This is part 4 of a four-part series on you and your medical scheme. Click here for part 1, part 2 and part 3.
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 determines 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 good-quality 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 information-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”, below).
• 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).
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.
CASE STUDY: MANAGING DIABETES
Fifty-seven-year-old Mrs Lawrence was diagnosed with type 2 diabetes at the age of 32 and was subsequently diagnosed with hypertension and hyperlipidaemia (high cholesterol).
Her cholesterol and blood pressure were under control, but her diabetes was not, because she lacked insight into diabetes as a chronic condition. Her glucose test revealed a blood-sugar level of 11.5 millimoles. A normal blood-sugar range for a diabetes sufferer is four to seven millimoles. (A mole is a unit of measurement commonly used in chemistry to denote amounts of atoms and molecules.)
During the interview with her care coach, Mrs Lawrence said she believed she had only to avoid sweet foods, such as chocolates or biscuits, to manage her diabetes.
The care coach referred Mrs Lawrence to a dietitian, advised her of the importance of exercise and physical activity, and provided her with a glucometer and arranged for her to be taught how to use it.
After two weeks, Mrs Lawrence had:
• Consulted a general practitioner, who performed a test to check her blood sugar level;
• Consulted the dietitian and embarked on a healthier diet for her and her family;
• Joined a gym and was regularly doing 35 to 40 minutes of cardiovascular training; and
• Reduced her glucose level to between 4.5 and seven millimoles.
MANAGED CARE IS REGULATED
Medical scheme trustees must ensure that their scheme’s engagement with a managed-care entity is for the benefit of its members, the Council for Medical Schemes (CMS) says.
A managed-care entity has to register with the CMS before it can contract with a scheme. Before the council will accredit a managed-care entity, it checks that the entity has the necessary resources, systems, skills and capacity, and that it is financially sound and its financials have been audited. Entities are accredited for two years. They must then apply to renew their accreditation.
The regulations under the Medical Schemes Act state that if managed care results in a limitation of your rights or entitlements by restricting cover for a disease, requiring your treatment to be in line with a protocol, or requiring your medication to comply with a formulary, the medical scheme must furnish the Registrar of Medical Schemes with a document outlining such limitations and any amendments to it.