Clinical specialist at Discovery Health, Dr Sandile Mhlongo provides insights on how disease management programmes place patients at the centre of care.
Today’s primary care physicians are custodians of preventative healthcare.
As a patient’s first port of call, primary care providers are uniquely placed to encourage the lifestyle improvement behaviours that keep healthy patients in this state. They also detect, diagnose and treat the early signs of chronic illness, nipping long-term complications in the bud.
It’s a mammoth responsibility in a world in which digitisation has disrupted traditional healthcare models and in which patients are ever-more empowered consumers of healthcare. Discovery Health’s new digitally-enabled, disease management programmes aim to support Premier Plus GP network doctors who treat chronic illnesses. These programmes facilitate evidence-based care (backed by local and international clinical guidelines) and offer enhanced benefits to both participating doctors and patients.
These programmes reinforce the role of the GP as a gatekeeper of patient care whilst placing patients at the centre of care, so empowering them to take responsibility for managing their health. Participation is voluntary. Efficiencies generated by each programme are plugged back into the system, boosting financial rewards offered to engaged doctors and enhancing patient benefits.
Discovery Health’s app-based electronic health record - HealthID - forms the digital backbone, allowing for clinical data capture, analysis of clinical progress, online benefit and medication applications and more. HealthID also allows for the sharing of outcome scorecards and quality reports with doctors for key clinical and efficiency insights.
Disease management programmes tackle NCDs strategically
Global evidence has emphasised the need for disease management programmes to stem the tide of non-communicable diseases (NCDs) that is crippling healthcare systems all over the world. A June 2018 WHO Fact Sheet on the theme, states: “High-impact, essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment.”
The WHO emphasises the so-called 4-4-80 principle: over 80% of all NCD-linked deaths stem from four leading chronic conditions (cancers, diabetes, cardiovascular and chronic respiratory diseases) and these are, in turn, fuelled by four modifiable risk factors:
- tobacco use (accounts for 7.2 million deaths per year)
- physical inactivity (1.6 million deaths annually attributed to insufficient physical activity)
- harmful use of alcohol (over half of the 3.3 million annual deaths attributable to alcohol use are from NCDs, including cancer)
- unhealthy diets (4.1 million annual deaths attributed to excess salt/sodium intake)
It’s estimated that, between 2006 and 2015, the accumulated losses to South Africa’s GDP from diabetes, stroke and coronary heart disease alone have cost the country around R27.5 billion.
Over the past six years, there’s been a 40% increase in the prevalence of Type 2 Diabetes Mellitus (T2DM) among members of Discovery Health Medical Scheme alone (with an 8.8% increase between 2017 and 2018). People living with chronic illnesses such T2DM, cost this medical scheme four times more than the average patient every year. And, Discovery Health’s data show that the sickest scheme members usually present with costly, complex, multi-morbidities. While 70% of Discovery Health Medical Scheme members with T2DM have hypertension and 57% of patients have hyperlipidaemia, a staggering 81% present with both hypertension and hyperlipidaemia.
According to a landmark study (Lancet) on Diabetes in Sub-Saharan Africa, between 1980 and 2015, the number of people older than 20 years with a BMI of greater than 25 kg/m² increased from 28 million, to 127 million. Over 90% of diabetes cases in sub-Saharan Africa are T2DM, so modifiable risk factors are major contributors to the burden of disease. The International Diabetes Federation reports that, globally, 425 million people have diabetes. Alarmingly, particularly on the African continent, outdated registries mean that the true extent of the diabetes problem isn’t known. This scenario pertains to other chronic illnesses also.
Tackling Diabetes, HIV, cardiac and mental health through key care partnerships
Discovery Health’s disease management programmes include Diabetes Care, launched in January 2017 and HIV Care, launched in January 2018. In 2019, Discovery Health will launch Cardio Care, for patients with chronic cardiac-health related conditions; as well as Mental Care, to support members with episodic and early onset major depression.
Doctors engaged in the programmes access:
- Enhanced digital tools that support clinically intelligent disease management through HealthID. This app-based platform enables doctors to view each consenting patients’ medical journey including consultations with other doctors, hospital admissions and so on
- Quality of care measurements for individual patients and a GP’s patient population (clinical scorecards, practice dashboards) with reports on patients’ short and long-term outcomes
- Higher remuneration (a monthly management fee for every enrolled patient and higher fee for extended consultations with patients)
- Benefits for patients (healthy lifestyle programmes through Discovery Vitality and more)
- Enhanced doctor-patient relationships through better understanding of patients’ needs.
What’s in it for patients?
- Comprehensive medical care
- Coordination of care through their GP to specialists and allied support services
- Active participation in their healthcare choices, enhanced education about their condition
- Additional risk benefits give access to a broad network of allied healthcare providers and health coaches
- Enhanced doctor-patient relationship
- Rewards for healthy lifestyle choices, in alignment with Vitality Active Rewards benefits.
Healthy lifestyle choices are fundamental to reversing NCDs. Published research and Vitality data both indicate that, compared to non-Vitality members, engaged members have 10% lower hospital admissions, 25% shorter hospital stays and 14% lower overall claims costs. The British Journal of Sports Medicine recently reported on the Vitality Active Rewards programme’s ability to improving physical activity through personalised activity goals, alignment to digital, wearable, activity-tracking technology and short- and long-term financial reward incentives to members. Vitality’s impact reduces the Discovery Health Medical Scheme’s claims costs by around 3% each year – generating total savings of approximately R11.6 billion since 2008.
Short-term data paints a promising picture
Statistically and chronologically speaking, it’s early days for Diabetes Care and HIV Care programme analysis. Yet, short-term data analysis verifies that enhancing doctor-patient engagement through disease management programmes, does result in improved adherence, with evidence-based care.
Data on members on the HIV Care programme show levels of just over 80% for both drug compliance and viral suppression, as well as higher screening rates than are evident for non HIV Care members. Our target is to reach 90% adherence for all three of these targets, as guided by UNAIDS’ ‘90-90-90 ‘Treatment for All’ campaign.
Diabetes Care was launched in January 2017. By December 2018, over 18000 Discovery Health Medical Scheme members had signed up. Around 80% of members have chronic heart problems too and many have also had a stroke or have retinopathy or peripheral vascular disease linked to unmanaged diabetes. Their cardiac and cardiac-renal co-morbidities are behind the highest diabetes-related claims to the Discovery Health Medical Scheme. Encouragingly, compared to non-programme members, members engaged in Diabetes Care have almost triple the number of visits to dieticians, biokineticists, podiatrists and optometrists. In terms of screening and monitoring tests, Diabetes Care members undertake significantly more HbA1c, lipogram and kidney function tests. Diabetes Care members also show far higher enrolment in chronic illness programmes that govern cancer, kidney and heart disease care, and have between 10 and 20% lower admission rates as well as up to 6% lower re-admission rates. Their in- and out-of hospital claims are also up to R2000 less per member, per month.
There has also been a month-on-month increase in the number of Premier Plus network doctors aligned to our disease management programmes.
Going forward: Recognising our doctors, improving care pathways
Our aim is that 2019 will bring progress around automation of regular doctor’s appointments for patients, via HealthID. We also hope to instil digital reminders to support patients in their adherence to prescribed medications and more. Doctors will also enjoy enhanced allied health care support. For example, Premier Plus doctors will be able to connect patients with a nurse educator, dietician or health coach, to support patients between doctor’s visits and answer patients’ day-to-day questions so that daily disease management habits become simpler for patients to understand. Programme members will also enjoy greater lifestyle rewards through Vitality, motivating them towards ever-healthier, daily lifestyle choices.
There is no question that these programmes will continue to improve patient outcomes and better the doctor-patient relationship.