Good managed care should take into account clinical and financial risk management, whilst considering the appropriateness and cost-effectiveness of health services within the constraints of what is affordable.
Very few medical schemes successfully deploy managed care interventions and, those that do, continue to struggle with common hurdles. The biggest challenge is to ensure that managed care is an integrated system and process of correct care where all providers are involved and responsible for 'nudging' the patient in the right direction.
As a result, the responsibility lies with doctors, pharmacists, hospital staff, funders and any other healthcare provider involved in the patient's wellbeing. Ensuring that each role-player contributes to the process is challenging and very few medical schemes are able to manage the process successfully.
However, getting it right, by placing a strong focus on practical, proactive care to ensure that patient diseases are adequately managed, could translate into huge cost savings. One recent case study found that high risk patients were responsible for up to 80% of a medical scheme's total cost and clinical risk exposure, despite the group's small size. Proactively managing the health of high risk patients could result in significant reductions in hospitalisation, length of stay, claims and overall healthcare expenditure.
The evident savings on healthcare costs clearly demonstrates the critical need for medical schemes to start investing in managed care initiatives.
Similarly, the survival of NHI is equally dependant on managed care and its associated costs. A critical success point is firstly whether the NHI has managed care in place and secondly, if it has quality clinical outcomes. Here the third party supplier has become government and essentially, irrespective of the managed care funding model implemented by the NHI, it will need to deliver good quality clinical services on which it will be measured.
