Making health care affordable and accessible
Medical scheme members are facing substantial increases far greater than general inflation! What is the solution? Sub-acute care in South Africa has been instrumental in making health care affordable and accessible
The greatest challenge facing the private sector is the rapid increase in spending particularly by medical schemes. As spending increases, so do contributions. Medical scheme members have been faced with substantial increases far greater than general inflation. Contributions have increased fivefold in the past two and a half decades.
In an attempt to curtail the increasing cost of private health care, a range of regulations governs the private sector with the key focus relating to the production and sale of pharmaceutical products with relatively little regulation of health facilities, equipment, quality and distribution of health care. Studies conducted have shown that approximately 2% of the medical scheme population in South Africa utilizes 20% of all cost. One can no longer ignore that there is a problem with high cost and inaccessibility of health care. There is clearly a need for a ‘disruption’ within the health care system to provide services and products that are affordable and accessible to all. Sub-acute care has been termed ‘disruption innovation’ by Harvard professor Clayton Christensen in 2009. Sub-acute care in South Africa has been instrumental in making healthcare more affordable and accessible, simultaneously yielding a high quality of care with quantifiable metrics to demonstrate the impact of interventions. The emergence of Sub-acute facilities has challenged many commonly accepted ideas in health care by the implementation of a set of actions designed to ensure the coordination and continuity of health care as patients transfer between locations and or different levels of care (transitional care) also known as Coordination of Care.
Researchers have identified at least 15 care coordination models that have improved the quality, efficiency or health related outcomes of care for the chronically ill. Furthermore, researchers have identified four care coordination processes associated with positive outcomes;
1. An initial, comprehensive assessment of the patient and the patient’s family circumstances
2. Development of a comprehensive care plan that addresses the patient’s medical, psychosocial and family needs
3. A designated individual to take the lead communicating and coordinating among the patient’s medical providers
4. Promoting family and patient engagement in care
Effective transition and subsequent coordination of care has been proven to lead to improved patient outcomes, reduced health care costs and reduced length of stay. There is evidence based research evaluating the effectiveness of the coordination of care relating to the reduction of hospital readmission. While not all health care providers have the resources to implement the coordination initiative and related programmes, these programmes have been the key focus of Sub-acute facilities in South Africa for nearly a decade.
The primary objective of Care Coordination is for an appropriate patient to receive appropriate care in the appropriate facility. As illustrated in Fig 1 below, there is great emphasis placed along the care continuum (that is preadmission, inpatient and post discharge) to ensure a well coordinated care plan is executed.
Effective Care Coordination is fully integrated when all barriers are considered, challenged and subjugated. These barriers are found at the patient, provider and system levels. The common characteristic being education and communication. In recent years, Sub-acute care has been an integral contributor to transformation of health systems and Coordination of Care, an effective tool. As the industry evolves, so does the need to develop and enhance tools (Coordination of Care), guidelines and pathways for communication between patient, providers and medical schemes.
Serious challenges face the private health care sector in South Africa, not least of all the rapid increase in expenditure and hence contribution rates in medical schemes. It was the conclusion of the Council for Medical Schemes to recommend that a national network of Sub-acute facilities be developed as soon as possible as a cost-effective alternative (Council for Medical Schemes: Fourie & Preller, 2008:2-6). Hence, is the solution more private health care regulation or to innovate and improve on services that already exist?