Chapter 27 Managed care

Question 1

The aim of managed care

Answer 1

• Managed care aims to manage claims costs while maintaining or even improving access to quality healthcare services.
• The role of managed care is to maintain the affordability of healthcare by ensuring its cost-effectiveness.
• examples of managed care programmes include:
• a restrictive formulary governing which medicines may be used for certain conditions.
• a requirement for a GP referral to be obtained prior to visiting a specialist.
• restricting access to a select network of specialists and GPs, with whom preferential charging structures have been agreed.

Question 2

The development of treatment protocols

Answer 2

• Managed care protocols need to be updated continually as new medicines and treatments are being made available.
• This is mainly due to technological advances and new disease emerging over time.
• They will also have to comply with the regulations insofar as they cannot unreasonably restrict access to healthcare for policyholders.
• The more restrictive a managed care is the higher the potential cost-savings.
• it is important that managed care organisations collaborate with medical experts to develop credible and recognised protocols, based on clinical best practice.

Question 3

Cost-effectiveness analysis in developing protocols

Answer 3

• Very often, cost-effectiveness decisions for medicines will be influenced by the results of international clinical trials.
• for treatments where the expected cost of prevention exceeds the costs of treatment, the benefit offered by these medicines is significantly greater than its costs, meaning their inclusion as part of medicine formularies is easily justified.
• it is also possible that very restrictive formulaires restrict access to quality healthcare.
• It is the role of legislation to ensure that managed care is not abused to unfairly exclude lives that need medical aid coverage, or to unfairly exclude access to required treatments.

Question 4

Risk of abuses in managed care protocols

Answer 4

• There is risk that managed care protocols can be abused beyond the aim of controlling healthcare costs.
• It is possible for some insurers to use managed care as a means to exclude relatively unhealthy lives.
• This is an abuse of managed care since the aim of managed care should be coverage of expensive treatments for diseases on an affordable basis, rather than the exclusion of lives with the respective disease.