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Teamwork could lower our medical costs

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Two weeks ago, my son cut his finger badly and it needed to be professionally bandaged and assessed for stitches.

I popped down to my doctor’s rooms and asked to see the nurse, who, by training, is very well qualified to bandage a finger and decide whether or not it needs to be seen by a doctor. I was told that the nurse does not see patients directly and only assists the doctor.

I had to see a doctor just for a bandage to be put on my son’s finger. This was an unnecessary cost to my medical scheme and, quite frankly, a waste of time for a doctor who should have been attending to more serious cases.

Dr Brian Ruff, co-founder and CEO of healthcare management company PPO Serve, explains that this management practice is born out of South Africa’s fragmented and chaotic private medical sector where each clinician works and bills alone. So, if the nurse had attended to my son, the doctor would not have earned a fee.

Ruff attributes our high rate of Caesarean section births to this fragmented structure. In the private sector, South Africa’s rate of Caesarean section is around 80% compared with 15% globally.

He maintains that because obstetricians do not work in teams with midwives, nurses and other birthing experts, as is the norm in other countries, if the obstetrician is not at the birth, they don’t earn a cent.

As it is impossible for an individual to be available 24/7, they encourage patients to schedule their dates of delivery via a Caesarean.

About 90% of births in the private sector are attended by a specialist. If [medical practitioners] worked in teams, it could free up specialist time
Professor Roseanne Murphy da Silva

Professor Roseanne Murphy da Silva, president of the Actuarial Society of SA, who argues that, while South Africa does have a shortage of specialists, it is worsened by the inefficient use of the specialists we do have.

“This is a function of the fee-for-service environment where all medical practitioners are paid a fee for service and there is no incentive to managing costs,” says Murphy da Silva.

This system also means that, rather than working in teams, specialists are in direct competition with general practitioners (GPs) and, as a result, are spending time on patients that could be cared for at a primary health level while creating a shortage of specialists for more serious cases.

A good example of this is the fact that most women believe that they need to see a gynaecologist for their annual pap smear. A nurse or, at most, a GP, is more than capable of conducting a basic pap smear, and a patient would only need to be referred to a gynecologist if the pap smear was abnormal.

This lack of coordination and the overuse of in-hospital specialists has, Ruff argues, resulted in an oversupply of hospital beds.

Based on the number of individuals who are members of medical schemes, private hospitals have four beds per 1 000 members. Countries that use integrated community and primary healthcare systems have a ratio of two beds per 1 000. Based on this ratio, Ruff argues that the current private hospital provision could provide services for 20 million South Africans.

In its 2015 annual report, the Council for Medical Schemes stated that “there is a strong negative correlation between the proportion of benefits paid to GPs and the proportion of benefits paid to hospitals.

“Medical schemes that have a high proportion of benefits paid to GPs tend to have a lower proportion of benefits paid to hospitals, while schemes that have a low proportion of benefits paid to GPs tend to have a higher proportion of benefits to hospitals.

“The results show the importance of primary healthcare interventions in bringing down the high cost associated with hospitalisation.”

Ruff believes that we can reduce the reliance on specialists for primary healthcare needs through the use of an integrated team-based healthcare model in which specialists, general practitioners, nurses and other practitioners such as psychologists proactively work together to look after a patient collectively. The consulting team is then paid on a value-contract basis rather than on an individual fee basis.

PPO Serve, in conjunction with Discovery Health, launched the first fully integrated team-based medical practice in Alberton, Gauteng, earlier this year.

The team of clinicians, made up of a full-time nurse care coordinator supporting a paediatrician, an internal medicine specialist, a social worker and an occupational therapist, as well as seven GPs, are not all in the same building but use technology to ensure the best care for the patients.

As Ruff explains, an intelligent care system is put in place to manage patient care.

For example, in the case of an elderly woman with dementia and diabetes who lives alone, the workflow system enables the team of caregivers and medical practitioners to create a system that assigns tasks and alerts to ensure the patient’s care is continually monitored.

The team then meet regularly to discuss some of their more complex cases.

The team are paid on a value-contract basis and not on fee-based service. So, irrespective of which member of the team the patient sees, the practice and members all receive payment.

The value of the contract is based on the age and medical severity of the patient and they can charge higher fees if they routinely achieve certain outcomes. So, if the average rate of emergency admissions for diabetes is reduced due to good patient management, the practice can charge a higher fee. Thus, doctors are better paid for keeping their patients healthy rather than only earning money when they are ill.

This is not dissimilar to the concept of the village doctor in China where the family would pay a monthly fee to the doctor only when they were healthy. If they became ill, the doctor was not paid.

PPO Serve is engaging with Discovery Health and other medical schemes to roll out similar initiatives across the country.

Murphy da Silva believes this approach to medical funding would be positive in driving down healthcare costs.

“We need to restructure on the side of service providers as to how services are delivered and funded through a multidisciplinary clinic with incentives to deliver cost-efficient services.

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