AllMed Healthcare Management Blog: 09/23/06
Saturday, September 23, 2006
Managed Health Care In South Africa
http://free.financialmail.co.za/
Under managed care, savings are generated by ensuring that only necessary, cost-effective treatment is prescribed in line with clinical protocols and drug formularies. To ensure these rules are adhered to, schemes contract doctor networks that agree to play by MHC rules in exchange for patient volumes and/or a premium on the standard consultation fee and/or a share in down-the-line savings to the scheme.
McLeod says schemes in SA have introduced all the easy MHC tools such as hospital pre-authorisation and chronic medicine programmes, but there is still little contracting and risk-sharing between funders and provider networks.
In the US, MHC includes the use of selective networks of contracted providers; ways of encouraging members to use the networks; and some risk-sharing with those networks. "This is the crucial and missing part of MHC in SA, because it is only through developing MHC programmes, which give doctors a stake in the outcome and force them to weigh up their decisions clinically and cost-effectively that you get the change in behaviour that brings the real win," she argues.
By US standards, SA still has a fee-for-service environment that is loosely managed. A study by US consulting actuaries Milliman USA found that in such an environment funds could expect to pay R100 for a claim compared with R80 in a moderately managed environment where there was some risk-sharing. The real win comes in a vertically integrated environment (where doctors, hospitals and a funder are located within one organisation such as some of SA's mine hospitals). There the cost falls to R50.
This explains why cost escalation persists in SA in the face of rapidly rising managed-care costs.
Labels: healthcare costs, managed care, south africa
posted by Dr. Skip
Verdict Against Hospital Over Peer Review Affirmed
In early 1998, Dr. Poliner's competitors began raising "concerns" about
some of Dr. Poliner's cases, ultimately resulting in a suspension of his
cardiac catheterization privileges-effectively denying him the ability to
treat his patients or attract new ones, the lawsuit claims. The peer review
committee charged with considering the complaints against Dr. Poliner
consisted primarily of his competitors.
Later that year, the hospital's medical board voted to restore Dr.
Poliner's privileges after several nationally known cardiology experts
testified that Dr. Poliner's care of his patients met or exceeded the
standard of care, and that his suspension was unwarranted. Despite the
return of privileges, the board upheld the original suspension "based on
the evidence available to him [Dr. Knochel] at the time."
"Judge Solis has ratified jurors' very strong feelings that their
verdict should send a very strong message to Presbyterian and other
hospitals that this type of conduct should stop," says Mr. Lynn.
"This has been a long and difficult process for Dr. Poliner," says
original lead trial counsel Charla Aldous. "Not many people would have had
his determination and resolve. Hopefully, the jury and court's decision
will have a positive impact on the peer review process throughout the
country."
Labels: Dr. Poliner, hospital peer review
posted by Dr. Skip
