South African Private Healthcare Research Articles

Optometrists’ experience of healthcare fraud, waste and abuse (FWA) and strategies to combat it

Background: South African private healthcare is funded through medical aids and out-of-pocket payments. Annually, R22 billion is lost to medical fraud, waste and abuse (FWA) threatening the sustainability of healthcare delivery. Healthcare providers are often accused of unethical practices and various forms of FWA.Aim: To assess the optometrists’ experience of FWA and the strategies to combat FWA.Methods: A quantitative study was conducted amongst optometrists using a structured questionnaire and data was analysed using descriptive statistics.Results: Most (75%) respondents were aware of FWA. About 41% of respondents were audited for FWA, of whom two-thirds were Black males. The Preferred provider Negotiators conducted 27% audits, followed by Discovery (16.5%), Government Employees Medical Scheme (7.8%) and Medscheme (5%). Iso Leso and Opticlear networks conducted 3.9% each. About 7.8% were found guilty of FWA, of whom 87.5% were Black practitioners and 12.5% Indian practitioners. Claiming for spectacles but dispensing sunglasses (5.9%) and over-servicing (4%) were highest ranked offences. Common sanctions were claw-back (75%) and indirect payment (37.5%). Practitioners implement identity checks (94%–96%), coding training (89%) and accurate record keeping (93%) as anti-FWA strategies. Excessive codes and lack of standardised tariffs were challenges to fighting FWA.Conclusion: Optometrists use identity checks, coding and billing training as anti-FWA strategies. Coding and billing complexities are the main sources of FWA cases. Black and Indian practitioners were more likely to be identified for FWA and found guilty than White practitioners.Contribution: The study highlights the forms of FWA and suggest integration of controls to effectively curb FWA.

Clinical and Economic Assessment of MyDiaCare, Digital Tools Combined With Diabetes Nurse Educator Support, for Managing Diabetes in South Africa: Observational Multicenter, Retrospective Study Associated With a Budget Impact Model.

In South Africa, diabetes prevalence is expected to reach 5.4 million by 2030. In South Africa, diabetes-related complications severely impact not only patient health and quality of life but also the economy. The Diabetes Nurse Educator (DNE) study assessed the benefit of adding the MyDiaCare program to standard of care for managing patients with type 1 and type 2 diabetes in South Africa. An economic study was also performed to estimate the budget impact of adding MyDiaCare to standard of care for patients with type 2 diabetes older than 19 years treated in the South African private health care sector. The real-world DNE study was designed as an observational, retrospective, multicenter, single-group study. Eligible patients were older than 18 years and had at least 6 months of participation in the MyDiaCare program. The MyDiaCare program combines a patient mobile app and a health care professional platform with face-to-face visits with a DNE. The benefit of MyDiaCare was assessed by the changes in glycated hemoglobin (HbA1c) levels, the proportion of patients achieving clinical and biological targets, adherence to care plans, and satisfaction after 6 months of participating in the MyDiaCare program. A budget impact model was performed using data from the DNE study and another South African cohort of the DISCOVERY study to estimate the economic impact of MyDiaCare. Between November 25, 2019, and June 30, 2020, a total of 117 patients (8 with type 1 diabetes and 109 with type 2 diabetes) were enrolled in 2 centers. After 6 months of MyDiaCare, a clinically relevant decrease in mean HbA1c levels of 0.6% from 7.8% to 7.2% was observed. Furthermore, 54% (43/79) of patients reached or maintained their HbA1c targets at 6 months. Most patients achieved their targets for blood pressure (53/79, 67% for systolic and 70/79, 89% for diastolic blood pressure) and lipid parameters (49/71, 69% for low-density-lipoprotein [LDL] cholesterol, 41/71, 58% for high-density-lipoprotein [HDL] cholesterol, and 59/71, 83% for total cholesterol), but fewer patients achieved their targets for triglycerides (32/70, 46%), waist circumference (12/68, 18%), and body weight (13/76, 17%). The mean overall adherence to the MyDiaCare care plan was 93%. Most patients (87/117, 74%) were satisfied with the MyDiaCare program. The net budget impact per patient with type 2 diabetes, older than 19 years, treated in the private sector using MyDiaCare was estimated to be approximately South African Rands (ZAR) 71,023 (US $4089) during the first year of introducing MyDiaCare. The results of using MyDiaCare program, which combines digital tools for patients and health care professionals with DNE support, suggest that it may be a clinically effective and cost-saving solution for diabetes management in the South African private health care sector.

Private healthcare sector spine surgery: patient and surgeon profiles from a large open medical scheme in South Africa.

Background It is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context and access to healthcare. Relatively little is known about the profile of spine surgery in South Africa, although one previous report from the public healthcare sector suggested a high burden of trauma and infection-related surgery. To our knowledge, there has been no formal investigation in the private sector. A holistic understanding of spine surgery within our setting may be beneficial for applications such as resource allocation and informing the training needs of future specialists. Objectives To provide insight into spinal surgery in the South African private healthcare sector by describing spine surgery characteristics within a large open medical scheme, including both patient and surgeon profiles. Methods This retrospective review included adult inpatient spine surgeries funded by the largest open medical scheme in South Africa between 2008 and 2017. An anonymized dataset extracted from the scheme records included patient demographics, ICD-10 codes, procedure codes and surgeon specialization. Descriptive patient and surgery data were presented. Furthermore, the association between patient and surgery factors and surgeon specialization was investigated using univariate and multivariate analyses. Results A total of 49,576 index spine surgeries were included. The largest proportion of surgeries involved members 40-59 years old (n=23,543, 48%), approximately half involved female members (n=25,293, 51%) and most were performed by neurosurgeons (n=35,439, 72%). At least 37,755 (76%) surgeries were for degenerative pathology, 2,100 (4%) for trauma and 242 (0.5%) for infection. Adjusted risk ratios (aRR) significantly associated with orthopaedic surgeon specialization included cervical spine region aRR = 0.49 (95% C.I. 0.39-0.61), trauma aRR = 1.50 (95% C.I. 1.20-1.88), deformity aRR = 1.77 (95% C.I. 1.33-2.35) and blood transfusion aRR = 1.46 (95% C.I. 1.12-1.91). Conclusion Spine surgery in South Africa's largest open medical scheme was dominated by surgery for degenerative pathology in older adults and was performed largely by neurosurgeons. This constituted a stark contrast to a previous report from the public sector and highlighted a mismatch between exposure during public sector registrar training and private practice post-specialization. The findings support the need for private-public collaboration as well as the importance of spine fellowships for all specialists intending to practice spine surgery.

Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme.

Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme. This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence. A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79year olds but declined among 40-59year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59year olds with little change among 60-79year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000. Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

Budget Impact Analysis of Empagliflozin in the Treatment of Patients With Type 2 Diabetes With Established Cardiovascular Disease in South Africa

This study aimed to estimate the budget impact and affordability of empagliflozin added to usual care compared with usual care alone, in a diabetic population with established cardiovascular disease, from a private healthcare payer perspective in South Africa. A budget impact model was adapted and localized. Epidemiological data were obtained from the South African Council for Medical Schemes. Clinical event rates were sourced from the EMPA-REG OUTCOME trial and drug costs from list prices. Clinical event costs were derived from a claims data analysis of the South African private healthcare sector and microcosting. Scenario analyses were performed on select inputs. The modeled outcomes included annual budget impact of empagliflozin, the incremental cost per life per month, cardiovascular deaths averted, and incremental cost per life saved, over 3 years. A total of 9 503 patients were eligible for empagliflozin (year 1), 12 670 (year 2), and 16 947 (year 3). The incremental cost was $1 272 297, $1 764 705, and $2 455 235, for years 1 to 3, respectively. The incremental cost per beneficiary per month was calculated as $0.012 (year 1), $0.016 (year 2), and $0.023 (year 3). The model estimated a 38.6% reduction in cardiovascular deaths, 305 lives saved, and an incremental cost per life saved of $17 999. Adding empagliflozin to usual care has a marginal budget implication and is highly affordable for private healthcare payers, with an acceptable incremental cost based on clinical outcomes.

EXPLORING RELATIONSHIP POWER IN SUPPLY CHAIN SUSTAINABILITY PRACTICES: A CASE STUDY OF A SOUTH AFRICAN HOSPITAL GROUP

Buyers and suppliers of healthcare products and services are more dependent on each other than ever before for the provision of scarce and unique resources, which highlights the need to implement supply chain sustainability practices. Firms controlling these resources hold excessive power over others. This study adopted resource dependence theory as a theoretical lens to explore the role of relationship power in supply chain sustainability practices between a South African private healthcare provider and its suppliers. The study employed a generic qualitative single-case study design. Semi-structured interviews were used to collect data from 12 participants at various levels of the case organisation’s hierarchy. The main findings revealed several types of environmental and social practice used in the supply chain of the private healthcare provider. Some of the environmental practices were effective waste management and recycling, while the social practices included supplier selection and periodic reviews. The healthcare provider exercised extensive power over its suppliers to implement these practices. By exploring the advantages and disadvantages of sustainability practices, the findings showed that relationship power acted as a driver of supply chain sustainability. Mutual commitment, continuous communication, and training support these practices. Healthcare managers must be aware of the importance of relationship power for supply chain sustainability practices implementation, and are advised to invest time and effort in building buyer—supplier relationships to aid sustainability. This study expands the literature on relationship power in supply chain sustainability practices in an underexplored developing country healthcare context. Keywords Sustainability; supply chain relationships; power; private hospital; single case-study

Moving from a bad to a good pricing regime: The South African private health care market

AbstractThe South African private health care market combines a highly concentrated demand side with expensive medical services. This combination suggests that medical insurance schemes are not using their full market power. To explain this puzzle, we construct a delegated bargaining model in which agency costs give rise to two different pricing regimes. In the ‘good’ pricing regime, the scheme incentivises its administrator towards aggressive bargaining behaviour with health care providers. The ‘bad’ pricing regime results when the scheme decides against such incentivation. Policy measures that push the number of providers above some critical threshold can force a change from the ‘bad’ to the ‘good’ pricing regime.

The Influence of Value Perspectives on Decision-Making in the South African Private Healthcare Sector

Abstract Background Value of Care in healthcare can be expressed as the outcomes (Clinical Outcome) divided by the total cost (Cost of Clinical Event) of a care episode. Patient’s Experience, an understudied factor in healthcare, has also been acknowledged as a contributor, yet it has not been thoroughly explored in relation to Value of Care. Objectives This study focuses on two of the multiple stakeholders involved in healthcare: the consumer (patient), and the provider (doctor). Given that these two stakeholders often have conflicting goals, a deeper understanding of the differences in their value perspectives regarding healthcare delivery is imperative. Method Using a self-developed Value Perspectives Survey, this study explores the differences in relative importance of three factors (Clinical Outcome, Cost of Clinical Event, and Patient’s Experience) identified as contributors to Value of Care. The aim is to gain insight into value perspectives of consumers (n = 662) and providers (n = 381) in the South African private healthcare context. Descriptive statistics were used to characterise the sample, while tests of mean differences identified whether differences exist between consumers and providers in terms of value perspectives and assessed differences in value perspectives as the severity of surgical and medical scenarios increase. Results Findings suggest that Patient’s Experience must be considered in the healthcare value equation. Differences in value perspectives were demonstrated between consumers and providers, and with the progression of severity in surgical and medical scenarios for both groups. Conclusion Understanding differences in value perspectives between consumers and providers can inform evidence-based, multifactor decision-making, and can furthermore inform a better understanding of how value perspectives differ between consumers and providers can inform value creation strategies in the South African private healthcare delivery context. In turn, this can inform the alignment of the South African private healthcare sector to the proposed Universal Health Coverage model of National Health Insurance.

Intuitive intelligence applied in the South African private healthcare sector

Intuitive intelligence applied in the South African private healthcare sector

Tympanostomy tube insertion practice in under-18-year-olds in the South African private healthcare sector insured by Discovery Health.

The reported rates of tympanostomy tube insertion (TTI) in children vary significantly internationally. Lack of adherence to evidence-based clinical guidelines may contribute to these differences. To study the rates of TTI in South Africa (SA) in children ≤18 years old in the private healthcare sector, both nationally and regionally, to compare these with international TTI rates, and to determine the use of preoperative audiometry and tympanometry. A retrospective analysis was done of data obtained from the Discovery Health database. Rates of TTI were analysed nationally and regionally and in different age groups, as was the use of tympanometry and audiograms. The SA TTI rates were much higher than published international rates except for the 0 - 1-year age group in Canada and Denmark and the 0 - 15-year age group in Denmark. There was a statistically significant regional variation in TTI rates as well as in the use of preoperative audiometry and tympanometry. SA private sector TTI rates are high by international standards. Significant regional variations may indicate over- or underservicing in certain regions. Further investigation of causes for the high TTI rate and regional variations is recommended. Education of healthcare professionals on recognised indications for TTI may improve patient selection.

The impact of generics and generic reference pricing on candesartan and rosuvastatin utilisation, price and expenditure in South Africa

Background In the South African private sector context, generically similar products are grouped together and the reimbursement rate is set at the average price of the generically equivalent products. Very little evidence exists in low and middle-income countries with regards to the impact of this policy over time. Objectives To determine the impact of the introduction of generics and generic reference pricing on candesartan and rosuvastatin in the South African private health care sector in terms of medicine utilisation, medicine price and medicine expenditure. Setting South African private health sector. Method Medicine claims for candesartan and rosuvastatin was obtained from a Pharmacy Benefit Manager in South Africa. The claims covered a 48-month period from January 2012 to December 2015 and provided a pre- and post-reference price period for analysis. Medicine utilisation was measured as the number of Defined Daily Doses dispensed per 100,000 beneficiaries. Medicine price and expenditure was calculated as the average per Defined Daily Dose. Main outcome measure Medicine utilisation, price and expenditure. Results Candesartan experienced an average 7.0% year-on-year decline in utilisation and rosuvastatin a 5.0% increase. Medicine expenditure reduced by an additional 34.6% and 20.9% for candesartan and rosuvastatin respectively. The total savings was 54.8% for candesartan and 31.9% for rosuvastatin. Conclusion The introduction of generics and generic reference pricing did not have an impact on medicine utilisation, but reduced the price and expenditure of both candesartan and rosuvastatin.

Emerging trends in the profession of Biokinetics: A 10 year perspective (2007-2017)

The consistent review of developing patterns in any healthcare profession is important, as this allows the determination of whether the current practitioner registry meets the healthcare demands, or whether the patient market has become oversaturated with practitioners. The South African Biokinetics profession has been established for 35 years, but as never undergone an examination of its developing trends. The aim was to determine the emerging trends of the HPCSA registered students-in-training, intern-biokineticists, and practitioners. Additionally to ascertain whether the practicing biokinetic registry is equitable to the potential South African private healthcare demand. The HPCSA Annual Reports of 2012/2013 and 2016/2017 identified the number of students-in-training, intern-biokineticists and biokineticists. CMS reports of 2013-2015 identified the South African NCDs and HIV/AIDS prevalence. Annual students-in-training, intern-biokineticists, and practitioner registrations are growing at average of 4.6%, 43.5% and 6.5% per year. However, the conversion of intern-biokineticists to practitioners is progressively dwindling, nevertheless, this attrition of intern-biokineticists is not significant (p>0.05). Positive growth in students-in-training, intern-biokineticists and practitioners HPCSA registrations were identified. The number of practicing biokineticists in the South African private healthcare sector is reaching saturation point relating to the rehabilitation of NCDs and HIV/AIDS patients. Key words: Intern-biokineticist, attrition and growth.

Medscheme Mental Health Programme

Medscheme Mental Health Programme

Longitudinal Study into the Dispensing Patterns of Benzodiazepines and Z-Drugs in a South African Private Healthcare Setting

Longitudinal Study into the Dispensing Patterns of Benzodiazepines and Z-Drugs in a South African Private Healthcare Setting

Tonsillectomy rates in the South African private healthcare sector.

Adeno-/tonsillectomy is a commonly performed procedure with internationally standardised and recognised indications. Despite this, there exists considerable international (190 - 850/100 000 people ≤19 years of age) and regional variation in rates. This cannot be accounted for by differences in clinical need or regional morbidity. To describe the adeno-/tonsillectomy rate in the South African (SA) private healthcare sector and regional variations thereof. To compare local rates with international rates and assess trends in adeno-/tonsillectomy practice. Analysis of 2012 and 2013 adeno-/tonsillectomy data provided by the largest SA private healthcare funder, accounting for 30% of the medical scheme market. Rates are expressed per 100 000 people ≤19 years of age. The tonsillectomy rate in the SA private healthcare sector was 1 888/100 000 people ≤19 years of age in 2012. In 2013, the rate dropped significantly (p<0.001) to 1 755/100 000. This is more than double the highest national tonsillectomy rate reported in the literature. There was also considerable regional variation in this rate within SA. The SA tonsillectomy rate is very high when compared with international trends and varies regionally within the country. The literature does not support an increased burden of disease as the reason behind this. Rather, it is differences in training and clinical practice of clinicians, as well as social and family factors, that have been implicated. The adeno-/tonsillectomy rate in the SA private healthcare sector is substantially higher than international norms. The reasons for this discrepancy require further consideration.

The operating room as a clinical learning environment: An exploratory study

Students undertake their clinical placement in various clinical settings for the exposure to and acquisition of skills related to that particular context. The operating room is a context that offers the opportunity to develop critical skills related to the perioperative care of the patient. Despite numerous studies that have been undertaken in this field, few have investigated the operating room as a clinical learning environment in the South African private healthcare context. The aim of this study was to determine nursing students' perceptions of the operating room as a clinical learning environment. An exploratory, interpretive and descriptive design generating qualitative data was utilized. Eight nursing students completed an open-ended questionnaire, and twelve nursing students participated in the focus group discussion. Four themes emerged, namely, ‘interpersonal factors’, ‘educational factors’, ‘private operating room context’, and ‘recommendations’. The opinion that the operating room offers an opportunity to gain skills unique to this context was expressed. However, despite the potential learning opportunities, the key findings of this study reveal negative perceptions of nursing students regarding learning experiences in the operating room. Exploration into the preparatory needs of students specific to learning outcomes before operating room placement should be considered. It will also be necessary to improve collaboration between lecturers, mentors and theatre managers.

The use of activity-based costing in South African private health care industry

The private health care industry is facing uncertainty and change as a result of the market inquiry being undertaken by the Competition Commission into the private health care industry, the introduction of the National Health Insurance and the possibility of fee regulation. This study seeks to determine the extent to which activity-based costing is used within the operations of private health care facilities in South Africa. A structured online questionnaire was used to collect the primary data; it was completed by 32 private health care facilities and three hospital groups. This study found that the level of activity-based costing adoption at a health care facility level increased from 1.2% in 1994 to 31% in 2013. The increase in the level of activity-based costing adoption indicates that the private health care facilities are willing to adopt and use innovative management tools and techniques to face their current challenges.

The impact of HIV/AIDS on compliance with antidepressant treatment in major depressive disorder: A prospective study in a South African private healthcare cohort.

BackgroundMDD and HIV/AIDS have a high prevalence worldwide with severe consequences for patients. In both conditions, compliance with treatment is key to successfully treat these disorders. In the current study, we examine the effect of MDD on the compliance with ADs in patients diagnosed with co-morbid HIV/AIDS and how different classes of ADs influence compliance in this group of patients.MethodsA prospective, cohort study design was used to analyse nationally representative medicine claims data submitted to a privately-owned South African Pharmaceutical Benefit Management (PBM) company. Two groups were distinguished in the database, namely patients with only MDD and patients with both MDD and HIV/AIDS, over a six-year study period. The study population was determined by the following inclusion criteria: patients older than 18 years, MDD should be diagnosed by a psychiatrist supported by an appropriate ICD-10 code, and all patients have to be on combination antiretroviral treatment (cARV) treatment. The medicine possession ratio (MPR) was used as proxy to determine patient compliance with AD medication.Results127 patients (i.e. 0.24%) met the criteria of co-morbid MDD and HIV/AIDS. Females have a significantly higher prevalence of MDD and HIV/AIDS when compared to males. Patients diagnosed with both HIV/AIDS and MDD (74.43. ± 32.03, 95% Cl: 71.51-77.34) have a statistical significantly (p < 0.0001) lower compliance with AD treatment vs. MDD patients (80.94% ± 29.44, 95% Cl: 80.56-81.33), but the practical significance thereof, is low (Cohen’s d = 0.2255). In this group only 26.83% of TCA had acceptable compliance compared to the 58.57% of SNRIs. Noteworthy observations were that 75% (p < 0.0217; Cramer’s V = 0.0388) of venlafaxine and 28.6% (p < 0.0197; Cramer’s V = −0.0705) of the paroxetine items were compliant in patients diagnosed with both HIV/AIDS and MDD.ConclusionsAD compliance is statistical significantly lower in depressed HIV/AIDS vs. depressed non-HIV/AIDS patients. However, these differences is of low practical or clinical significance, meaning that depressed HIV/AIDS patients would have missed approximately two AD doses (6.5% of a 30-day treatment period) more than the non-HIV/AIDS depressed patient over the same treatment period.Electronic supplementary materialThe online version of this article (doi:10.1186/s12981-015-0050-2) contains supplementary material, which is available to authorized users.

The influence of co-prescribed GABA-ergic drugs on anti-depressant compliance in patients with depression: A prospective study in a South African private healthcare cohort

Background: Despite the progress made in recent years regarding our understanding of the neurobiology of major depressive disorder (MDD), approximately one third of patients remain unresponsive to treatment. Co-prescribing of GABA-ergic drugs (GDs), such as sedative hypnotics, with antidepressants (ADs) is not uncommon, although how they benefit the outcome, if at all, remains controversial. Adequate compliance is central to a positive outcome, although its impact with respect to drug usage patterns has not been considered. The aim of the current study is to establish how the co-prescribing of GDs is associated with altered antidepressant compliance and which antidepressants (ADs) are associated with the worst compliance in combination with GDs.

National survey of paediatric audiological services for diagnosis and intervention in the South African private health care sector.

A national survey of early hearing detection and intervention services was undertaken to describe the current status of diagnostic and intervention services in the South African private health care sector. All private hospitals with obstetric units (n = 166) were surveyed telephonically. The data was integrated with data collected from self-administered questionnaires subsequently distributed nationally to private audiology practices providing hearing screening at the respective hospitals reporting hearing screening services (n = 87). Data was analysed descriptively to yield national percentages and frequency distributions. Average reported age at diagnosis was 11 months. Most participants (74%) indicated that less than 20% of infants fitted with hearing aids received amplification before the age of 6 months. Most (64%) participants indicated that the average period between confirmed diagnosis and hearing aid fitting was 1 month, on par with international benchmarks. Only 16%-23% of participants included all diagnostic procedures recommended by the Health Professions Council of South Africa's 2007 position statement for minimum diagnostic test batteries for infants and young children. Diagnosis of hearing loss, hearing aid fitting and audiological intervention is delayed significantly in the South African private health care sector. Improved services should include integrated systematic hospital-based screening as part of birthing packages with diagnostic referral to specialist paediatric audiologists for accurate assessment and management of patients in a timely manner.