Andrew Gillingham: Business Day,

ULTIMATELY, healthcare professionals determine whether beneficiaries of medical schemes receive best-value care and they should be at the centre of any health risk-management strategy.

Pieter Dorfling, divisional MD of Medscheme Health Risk Solutions, says healthcare professionals interact directly with medical scheme members. As such they are in the best position to influence what happens at the doctor-patient interface in terms of health risk-management objectives.

He says the first step in unlocking the potential of this dynamic lies in a collaborative approach between funders and providers of care. "For health risk-management to be taken to new levels, innovative solutions in collaboration with providers of care should complement current approaches."

He says that medical schemes strive to deliver the best value to their members for the premiums that they pay and most purchase a variety of health risk-management offerings to achieve these goals.
However, although these are important tools for managing healthcare expenditure, they have a finite ability to achieve the best possible care.

"There is huge potential for funders and healthcare professionals to work together to achieve best value for members. However, the adversarial relationship that commonly exists is not conducive to achieving this goal."

Explanations for this relationship tend to focus on inadequate tariffs and a perceived impact of managed-care interventions on professional autonomy and practice administration.

"Doctors are mandated to provide the best possible medical care for each individual patient without explicit consideration of the cost-effectiveness and affordability. On the other hand, medical schemes carry the responsibility for funding the delivery of care for an entire group of people while ensuring the financial viability of the fund.

"Clearly these are fundamentally differing perspectives that may easily result in providers and funders being at odds with one another. This is shortsighted, as the philosophy of providing best-value care to all patients is fundamentally identical.

"Sharing information with healthcare professionals should be seen as a true partnership to achieve the common objective of best value for patients and their medical schemes."

He says health risk-management is unlikely to evolve to a new level without the positive participation of healthcare professionals.