A big, big idea to reform private healthcare

The dynamics of private healthcare in South Africa are like a multigang bar-room brawl, with protagonists slugging it out, bloodying noses on all sides, retreating for a moment, and then rushing back into the fray. It’s easy to stand on the fringes, braying for changes and reform. It’s a lot harder coming up with suggestions that could move things towards a reconciliation where the ultimate goal of good healthcare in our country is realised.

For a long time I thought I had — an idea that addresses the underlying theme throughout my recent posts on our dysfunctional healthcare system, ie that of an absence of trust between all parties involved.

To recap in a single sentence: medical funders do not trust the doctors who supply the services, patients cannot trust the medical funders to provide the care they believed they signed for, and patients cannot, or perhaps should not, trust their doctors who have bought into this whole system by signing contracts with the medical funders. In all of this, the patient comes last and suffers the most.

I had an idea to change all that by putting people first, and providing a system whereby funders could re-establish trusting relationships with willing doctors who were paid their worth based on a system of recognition of quality of service, not one of cost control.

My idea is about putting people in charge where possible of their medical decisions. The biggest expenses in healthcare lie in having surgical procedures. A system that allows someone to be an equal partner in the decision-making process before surgery is of great value as proof of ethical, top quality medical practice.

The principles are very clear and written into law. A person should consent to an elective surgical procedure only if told all the information about the procedure, the reasons, the alternatives, the consequences of not having it, the risks, and the total cost involved. “Informed consent” is established in our Constitution as an essential obligation of a doctor’s care, and failure to do so is a human-rights violation.

I envisaged a comprehensive, detailed, signed consent document with all the information mentioned above being the ethical yardstick or proof that a medical funder could use to be reassured that their member was an informed partner in the decision-making process. Similarly, presentation of such a signed document to funders would identify the doctors willing to subscribe to high quality, higher fees, and lower turnover practice. In an industry where funders believe as much as 30% of the annual R90 billion is spent unnecessarily this could be a big deal.

The “experts” said it couldn’t be done, that the level of doctor-patient interaction required could not be put to paper adequately.

“Doctors and patients are too individual, and no single document can accommodate the variables,” they said.

My business partner and I disagreed, and set out to design a system that would do exactly that. And we have. A user on our system can take a detailed consent tailored to their own and the patient’s individual needs in a few minutes, producing a document that is without parallel in terms of its flexibility, openness and transparency.

Getting there was extremely difficult. We chose our first software company based both on reputation and first impressions. Perhaps the manufacturing section, the indoor basketball court and the cafeteria, the wall-to-wall sea aquarium in the boardroom won us over. That the aquarium never had any fish in it in the weeks that followed should have been a warning sign, but we persevered. The functional specifications for the software were done, and a final account presented. We were told, as we were individuals and not representatives of a company that we would have to pay 50% of the proposed development fee up front. We did. A week later the company went into liquidation, taking R350 000 of our cash with it for no return.

We could have given up at that stage, but we had had such glowing assessments of our concept from many sources (Neville Koopowitz, then chief executive of Discovery, at a meeting called it the best idea he had seen coming from a doctor) that we regrouped, sought funding from the Department of Trade and Industry and persevered. It took four software companies to produce a beta form of the software that could showcase our concept’s potential.

The timing of our launch was disastrous — 2008, as financial markets around the world crashed. Two years of talks followed, discussions with roleplayers in all aspects of the industry who could benefit by being involved, seeing us on several occasions tantalisingly close to signing deals that would set the stack of dominos tumbling and bring a new paradigm into the industry.

But we failed. The environment was substantially risk averse. South African executives of multinational companies feared drawing attention to themselves. Leaders in other fields whose businesses were doing quite nicely, thank you, had no real incentive to change and risk rocking the boat with a radical idea.

To be fair, the system could only work if there was agreement between doctor groups and funders to explore the new paradigm of a new class of medical doctor, using tools like ours to enable that possibility. We faced a marketing nightmare, asked to provide high numbers of users to justify an organisation’s interest, when doctors had no incentive to become users based on a faint and vague promise from funders they disliked and distrusted, and saw no way through it.

It’s sad and demoralising, particularly when I saw how well my patients liked being equal partners in their care.

Perhaps we have to reach rock bottom as a healthcare industry before the incentive to apply real change comes our way, like an addict or an alcoholic. That prospect is scary, and who knows how many people will have to suffer before then.

When we do, if I’m still around, somebody give me a call? We’re still online. Just.