), a custom-built patient centric clinical workflow system for shared use by a multi-disciplinary team (MDT)
- A risk-adjusted global fee for the GP Practices with significant additional compensation based on outcomes (average a third of total income, half for top performers)
- Active outcome monitoring, data directed interventions
- MDT meetings for CME and complex patient case study discussions
Aim/relevance:
South Africa has a two-tiered health care system. 80% of the population uses the under-resourced public sector, the remainder uses the better resourced but expensive private sector. The government’s goal is for a unified National Health Insurance scheme.
The current private system is dysfunctional – medical scheme cover is expensive because of hyper-specialisation, overservicing (incentivised because of FFS) and waste. Doctors work alone, competing rather than collaborating with colleagues. Comprehensive patient information is unavailable. This impacts on quality of care. The system can manage trauma and single disease crises, but not complex, multimorbidity patients, who drive the system’s cost.
TVCT is transforming this by providing quality health care at a lower cost, consistent with the NHI’s vision.
Patient description and involvement
TVCT is a population medicine programme for integrated care of the enrolled population of GP Practices in a defined geography.
The population is divided into risk cohorts – healthy, significant condition, at risk, high risk based on clinical profiles, to manage individual needs more efficiently.
Upon enrolment a Whole Patient Assessment is done on the ICS which provides the team with clinical and psycho-social information. Data is combined with scheme data to create a clinical summary and assign care plans for proactive patient management.
Methods
The population under care is managed by:
- Leveraging the GP medical skills via the Care Coordinators and AHPs as opposed to over-utilising expensive specialists
- Preventing unnecessary hospitalisations – unnecessary surgery, readmissions, admissions where it is safer from the strengthened PHC system
- Incentivising better care by linking a portion of clinician payments to well-defined outcomes (15 Primary health care measures and 5 Admission and spend metrics)
Size/scope
TVCT has been operating in Pretoria North since September 2019. Originally 2300 members, TVCT has grown by 158% to nearly 6000 members. The team currently consists of a TVCT Coach, 5 GP practices with 19 GPs, 3 Care-Co-ordinators, 3 AHPs and a palliative care specialist.
Having secured a permanent 3rd party scheme contract it is now set to expand to the rest of South Africa, projected to grow to half a million lives by 2030.
Important preliminary results
The project has had 3 formal evaluations by end 2022. The VBC scores were 46%, 29% (during Covid) and 70%. The improvement in the third score was driven by the Admission and Spend metrics. Currently, overall hospital admissions are 2.4% lower than expected admissions for the given population.