• ISSUE 01
• LENMED GROUP
• INDUSTRY NEWS
• CLINICAL GOVERNANCE
• ALL ISSUES

Cost per Event Profiling and Clinical Efficiency

Clinical profiles are one of the tools which Lenmed employs to empower specialists. Profiles are intended to empower specialists with information to drive efficiencies.

Medical scheme members are increasingly opting for more affordable medical schemes with efficient hospital networks. Medical schemes select the most cost-effective hospital groups and hospitals for network participation. Hospital efficiency is the aggregation of efficiencies across doctors.

At the same time medical schemes are increasingly adopting a hard stance against so called “outliers”. This includes a variety of punitive measures such as lower tariffs and restricted admission rights.

"South Africa has significant needs and only very limited resources. It is the responsibility of all to ensure that resources are used efficiently, which means improved efficiencies = increased access. Improving and maintaining clinical efficiency improves Lenmed’s ability to compete for and retain network deals in the process improving sustainability and patient volumes for the group and its specialists."
Amil Devchand, Deputy Chief Executive Officer

One of the typical errors highlighted by the medical schemes is the incorrect allocation of Primary ICD 10 diagnosis during the admission – resulting in a different DRG with different cost expectations. Another typical error is the insufficient coding of secondary ICD10 diagnosis and non-coding of comorbidities and chronic conditions, resulting in a lower severity DRG, that is without complication and comorbidities with a low-cost expectation – resulting in the case looking inefficient or higher than expected. Common comorbidities not coded include Diabetes, Hypertension, Asthma, HIV/AIDS & Obesity.

Lenmed is currently finalising individual specialist profiles, and these will be made available to you through your hospital manager.