An alternative reimbursement model has been launched that will benefit patients and encourage best practice among clinicians in the private healthcare sector.
With the event-based contract (EBC) model, a medical aid can make a single, fixed payment to the individual healthcare team members who are treating a patient for an episode of care.
EBC was spearheaded by the South African Society of Anaesthesiologists (Sasa) and rolled out to Discovery Health's arthroplasty network. For example, a hip or knee replacement requires a team of professionals comprising a minimum of an anaesthetist, an orthopaedic surgeon, an appropriate hospital facility and a physiotherapist. The contract will cover the period for eligible patients from surgery into the recovery and rehabilitation period.
The model is the result of four years of extensive research and consultation with the healthcare sector, and is aligned with the Health Professions Council of South Africa’s (HPCSA’s) ethical rules and South African legislation.
“Sasa is committed to enhancing the delivery of healthcare services, ensuring that patient care is secured above all else. This led us to explore models that incentivise greater accountability and more collaborative work among clinicians, and offer both the funder and patient cost certainty, without compromising the patient’s care. The new contracting model achieves all of these goals,” says Natalie Zimmelman, Sasa chief executive.
Protects the patient without adding cost
It should not increase medical costs for patients and will, in fact, probably result in lower fees for private healthcare services over time, as all players in the healthcare system seek better efficiencies with good health outcomes, she adds.
Zimmelman says that the EBC is appropriate for the South African market – “which does not have the kind of sophisticated regulatory processes and active oversight seen in many other markets” – in that it promotes a greater level of transparency, and makes clinicians and facilities (clinics and hospitals) more accountable to each other and to their professional peers.
“This new patient-driven care model protects the patient without adding cost. Because the clinician contracts directly with the funder, they will share the risk, and it will drive collaborative care and information sharing, while keeping the patient at the centre. Ultimately, it’s always about putting patient safety first while ensuring the sustainability of the South African healthcare sector.”
Sasa also notes that this model can be used as an example of a mechanism for the procurement of private healthcare services under the National Health Insurance.
"The Sasa EBC is an example of a positive move towards enhancing and placing value on the integration of anaesthetic services in holistic patient care, supported by an innovative fixed-fee reimbursement model. The approach provides regulatory certainty and societal peer review, and entrenches quality-of-care principles through the monitoring of team processes and care outcomes," says Darren Sweidan, Discovery Health’s head health professional unit.