Schemes make sure you get the full treatment

Treating a serious medical condition often requires the intervention of a number of practitioners, such as doctors, specialists and therapists. If their interventions are co-ordinated, it is more likely that patients will receive better-quality treatment

Spiralling healthcare costs have resulted in medical schemes introducing measures to contain what is spent on treating members to what is necessary and appropriate. Many of these measures fall under what is known as managed care, which has become an industry in its own right.

You, as a medical scheme member, may already have interacted with your scheme’s managed-care entity, or may do so in future, in any of the following circumstances:

• When you obtain pre-authorisation for hospitalisation or for certain expensive procedures or diagnostic tests, such as a colonoscopy or ultrasound. Your need to be admitted to hospital and undergo the procedure or test, with all the expense this entails, is evaluated.

• When you are in hospital and your treatment is subject to hospital case management. A case manager, a qualified medical professional, works with your doctor or specialist to ensure that you receive no more than the “appropriate” level of care in an “appropriate” facility. For example, if your condition permits, you might be moved from a high-care ward to a less-expensive general ward, or from a hospital to a less costly rehabilitation facility.

• When a managed-care entity manages or co-ordinates the treatment of your illness, such as cancer or HIV/Aids, or a chronic condition, such as diabetes or chronic renal failure. Most schemes have disease-management programmes, which are aimed at educating you about the nature of your illness and equipping you to manage it in a way that keeps you as healthy as possible.

• When you have to obtain authorisation for medication that is managed in terms of a medicine-management programme. The managed-care entity deter mines whether the medicines prescribed for you, usually for chronic conditions, are appropriate and effective and do not duplicate or interfere with others already prescribed. Medicine managers also identify the most cost-effective drugs. Many schemes have a list of cost-effective drugs, known as a formulary.

• When your hospital claims are checked to verify them. Most medical schemes also subject your account to a hospital audit programme to ensure that you have been billed correctly.

• Pregnant women may be enrolled on a scheme’s maternity programme to ensure that they have the necessary check-ups, but are not referred for any unnecessary scans.

• Your dental or optical benefits may be monitored to ensure that the scheme pays only for essential, cost-effective treatments for your eyes or teeth and not for cosmetic or non-essential procedures.

Jeremy Yatt, the principal officer of Fedhealth, says there is a link between what it costs schemes to provide their members with treatment and the quality of the treatment supplied by healthcare providers. The treatment of a medical condition usually involves providers from different specialties and requires a number of interventions. The benefit of any one intervention depends on the effectiveness of the other interventions.

Yatt says the primary healthcare system in South Africa is fragmented: there is no co-ordination between general or family practitioners and other healthcare providers, which may result in unnecessary hospitalisation, tests being duplicated, conflicting clinical advice and adverse reactions to medication.

For a patient to receive goodquality treatment, his or her healthcare provider must have access to the patient’s medical history so that the provider is aware of all the factors that might affect the patient’s treatment. With this in mind, Fedhealth is developing a co-ordinated care initiative to ensure that patients receive the best care possible, Yatt says.

Co-ordinated care consists of various elements, including managing high-risk beneficiaries, family or general practitioners acting as the main co-ordinator of the patient’s care, and systems to facilitate infor mation-sharing among the different healthcare providers responsible for the patient’s health.

BENEFICIARY MANAGEMENT

A high-risk beneficiary management programme aims to identify and manage beneficiaries (members and their dependants) who suffer from, or are at risk of, serious medical conditions. Unlike traditional disease-management programmes, which focus on treating each individual disease, it aims to link all aspects of a patient’s health, lifestyle and treatment, Yatt says.

The main focus of the programme is to empower beneficiaries to understand their health. This is done by appointing a health coach to manage a beneficiary’s treatment, while educating him or her about the treatment process and his or her condition.

Educating beneficiaries about their condition and how it is being treated addresses the asymmetry of information between patients and healthcare providers. Patients who are educated about their condition are better equipped to provide their doctors with relevant information, which will help to ensure they receive the most appropriate treatment. Education also enables patients to take control of their lifestyle, including exercise and diet.

FAMILY PRACTITIONERS

Yatt says that family practitioners (FPs) are at the centre of co-ordinated care, ensuring that patients receive appropriate treatment timeously. This includes monitoring a patient’s health issues and documenting his or her medical history.

Fedhealth implemented its family practitioner network in 2012, to ensure that beneficiaries have access to quality primary care, Yatt says. If a beneficiary requires treatment of a more specialist nature, the FP can refer the member to an appropriate specialist.

Fedhealth’s research has found that co-ordinated care has the following positive results:

• Patients are better able to manage lifestyle diseases such as hyperlipidaemia and diabetes (see “Case study: managing diabetes”).

• There is a reduction in hospital admissions and visits to emergency rooms. Fedhealth has found that beneficiaries who move to a system of co-ordinated care experience a 26-percent decrease in hospital and emergency-room admissions.

• The costs of hospital treatment are reduced. Fedhealth has found that beneficiaries who do not consult an FP before being admitted to hospital incur expenses that are 9.4 percent higher than the average cost of a hospital admission, whereas beneficiaries who consult an FP have costs that are 2.9 percent lower than average. This is because these beneficiaries receive more appropriate treatment, have fewer complications and stay in hospital for shorter periods.

• The duplication of care for high-risk beneficiaries who have diabetes and cardiovascular disease is prevented. The out-of-hospital costs for beneficiaries who consult a number of FPs, or go directly to a specialist, are R17 422, whereas the costs for beneficiaries who consult a co-ordinating FP are R10 900. This is because patients receive the most appropriate care and unnecessary treatment is eliminated.

PERSONAL HEALTH RECORDS

Medscheme, Fedhealth’s administrator, is developing personal health records to empower patients and the healthcare providers who treat them, Yatt says.

In line with the integrated-care approach, managed-care entities are introducing electronic heath records for members, Yatt says. Billions of lines of claims data are translated into easily accessible records that provide your doctors with an overview of your previous consultations, hospital admissions, blood and other diagnostic test results, and medicines (see “Sharing health records helps patients”, below).

By centralising a patient’s health records in a system that is accessible to every practitioner, the FP has valuable information about in-hospital treatment, such as diagnoses, test results, prescriptions and discharge instructions. This enables the FP to co-ordinate follow-up care and reduce the risk of readmission, Yatt says.

Similarly, granting patients with chronic conditions access to their health records encourages them to be actively involved in their treatment, he says. Engaged patients are more likely to adhere to treatment plans and modify their behaviour to improve their health.