Patient flow

The movement of patients through a medical centre needs to be well managed or it can result in long waiting times, increased length of stay, and adverse health outcomes. The Covid-19 pandemic highlights the challenge as hospital networks experience a simultaneous surge in demand and a reduction in volumes of elective surgeries. Getting patients to the best place or unit at the right time for their condition across all current and incoming patients is no easy task.

Fortunately, as advanced, targeted solutions become increasingly affordable and accessible, healthcare providers have the opportunity to rethink their strategies.

Transformation to intelligent operations

Our research finds that the use of intelligent operations allows healthcare providers to refine back-office processes and activities, make the customer experience frictionless and increase profitability and customer retention while leveraging human resources more effectively. The move to intelligent operations is possible through applied intelligence – the combination of data with the power of automation, analytics and artificial intelligence (AI) at scale. This way, healthcare providers can rapidly achieve efficiencies and next-level performance.In practice, this means claims management will be more streamlined. A digital claims-monitoring tool can identify claims stranded with medical aid schemes, provide a timely alert, raise late payment charges, and automate follow-ups. An AI system can also make a prior authorisation for a procedure more efficient by validating the information associated with the request and thus freeing human resources to focus on higher-value tasks. Lastly, AI tools can simplify clinical coding, reduce claim denials and under-recovery of revenue by adding AI and automation to clinical document review.

At the core of this success is the effective use of data. With accurate data on length of stay, occupancy, patient experience, and financial risk, hospitals can enhance the prediction of patient flow to optimise hospital resources. Hospitals can improve operational planning and execution; enhance patient, doctor and staff experiences; and improve clinical outcomes.

Next-level healthcare performance

Africa’s healthcare providers need to solve for an outcome – they have to work with what they have now while preparing for what they want to do next.

Immediate steps to take include:

• Accurate data collection
• Capture data insights through visual dashboards
• Train staff members to seek insight and make data-driven decisions to target value
• Prioritise efforts – focus on near-term opportunities and sustained solutions based on value

After this, it is important to implement the right type of automation. If the work is transactional and rules-based, it is well-suited to robotic process automation (RPA), and if it is knowledge-based, then it’s a job for AI. Next, they can find and make use of AI and analytics solutions that can be delivered cost-effectively via the cloud. Ultimately providers can refocus and upskill revenue cycle resources.

In dealing with overcrowding or improving patient flow, healthcare providers should explore the data on key metrics across multiple dimensions. For example, monitoring data on admissions and excess days per unit, physician and service line, can help with understanding the opportunity cost of inefficiencies. Next, they should create data-centric operations where staff embrace the power of data and use it effectively to work smarter. This in turn leads to the start of a culture shift where staff can be educated, upskilled and exposed to technology and data tools to remove fear. It is important to focus on areas for ongoing analytics such as the optimisation of bed allocation, or occupancy and discharge prediction to build agile operations.

Roadmap

Hospitals should then create a roadmap to becoming connected and cognitive. Leading hospitals are connecting the visibility of surgical flow, patient flow and staffing to provide better patient care and a better experience for staff and physicians.

In conclusion, healthcare providers need to find alternative, cost-effective ways of providing healthcare services, and the future of healthcare work is being driven by technological advances that improve sustainable care. Transforming processes to intelligent operations through Applied Intelligence helps healthcare workers direct their focus on patient care rather than administrative tasks, thus improve hospital efficiency. Using healthcare analytics and exploring the use of data, can help with better revenue cycle management and improve patient flow. By handing over some tasks to machines, healthcare providers can optimise human performance and free up healthcare workers to do more important work in personal patient care.

In the past, medical schemes have generally passed annual increases in the inflation plus 3% to 5% range, which would have meant total increases in the 6% to 8% range. However, increases for 2021 have generally been in the 4% to 6% range (with several schemes surprisingly announcing increases of even lower than 4%).

Although the Council for Medical Schemes in Circular 52 of 2020 (released on 23 July 2020) requested schemes to contain increases to National Treasury’s expected 2021 average CPI of 3.9%, demographic and utilisation factors will always prevail to ensure schemes can ensure financial sustainability, which is why several schemes have increases at a higher rate.

Lower increases

Understanding why the increases have been lower for so many schemes is simple. A lower demand for elective or non-urgent surgeries for a protracted period during 2020 has meant claims were substantially lower than budgeted for. In addition, some of the prohibitive lockdown measures also resulted in lower trauma-related claims. However, this has to be countered by the fact that testing and treatment for Covid-19 was added to the Prescribed Minimum Benefits (PMBs) early in May 2020. This meant that provided any medical scheme members followed the proposed treatment pathways, medical schemes were obliged to cover Covid-19 tests from risk, as opposed to day-to-day benefits, irrespective of whether a member tested positive or negative.The PMB guidelines were subsequently revised a couple of times, but the executive summary is that the guidelines set out what and how medical schemes must cover Covid-19 tests and treatment. By way of example, the PCR tests after referral by a healthcare professional are included at PMB level of care, but the rapid tests are not. The guidelines also cover what is not included at PMB level of care, such as the testing of employees retuning to work. If unsure about what is (or isn’t) covered, it’s best to confirm with your medical scheme.

Other factors that will come into play during 2021 are the pent-up demand for elective and non-urgent surgeries when lockdown restrictions are completely relaxed, and patients have the confidence to undergo the delayed procedures. A further expected impact will be the cost of providing cover for Covid-19 vaccines, and probably the largest and at this stage completely unknown factor, could be the cost of treatment for members during the expected resurgence (or second wave) of Covid-19. Medical schemes have therefore had to play a careful balancing act with the objective always being to protect their long-term financial sustainability.

The actual experience from scheme to scheme will also have been impacted by the underlying demographic and financial profile of the scheme. Medical schemes with younger age profiles or those in a robust financial position will in all likelihood be those with the lower increases for 2021, while the opposite will hold true for schemes with older member profiles or poorer financial positions.

The 2020 Sponsors of Brave campaign – a partnership between Adcock Ingram OTC and News24 – aims to celebrate the unsung heroes and brave professionals in healthcare. In particular, season 2 recognises that pursuing a career in healthcare during the height of a pandemic is the definition of a Generation of Brave and aims to shine a spotlight on the succession of healthcare heroes.

Setting the bar high

Season 1 of the Sponsors of Brave campaign was a runaway success, showcasing the depth and breadth of heroism all around us. Some 3800 heroes from the front lines of healthcare in South Africa were nominated and 12 finalists emerged to have their stories shared and amplified. By the end of the competition, over 3.2 million readers engaged with the campaign, and two worthy winners were chosen, earning R25,000 for each of their preferred charities and a trip to an overseas medical conference of their choosing.

Nominations cast a wide net, culminating with two winning entries: Pharmacist and community cornerstone Nontutuzelo Sibango from the Eastern Cape who captured the public’s heart through her work supporting young athletes in her community and clinic founder Dr Hugo Templeman of Ndlovu Care Group in Limpopo was the Judges choice

Yudhveer Singh, spokesperson for Adcock Ingram OTC Division remarked that “We were blown away by the scale of nominations and the calibre of the healthcare professionals who ultimately won in the first season. It is exciting to anticipate what new champions season 2 will introduce as we recognise aspiring healthcare professionals who personified practicing the Hippocratic oath during Covid-19”.

Time to step up

Now, as our energy to face what is left of 2020 wanes, we need fresh faces that bring new stories and successes to celebrate and reinvigorate the nation. This is why the focus for season 2 is on students, graduates and those in community service gearing up to enter the healthcare profession during this unprecedented time in history.

Despite everything 2020 has thrown at them – business and school closures, shrinking term dates, rising unemployment, and exceptional uncertainty – our budding healthcare professionals have proven to be resilient.

“This year has been incredibly trying, but our Sponsors of Brave campaign is all about hope and heroism,” says Andrea Firth, Commercial Editor of BrandStudio at 24.com “Bravery is not about the absence of fear, but of continuing on despite it. We want to give credit where it is due, and we want to demonstrate to this next generation – who have already faced so much – that we believe in them, and we will invest in them and their futures.”

Are you part of the next generation of Brave? Nominate and win.

Are you an aspiring, current or recently graduated healthcare student or currently completing your community service year? Adcock Ingram OTC and News24 are encouraging you to nominate yourself or a deserving candidate and you could win one of 10 x R5000 weekly prizes.

In addition, featured nominees could also stand a chance to win an impactful mentorship and two lucky students will walk away with R25,000 towards their studies.

Mentor’s will also be in line to win a trip to an overseas medical conference of their choice to the value of R50,000 and the opportunity to pay-it-forward by donating R25,000 to any registered NPO charity they wish to support.

Visit https://partners.24.com/SponsorsofBrave/ website for more entry criteria, and to nominate yourself, a worthy candidate or to become a mentor.

Lee Callakoppen, Principal Officer of Bonitas Medical Fund announced an unprecedented 0% increase on its BonFit Select plan and a weighted increase of 4.6% across all plans. The highest increase is 7.1%. ‘Members on our growth options, which contribute to 91% of business, will only experience an increase on 3.9%. I think, looking at the pricing and the benefit richness we offer in comparison to the market, the changes for 2021 will be well received.’

He says, ‘The guidelines received from the Council for Medical Schemes (CMS), clearly highlighted that medical schemes should limit contribution increases as far as possible. We crunched numbers and worked tirelessly to find the sweet-spot between sustainability and ensuring affordability. Not an easy task, especially in a weakened economy. We took a responsible stance, with a long-term view, to ensure that our members wouldn’t have to pay the price of a low increase for 2021 in the coming years. One of our core considerations was finding ways to ensure members could get access to full healthcare cover and avoid out-of-pocket expenses and co-payments.’

Pricing and technology

Seven of our current options are priced between R1500 and R3000 which is where the medical scheme market is experiencing growth currently. Member behaviour has changed significantly and demand is for innovation, accessibility and technology. This has the benefit of attracting, a younger, target audience and driving sustainability.

We can’t talk about 2020 without mentioning Covid-19. Key trends that emerged from a medical schemes perspective were:

–        Changes to benefit structures and PMBs

–        Lower than anticipated investment income as markets slumped

–        Changes in claiming patterns in terms of seasonality and volume, due to the lockdown measures that came into effect

–        And a Consumer Price Index that was lower than previous years which is expected to be at around 3.9% in 2021

In an industry like ours, it’s challenging to be different – to innovate, disrupt…to be better. But not impossible. The Fund needed to make short-term decisions with the long-term view and sustainability in mind.

One of the highlights over the past few years, has been the introduction of four Efficiency Discounted Options (EDOs). Plans whereby members use network healthcare providers and pay around 15% less for the same benefits. The EDOs cover over 74,000 lives and the principal members who join are around 10 years younger than the average Bonitas member.

2021 – changes, contribution increases and enhancements

Over the past five years, we have proactively driven innovative product design, actuarial modelling and constant engagement with various stakeholders. We believe we offer the ultimate split risk solution, with a comprehensive product range and diversified membership base.

To stay at the forefront of innovation we have introduced:

Edge – a new category driven by technology, intelligence and innovation, with two plans called BonStart and BonStart Plus. These are designed for economically active singles or couples, living in the larger metros.

The plans include access to: A private hospital network and full cover for emergencies; PMB chronic medicine; excellent day-to-day benefits including unlimited GP consultations; layers of virtual care, dental and optical benefits; preventative care; wellness screenings; contraceptives and more. The cost: R1452 and R1731 respectively for the principal member.

Managed Care

One of the leading trends worldwide is the rise in non-communicable diseases, such as diabetes, high blood pressure and oncology. In fact, during this global pandemic, the impact lifestyle diseases and comorbidities had on Covid-19 patients was put in the spotlight. 20% of our members have multiple comorbidities which means, even without the pandemic, we need a stronger focus on preventing and managing lifestyle behaviours. Poor diet, smoking and lack of exercise are the three lifestyle factors that contribute to over 80% of chronic conditions.

Managed Care continues to be a focus to empower members to take charge of their health and support them along the way. 

Home-based care

During Covid-19, home-based care received renewed interest and focus. This dovetails with our strategy to move more care to the home and out of hospital. As an example, post-surgery or mild pneumonia, treatment can be effectively provided at home through the assistance of nurses. Not only is home-based care a cost effective delivery of care but it also promotes healing. Studies show that patients recover faster in their comfort of their own home.

Day hospitals

We believe the use of day hospitals and clinics should be encouraged, where possible. Some procedures such as cataract surgery, circumcisions and scopes are better suited to be performed in day hospitals or clinics versus larger hospitals. There is minimum disruption to members, speedier recovery times, less risk of infection and day hospital are also a more cost effective alternative.

Technology

One of the key learnings has been adapting to a new way of working – with virtual technology at the forefront. The WhatsApp channel we introduced has the most room for potential. This platform is convenient for members and allows them to manage their medical aid through live chats.

Virtual Care

There was a positive response to the launch of the new Bonitas Member Mobile App and free virtual care for all South Africans. This provided access to GP consultations for a range of conditions, including Covid-19, as well as free delivery for chronic medicine.

At the heart of the model is the GP. This aligns to our care coordination initiatives, ensuring members receive the right level of care and support in managing their conditions. It allows access to a virtual nurse, advice in an emergency, auxiliary and home- based care, ensuring members have comprehensive support for any condition, in any circumstance, through our virtual based model.

We’re pleased to announce that this model is unique and will guarantee a further level of differentiation for Bonitas.

Mental health

Is fast becoming the next pandemic and is a significant Managed Care risk. Studies show that around 20 -25% of patients with pre-existing mental health issues feel they are coping badly or deteriorating due to the pandemic. We predict that depression and post-traumatic stress, which has historically been on an upward slope, will increase further in time.

We have built a resource hub on our website to help people understand the condition and steps they can take to remain mentally healthy. The app also has a screening tool to help identify warning signals of mental distress. For those who need medical treatment, the focus is on ensuring that care for the mental illness is provided effectively.

The Wellness Extender

Is one of our key benefits as it provides access to another layer of care paid from risk. In 2021 the Wellness Extender can be used to pay for up to three months subscription fees for Run/Walk for Life to help our members get healthier.

Conclusion

We are looking forward to new and innovative ways of empowering members to manage their health in 2021 and beyond.  Our focus is on more primary healthcare, utilisation of preventative care benefits, digitally enabled solutions and self-help facilities for members who want access to their benefits 24/7. Our goal is to improve integration of care, enable more access to out-of-hospital services, clinical information and benefits via various solutions.

We have listened to our members’ needs and will be rolling out various tools and services to provide additional clinical support, an easier claims process and access to various helpful tools on our website. We are a medical aid for South Africa and our commitment of providing quality care, connecting with our customers and driving innovation is unwavering.’

Almost five months ago elective surgeries came to a standstill. This was reflected in claiming patterns in the private healthcare sector during lockdown – a disruption of the norm globally. In South Africa, elective surgery in both the private and public healthcare space and specialists’ visits are just two of the areas which have been affected by Covid-19. The link between the two is clear: Fewer specialists’ visits mean fewer referrals for surgery.

So what exactly is elective surgery?
The term can be ambiguous. It does not mean, as the name implies, that the surgery is optional but rather that it doesn’t need to be performed immediately. It can be scheduled at the patient’s and surgeon’s convenience. Some of these surgeries are necessary to prolong life, for example an angioplasty or, as in most cases, improve the quality of life. In brief, elective surgery is ‘A planned, non-emergency surgical procedure’.

Elective surgeries dropped by over half
According to Lee Callakoppen, principal officer of Bonitas Medical Fund, “there has been a 60% reduction in hospital authorisation requests compared to 2019. A study release in March predicted that an estimated 28.4 million elective surgeries worldwide, would be cancelled during the 12 weeks of peak disruption due to the global pandemic. This has been a similar experience to other industry role players and is predominantly due to a combination of member fears related to Covid-19, lockdown and provider caution.”

Surgeries delayed not cancelled
The postponement of surgeries was done to prevent patients taking up hospital beds and to avoid unnecessarily exposure to the virus – a strategy that worked well to flatten the curve. Surgeries were delayed based on provider discretion and subsequent patient engagement. Callakoppen says: “Providers are best placed to make these clinical decisions in the interests of their patients. If the procedures were emergencies or urgently required to enable member quality of life, those would have proceeded.”

The public sector too experienced backlogs in terms of elective surgeries. Examples are procedures including but not limited to, cataracts, orthopaedic surgeries, scopes, caesarean sections, tonsillectomies and adenoidectomies.

BHF cautioned funders
In July, The Board of Healthcare Funders (BHF) and its members in the healthcare funding space requested members of medical schemes to proceed with caution in scheduling elective surgical procedures. Dr Rajesh Patel, head of benefit and risk at the BHF, said: “While the relaxation of the lockdown restrictions is good news for people, the country and the economy at large, we are still in the eye of the storm.”

The way forward?
“As we move toward Level one, elective surgeries are almost back to normal,” says Callakoppen. “It’s time to address the backlog of surgeries not considered emergencies during lockdown. These include slow-growing cancers, orthopaedic and spine surgeries, airway surgeries, surgeries for non-cancerous tumours as well heart surgeries. We caution against a rush of elective surgeries though. Any surgery has an impact on the immune system, which means the patient has a greater risk of contracting Covid-19 and developing complications from it.

“It must further be noted that in some instances surgery is often recommended by specialists as one of the key courses of action. But we have noted that managed care protocols, in many instances, improve clinical outcomes with lower risk to the patient. One such example of this is spinal surgery, which is often unsuccessful. From a Bonitas perspective, we have noted that in the back and neck programme, which enforces functional rehabilitation has been far more effective for our members. In addition, the risk to the member is significantly lower.”

Bonitas recommends the following is taken into account:

• That elective surgeries should only be resumed in instances where not having the procedure will severely impact the members’ health and quality of life
• That the current state of a patient’s healthcare is assessed – individuals with chronic conditions such as diabetes, asthma HIV/Aids and hypertension, are at high-risk of developing Covid-19 complications
• The patient’s age is taken into consideration (older individuals are identified as one of the most vulnerable groups)
• The impact of waiting on the patient’s healthcare outcomes (for example, is it essential that the surgery takes place now or can it safely be deferred for a few months)
• Alternative care protocols – in some cases surgery, which should be a last resort, is prescribed without considering other treatment protocols such as rehabilitation. The most common examples of this include back and spine procedures, elective c-sections as well hip and knee replacements
• The use of day hospitals and clinics, where possible, to limit the possible chance of infection

We may have flattened the curve but we are by no means out of the woods. Current Covid-19 cases in South Africa prove that.

What is happening in hospitals?
“Surgeries are being resumed responsibly with due collaboration and consideration exercised between the surgeon, the patient and hospital staff,” says Callakoppen. Where there are capacity constraints, surgeries will be classified in terms of priority at the various hospitals. Pre-operative screening will continue. Facilities will continue to utilise separate zones for Covid-19 positive patients, Persons Under Investigation (PUI) and those for whom the status is unknown at the point of admission. Surgeries will be carefully planned and scheduled.

Specialist visits on the up
“Consultations are starting to increase once again but providers in general are likely to remain prudent. However, we urge people who have not had their necessary annual check-ups, particularly our high risk members, to consult with their doctors. There may be members who have put these consultations on hold and are now more comfortable to visit a specialist. But care coordination is essential. Your GP should be your first point of contact – particularly in cases where you are not already under specialist care.”

Callakoppen says that members may also need to be physically examined if they are no longer as responsive to their medication, are concerned about general matters relating to their health or have received a specialist referral from their GP.

“The healthcare of our members is critical, particularly as we want to prevent them from developing unnecessary and preventable complications further down the line. It is important that we don’t have tunnel vision and only focus on Covid-19. We need to consider the overall healthcare needs of our members. Healthcare professionals are best positioned to decide if surgery should go ahead or not but it is ultimately the patient’s decision on how to proceed.

“We strongly urge patients to make informed decisions and weigh up the pros and cons. During the pandemic we all need to act responsibly and make informed decisions that won’t place patients, healthcare providers and the healthcare system under more pressure than necessary.”