Health provider networks have an essential role

Health provider networks are essential in creating access to affordable, quality healthcare for more South Africans. In the current regulatory environment, they are also essential in ensuring the sustainability of medical schemes. So says Dr Ali Hamdulay,

They were commenting on concerns raised by the Health Professions Council of South Africa (HPCSA) that practitioners who participate in provider networks that contract with medical schemes may feel pressurised to make decisions that are not in the best interests of the patient. On the contrary, patients accessing the designated provider networks established by Metropolitan Health Risk Management on behalf of medical schemes and employer groups can expect a range of benefits that includes an unrelenting focus on improving health outcomes, reinforcing quality and ensuring that health practices are always aligned in the best interests of patients.

However, they believe that the concerns raised by the HPCSA should be investigated further, with the Council for Medical Schemes and Board of Healthcare Funders (BHF) best placed to work with the HPCSA in addressing these issues.

Specific provision is made in the Medical Schemes Act (MSA) for Designated Service Provider (DSP) networks, and claims related to the MSA can be raised through the BHF as the representative body for the majority of South African medical schemes. Further investigation and resolution of this matter is important to ensure commercialism does not overshadow the altruistic values embraced by any healthcare organisation.

According to Dr Hamdulay, “Improving health outcomes and quality assurance through peer review are central aspects of the health provider networks we establish. Patients accessing these networks are assured of receiving appropriate, quality, cost effective healthcare that ensures optimal benefit usage, while at the same time delivering the best possible health result.”

The designated provider networks established by Metropolitan Health Risk Management are managed according to protocols and policies based on an evidence-based approach to healthcare. Dr Hamdulay explains that this means the best current evidence – in the form of the most up-to-date information from relevant, valid research about the effects of different healthcare practices – is the basis for delivering healthcare across their networks.

Metropolitan Health Risk Management ascribes to the ‘willing provider’ philosophy in building provider networks for healthcare services. This means that a patient’s current doctor is invited to join the network and ensures existing patient-doctor relationships are retained. The approach promotes a seamless implementation for practitioner and patient.

Consistent quality of care across all network practitioners is encouraged through peer review protocols. These protocols and policies are developed by highly qualified, experienced medical professionals and in close consultation with professional provider organisations such as the Independent Practitioners Association (IPA) Foundation and other organised groups of medical practitioners.

Another reason provider networks are highly effective in improving healthcare outcomes is the alignment and high level of collaboration that occurs between medical scheme, participating practitioners and managed care company. Says Dr Hamdulay, “A highly collaborative approach lies at the heart of how we establish and manage provider networks.” Dr Behrman explains that, in addition to including providers already servicing the members of a scheme, a ‘willing provider’ approach ensures the network is open to all providers, irrespective of whether or not they are IPA members. The only requirement is their willingness to accept practice profiling and peer review. Metropolitan Health Risk Management’s close working relationship with professional provider organisations such as the IPAF ensures that the provider perspective remains central to decision-making at all times.

The high level of collaboration also encourages greater integration across the health value chain. This facilitates alignment with other health management interventions, such as disease risk management programmes. The improved care coordination leads to better long-term health outcomes.

While highlighting the focus on collaboration in the best interests of the patient, both doctors are very clear that there is absolutely no intention of collusive or anticompetitive behaviour that could potentially harm patients, schemes, doctors or the industry. Designated service provider (DSP) networks simply offer patients a guaranteed service, with monitored, peer-reviewed outcomes, at an affordable price without co-payments.

Another vital role for provider networks in the current regulatory environment is managing appropriate and cost-effective healthcare delivery for Prescribed Minimum Benefits (PMB). The legislation is very clear in this respect. In order to ensure the costs associated with PMBs are manageable, medical schemes may appoint a designated service provider (DSP) network and only fund diagnostic, treatment and care costs that fall within established formularies and treatment protocols.

According to Dr Hamdulay, no medical scheme could afford to fund PMBs in the long run without essential tools such as designated service provider (DSP) networks and appropriate protocols. The implementation of National Health Insurance (NHI) may be imminent at some future point, however, there is broad consensus that medical schemes need to remain viable, and have the potential to be an important building block for universal health coverage. Designated service provider networks play an essential role in supporting scheme sustainability.

Drs Hamdulay and Behrman believe that, as health reform processes roll out and the healthcare environment evolves, well-managed provider networks, underpinned by a collaborative approach, have the potential to bring affordable, quality healthcare to many more South Africans.