Developing a channelling framework for healthcare service providers networks for a medical scheme in South Africa

Abstract

This study aimed to develop a channelling framework for healthcare service provider networks for medical schemes in South Africa. Healthcare costs are continuously on the rise and schemes, competing for the same member base, have to find innovative ways to curb costs as simply increasing member contributions will make membership unaffordable for many. The medical scheme industry is a complicated one. It is highly regulated and complex, with many stakeholders involved. Self-administered schemes are not allowed – according to the Medical Schemes Act (MSA) – to provide incentives or rewards to members to channel members towards specific providers. One of the innovative ways to curb costs, which was tested in this study, is channelling members towards cost-efficient, high-quality specialists. Specialists were ranked according to their practice profile, which is based on national benchmarking norms between their peers. The ranked specialists were divided into three groups: those with a cost impact score of <0% (Group 1) – the most efficient group, those with a cost impact score of 0% < 15% (Group 2), and those with a cost impact score of ≥ 15% (Group 3). Mixed-method research strategies were applied through the analysis of secondary data and semi-structured interviews to validate the research. The possibility of using network channelling to rank providers as a way of managing costs was first tested using hypothetical channelling based on historical data. The data showed promising results with an estimated saving of more than R4 million for only three procedures. Through innovative artefacts designed using the Action Design Research (ADR) process, referral lists based on specialist rankings were compiled in two iterative design phases. The first (-design) phase consisted of a pdf artefact. The artefact was distributed to 5 258 general practitioner (GP) practices. After a six-month period, actual data showed a saving of R3,6 million for the same three procedures. This was extrapolated across all procedures and a saving of close to R49 million was estimated. The learnings from the -design phase were used to create and implement an improved, digital artefact in the second (-design) phase. The digital artefact was created using an external provider. The digital artefact had the advantage that it was available on the healthcare provider’s practice management software application, making it easy to access. The digital referral list also made searching for a provider easier. The search functionality allowed for a search per area or hospital or discipline. The top ranked providers were displayed first, leading to more referrals to these providers, with a 52% increase in referrals to Group 1 specialists within the sample group of 20 GPs who tested the application. This led to an actual saving of R448 156, and an extrapolated overall estimated saving of close to R40 million. The use of a ranked referral list proved to be a valuable tool which could possibly assist with cost containment. The digital artefact (iCanRefer™) is available to all providers, as the application is web based and can be linked to any practice management system.