In the media

Medscheme and SASES to Pilot New Funding Model

31 August 2015

Medscheme and the SA Society of Endoscopic Surgeons (SASES) have revealed a joint plan to address the challenges associated with funding laparoscopic (keyhole) surgery.

According to Senior Actuary at Medscheme, Simon Dreyer, a laparoscopic appendectomy can cost nearly 50% more than an open appendectomy due to the cost of additional consumables that are used by surgeons to perform laparoscopic surgery.

“It’s because of this that we currently have interventions in place to restrict the funding of a number of endoscopic procedures, these include protocols allowing funding when certain criteria are met, letters of motivation from surgeons and co-payments,” said Dreyer.

Using laparoscopic appendectomy as an example, Dreyer explained that the average cost of the consumables are just over R4,600 per case. However, in some cases the cost of consumables used by surgeons can approach R20,000, while in other cases surgeons are able to do the same procedure using consumables costing less than R2,000.

Chairperson of SASES, Dr Dick Brombacher, noted that the current funding interventions in laparoscopic surgery, especially where surgeons are expected to write a motivation are not only an additional administrative burden but also intrusive on clinical autonomy.

“As a society we wanted to work with Medscheme to understand what was driving the costs and then work together to find new solutions to address the funding and clinical outcomes of laparoscopic surgery. We chose to start with laparoscopic appendectomy as a pilot with the intention of expanding the learnings to other procedures,” said Dr Brombacher.

The proposed pilot will involve a network of contracted surgeons who agree to keep the cost of laparoscopic consumables below a determined price. In addition, there will be one tariff for appendectomy irrespective of whether it is done laparoscopically or open, removing any financial incentive to do the procedure laparoscopically.

“Surgeons who participate in this pilot will not be required to motivate to do a laparoscopic appendectomy. Their clinical outcomes and costs would be monitored and where indicated, outliers will be subject to peer management from SASES. Surgeons will be completely free to use whatever consumables they want as long as they keep within the determined cost for consumables and their clinical outcomes were good. SASES will support them and we have already had some discussions with the device companies,” said Dr Brombacher.

According to Dreyer, this initiative will reduce the cost of current laparoscopic appendectomies, allow for more of these procedures and still be cost neutral for medical schemes. “It’s critical that the hospital groups and device companies also review their pricing and there have already been discussions with some of the major hospital groups and device companies,” said Dreyer.

Ultimately, the member will benefit and this initiative could be expanded to other procedures going forward. “We wanted to test this proposal with our surgeons before Medscheme engaged their client medical schemes on this,” said Dr Brombacher.

CEO of Medscheme, Kevin Aron, added: “Ongoing confrontation and litigation are unlikely to solve the current healthcare challenges we are facing as an industry. This is a great example illustrating how funders and healthcare professionals can work together to find solutions.”

“By engaging and sharing information we are able to understand their challenges as surgeons and they are able to understand ours as funders. It’s when common ground is found that new and innovative solutions can be formulated jointly. We can now take a mutually agreed solution to our client medical schemes for the benefit of their members,” concluded Aron.

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Source: eHealth News


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