SENSE AND SENSIBILITY IN
MANAGED CARE
Purpose of the presentation
• To argue that managed care as it is currently structured,
CANNOT succeed managing costs of care
Presenter logo
to come here
• To build a case for a shift from a Biomedical Model to a Biopsychosocial Model of Managed Health Care
• To argue for disease prevention and health promotion in
managed health care
• To agitate for greater empowerment of clinicians in health
promotion and cost management
• To agitate for tailored intervention in member/patient health
education
Burning platform: (Un)managed health
care ?
….”The amount South African medical schemes spend on managed care
has steadily increased over the last 13 years……..”.
Presenter logo
to come here
“….The main reasons trustees are investing in managed care are to
manage the increasing cost of belonging to a medical scheme and to
improve the management of chronic diseases.”
“Given that the cost of benefits continues to rise above inflation, the jury
is out on how effective the current form of managed care interventions
are”.
Dr Andrew Good, (Health Management Review Africa • 2nd Quarter
2013)
We all would identify with these view, but main question is why
savings are illusive.
Treating illness is a costly business…
…Promoting wellness is common sense
Presenter logo
to come here
Its all in the sciences
Still based on the Biomedical Model of Health
• Relies on:
Presenter logo
to come here
• Presence of disease or illness/injury instead of focusing on health
• Protocols & Formularies for disease management instead of
promoting health
• Clinical management by providers networks
• Rules of the scheme
• Health information dissemination to members
However evidence across schemes suggests that the burden is
mainly from chronic illnesses linked to lifestyle choices NOT
biology defects!!!
The model has many practise limitations
On the wrong side of the health and cost curve while focus on illness
Presenter logo
to come here
• Interventions follow clinical diagnosis which is way down stream and
normally costly
• Intervention is after a decision to spend by a member has been taken
• Interventions miss the patient-provider transaction point
• Determinants of poor behaviours not taken into account
• Rules are easily side-lined by the parties with patient and provider interests
prevailing over cost considerations
• Provider incentives not aligned with scheme objectives
Above all, by not aligning with the National Health Plan which
has made the shift, the industry is missing a great opportunity
to make a real difference in the health system
Better science of health?
Bio-psychosocial Model
Biomedical Model
Biological, psychological and social linkages to
health and illness.
Main focus is biological process to disease.
Other factors considered as almost irrelevant.
Acknowledges role for primary prevention.
Limited scope for primary prevention.
Views body and mind as intertwined.
Body and mind are separate.
Facilitate patient empowerment and internal health
locus of control.
Disempowers patients and promotes a external
health locus of control.
Emphasises both health and illness but promotes
health/wellness.
Emphasises disease or illness.
A comprehensive model is the sure way to improve health
and quality of life
A solid base for disease prevention and
health promotion
Disease prevention
Health promotion
A wide range of interventions aimed at
reducing risk or threat to health.
Process of enabling people to increase control
over, and to improve, their health.
Disease prevention begins with a threat to health-a disease or environmental hazard.
Health promotion begins with people who are
basically healthy and seeks the development of
community and individual measures which can
help them to develop lifestyles that can maintain
and enhance their state of well being.
All prevention categories aligned with
Biopsychosocial health model
Seeks to protect as many people as possible from
the harmful consequences of that threat.
Recognises social determinants of health.
Only by targeting the right factors at the right time can we
win the war on costs.
Creating a pathway for all stakeholders’
involvement
Multi-levels of interventions
Presenter logo
to come here
• Regulatory/Macro level
• Scheme governance structures such as trustees
• Organisational design and internal processes
• Service providers such as doctors and hospitals
• Patients/Members
Everyone has a role to play in achieving the aims of
managing costs, ensuring care access and quality care.
Approach:PRECEDE-PROCEED MODEL
Risk logic model
Change logic model
Practical implications of such as change
Managed care will intervene before consumption can we win the
war on costs while provider quality care
• Legislation:
Presenter logo
to come here
• Incentivise prevention of diseases through multidisciplinary approaches
that are scientific and evidence based
• Organisational
• Rethink organisational design/operating models to support impartial
monitoring and evaluation of managed care programs
• Members/patient demands
• Encourage a culture of self empowerment and risk appreciation to self
and scheme reserves
• Providers
• Consider determinant of bad behaviour as critical in the health care
value chain
Example: Empowering patients
Intervention: Arthritis Self Management
• Patients are taught pain control techniques, self-relaxation, and proximal goal setting
combined with self-incentives as motivators to increase level of activity.
Presenter logo
to come here
• Taught problem-solving self-diagnostic skills and how to take greater initiative for their
healthcare in dealings with health personnel.
•
Skills are developed through modelling of self-management skills, guided mastery practices,
and informative feedback.
• The program is implemented in groups in community settings by leaders who lead active
lives despite their arthritis.
Enduring healthful changes achieved by training in selfmanagement of arthritis as revealed in a follow-up assessment 4
years later.
Presenter logo
to come here
Source: Bandura. A. (Health Educ Behav 2004; 31; 143)
Example: Targeting clinician behaviours
Objective: Understanding why clinicians are poor in adhering
to clinical guidelines
Presenter logo
to come here
• Target points for behavioural modification:
• Knowledge of the guidelines
• Self efficacy to implement them
• Attitudes towards implementing them
• External/environmental factors affecting adherence
Example: Targeting clinician behaviours
Sequence of
behaviour change
Presenter logo
to come here
Knowledge
Attitudes
Behaviour
Lack of familiarity
Barriers to
guideline
adherence
• Guideline
accessibility
• Volume of
information
• Time to needed to
stay informed
• Lack of awareness
• etc
Lack of agreement
with guidelines
• Applicability to
patients
• Lack of self efficacy
to implement
External factors:
• Can’t reconcile with
patient preferences
• Lack of time
• Lack of
reimbursement
• Lack of motivation
• etc
Source: American Medical Association (1999)
• etc
Overall benefits
• Aligned goals and objectives from bottom up and top down
• Everyone is a key stakeholder in cost management and
scheme sustainability
Presenter logo
to come here
• Everyone is a key stakeholder in patient health outcomes
• Service providers feel intellectually recognised/rewarded
NOT undermined
• Governance focusses on health outcomes not outputs
• Always cheaper in the long term than restricting service
access or dealing with ever increasing treatment costs
What are the costs
• Emotional cost: Paradigm shift from Blame Games to Vision
Sharing
Presenter logo
to come here
• Financial cost: Investment in health promotion and health
education as part of managed care
• Human cost: Contextualising clinical protocols and disease
management programs
• Lobbying for updating the managed care act to be in line
with new realities
But: Benefits >>>Costs
Concluding remarks
Managed care is probably the most strategic asset
the industry has to help reshape the national health
system
Presenter logo
to come here
• Can help show the State how to prioritise prevention and self
empowerment in the context of scarce resources
• Can contribute towards goals of sustainable consumption of health
care services
• Can bring various stakeholders to reconfigure delivery of care
Above all, managed care can help end grudge buying of cover,
suspicions of member prejudice and self enrichment
THANK YOU