The reality is that it may well be that life turns out to be that cool and easy, trouble-free adventure UT what if there are adverse events that occur? The cost of living is such that, for people to maintain their standards of living they have to have some kind of insurance for bad days. If one decides to buy a car that costs hundreds of thousands of Rand, it would sound suicidal not to insure it against accidents or other adverse events depending on the individual situation of anyone. That is how insurance ends up being part of the normal budgeting of many households.
It is understood that many Black South Africans have got so many insurances that they don’t even know the reasons why they took them up at the first place. All of our assets especially the most valuable ones ought to be guarded against misfortune. Health is wealth, it is said. As the most important asset that one possesses, it only makes sense that one should protect it and devise means to restore it to its original status in case of trouble. According to Investigated, Health insurance is a type of insurance that pays for medical expenses in exchange for premiums.
The insured individual pays monthly or annual premiums and the insurer contracts healthcare providers (hospitals, medical practitioners) to provide benefits to its members at a discounted rate. When taking up a contract with an insurance, the insured person receives a booklet with the list of providers and the specific costs that are to be paid by either parties (insurer and insured). The costs covered can include medical tests (bloods samples, ultrasound, X-rays…. ), drugs and treatments referred to as covered services.
There are of course limitations and exclusions that should be specified in the service provider booklet. So before any medical procedure is performed the insured person should check the quality of the cover provided. In the case of arterial cover of a specific service, the insurer may request out-of-pocket fee from the insured. The type of insurance and the premiums will determine the extent of the cover provided. There are different ways to purchase a health insurance: * directly from the insurance company through an agent or through a broker.
If for instance a person wants to take a health insurance with Old Mutual Health Insurance, he could meet with a broker, explain the contract and the amount of cover and then enroll. * employee-sponsored programs. Public service employees are enrolled into a medical aid as part of their package. The health insurance is GEMS and it offers extensive cover for government employees. In the Port-Elizabeth area , there are a lot of leather factories and the employers have got into contract with some general practitioners and their employees can attend these Gaps at ‘ no cost’ in case of medical need.
ADDITIONAL COSTS it is important to note that apart from the premiums there are also other potential costs involved when one takes up an insurance. Other possible costs that can be incurred by the insured are deductible, coinsurance, escapement, and stop-loss limit. Deductibles are amounts that the insured pays out of the pocket. It means that the insurer pays an amount and the insured pays the other portion. In general the higher the premium the lower the deductible. Co- insurance refers to the percentage of expenses paid by the medical aid. Usually the insurer and the insured split the costs at a certain percentage e. . 80/20. Escapement refers to a set cap amount that one pays each time a medical service is rendered. For instance the insurer can allow visits to a medical doctor and fix the amount to be paid by the insured at ROR out of the RARE that could be harder for a medical consultation. The stop-loss limit is the cumulative amount in Rand of covered expenses in excess of the deductibles after which the coinsurance payment stops and the insurer pays 100% of covered expenses. The goal of the stop-loss limit is to limit the out-of-pocket costs for the insured person.
There are different types of plans that one can take namely indemnity plan, health maintenance organizations (HOMO), preferred provider organization (POP) and point of service (POS). TYPES OF PLANS An indemnity plan is a type of insurance that reimburses one according to a schedule for medical expenses , regardless of who provides the service. The indemnity plan covers things like surgical expenses, major medical expenses and hospital stays. With this indemnity plan, the insurer pays a per day for a specific number of days. The Health maintenance organization (HOMO) is a very used type of insurance by employers.
Homos give a broad coverage of health benefits to the insurers for a fixed periodic payment. This is the type of insurance used in the Leather industry in which the employer contracts some Gaps to attend to their patients. The GAP can then refer the patient to the appropriate specialist if needed. The point of service (POS) is a kind of combination plan with aspects of HOMO, POP and indemnity plan. It is a more flexible plan that allows members to decide the POS plan s practitioner to arrange in-network care, or to go outside of the network and pay a higher portion.
QUESTION 1. 2 The Department of Health declares that National health Insurance (NIH) is a way of providing good healthcare for all South Africans by sharing the money available for healthcare among all of its people. The idea is to build an equitable system of healthcare delivery and to minimize the gap existing between private and public spending on health. Indeed according to the Health Economics Unit of the University of Cape Town, the average spending on healthcare by a person covered by a medical scheme was ERROR in 2009 versus RI 925 in public health services.
It is also reported that 68% of South Africans rely entirely on public health services while 16% are covered by medical schemes and 16% pay from their own pockets for Gaps and dentists but still use public hospitals for serious illnesses. The minister of Health states that it will take 14 years to complete the NIH project. The first five years will be a process of building and preparation… This will involve a massive amount of work, one can imagine. This is paperhangers mission to overhaul the whole health system of a country.
The implications for health care management are massive. As with any situation where change is needed there will a massive reorganization of the management from the top to the bottom. THE TASK OF MANAGEMENT All the levels of management must be involved in the implementation of the NIH. The core functions of management involve planning, organizing, leading and controlling. The different layers of management in the health system must buy into the vision of the government to implement NY-II. All their efforts must be geared towards achieving a successful program.
At an executive level, the actual minister of health has made it a priority to overhaul the management system in the heath sector. He is at true champion of the NIH through his utterances and commitment. This commitment is then filtered to the lower levels of management from the nation, province, municipalities and districts. The facility managers have then got the task to insure proper functioning of their units. We will detail the functions of management and the effect of the NIH on them. Planning: The initial phase of planning was undertaken prior to the implementation of the pilot project debuted in April 2012.
In a way, this pilot phase can be understood as a stage in planning before the full implementation of the NIH. This phase will last up to to 2025. During this phase, data will be collected and regular feedback submitted to the national DOD allowing it to adjust the targets and methodology before full implementation. There will be auditing conducted regularly in this regard. There is the creation of the OCHS (office of Health Standard Compliance) that has the role to insure that facilities entering into contract with the NIH conform to a set number of criteria in order to be accredited.
The management must make sure that the NIH is financially sustainable. This will be done by lobbying the private sector for donation, increase the health budget , assuring compliance of the South African public through employers, individual donations… In the planning phase , there will be rearrangement of the private lath care system in order to minimize the administrative burden. There will be an overhauling of the health care system and improvement of its management. In this regard, 5 categories of hospitals have been created: districts, regional , tertiary, central and specialized.
Organizing: In the first 5 years from 201 2, the NIH will pilot and strengthen the health system. There needs to be reorganizing of the system as mentioned earlier into the 5 hospital types. There have been 6 areas identified for strengthening: * management of health facilities and health districts * quality improvement infrastructure development * human resource planning development and management * information management and system support * establishment of NIH funding The whole health system is set to be reorganized and all managers would play a huge role in this regard.
Controlling: The role of controlling is to make sure that everything is going according to plans. Here monitoring and evaluating plays a big role. In this instance 3 points can be made derived from the White paper on the NIH: * service providers contract will be controlled. There would be checks in place in terms of quality standards, cage of provision like disease prevention and promotion of healthcare and acceptance of capitation. * Quality check will be maintained through improvement of quality of services in public hospitals, , cleanliness, waiting times, medicines, safety. One of the units of the OCHS is the ombudsman. Its function will be about customer care (checking if people have complaints during the implementation of the NIH) In conclusion, NIH will have a profound effect on the health care management. It is meant to overhaul the whole system as we know it from the top down. There ill be new structures edified, new and different ways to do things. Managers will be required to have the qualifications to do the job but most importantly they will be required to show leadership. In this extract the minister slams the brutality of the private healthcare system.
He asserts government s commitment to build a more equitable system that is less prone to centralization. Them, A (2012) on a e-Health communication quotes the minister of health (MOM) stating “In 2001 we had 180 medical schemes, we are now left with 95. They are simply collapsing under the weight of what is being charged. This proves that it is the law of the jungle and only the fittest will survive . The facts in the healthcare system in South Africa are as follows: * 8. 5% of the GAP is spent on healthcare, that makes SAC’S spending almost in line with developed nations and far above that of equal development countries. The average amount spent on healthcare for each person covered by a medical aid was ERROR in 2009 versus RI 925 for a person relying on public health services. (Health Economics Unit, CUT) * 68% of South Africans rely entirely on the public health services, 16% are members of a medical aid and 6% pay out-of-pocket. If we analyze these numbers the minister ‘ s statement makes so much sense. The bulk of the money allocated for healthcare is spent in the private sector even though it serves only 16% of the population.
The skewed distribution of health professionals in the private sector versus the public sector underpins this skewed channeling of funds: According to the AS Health Review (2008): * only 3 out of 10 registered doctors and 1 in 10 dentists are in public hospitals * 4 out of 10 professional nurses work in public services * only 1 in 10 pharmacists work in public service only 1 in 20 psychologists are in the public sector These data afore mentioned show that either the private sector is more lucrative or the public sector does not have the capacity to absorb the professionals needed.
This inability to attract professionals could be due to lack of funding of posts, poor salaries or working condition…. Professionals then follow the law of the market where they can make a good living. According to the Health Economics Units of I-ACT (2009), the sources of funding of the healthcare system in South Africa are as follows: * General tax funds: this is money collected by he government through income tax, VAT and other taxes. Medical schemes * Out-of-pockets payments In 2006, general tax accounted for 40% of total expenditure on healthcare, medical aid contributed to 45% and out-of-pocket for 14%. GENERAL TAX FUNDS As we mentioned earlier on , in AS everyone pays tax on one form or another. VAT and levy on petrol being one way of collecting revenue. The other one is the income tax that applies mainly to workers earning above a certain threshold of Income.. This chart shows the general tax revenue and adapted from the Budget review of 2008 from the National Treasury.
This chart gives us an idea on how inequitable the system is as poorer people have to pay the VAT and the petrol levy despite earning very little. On the other hand personal income tax and corporate income tax account for more than 50% of the general collected taxes putting a burden on the working, middle class individuals that we know by now mostly belong to a medical scheme. MEDICAL SCHEMES Medical schemes are governed by the Medical Schemes Act, 1998 (Act 131 of 1998).
Mueller et al (2011) stipple that this Act aims to protect the interests of members of medical schemes by setting out guidelines on the terms and notations for membership of schemes. Healthcare organizations are challenged to provide quality care and at the same time keep costs low. The MOM notes that the system of medical aid is just not sustainable in the long run. Because the market is so brutal many medical schemes had to close. Those remaining in business have overtime increased the premiums and limit the benefits.
This then leaves even contributing members in the cold for some procedures. The chart below shows that the poorest part of the population spends up to 14% of its income towards medical schemes contribution. That is quite phenomenal and the subsequent decrease in disposable income becomes a severe liability for families. Figure taken from Health Economics Units, I-ACT OUT OF POCKET PAYMENT (POOP) The POOP is used when individuals consult Gaps, Specialists, hospitals and pay directly the fees required.
It is nevertheless noted that in case of grave health situation they tend to revert to the public health service adding additional burden on it. Another factor of interest is that the contribution of these individuals does not go into a pool of health for the whole population,. It is a sort f pay as you go system that only benefits the individual concerned. In conclusion it is of interest to note that AS invests a huge portion of its GAP into health system . Nevertheless because of the very unequal nature of the society, the private sector still consumes a huge chunk of the healthcare money.
This brutal system has caused the demise of certain medical schemes with the remaining ones escalating fees and reducing benefits, Healthcare organizations need then to be effective and efficient in order to be sustainable. NIH aims to address these different issues during its implementation. QUESTION 3. 1 Wiggins believes that few topics have got the potential to change healthcare delivery , quality and efficiency than IT. Nowadays with the ubiquitous presence of cellophanes , pads and other mobile computing, the wise businessman is the one who can take advantage of these technologies.
Computers are becoming more and more powerful adding more capabilities to their arsenal. A management information system (MIS) according to Williams and Sawyer (2005:452) is a computer-based information system that uses data recorded by TIPS (transaction processing system) as inputs into programs that produce routine reports as output. In the field of health the TIPS could be any inputs that is required like number of patients at a clinic, waiting times, costs of medications, personnel employed… He manager needs the output to aid in decision making. Collecting data Leeds to information and knowledge and from this, value has to derive that can be used accordingly. (Mueller et al (2011:161)). According to a paper Report to The Congress (2004), IT allows health care providers to collect, store,retrieve, and transfer information electronically. However, more specific discussion of IT in health care is challenging due to the lack of precise functions, the volume of applications, and a rapid pace of change in technology.
Furthermore the paper cites issues of confidentiality and expenses as barriers to broader adoption of IT. It is also reported that the fragmentation of the system makes it difficult to communicate with other providers. Indeed there is a collection of vendors of applications on the market to serve the healthcare, thus creating a lack of standardization. The cost of initialization and the necessary cultural change in the organization are also cited as possible reasons why the uptake of the technology is so poor in the health care sector.
Indeed it is quite mind boggling to notice that in many surgeries IT is practically inexistent bar maybe for patients’ records and billing. The various IT applications fall into 3 categories: * administrative and financial that facilitate billing, accounting and other administrative tasks * clinical systems that help in the care process * infrastructure that supports both administrative and clinical applications. APPLICATIONS OF IT IN HEALTHCARE We are going to classify the applications in healthcare into 2 main categories : for physicians and for hospitals.
For Hospitals, IT could be used in: Administrative billing and financial general ledger * Patient registration * Accounting * Personnel and payroll * Electronic materials management including drugs at the pharmacy Electronic health record * Picture archiving like X-rays, and ultrasound… * Electronic monitoring of patients in ICC * Servers and wireless * Results reporting of laboratory and other tests. Inn this case the NILS has established a system of remote access to laboratory results in the Nelson Mandela Bay districts hospitals that is operational. Bar-coding technology for drugs, medical devices and inventory control For physicians, some applications of IT could be: * Administrative billing and financial accounting * Scheduling of patients and/or procedures * Clinical online reference (Apostates and Netscape software are very popular tools) * Laboratory results online (Patriarch, NILS) * Computerized provider entry * Email communication with patients * Clinical decision support systems * Servers and network There are endless potential applications for IT in healthcare. The poor intake of the technology is understandable on a cost/benefit ratio point of view.
There is no doubt a properly implemented system would bring about more quality and efficiency in the healthcare and that would necessitate a change in the culture prevailing in this specific industry. QUESTION 3. 2 As we saw previously, gathering information per SE is not enough. How often do we collect data that never get worked out. Behind the numbers, there are a lot of possible decisions making. We said previously that value has to derive from the raw numbers. That is where knowledge comes into play. Wisdom is required to understand the numbers and act on them.
The healthcare manager has a lot of functions in a health information setting that will be discussed point by point. RIGHT IT SYSTEM The healthcare manager must ensure that the system utilized is the one needed for the specific organization. For instance in the area of Nelson Mandela bay, there is an MONGO that deals specifically with HIVE/AIDS, the system that was developed was outsourced from the USA and the details of the diseases are those that are mostly found in infected individuals and the staging of the patients is also done automatically after inserting a number of inputs.
The first role of the manager is to find the right application for the organization and the type of data that is needed. ETHICS ISSUES The IT system must be compliant with the professional- and legal requirements. A case in example is the collection for instance of DNA through blood samples or saliva specimen. The mere fact of keeping a database of one s genetic material could be scary. The manager must ensure that data collected are used for the purpose that it was meant for and only that. CONFIDENTIALITY, SECURITY The healthcare manager must make sure that the data collected are confidential and secure.
The access to those data must be by authorized personnel only. Patients have trust in their service providers and confidentiality is one of the liars of the relation patient-provider. In case of breach of trust it could spell disaster for healthcare delivery. Disciplinary procedures must be in place in case of breach of trust. COLLECTION OF DATA The manager must have a process in place to collect data. It can be done periodically so as the data capturers have them ready when needed. Data must not gather dust, to use a metaphor. The collection and retrieval of data must meet legal requirements.
MAINTENANCE AND REPLACEMENT Hardwire do break down. Software do get virus and malfunction. The healthcare manager must insure that there is a backup system in place. There must be alternative sources of electricity in case of load shedding. A system that depends heavily on IT could be paralyzed if there is no backup or power failure. TRAINING OF STAFF The other component of an IT system that often gets overlooked is the personnel aka parser. It is often assumed that they just have to insert data and little attention is paid to them.
They are the gates of entry of the outputs that are to be analyzed later. If they don’t have the skills to work properly one could be working with truncated or wrong data. The manager must see to it that they are adequately trained for their tasks ANALYSIS OF DATA Gathering data without applying knowledge to it is useless. The manager must be skilled enough to be able to analyze the data collected and act on them. Only then, do the data have any meaning. The data collected can be useful in HER , budget and infrastructure allocation.
In conclusion the healthcare manager has a pivotal role to play in the health information management. He must make sure that the proper management system is in place, the personnel is well-trained, the legal and ethical requirements are met and he must have the knowledge and wisdom to understand the data collected and act on them accordingly. QUESTION 4. 1 It is undependable that a country like AS that spends a big percentage of its revenue on healthcare has got such a poor perception from the members of the public regarding the quality of the services rendered.
All stakeholders in the healthcare system should be involved in improving the health outcomes and help the country achieve its MEG targets at the minimum. The Institute of Medicine in the USA has defined quality of care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge . In this definition emphasis is put on populations and individuals receiving the care that will deliver the best outcomes possible.
The stakeholders in healthcare quality are multiple and include: * the ministry (from the state) and the board of directors (private organizations) * healthcare managers * clinical practitioners * non-clinical managers * quality coordinators * patients / consumers of health * professional institutes and professional regulatory bodies insurance funding systems * facilitators and surveyors * health we will explain the role of 5 of these stakeholders in the quality of healthcare. 1. The ministry / board of directors The accountable , legal ownership authority with reference to the state is the ministry.
In private the board of directors has got the legal and accountable power. Both have got the legal responsibility to regulate the service delivery and to account for the quality of the services rendered. In a system where accountability is paramount, ministers of health have resigned after adverse incidents incurring in their establishments despite them not being physically responsible. This shows the high moral burden that the executive should be bearing in terms of quality and service delivery.