Many medical schemes today have adopted disease management programmes that support patients in managing a range of conditions including diabetes, asthma, allergy, depression, bipolar mood disorder, hypertension, cardiac failure, osteoporosis and suicide t
Dr Laubi Walters, Executive Manager: Medscheme SA, who manages these programmes for a number of contracted schemes, including Fedhealth, says the programmes allow the schemes to measure improved member health outcomes. "We focus on conditions which can be significantly improved by a patient's self-care efforts. We also work closely with healthcare providers. In essence, we try to realise the full value of utilisation patterns and evidence-supported healthcare knowledge that already exists, by pro-actively disseminating and sharing relevant information with both patients and their health-care providers."
He does concede that this can often be a challenging task as there are many factors that contribute to the effective measurement of health outcomes. "The accuracy of health outcomes measurement depends largely on the quality of the data collected and it is important at the end of the day to be able to attribute any improvement in the clinical outcomes directly to the disease management programme rather than another unrelated intervention," he says.
The process starts with high risk members being identified. These members are stratified based on their predictive clinical and financial risk and are then pro- actively contacted. There are two levels of interventions, the first being general holistic interventions and the second level intensive condition-specific.
The first level is designed to perform a high level risk analysis with respect to knowledge, adherence to treatment and severity of the condition while the second focuses on intensive disease counselling, referral to treating providers, sharing of information with treating providers and following up on the progress of the member.
The programme design allows for the tracking of individual members over time in order to measure their individual outcomes.
Randomised controlled studies of members on this kind of programme have shown distinct benefits including a reduction in the utilisation of hospital services. The bulk of savings emerged within the medical admissions category. "This is significant," says Walters, "as the increase in out of hospital costs, supports the move towards primary health care which is in line with the NHI focus."
It also is good for scheme sustainability.
Fedhealth Principal Officer, Peter Jordan says, "A reduction in hospital admissions and specialist visits equates to improved health of our members, reduced emergency room visits due to improved health, increased general practitioner (GP) visits due to greater awareness of health issues and increased pharmacy costs due to compliance with treatment regimens."
Jordan says members also benefit by receiving condition-specific counselling and communication which results in a better understanding of their conditions and ultimately empowerment which leads to a better standard of living. Members on the programme have access to a dedicated health line as well as contact with experienced clinical care managers who provide them with immediate, professional health advice or information on symptoms, chronic illness, injury, nutrition or a healthy lifestyle.
"Members receive advice about the right care, at the right time in the right place. We firmly believe these cost savings could equate to lower contribution increases in the future," concludes Jordan.