NEJM Catalyst publishes study: "Improving diabetes care in South Africa through a shared-value model"

Authors

Members of the Discovery Health SRM and Risk Intelligence team collectively responsible for the design, implementation, and analytics associated with the Discovery Health Diabetes Shared-Value Programme: Jane Ball (Chief specialist: Population Health Management), Nikash Bagirathi (Head of Care Management), Claudia Pastellides (Actuary), and Xolani Masombuka (Analyst).

Quick overview

In March 2025, NEJM Catalyst published a study titled, "Improving diabetes care in South Africa through a shared-value model". The study was carried out by Discovery Health's Jane Ball, Claudia Pastellides, Nikash Bagirathi, and Xolani Masombuka. It explores the implementation and outcomes of the Discovery Health Diabetes Shared-Value Programme (DHDSVP). This Programme kicked off in 2021, and is available to Discovery Health Medical Scheme members who have type 2 diabetes and addresses uncoordinated or suboptimal quality of care, and the rising costs associated with treating this condition. Scheme members are invited (voluntary) to join the Programme by a dedicated primary care provider who will work with them in managing the condition. Regular monitoring, patient education, proactive management, and incentives for both patients and healthcare providers who meet targets define the 'shared-value' approach. From 2021 - 2023, Scheme members enrolled on the Programme showed meaningful improvements in HbA1c testing rates, glycaemic control, and disease stability, with reduced hospital admissions and length of stay. The linked reduction in health care expenses meant savings for the Scheme. The research shows how a shared-value approach is key to improving quality-of-care outcomes for members with diabetes and reducing healthcare costs.

Enhancing diabetes care through a shared-value model

Diabetes is a growing health concern in South Africa, with type 2 diabetes being particularly prevalent. The same trends are apparent for Discovery Health Medical Scheme (DHMS) members: In 2014, 2.8% of the 2.9 million members of the Scheme had been diagnosed with type 2 diabetes. By 2023 this had increased to 5% of the Scheme's then 3 million members.

Hospital admissions are the primary cost for this cohort, accounting for, on average, 70% of total health care expenditure per annum for these members. This cost grew from R3.0 billion in 2014 to R10.6 billion in 2023 (compound annual growth rate of 14.9%). Furthermore, in 2020 only 56% of DHMS members living with type 2 diabetes had at least one HbA1c test in the year but only 65% of members had an in-range result.

For people living with type 2 diabetes, improved process measures and clinical metrics have long been associated with better health outcomes and lower health care costs.

Developing a proof of concept shared-value model for type 2 diabetes care

In 2020 the Discovery Health team set out to develop a proof of concept shared-value model that would enhance care for Scheme members living with type 2 diabetes. This, in alignment with the Discovery Group's stated core purpose of making people healthier and enhancing and protecting their lives. The business case relied on determining the value that could be unlocked through an investment in short-term actions that create substantial legacy benefits over time.

The Discovery Health Diabetes Shared-Value Programme was designed with two key objectives in mind:

• Improve clinical outcomes and quality of life for members who have type 2 diabetes; and
• Delay disease progression and arrest the rising costs linked to advancing diabetes.

Achieving these objectives (setting targets) would generate value - cost-savings - that could be channelled back into the system in a virtuous, shared-value cycle, creating a sustainable model that benefits all stakeholders (patients, medical practitioners and health funders) and enhances the overall value of the health system.

Progression of type 2 diabetes was mapped across four distinct disease stages based on clinical guidelines and the severity of the disease, from early diagnosis to advanced complications. This allowed us to track progression of disease in Scheme members over time and map the impact of the Discovery Health Diabetes Shared-Value Programme on disease management.

We established in-range HbA1c targets - based on international diabetes management guidelines - to ensure optimal glycaemic control and reduce the risk of diabetes-related complications.

We analysed costs associated with out-of-range HbA1c results and disease progression through the four disease stages. It was found that members with out-of-range HbA1c results incurred higher healthcare costs compared to those with in-range results. These costs were associated with increased hospital admissions, longer lengths of stay, and more frequent medical interventions. Additionally, as members progressed through the four disease stages, the costs associated with their care increased significantly. This highlighted the importance of maintaining in-range HbA1c levels to manage costs effectively and to secure quality of life for members.

How does the Diabetes Shared-Value Programme work?

The Discovery Health Diabetes Shared-Value Programme was launched in 2021 and continues to date. Our research, published in NEJM Catalyst, reports back on the first three years of the programme.

• Digital, peer-reviewed journal NEJM Catalyst brings health care executives, clinical leaders, and clinicians together to share innovative ideas and practical applications for enhancing the value of health care delivery and showcasing actionable solutions through which to address urgent healthcare challenges. NEJM Group is a division of the Massachusetts Medical Society.

The Programme supports members who have type 2 diabetes in managing their condition more effectively through regular monitoring, education, and proactive care, in partnership with a dedicated primary healthcare provider or related healthcare professionals. Medical practitioners in the DHMS network are able to invite members who are registered with type 2 diabetes to voluntarily enrol in the diabetes disease management programme and also to nominate the doctor as their primary care provider (who coordinates their health needs, including diabetes management). Enrolled members access additional benefits to support shared decision-making and self-management, such as cover for extended (one hour) primary care doctor consultations and for visits with a biokineticist and dietitian, and more. Key metrics such as haemoglobin A1c (HbA1c) testing rates, glycaemic control, and disease stage stability are closely monitored.

• Improved health outcomes: By focusing on regular monitoring and proactive management, the Programme aims to improve glycaemic control among members. This leads to better health outcomes, which in turn reduce hospital admissions and bring about shorter lengths of stay in hospital, with cost savings for members and DHMS.

• Incentives and support: The Discovery Health Diabetes Shared-Value Programme provides incentives for both patients and healthcare providers:

  • For patients, this includes rewards for maintaining in-range HbA1c levels or participating in regular health check-ups and more.

  • For healthcare providers, the Programme offers support and resources to help deliver high-quality patient care alongside shared-value remuneration where a) the patient cohort achieves disease stability and b) meets HbA1c in-range targets (even where disease stability is not achieved), together giving practitioners up to R1500 a year over and above standard pay for their services.

Summary of findings from our study 'Improving diabetes care in South Africa through a shared-value model'

The study factored in data from a total of 149,777 medical scheme members over a three year period (January 2021-December 2023).

From 2021 to 2023, the proportion of DHMS members living with type 2 diabetes and enrolled on the Discovery Health Diabetes Shared-Value Programme went from 42% to 47% of Scheme members who live with type 2 diabetes. At the end of 2023, there were 1,612 medical practitioners and 65,804 members participating in the Programme.

Over our 3-year study period (January 2021-December 2023), participants in the Discovery Health Diabetes Shared-Value Programme demonstrated significant improvements in four important areas:

1. HbA1c testing rates: Regular HbA1c testing is crucial for monitoring blood sugar levels and adjusting treatment plans accordingly. The Programme's emphasis on regular testing ensured that members received timely and appropriate care, leading to better glycaemic control. The increase in HbA1c testing rates and in-range results for members enrolled in the programme shows the value of superior diabetes care.

   • Members enrolled in the shared-value Programme had an average HbA1c testing rate of 82% over the study period, compared to 57% for those not enrolled.

2. Glycaemic control: Improved glycaemic control is associated with a lower risk of diabetes-related complications, such as cardiovascular disease, kidney disease, and neuropathy. The Programme's focus on proactive management, and patient education played a key role in achieving these results.

   • Across all members who live with type 2 diabetes, the proportion of members achieving in-range HbA1c results increased from 56% in 2020 to 61% in 2023, and here members enrolled on the Programme outperformed non-members by up to 3% each year.

3. Hospital admissions and length of stay metrics: By improving glycaemic control and preventing complications, participation in the Diabetes Shared-Value Programme helped reduce the need for hospitalisations. In 2023, members enrolled in the programme had a 12% lower hospital admissions rate and a 7% shorter length of stay on average than non-members.

4. Disease stability:By the end of 2023, the enrolled population had a 7.4% higher rate of disease stability than the type 2 diabetes population not participating in the Programme. This improvement in disease stability resulted in an overall cost saving of 1% (not only diabetes-related costs) for this cohort.

This enabled the DHMS to increase the remuneration paid to participating medical practitioners for diabetes management by 14%, accounting for 63% of the total savings. The remaining 37% of savings were retained within the health fund.

• Provider eligibility criteria reached: Over the 3-year period since implementation of the shared-value Programme, there was also an increase in participating medical practitioners achieving the eligibility criterion of an HbA1c testing rate of ≥70% for their member population, and an increase in enrolled patients with an in-range HbA1c result.

By the end of 2023, the shared-value Programme had been running for three years. Among members enrolled during this period:

• 44% had maintained an HbA1c in-range result over three consecutive years.

• We saw a 17% lower total risk-adjusted cost for these members compared with members with an out-of-range HbA1c result.

• In the HbA1c in-range group, these savings were driven by a 16% lower hospital admission rate and a 6% shorter length of in-hospital stay, leading to an overall 19% reduction in in-hospital costs.

Conclusion

The Discovery Health Diabetes Shared-Value Programme is an effective driver of improved quality-of-care outcomes for DHMS members living with type 2 diabetes.

Our results highlight the positive impact that consecutive years of glycaemic control (in-range HbA1c results) and disease stage stability have on a patient's health and on the total health care costs associated with type 2 diabetes.

The Programme emphasizes the importance of proactive diabetes management, encouraging patients to take an active role in their care. By providing incentives for both patients and healthcare providers, the Programme creates a collaborative environment that promotes better health outcomes.

The positive outcomes recorded over the first three years of the Programme validate the importance of focusing on clear, clinically relevant targets. The Programme's success is attributed to several factors, including regular monitoring and feedback, patient education, and support from healthcare providers.

Our findings further substantiate that outcomes-based remuneration can be an effective tool for enhancing value in the healthcare system.

The success of the Discovery Health Diabetes Shared-Value Programme paved the way to Discovery Health introducing care programmes now operational across a number of other chronic conditions (including cardiovascular disease, chronic kidney disease, and HIV) that can be effectively managed in the outpatient setting.

• Read the full study, titled "Improving diabetes care in South Africa through a shared-value model" in NEJM Catalyst.

Interested in knowing more or reporting on these findings?

Please contact us on MEDIA_RELATIONS_TEAM@discovery.co.za to request any updated data available since publication and to obtain any further context required.

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