Collaborating for better outcomes
Dr Wayne Riback, General Manager: Healthcare Professionals Strategy Unit (HPSU) at Medscheme, was invited to present virtually at a recent International Federation of Health Plans (iFHP) Value Based Health Care member network forum. He shared details of the Medscheme Arthroplasty (joint replacement) global fee programme, which generates improved cost management for schemes and better outcomes for patients.
Dr Riback’s presentation specifically focused on two experienced third care parties, ICPS and JointCare, that manage the programme in collaboration with Medscheme. Via the global fee programme, primary hip and knee arthroplasty procedures are managed for 12 Medscheme administered schemes.
Hip and knee arthroplasty procedures regularly feature in the top 10 costs for the schemes each year, but through programmes such as this, costs can be better managed, with the advantage of additional benefits in respect of improved outcomes and enhanced member experience.
The programme has been in place at Medscheme since 2013, at a time when outcomes-based global fee models were a novel concept and were viewed with apprehension by providers (both healthcare professionals and facilities).
From a small start of only 13 orthopaedic surgeons on the network, it has grown to more than 240 contracted surgeons. It is the largest arthroplasty network in the country and covers all geographical regions. Most participating scheme members have access to a surgeon within a 30km radius.
The global fees cover the pre-op, in-hospital and post-discharge (four weeks) period and include provider fees (orthopaedic surgeon, anaesthetists, physiotherapist), facility costs (including ward fees, theatre costs and medication/consumables) as well as prosthesis costs.
Aligned with the Health Market Inquiry report, the programme is a key contributor by Medscheme to its scheme’s clients in respect of value based contracting and outcomes measurement. Ultimately, our focus should be all about putting the scheme member at the centre of the treatment journey, as well as supporting financial savings and sustainability for the schemes we administer.
How the global fee programme works
A critical success factor in the programme was the development and implementation of accredited care pathways, including patient pre-surgical optimisation and standardisation of care from both pre-admission into the post-operative and discharge period. This is supported and validated through a robust set of clinical outcomes and quality measures, that enhance the member experience and value as well as drive efficiency for the schemes. Some of these outcomes are detailed in the image below.
Patient Reported Outcome Measures (Proms) and Patient Reported Experience Measures Prems) are measured by a third party and have returned good outcomes. Medscheme has also initiated its own Arthroplasty Prems survey to better understand and improve members’ experience.
The programme has grown over the years to incorporate:
- Same-day discharge arthroplasty in an ambulatory setting in 2022, and
- Collective bargaining through the development of a multi-scheme collective arthroplasty network in 2024.
Future developments will include setting up a revision arthroplasty global fee.
Positive feedback
Dr Riback’s presentation highlighted the success of the programme and the response from the forum was extremely positive. “Thanks for another great VBHC discussion today. Wayne’s presentation was terrific and probably set the benchmark for VBHC initiatives,” one forum member said.
The Healthcare Professionals Strategy Unit, via Dr Riback, appreciated the opportunity to showcase and represent the sterling work done via an international platform. The success of this programme is a culmination of continuous work and input from numerous functions and individuals within Medscheme, and as such this is an accolade to be deservedly shared by many.
What is the iFHP?
iFHP is an international association with a global network of healthcare funders that facilitates the exchange of knowledge and best practices among health insurers/funders to improve the quality and efficiency of healthcare systems worldwide. Medscheme is represented in the iFHP by Dr Jenni Noble-Luckhoff and Dr Wayne Riback on matters related to managed care within the administrator/funder environment.
