CDL leads to outsourcing

2004/09/30

Managed Healthcare is traditionally a matter of managing access to medical services and the cost, quality and time involved. In addition, to moderate costs and protect medical aid members as far as possible from the double whammy of rising costs and decreasing benefits.

Lately, outsourcing of specialised managed care services by medical aids has increased and it’s clear that the change is a direct result of the new Chronic Disease Management legislation, which came into effect at the beginning of 2004. In terms of the legislation, medical aids are obliged to provide chronic care for 25 diseases including those on what’s known as the Chronic Disease List (CDL).

The legislation prescribes minimum benefits for medical aid members, with chronic conditions, entitling members to unconditional access to certain basics specified by the CDL, including diagnosis, treatment and medical management.

This scenario places new strains on the actuarial viability of medical aid funds, as many previous options to manage the costs of the likes of diabetes, HIV/Aids, heart disease and asthma, are no longer valid, says Dr Mario Greyling of assistances services group, Europ Assistance, which provides outsourced call-centre driven, chronic disease management programs.

“While few would argue with the humanitarian benefits of the legislation, the financial flip side of the coin is that claims on medical aids for these diseases are increasing.
Clearly it’s preferable to manage those claims and if that cannot be achieved through declining or restricting covers as in the past, other solutions need to be found,” says Greyling.

Then there’s the proposed Risk Equalisation Fund (REF).

The REF has the laudable objective of subsidising, medical aids with a bigger proportion of older, higher claimers, but the jury is still out on the extent to which this will be workable.
“It’s just one more reason why medical aids have to look after their chronic patients via various managed care interventions, including the appointment of designated service providers and compiling formularies and medical treatment protocols for the CDL.
“Pre-authorisation and telephonic risk assessment coupled with an outcomes based chronic disease management program is then achievable via a regular program of telephone calls to chronically ill members that assists them in managing their disease backed by an assistance line and education linked to their condition,” says Greyling.
“Costs are reduced by ensuring that members adhere to their treatment, that they use more cost-effective medication and by reducing members’ unnecessary visits to hospitals.”