ICPS offers a win-win for arthroplasty
• Better, more affordable care in hip and knee surgery
There are numerous complex reasons for the private healthcare sector struggling to deliver affordable and quality healthcare to patients, says Grant Rex, CEO at Improved Clinical Pathway Services (ICPS).
One of the reasons is that healthcare practitioners practise in a relatively isolated way, often without the benefit of a multidisciplinary team approach or reference to evidence-based best practice, says Rex.
Healthcare practitioners furthermore charge for their services on a fee-for-service basis, with no agreed guideline about what to charge for and how much to charge.
“Medical schemes are concerned with limiting their exposure to the risk of healthcare practitioners charging on a feefor-service basis with no reference to what is cost effective nor to what services produce the best clinical outcomes.
“Simply reimbursing for any service on a fee-for-service basis will not result in the longevity of schemes as the risk that they insure is proving to be unwieldy and expensive.”
Rex says ICPS has developed an innovative programme that improves the affordability and quality of healthcare.
“We provide clinical decision support to a network of healthcare practitioners in private practice who enter into a service-level agreement with ICPS and perform hip and knee arthroplasty on patients for a fixed fee, using standardised evidence-based guidelines as a clinical reference.
“Hospitals are contracted on a discounted fee-for-service basis, and prosthesis suppliers are contracted on the basis of a negotiated fee per system.
“The quality of the care provided in these arthroplasty cases is retrospectively assessed, and feedback [is] provided to the network clinicians for continued improvement in care. As a result, there are better clinical outcomes for patients, fees are affordable for the schemes and the patients they insure, as well as being fair to the healthcare practitioner,” Rex says.
ICPS provides clinical decision support to network clinicians by means of standardised clinical pathways, clinical outcome measurements and feedback to the network clinicians, which together deliver continuous quality improvement of patient care.
Rex says ICPS facilitates access to hip and knee arthroplasty for medical schemes’ qualifying members.
For medical schemes whose benefit options ordinarily exclude arthroplasty, ICPS facilitates improved access to arthroplasty by making it possible for these medical schemes to offer this treatment to qualifying members.
For medical schemes whose benefit options ordinarily Healthcare practitioners often practise without a multidisciplinary approach or reference to evidence-based best practice, says Grant Rex, CEO at Improved Clinical Pathway Services.
include arthroplasty, ICPS provides an alternative, alongside the conventional fee-for-service arthroplasty option, facilitating access to arthroplasty by either reducing the need for, or amount of, copayments.
The overall cost of arthroplasty to the medical scheme is
reduced and the clinical outcomes are improved.
Rex says a “patient is assessed pre-operatively by the treating surgeon, anaesthetist and physiotherapist, in relation to evidence-based orthopaedic, medical, and anaesthetic aspects of their state of health”.
ICPS has 70 teams, delivering arthroplasties in all nine provinces.
ICPS initially entered into contracts with the Transmed and Medihelp medical schemes, which led to 762 cases being taken out of the overburdened state sector. Waiting times for arthroplasty in the state sector are very long, examples being an average of eight years at Chris Hani Baragwanath Hospital, and an average of four years at Albert Luthuli Hospital.
“Clinical outcomes measured in more than 2,000 cases under the ICPS programme show enhanced patient recovery, as evidenced by reduced hospital stay from 6.9 days on average to 3.2 days.
“This shorter hospital stay reduces the risk of postoperative infections, and reduced high-care utilisation results in decreased incidences of deepvein thrombosis and pulmonary embolism,” Rex says.
“The available data shows a reduced acute complication rate which is also evident from the 90-day readmission rates, which have declined on average from 12% to 4.5%,” says Rex.
He notes that ICPS achieves an average cost saving of between R20,000 and R30,000 per arthroplasty case, which benefits medical schemes as hip and knee arthroplasty combined are their biggest single cost item and amount to a spend of nearly R2bn per annum.
A 20% saving implies a R400m saving a year for the industry, which could result in lower premiums to members, or at least help limit annual premium increases to around the percentage increase in the consumer price index.
“Our group has performed several thousand major joint replacements with clinical complications at 50% of the national average and costs 10% to 30% less than the average excluding the savings from lower complications,” says Rex.