MANAGEMENT OF GP & SPECIALIST COSTS

MHS COORDINATED PROVIDER NETWORKS (CPNs)

A Strategic Overview

Coordinated Provider Networks consists of a comprehensive, multi-disciplinary network of established health service provider groups that are linked together via agreements with MHS for the purpose of providing rational, appropriate, cost effective healthcare to members of contracted Medical Aid Schemes/ Administrators in return for certain pre-negotiated benefits. The Networks include GP Groups, Dental Groups and Clinical Specialist Groups.

The principles that govern the processes of CPN

These are largely the principles of collaboration and include the following:

Participation – Central to any collaborative process is the principle that initiatives that influence the lives or livelihood of other persons, should be designed and managed in conjunction with representation from the affected parties.

Joint Ownership – Products and services that are developed jointly with the affected parties are much better accepted and instill a sense of ownership and loyalty with the affected parties. Such sentiments are not only absent from imposed products but such imposed products are more often than not viewed with suspicion and resentment by the affected parties.

Decision Accountability – Contentious issues must be debated but decisions on the ultimate courses of actions must be vested with the most appropriate person to make the decision and accept accountability for the decision. E.g. Clinical decisions should reside with Clinicians and actuarial decisions with Actuaries. However combined clinical-actuarial debate promotes insight and understanding, leading to decisions emanating from a broader perspective.

Leaders and Followers – The courage to accept accountability in ones own field of expertise must be balanced with constructive debate around issues outside ones own field of expertise, culminating in a respect and understanding for final decisions and support of the accountable person/entity.

Self Regulation – If the industry can regulate itself, design and promote self-regulation but facilitate such self-regulation with information and expertise and co-opt Networks of Providers that promote self-regulation, quality assurance and cost effectiveness.

The CPN Processes

The CPN Processes are divided into five components, viz.:

The Forum for Health Promotion and Accountability – is an alliance between representatives of the Clinician Networks and senior Fund management. Recognition is given to the interdependence that exists between Clinicians and the Healthcare Funding Industry. The Forum meets three times a year in order to debate problems and seek joint solutions in line with the principle of “Leaders and Followers” as described above. The ultimate purpose of the Forum is to develop mutual understanding and trust.

The Evaluation of Cost Effectiveness – This is primarily a review of utilisation trends as tariffs and prices are set separately. The tools consist of high-level Benchmarks that are risk-adjusted to accommodate variations in age and gender as well as the varying demands of different chronic conditions. With the Benchmarks as a point of departure, further drill-down options include more detailed practice profiles, summaries of the transaction details that make up the Benchmarks as well as access to the individual transactions that made up each Benchmark – the latter is subject to measures to protect patient confidentiality. It must however be emphasised that these utilisation evaluation tools are never used to pass judgement. They merely serve to focus questions for the purpose of assisting quality assurance.

Quality Assurance – This function is performed by Local and Regional Area Managers that are appointed for the task by MHS in consultation with the Networks. These managers are practitioners that are held in high esteem by their peers and that have a sound understanding of the circumstances of practice in their area. Their functions include:

-          Evaluation of the nature of practice, using the Benchmarks as a point of departure. Appropriate practice is motivated as such to the Funds.

-          Peer Mentoring in instances where inappropriate practice requires addressing.

-          Training programmes and marketing of the CPN processes.

Peer Reviews – are used as a last resort when all else fails. The reviews are coordinated by the Local and Regional Area Managers and are held within the Network to which the practice under review belongs in conjunction with Fund representation. The outcomes could include a finding that the practice indeed practiced reasonably, a warning could be given or the suspension of direct payment may be recommended. In extreme situations a practice may be handed over to the relevant authorities.

The Managed Care Fee – Achievers of the Benchmarks receive a managed care fee per consultation (in the case of General Practitioners). Other disciplines are remunerated according to the most appropriate model for that discipline e.g. Dentists are remunerated per patient managed. The purpose of the managed care fee is to remunerate active and successful participation towards realising the goals of Managed Healthcare.

Results

The tangible results are measured as savings achieved. There are three phases to savings. These are:

-          The Pre-savings Phase where the processes are set into motion and participation is facilitated. This phase may last for six to nine months but in instances where the processes are known and accepted, usually is a shorter period.

-          The Savings Phase which entails a reduction in utilisation volumes as well as a shift from expensive to less expensive but equally effective options. This lasts for about eighteen to twenty four months.

-          The Maintenance-of-Savings Phase which starts by agreement on a new (lower) level of acceptable utilisation patterns and a maintenance of such a level of utilisation forward in time, allowing for tariff/price increases at a constant utilisation trend.

Estimation of savings is based on sophisticated projection models based on the age and gender as well as the epidemiology of the beneficiary base as far as can be ascertained by the data on hand. Targets for realistic savings are set and once achieved are maintained in order to prevent under servicing. Maintenance of savings is measured by means of a model that evaluates utilisation trends around the previously determined ideal utilisation level.