SAMED Date: 5 August 2014 Agenda Acronyms DSP- Designated Service - PowerPoint PPT Presentation

SAMED Date: 5 August 2014 Agenda Acronyms DSP- Designated Service Provider PP Preferred Provider PMB Prescribed Minimum Benefit DTP Diagnostic/Treatment pairs PMB LOC PMB Level of Care CDL- Chronic Disease

  1. SAMED Date: 5 August 2014

  2. Agenda

  3. Acronyms • DSP- Designated Service Provider • PP – Preferred Provider • PMB – Prescribed Minimum Benefit • DTP – Diagnostic/Treatment pairs • PMB LOC – PMB Level of Care • CDL- Chronic Disease List • PBM – Pharmacy Benefit Management

  4. DSTM Don’t Shoot the Messengers

  5. Motivations Doctors know their patients and the clinical history What is the expected outcome? What is the potential cost? What alternatives have been tried? What co morbidities are relevant ?

  6. Scheme Limits • Each scheme has multiple benefit options each with their own limits • Consistency of decision making is not possible because different members have different benefits • PMB conditions always change the picture, provided it is a PMB. Always consider PMB level of Care

  7. DSP • Pre selected each benefit year – Hospitals and Specialists • Benefit option specific • Applies to PMB or non PMB conditions • Co payments for not using DSP (Up to 40%) • 50km rule applies • PMB will not be paid at cost if DSP is not used

  8. Case Manager • Funder / Hospital case manager • Have a relationship with the doctors, schemes and the medical advisors • Facilitates the authorisation process • Facilitates communication with patient and family • Co Ordinates any discharge planning required

  9. Which Link is Broken? Family Hospital Patient Doctor Scheme

  10. The Way Forward Communicate Communicate Communicate Together we can achieve more and the patient will be the biggest beneficiary

  11. Dr Thys Kruger Medical Advisor

  12. The South African Joint Outcome Study (SAJOS1) Protocol Number: SAJOS1-02 PharmaEthics Approval Number: 10043675 Final Ethics Approval Date: 25 May 2010 A descriptive study assessing the care provided to a cohort of beneficiaries who received funding for an arthroplasty of a major weight bearing joint in a group of more than 654, 000 beneficiaries with medical scheme cover in the private healthcare environment in South Africa.

  13. SAJOS1 Outcomes • Assessing the two year quality of life (QoL) (SF20) and functional impairment (Barthel) of patients who received funding for hip or knee arthroplasty surgery. • Identifying factors that could influence future funding decisions and/or contracting. • Assessing the level of care provided to the cohort.

  14. Methodology • A group of beneficiaries of medical schemes (>654,000) who contracted hospital benefit management services from MSO received funding for a major joint arthroplasty (1393). – The beneficiaries (1393) were contacted within 2 weeks of the initial procedure date after a period of 2 years to assess the current quality of life and possible impairment. – A meaningful population (227) agreed to completed the questionnaires (SF20 and Barthel Index. – Whilst 55 beneficiaries were confirmed dead after 2 years. • The financial outcomes of the 1393, QoL and functional impairment in addition to adverse events reported, in addition to drivers of high risk outcomes were assessed and reported on.

  15. Financial Results

  16. Indications & Surgeon Experience

  17. Qi and Barthel 1. Both the SF-20 and the Barthel Index were found suitable for use in the study group 2. Most patients reported: able to walk (97%), straighten their legs completely (99%), bend their legs completely (89%), no difficulty in getting moving after they had been sitting or lying down for some time (63%), and never walked with a limp (56%). This indicates a high level of functioning two years after surgery. 3. Poor functional outcomes in the age group 75 years and older 4. Females and the obese population reported poorer general health outcomes especially with the presence of respiratory symptoms. 5. Over 90% said that they would choose to have a joint replacement again.

  18. Subsequent Admissions

  19. Serious Adverse Events

  20. High Risk Outcomes

  21. SAJOS1 Main Conclusions Most beneficiaries enjoy a good quality of life post procedure • Surgeon experience is a major factor considering cost and high risk outcomes • Re-admissions and complications is a concern • Centre’s of excellence will be ideal (DSP/PP) • There is an urgent need for a registry in South Africa

  22. SAJOS1 Study Publication Available at or e-mail

  23. Way Forward • Centre’s of excellence • Multidisciplinary team approach • Risk sharing – Global fee structures • Health economic modelling and impact studies • Sustainable business structures - ? Societies – collusion • Transparent communications

  24. Thank You

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