Clinical benefits management puts Telkom in the spotlight

The healthcare industry has experienced a raft of changes in the past three years that target specific, historic problems. One critical current and fundamental shift for medical schemes is the need to manage clinical benefits and not simply operate a financial billing system.

The change has come about because there was no way to uncover fraud under the old system because it did not handle overall disease intervention. Traditional Board of Healthcare Funders (BHF) tariff structures were purely billing-based, with underlying systems that paid claims purely on a financial basis. Today, however, systems must adjudicate the clinical merit of claims.

Another area coming under scrutiny is the medical scheme member benefits. The old system saw benefits prescribed by schemes' trustees and administrators. The new system, with ongoing intervention by government and the Registrar of Medical Schemes, prescribes a fixed set of benefits.

Minster of Health, Manto Tshabalala-Msimang, says not regulating the fee structure for services provided by hospitals and health professionals such as those in the private hospital market allows medical scheme members to be exploited.

The balancing of regulator management and scrutiny of non-healthcare costs within the administrators will prove challenging. Both of these will add many basis points back into the member's scheme fund accounts.

A report released by the Council for Medical Schemes this year stated that the medical schemes increase costs to members every year, but that there was no corollary increase in quality of services rendered.

The minister announced in July that she will establish an Office of Standards to investigate quality issues at various hospitals.

The Risk Equalisation Fund was possibly the biggest news for consumers this year. It's essentially a cross-subsidisation mechanism that sees schemes with low-risk members subsidise schemes with higher risk members.

But just the requirement to manage clinical benefits is already having a significant impact on the healthcare industry, putting Telkom firmly in the spotlight.

To get it right means that the industry must first overcome a major stumbling block. The clinical component of the data is nowhere near 100% accurate, and it's common knowledge that most doctors use a cheat sheet to reduce the number of diagnostic codes from in excess of 60 000 to what can be fitted onto a more practical, for them, A4 piece of paper.

That presents a problem to the schemes that claim to have been adjudicating claims on clinical merit for some time now. They've been doing it on the information given to them by doctors. But if doctors are giving them "cheat sheet" information, then it's useless.

To get it right, and this is where Telkom plays a crucial role, doctors must have access to the full list of diagnostic codes and the scheme that administers patients' funds over some form of computer network.

The reason for that is that the result of a consultation can now have a direct impact on what the next available benefit to a medical scheme's member is going to be. If a doctor diagnoses a patient with diabetes, then the next available protocol or benefit may come from a completely different risk pool. The benefits only become available to members, or patients, after the doctor submits the diagnosis to the scheme. If the protocol is not immediately effected, then the knock-on financial effect to the scheme could be severe.

Some diagnoses have immediate effects that expire and others give patients time to follow through.

The lack of a reliable network and communications infrastructure severely impedes and can even cripple the process.

The high cost of communications in South Africa under Telkom's monopoly is a major stumbling block to government's plan to effect its healthcare strategy. Increasing regulation will only increase the requirement for a reliable and cost-effective supporting communications infrastructure and the sooner government can enable a range of competition in the market, the sooner it will realise effective gains.