Medscheme and SASES appendectomy-funding pilot study has ended

In a joint presentation between Medscheme and the SA Society of Endoscopic Surgeons (SASES) a new plan was revealed to address the challenges associated with funding laparoscopic (keyhole) surgery.  The concept and a proposed pilot project which will address the high cost of consumables was presented at the prestigious ASSA SAGES congress held at the Durban International Convention Centre earlier in the month.

The congress was attended by surgeons and gastroenterologists in the public and private sector.  Simon Dreyer, a senior actuary at Medscheme and Dr Dick Brombacher, chairperson of SASES outlined the project in joint presentation.

Dreyer outlined the longstanding challenges of funding laparoscopic surgery in an environment where financial resources are limited.  He went on to indicate that as an example a laparoscopic appendectomy can cost nearly 50% more than an open appendectomy.  “It is 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,” Dreyer indicated.

One of the key issues driving the price of laparoscopic surgery was the cost of the additional consumables that are used by surgeons to perform laparoscopic surgery. Dreyer illustrated this using laparoscopic appendicectomy as an example. The average cost of the consumables was just over R4,600 per case but there was a large range in the cost of the consumables used in this procedure.  Dreyer illustrated examples where in some cases the cost of consumables used by surgeons approached R20,000 and in other cases surgeons were able to do the same procedure using consumables costing less than R2,000.

Dr Brombacher indicated that the current funding interventions in laparoscopic surgery, especially where surgeons were expected to write a motivation were 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,” stated Brombacher. He went on to state that the large variation in the use of and cost of laparoscopic consumables came as a surprise and he added, “I wanted to share this information with all laparoscopic surgeons”.

Dr Brombacher went on to propose a solution to the members of SASES whereby a network of interested surgeons will be contracted who agree to keep the cost of laparoscopic consumables below a determined price.  In addition there will be one tariff for appendicectomy 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 appendicectomy. 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 where good.  SASES will support them and we have already had some discussions with the device companies,” stated Brombacher.

Dreyer went on to indicate that this initiative will reduce the cost of current laparoscopic appendicectomies, allow for more of these procedures and still be cost neutral for medical schemes.  Dreyer said, “it is 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”.  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. The ASSA SAGES conference was the ideal platform and I am delighted that there was an overwhelmingly positive response from surgeons on this joint initiative,” stated Brombacher.

Kevin Aron, the Chief Executive Officer of Medscheme said, “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 were able to understand their challenges as surgeons and they were able to understand ours as funders. It is 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.”

 

January 2017

This pilot phase of this study has closed and further enrollment of patients is no longer possible.

Data will be analysed and the various role-players will decide on how to proceed.

Further information will follow.

 

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