Johannesburg - Discovery Health was in discussions with doctors to move away from the fee-for-service method of paying for health-care claims.
Instead, doctors and hospitals could be paid a certain amount for each treatment episode they perform, meaning different specialists cannot submit varying claims for the same patient.
Chief executive Jonathan Broomberg said the medical scheme had had this arrangement with some hospitals for seven years and this had contributed to it achieving the lowest cost inflation, as reflected in the Council for Medical Schemes’ 2008 to 2011 annual reports.
He said this was one of many proposals that Discovery Health wanted to put forward to deal with the constantly escalating costs in the private health-care sector, which he blamed on the fragmentation of the system.
“At the heart of this fragmentation is the way we pay doctors, which is fee-for-service. This encourages the delivery of more services than necessary… We have to leave it behind.”
Schemes would look at their data and see what the average cost was for a certain procedure and then say they would pay everyone, including doctors and blood test takers, a single combined fee, as a team. He said in this system patients would have less unnecessary intervention. He said doctors in South Africa worked in silos in their practices, which was part of the problem.
“When a patient is admitted to the hospital, they see three or four specialists who do not send notes to each other or to the general practitioner and, therefore, duplicate tests.”
Broomberg said the teams would not need to work in hospitals but could form clinics. They would not need to physically move around, instead using digital technology to co-ordinate the care and manage the patient from different locations.
He said this would mean the way medical schemes paid doctors would change. They could pay a team looking after a patient together instead of paying out claims for all doctors who were involved.
Another trend Discovery wanted to propose to doctors and hospitals was the creation of same-day surgery hospitals. South Africa has few of them.
Broomberg believed that 70 percent to 90 percent of procedures like knee surgery, colonoscopies, gastroscopies and eye surgery could be done without overnight admissions.
Specialisation of hospitals was also on Discovery’s discussion agenda. “Our private hospitals are a one-size-fits-all, and have the full range. What the science and evidence is showing is that when they specialise in certain disciplines, they become better and cheaper.”
He said medical leadership was embracing these proposals. “We can get there. It’s hard because we are talking about vested interests, people used to how they work. We’re working hard to get consensus.”
Dr Mark Sonderup, the SA Medical Association spokesman, said for Discovery to expect everyone to form teams was based on the assumption there was sufficient distribution of doctors, even in peri-urban and rural areas. This was not the case. He did not think it was Discovery’s place to advise medical staff to work alone or not. – Business Report