Shifting the focus of disease management

Medical schemes have long battled with the challenge of containing costs without limiting patients’ access to medicines and treatments but the application of technology is now revolutionising disease management and keeping patients healthy in the first place says Agility Global Health Solutions.

Agility Global Health Solutions - a healthcare solutions company which administers a number of medical schemes and health insurers including Resolution Health in SA - has developed a novel managed care offering called Patient Driven Care (PDC™).

PDC helps keep members with chronic diseases and high-risk behaviours healthier by making benefits available to them in a structured and timely manner. This preventative care model allows medical scheme administrators to analyse disease and behavioural profiles of high risk or high healthcare utilisation members and intervene with remedial action before they become ill or their condition deteriorates. 

"Via a combination of technology prompts and human intervention through Personal Health Co-ordinators, scheme members are encouraged to take a preventative approach to their health by, for example, remembering to fill scripts and undergo regular health screens and checks," says Agility Global Health Solutions Product Development Director, Professor Jacques Snyman.  "Rather than providing a long list of formularies or protocols to the doctor, PDC is centred around each individual’s unique disease needs and treatment."

Integrated approach to member's health

High-risk scheme members are assigned a Personal Health Co-ordinator - similar to a personal or private banker. Each Personal Health Co-ordinator is dedicated to looking after specific members and is also empowered to approve procedures and hospital stays. Every co-ordinator works with a cluster of healthcare professionals, including a pharmacist and doctor who may be called on for expert advice. 

These clusters are designed to provide an integrated approach to the member’s health – so if a patient with HIV also has a skin condition or diabetes, the Personal Health Co-ordinator is able to review the case holistically. 

"Many traditional managed care models tend to be based on the premise wherein different conditions are allocated to different case managers, so a member with numerous diseases will often need to interact with various individuals,” says Snyman. “This model can be inconvenient and confusing for the member, while simultaneously preventing a single view of the beneficiary."

According to Snyman, the PDC model allows Personal Health Co-ordinators to develop in-depth knowledge about each member’s case. The member also benefits from this approach, as they are able to contact their personal co-ordinator and circumvent much of the inconvenience and confusion – particularly that relating to the authorisation process within medical schemes.

For example, a quadriplegic patient will clearly require a wheelchair when discharged from hospital – something they may not have considered beforehand. The PDC system anticipates this need and grants authorisation before the patient is discharged from hospital. 

With 56% of medical scheme members displaying at least one or more healthcare risk factors and at least 20% being at high risk for chronic disease, research conducted by Agility Global Health Solutions found that medicines did not necessarily drive up costs, but increased hospital stays did.

"The industry shift towards savings accounts and hospital plans meant that the only way members could access their funds was via admission to hospital," says Snyman. 

But by using technology to track and manage patients’ health care, schemes are able to ensure members stay healthy and don’t need costly interventions later. Following the implementation of PDC, Agility Global Health Solutions found that patients’ length of stay in hospital decreased by 22% and the admission rate of chronic patients dropped by between 15-20%.  In addition, medicine costs decreased largely because health events drive prescriptions. 

"The increased initial expenditure in medical costs associated with the introduction of a PDC model is offset by a significant reduction in the most serious chronic conditions," says Snyman.  "Healthier members directly translate into lower healthcare costs."

(Press release, Bespoke Communications, June 2011)

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