About the I CARE NETWORK
The I-Care Network (or abbreviated, the "ICN") is a private company with purpose of acting as a mouthpiece for all aspects of the specialty of ophthalmology concerning private medicine in South Africa and Namibia. These include interaction with the Medical Funding Industry, Government and other stakeholders.
The intention of the structure is not to compete with the other ophthalmology structures, namely the Ophthalmological Society of South Africa (OSSA) and the Ophthalmology Management Group (OMG), but rather to complement these structures in areas where they lack the ability to serve private ophthalmology to its fullest extent. For this reason, memoranda of understanding were signed between the ICN and OSSA, as well as with the OMG.
The ICN consist of shareholders from the specialty of private ophthalmologists, as well as private hospitals where these specialists render their services. Ophthalmologist shareholders in the ICN must also be active members of OSSA, as well as active shareholders of the OMG. Hospital shareholders may consist of any hospital at which private ophthalmologists render their services, including the three corporate private hospital groups (Netcare, Mediclinic and Life), as well as the National Hospital Network (the NHN).
Since there are currently discrepancies in networks formed by the funding industry where an ophthalmologist may be part of a specific funding network, while the hospital where the doctor is working may not be part of the network, the goal of the ICN is to align these entities into a single network with a broad representation to enable access to members of medical schemes across South Africa and Namibia.
In terms of the quality of services, the network draws on the professional expertise from the various subsocieties of OSSA in their development of academically sound protocols for the treatment and management of various ophthalmic conditions to ensure quality, patient focused care. A comprehensive "Big Data" data collecting project forms an integral part of the ICN. This feeds the required information into a voluntary peer review system, which ensures that a high quality of services is made available to patients requiring ophthalmic care. A data sharing arrangement with participating hospitals, where comprehensive information per surgical or treatment event is collated into this single Big Data Repository, with secure access rights to all parties while ensuring anonymity of patients, practitioners and hospitals, for the purposes of analysis and profiling.
It is foreseen that a variety of alternative reimbursement models (ARMs) will arise from this venture in future, jointly designed by the participants in the network. The aim is to offer various ARMs per event to the Funding Industry, which will include the ophthalmologist, facility, and possibly in future, the anaesthetist.
It is envisaged that all procedures performed on the members of schemes who make use of the ICN network will be pre-authorised through the integrated "Big Data" project, housing the National Ophthalmic Registry.
Governance in the ICN occurs through an elected Board, which consists of both ophthalmology and hospital representatives.
The ICN is the first of its kind for ophthalmology, and possibly the first initiative for the whole of medicine in South Africa and Namibia.
Introduction
The purpose of the ICN is to be a patient centered eyecare network, which is governed collaboratively by input from the ophthalmology profession and hospitals using peer review, quality metrics and evidence based protocol driven services.
The establishment of this network is in direct response to funder DSP networks, which are often facility based and does not consider the Ophthalmologist as the primary entry point of eyecare, and not the hospital. Patients do not consult with hospitals - they consult with healthcare professionals. Patients are very seldom aware that they may require eye surgery when booking a consultation and the current market trend of creating separate practitioner and hospital DSPs offer little value in an environment where patients should be the main focus of care. This is especially important in a high technology discipline such as ophthalmology, where technology has a very short half-life and access to cutting edge technology, high quality facilities, and suitably trained staff is vital. Merely placing a hospital on a DSP network is no indication that it has the required equipment, facilities or skill available to render quality ophthalmic surgical services. The primary requirement for ophthalmic surgery is the ophthalmologist, and facilities cannot reasonably be considered a DSP if they do not have ophthalmologists associated with that facility.
One current unilaterally implemented surgical DSP network has between 63 and 138 facilities on various plan options which are unable to render ophthalmic services, and yet are considered a DSP. Concerning this DSP, 152 of ophthalmologists are unable to render surgical services to patients on all plan options for this specific scheme in facilities in which they normally operate. It is to the detriment of clinical care if ophthalmologists have to operate in facilities which they do not normally use. It is also to the detriment of certain hosiptal facilities which are not network facilities, as patients on certain schemes options might be faced with co-payments for using such facilities, even when the ophthalmologist regularly operates there.
Belonging to a practitioner DSP network is no guarantee of quality of service and patients could still be faced with a co-payment if the DSP ophthalmologist does not operate in a network facility. Patients are therefore faced with a co-payment for using a non-network facility, often through no choice of their own, or have to face increased risk factors of an ophthalmologist operating in a theatre facility which the surgeon does not normally use. Patients with financial constraints on lower scheme plan options are often those that have the highest probability of facing a situation where a network ophthalmologists does not operate in a network facility. These patients are the most vulnerable and often do not have the financial resources to make co-payments or to fund a second consultation with an ophthalmologist who does operate in a network facility. Medical Schemes are also very unlikely to fund such second consults from Risk, even if it is a PMB condition.
The Aim of the ICN is to establish a patient focussed network which consists of Ophthalmologists and the facilities in which they normally operate, which will result in improved patient access and outcomes at the same, or even lower costs per event. The main aim of the network is to provide value based care, with a focus not only on cost, but also on quality clinical care and outcomes. This network will be governed jointly by the profession and hospitals, using evidence based protocols, agreed quality metrics and Peer Review. Various outcome measure tools will ensure that clinical outcomes are recorded and peer reviewed by the profession. Establishing a value based care network is also in line with recommendations of the Health Market Inquiry, which recommends that schemes should do value based purchasing and no longer strictly fee for service. The network will have outcomes based measures, which will allow for value based negotiations.
The ICN would also form an ideal platform to negotiate with the NHI Fund, once it is established and starts purchasing eyecare services from the private sector.
Network components
Ophthalmologists
In collaboration with the OMG, the 248 members from their membership will form the core of the network, as the primary clinical entry point into the network. From there, patients will be clinically managed and surgical services will be conducted within the network facilities, if surgery is clinically indicated.
Facilities
The Network facilities will eventually consist of the 148 hospitals where network ophthalmologists currently render ophthalmic surgical services. The network is envisaged to accommodate specialist eye hospitals as well as acute and day hospitals, making it all inclusive from a facility point of view, and removing eyecare from other, inappropriate scheme DSP arrangements. The network will not be exclusionary of any hospital groups, or independent hospitals, as long as specific facilities are willing to abide by the terms of the network regarding entry criteria, governance and tariffs.
Eligible facilities will be graded into 3 categories, depending on availability of services and equipment. Each category of facility will have a different negotiated reimbursement rate for the facility. Facilities which are not Eye Specific specialised facilities, will not be able to register for Category 1, even if they have overnight facilities available. An example of this would be an acute general hospital with wards and ICU facilities in which an ophthalmologist operates as part of this network agreement. The required equipment and services will be agreed upon by hospitals and the ICN. Facilities will be jointly graded. The specific criteria for each facility will be confirmed as the model evolves.
- Category 1 Facility (Specialised):
- Uncomplicated Basic Ophthalmic surgeries, Complex Ophthalmic Surgeries with overnight stay.
- Category 2 Facility (Advanced):
- Uncomplicated Basic Ophthalmic surgeries, Complex Ophthalmic Surgeries.
- Category 3 Facility (Basic):
- Uncomplicated Basic Ophthalmic surgeries only
Anaesthetists
Ideally, Anaesthetists working within the network facilities and with the network ophthalmologists should form part of the network initiative, but in the initial stages, this will not be explored. SASA will be approached at a later stage of development to provide inputs on clinical governance of Anaesthetists within the network.
Contract and Payment arrangements
It is foreseen that a variety of alternative reimbursement models (ARMs) will arise from this venture, jointly designed by the participants in the network. The aim is to offer various ARM mechanisms per event to the Funding industry, which will include the ophthalmologist, facility, and possibly in future, the anaesthetist.
Due to the alignment of doctors and hospitals within the network, this will result in the optimization of resources and efficiencies from both parties.
Tariff negotiations will be done through the network with input from all parties concerned. All billing will still be submitted to scheme directly by those rendering the services, at the agreed network rates.
Governance
Governance Committee
Governance in the ICN will be conducted by an elected committee, which will consist of both Ophthalmologist and hospital representatives. Representatives from hospital groups may be invited according to the need, as well as representatives from the SA Society of Anaesthesiologists, should they decide to join the network. The exact company structure is being finalised. The committee will also have sub-committees looking at various aspects of governance. It is not foreseen that the network will have formal administration capacity in the initial phases, and will be administered through existing structures from those entities with which the network has an agreement. Future administrative needs will determine whether a formal administrative structure is required going forward. The funding of a formal structure will be discussed at such a time and an administrative levy will be rendered to medical schemes making use of the network, in the form of fees for providing outcomes measures, or for pre-auth administration. It is not foreseen at this time that the company will have to register as a Managed Care Organisation with the Council of Medical Schemes.
Use of the National Ophthalmic Registry
Within the context of ICN, the patient remains the primary focus of the Ophthalmology profession. Cost containment and network initiatives cannot be implemented without measuring the impact that it has on quality health outcomes for the patients. To this extent, a National Ophthalmic Registry (NOR) is under construction, which is a clinical tool developed on international best practice standards for surgery, and fully owned by the Ophthalmology profession. The NOR is an expansion of the current Cataract Registry, which is in operation since 2015.
The current cataract registry functions as a pre-authorization tool which enables us to monitor patient health outcomes and build scheme rules and/or motivations directly into the tool, reducing administration for Medical Schemes, hospitals and ophthalmologists, enabling improved service for patients requiring cataract surgery. As mentioned above, this facility is in the process of being expanded into a Big Data Repository, covering the complete field of Ophthalmology. Current inclusions are Cataract- and Xen Stent surgery, with intravitreal injections under consideration as the next addition.
All Cataracts and Xen Stents performed on scheme members of schemes who make use of the ICN network will be pre-authorised through the NOR. This process is not optional and forms part of the Peer review platform on which the network is built.
The current cataract registry will be expanded to provide for data collection of other services, such as Intravitreal injections, utilising various outcomes measures, such as those provided by the International Consortium of Healthcare Outcomes Measures (ICHOM - www.ichom.org). Hospital reported outcomes data will also be included in the NOR and aggregated outcomes data will be shared with all participants in the network. Individual facilities will be able to compare themselves to aggregated data and a process of benchmarking, profiling and peer review will also be included on outcomes data, with concurrent consideration of claims data, if available.
To ensure compliance with Competition Law, most notably the sharing of competitor data, the Ophthalmic Risk Management (ORM) company currently administers and manages the cataract registry on behalf of the ophthalmic industry. This includes taking responsibility for the data analysis and reporting of the data within the registry.
Protocols
The network will utilise approved academic clinical protocols, where available, drafted by the profession to ensure quality, patient focused care. Medical Funders will have to agree to the use of these protocols as part of the network agreement, as clinical quality cannot be ensured if funders do not apply evidence based funding protocols. Examples of such protocols are the SA Glaucoma Society Glaucoma Protocol, The SA Vitreoretinal Society AMD, RVO and DME protocols and others.
Peer Review
Peer review of Ophthalmologists will be conducted by the profession, as is required by the Health Professions Act. Peer review will occur in line with the requirements as set out in the Memoranda of Understanding with both OSSA and OMG. Hospitals will be reviewed by a joint Hospital/Ophthalmologist committee, based on agreed clinical and claims metrics included in such a review.
Data Collection
Apart from the Cataract Registry, claims data with access to approximately 80% of Ophthalmology claims data in the private sector for a period of two years is available to the specialty. Analysis of such data is very important during such a project. The current system has the capability of discriminating between different types of subspecialist ophthalmologists and profiling them accordingly.
As part of the ICN, a data sharing arrangement with Hospitals (where comprehensive information per surgical event is collated into the NOR with secure access rights to all parties) is under way. The details and terms of this agreement will be finalized as part of the design of the ICN. It is envisaged that such a facility will greatly assist in the success of the joint venture and in profiling surgical events.