Outdated managed care models call for a different approach

The introduction of managed care methodologies in the 80’s was heralded as the most important evolution of the healthcare sector in decades.

However leading player Resolution Health, which utilises the managed care systems of administrators, Agility Global Health Solutions-Africa (Agility GHS-Africa), takes the controversial view that old style managed care models have reached their ‘sell-by’ date and that they emphasise denial of benefits instead of members’ wellness.

It’s claimed that key in this scenario is the increasing trend towards outsourcing of services and that this creates various problems notably where schemes need to weigh up the benefits of curbing costs versus increasing or and retaining membership.

Resolution’s Principal Officer, Mark Arnold says the Resolution/Agility approach is different in that, while it seeks continuous improvements, cost containment, technology improvements, streamlining and improved integration of deliverables, above all it remains supremely ‘customer centric.’

Adds Arnold: “The current broadly used managed care model in South Africa, notably in terms of smaller operators and schemes, is heavily premised on outsourced third party specialists.

“We believe this is inherently flawed on many levels. For instance, there’s a risk that data integrity can be compromised, costs to the scheme can be higher, closed schemes often cross-subsidise open ones and real-time, on-line servicing capability is limited.

“Also, data quality tends to be mediocre, thus inhibiting clinical risk management while outsourced claims processing can be a major source of on-going friction between patients, medical aids and healthcare providers.

“The solution in our view is actually the reverse of this trend, ie greater centralisation of managed care functions and improved systems integration across the board to ensure high levels of automation, service and accurate verification of treatments and claims that facilitates, rather than impairs or misdirects, customer wellness benefits.

“Up-to-date, online client profiles (medical histories, credit records etc) segregation of risk, opening up of benefits, accurate risk rating and enhanced patient driven healthcare are just some of the outcomes of this model.

“On-line patient and healthcare provider-friendly pre-authorisations within minutes, based on approved treatments and procedures are some of the value adds.

“Moreover, using this model we have built up a substantial body of clinical intellectual property and this highly automated, knowledge intensive system ensures faster turnaround times on all our business processes in general.

“There’s also as intensive inbound and outbound stakeholder communication which of course is welcome among members and actually contributes towards

the smoother running of the various business processes.

“Other benefits include greater operational leverage, reduced operating costs and greater integration of employee wellness programmes into the overall managed care function, which, after all, is what it’s all about.

“Further, this enables personalised management of high risk patients that drives down event rates and reduces operating costs and that in turn, helps to improve solvency ratios with all the benefits for all our stakeholders that that implies, benefits incidentally, which we are beginning to see in our financial performance.”