24 July 2015

SA medical schemes in favour of improving clinical quality healthcare

The private healthcare industry has welcomed the release of the eleventh annual report on the clinical quality of healthcare in South Africa, which was released at a conference of healthcare stakeholders in Centurion, Gauteng on 22 July 2015.


The report highlights key aspects in the provision of quality health care. Eighteen medical schemes representing 79% (6.78 million) of medical scheme beneficiaries in South Africa willingly provided claims data from 2010 to 2014 to enable the assessment of the value of healthcare that members are receiving from their medical schemes. The healthcare industry commends participating schemes for taking part in this voluntary process.

Read: How do I choose a medical scheme 

The intention of Health Quality Assessment is to measure a broad range of important health issues, including the development of better understandings of the burden of disease in South Africa.

A range of 190 measurements were used to assess access to and utilisation of primary care and preventative measures, care of expectant mothers and their new born babies, the effects of provider and patient driven demand on the provision of healthcare and the management of chronic conditions such as HIV, diabetes, hypertension, TB, obesity, heart disease, respiratory conditions, and cancer. 

The process for measuring the clinical quality of health care delivery in the private sector was initiated by Health Quality Assessment (HQA) eleven years ago. Louis Botha, CEO of HQA says the philosophy that drives the process is that you cannot manage what you don’t measure. 

Read: What to look out for when choosing a medical scheme 

Botha explains that the results provide participating schemes with valuable information about, among others, clinical quality and trends that inform decisions regarding access to care, benefit improvements, rule amendments, managed care applications, provider/network contracting, member/provider education, system changes and/or to address problems with coding.

It enables participating medical schemes to assess their own performance in the delivery of quality health care, relative to other participants and against international norms and standards.

Overall positive trends

The 2015 Health Quality Assessment results show that there is progress in clinical quality of care provided in the private healthcare sector, albeit slow. Of the indicators analysed, 32% are showing consistent improvements over the last few years; 32% are showing mixed trends; and 37% are showing declining trends.

The latter trend confirms that more work needs to be done, but the importance of the HQA process is to identify these trends and implement intervention strategies. In fact, a number of the medical schemes participating in the annual HQA surveys have already implemented such strategies and their members are beginning to reap the benefits.

The detail indicators are grouped into three dimensions. Of these the process indicators pertain to the quality of care provided in terms of the management of primary care and screening, and the management of chronic diseases.

Read: List of chronic diseases

The process indicators are grouped further into four main groups: primary care and screening, care of expectant mothers and their new born babies, HIV management and other (non-HIV) chronic disease management.

High level of hospitalisation

Three of these four main indicators have shown overall positive trends. These include primary care; maternity care and management of newborn; and HIV management. However, the management of chronic diseases (excluding HIV) has shown a declining trend. 

The high level of hospitalisation for chronic conditions is a particular concern. There are potentially three factors that contribute to this trend, namely, patients with chronic conditions are not managed adequately and holistically enough; patients are not taking responsibility for their own care; or patients are not aware of the fact that the management of their chronic conditions are part of the prescribed minimum benefits that are covered in full by all medical schemes. 

The good news is that the medical scheme industry is now aware of these trends and can use this information to achieve better results faster and implement solutions to turn around negative trends.

The industry can also learn from the successes that have been achieved with respect to the management of patients on anti-retroviral medication.  One of the challenges would be to apply some of the learnings from the management of patients on anti-retroviral medication to the management of other chronic diseases.

A significant improvement of 12.98% has been achieved in the management of HIV over a five year period. These improvements have come off a much higher base than what is the case for the other chronic diseases. 

Read: 25 conditions your scheme must cover

Although the results revealed overall encouraging trends it would appear that curative treatment outweighed prevention and proactive interventions. In future, assessments would be conducted on a continuing basis and results will be made available to schemes quarterly instead of annually.

The intention is then for the results of the HQA surveys to become a management tool rather than a static report.

Industry participants

The 18 medical schemes that participated voluntarily in the 2015 HQA Clinical Quality Report are Bankmed, Bonitas, CAMAF, Discovery HMS, Engen, GEMS, Hosmed, Medihelp, Nedgroup, Netcare, Polmed, Profmed, Remedi, Resohealth, Samwumed, Sizwe, Transmed and Wooltru. 

HQA enjoys the support from member organisations, namely Agility GHS, Aspen Pharmacare, Board of Healthcare Funders, Carecross, CDE, Discovery Health, IPASA, IPA Foundation, PMSA, Medscheme, Metropolitan Health, LifeSense, Medipost, Momentum Health, MSD, MSO, SA Medical Association, Sancreed, Servier, Sechaba, Strata Healthcare Management and Universal Care. 

HQA’s members represent most spheres of the health care industry and collaborate on HQA’s CAB (Clinical Advisory Board) to develop relevant health quality indicators. It is endorsed by Board of Healthcare Funders (BHF), SA National Consumer Union (SANCU) and the Council of Medical Schemes (CMS).

HQA fully supports the Department of Health’s initiatives to improve clinical quality in the public sector and the Council for Medical Schemes’ drive towards improving health quality in the healthcare industry. "As an independent, non-profit organisation HQA believes it is ideally positioned to assist in that regard," said Botha. 

Read more:

Medical Aid schemes are squeezing community pharmacies and consumers  

Your medical scheme and the budget 

Could PMB's be on the way out out? 

Image: Medical device from Shutterstock


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