Spiralling healthcare costs have led to medical schemes introducing ways to contain what is spent on treating members. Many of these measures fall under what is known as managed care.
You may have interacted with your scheme's managed-care entity in the following ways:
- When you obtain pre-authorisation for hospitalisation, expensive procedures or tests such as a colonoscopy or an ultrasound. The managed-care entity will decide whether you need to be admitted to hospital to undergo a procedure.
- When your in-hospital treatment is subject to case management. A case manager works with your doctor to ensure that you receive no more than the "appropriate" level of care in an "appropriate" facility. You might, for example, be moved from a high-care ward to a less-expensive general ward.
- When a managed-care entity manages or co-ordinates the treatment of a serious illness, such as cancer, or a chronic condition, such as diabetes. Most schemes have disease-management programmes, which are aimed at educating you about the nature of your illness and equipping you to manage it.
- When you have to obtain authorisation for medication. A medicine-management programme ensures that you are prescribed appropriate and effective medicines and checks that they will not duplicate or interfere with any other medication, and determines which drugs are the most cost-effective.
- When your hospital claims are verified. In most cases, the hospital's account will be audited to ensure that you were 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 treatment and not for cosmetic or non-essential procedures.
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.
Jeremy Yatt, the principal officer of Fedhealth, says the primary healthcare system in South Africa is fragmented: there is no co-ordination between general or family practitioners and other healthcare providers. This can 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. "With this in mind, Fedhealth is developing a co-ordinated-care initiative to ensure that patients receive the best care possible," Yatt says.
What is co-ordinated care?
Co-ordinated care consists of various elements:
1. High-risk beneficiary management
This management programme identifies and manages beneficiaries who suffer from, or are at risk of, serious medical conditions. Unlike traditional disease-management programmes, it aims to link all aspects of a patient's health, lifestyle and treatment, empowering the patient to understand his or her health. A health coach will be appointed to manage a beneficiary's treatment, while educating him or her about the treatment process and how to manage his or her condition.
2. Family practitioners
Yatt says that family practitioners (FPs) are at the centre of co-ordinated care, ensuring that patients receive appropriate treatment timeously. Fedhealth implemented its family practitioner network in 2012 to ensure that beneficiaries have access to quality primary care. 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 helps patients to manage lifestyle diseases such as hyperlipidaemia and diabetes better. It has also found that beneficiaries who move to a system of co-ordinated care experience a 26-percent decrease in hospital and emergency-room admissions. The cost of hospital treatment is also reduced: Fedhealth has found that beneficiaries who don't consult an FP before being admitted to hospital incur expenses that are about 9.4 percent higher than the average cost of a hospital admission.
3. Personal health records
In line with the integrated-care approach, managed care-entities are introducing electronic health records for members. Billions of claims data are translated into easily accessible records that provide your doctor with an overview of your previous consultations, hospital admissions, blood and other diagnostic test results, and medicines.
"By centralising a patient's health records in a system that is accessible to every stakeholder, the FP has valuable information about in-hospital treatment, enabling them to co-ordinate follow-up care and reduce the risk of readmission," Yatt says.
A STORY ABOUT HOW MANAGED CARE WORKS
Mrs Lawrence is 57 years old and was diagnosed with type-two diabetes at the age of 32, and subsequently 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 before intervention revealed a blood-sugar level of 11.5 millimoles (a normal blood sugar range for a diabetes sufferer is four to seven millimoles).
During the interview with the care coach, Mrs Lawrence disclosed that she believed she had only to avoid sweet foods such as chocolates or biscuits. The care coach referred Mrs Lawrence to a dietician, 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 the dietician and embarked on a healthier diet for her and her family. She had also joined a gym and was regularly doing 35 to 40 minutes of cardiovascular training. She managed to reduce her glucose level to between 4.5 and seven millimoles.
Please Visit: www.fedhealth.co.za