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Tuesday, May 26, 2015 - 02:16
Lacking co-ordination

Over the last 10 years there has been an alarming rise in the burden of disease in South Africa, specifically non-communicable diseases like hypertension, diabetes, high cholesterol, asthma, depression and cardiac failure.

The prevalence of diabetes alone has grown by over 10% per year since 2008, according to the private healthcare sector. What is even more concerning is the rise in the number of medical scheme beneficiaries who have multiple chronic conditions. Significantly, the number of beneficiaries with multiple chronic conditions increased by 25% in the private healthcare sector in 2013.
Peter Jordan, Principal Officer of Fedhealth, says that predictive modelling techniques have shown that just 2,5% of its clients are likely to drive 30% of medical scheme costs. “Virtually all of these members have multiple chronic diseases. The concern is that they have no co-ordinated care. Over 60% of these individuals receive fragmented care and we can see that those beneficiaries whose care is fragmented cost nearly double compared to those who are well co-ordinated.”
This is particularly significant when one considers that one of the biggest challenges facing medical schemes today is that of affordability; that is, keeping the monthly contributions that members pay down to affordable levels, whilst still ensuring they have access to good quality healthcare. Rising claiming patterns on the back of fragmented care are fast proving unsustainable for an already stretched system.
Jordan says those beneficiaries with co-ordinated care generally tend to see a single family practitioner who co-ordinates the care across the different specialities/medical disciplines. The general practitioner has a holistic view of the beneficiary including all feedback from all specialists and other healthcare providers as well as pathology and radiology results etc. In contrast in the group receiving fragmented care, beneficiaries tend to see multiple family practitioners and specialists for different aspects of their illnesses. There is no communication between all these different service providers and no single doctor has an overall comprehensive view of the beneficiary. “This fragmented care results in increased costs due to duplication of tests, but even more importantly increased hospitalisation and emergency room visits due to poor clinical outcomes often as a result of drug interactions.
“As schemes we have already started implementing measures to coordinate care in order to improve clinical outcomes and reduce contributions. The introduction of the GP and Specialist networks was a first step in the process and a way to prevent co-payments for our members. The care co-ordination approach was further enhanced by offering beneficiaries unlimited benefits for seeing a Fedhealth network GP as the primary care co-ordinator. These networks have been working really well but need to be taken to a new level to further impact on member outcomes and contributions by improving care co-ordination.”
A key focus therefore is the interaction between family practitioners and specialists in order to drive this strategy.
“Most successful healthcare systems have identified care co-ordination as key to the sustainability of healthcare funding. Unmanaged direct specialist access has been identified as a key factor that fragments care and is not a sustainable delivery model of any well-functioning healthcare system. In addition a number of submissions from key stakeholders to the upcoming market enquiry into healthcare have identified specialist referral management as an important structural change that needs to be implemented to address cost effectiveness and quality,” says Jordan.
“The last thing we are trying to do is be prescriptive and restrict access of members to specialists. This is all about facilitating the appropriate access to the most appropriate specialist. It is also about ensuring continuity of care which includes the quality of the specialist referral as well as the quality of the specialist response back to the family practitioner. We want members with complex conditions to continue seeing their specialists when indicated – but we want the beneficiary’s family practitioner to co-ordinate this across all specialities, have a holistic view of the beneficiary and ensure continuity of care.”

Copyright © Insurance Times and Investments® Vol:28.5 1st May, 2015
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