ICON puts its money where its mouth is

A groundbreaking case study on the impact of ICON’s model in a leading South African medical scheme has demonstrated conclusively that it is possible to improve healthcare outcomes without spending more – and that collaboration is the key.

A collaboration between ICON – the Independent Clinical Oncology Network – and one of SA’s leading medical schemes has shown that it is possible to achieve an impressive 13% saving on direct oncology costs – in the treatment of certain cancers – without reducing access to treatment or sacrificing patient outcomes.

By adopting ICON’s evidence-based treatment model, which plugs into existing medical scheme administration processes and enables standardised treatment delivery and streamlined payment decisions that maximise available resources, the medical scheme was able to reduce costs while achieving the same or better patient outcomes on a number of key metrics including hospitalisation rate and average patient stay days. All while paying doctors the same.

“The findings of this study are dramatic,” says Dr Ernst Marais, COO of ISIMO Health, the parent body to ICON. “It shows it is possible to manage financial risk through appropriate clinical behaviour. This represents the start of a new era in healthcare management where the focus shifts from cost saving to investing in value. It’s not about cutting corners but about giving the right care to the right person at the right time.”

Letting the numbers tell the story

The study compared clinical and claims data for a low-cost scheme option from 2015 following the implementation of the ICON model, with baseline data from 2014, gathered prior to the scheme’s adoption of the model, and monitored the cost differential over that period.

The overall performance measure accounted for inflation and was adjusted for case mix – so that patients in the same cycle of treatment and stage of disease were considered. In order to keep the measurement statistically stable, case mix was stratified by the following factors:

  1. The top seven most common cancers by cost and prevalence. These included: breast cancer, prostate cancer, lymphoma, colo-rectal cancer, lung cancer, GIT cancer (excluding colo-rectal), gynaecological cancer (excluding ovarian) – accounting for more than 70% of costs and 70% patients.
  2. Patient age, defined by six age groups
  3. Cancer stage
  4. Months from death, either alive or 0-3 months from death

According to Murray Izzett, Business Intelligence Manager at ICON, the study drew on clinical data provided by ICON’s eAuth© system – an online system that allows doctors to submit their patient diagnosis and full treatment plan directly to medical schemes – and financial data from claims, provided by the medical scheme.

“To be able to carry out this kind of analysis it is essential that you have reliable data and we were fortunate that both ICON and the medical scheme have rigorous data gathering systems in place to facilitate this,” he said.

In addition, continued Izzett, you need a big enough sample size of congruent data, which is why the study chose to focus on the top seven most prevalent cancers representing roughly 70% of the oncology patient population.

To go far, go together

“A third vital ingredient for this kind of research is that you need willing partners who share your objectives,” said Izzett. “This is not something that ICON could do on its own. Firstly, the network relies on its participating doctors (which account for more than 80% of the country’s oncology professionals) to keep their records updated and to use the eAuth© system. Fortunately, there is a more than 90% compliance of this in the network – which is incredibly high because doctors see the benefits in participating.

“Secondly we are extremely grateful to the medical scheme that was willing to participate in this project with us. Not only did they provide the claims data that is a crucial part of the model, but they were willing to take the chance to explore new ways to improve healthcare in this country.”

This kind collaboration is the future of the healthcare industry more broadly, commented Dr Marais. “In the face of spiralling healthcare costs, something has to be done. Innovation and collaboration hold the key.

“If improving quality and cutting or capping costs is an objective everyone can agree on – then how we get there becomes easier to achieve.”

Risky business

ICON’s innovative model is a risk sharing one, which means that ICON is prepared to risk having to pay in the difference to the medical scheme should the scheme lose money as a result of adopting ICON’s system.

“But as we went into this case study, we were confident that this would not happen,” said Dr Marais. “ICON has been honing its approach for close on a decade and we believe passionately in the product. It is gratifying that our belief has been rewarded with this evidence.

“The participating scheme sought an independent review of the analysis approach to ensure that a true, case-mix-adjusted saving was being measured and that costs were not just being diverted to other areas of claims. This was necessary as this magnitude of saving had never been achieved before by them using a risk sharing arrangement.”

Prioritising patient well-being

Apart from 13% reduction in cost, the model had other benefits that the scheme was not expecting including a reduction in hospitalisation.

The data showed that in 2015, the proportion of oncology-related hospitalisations declined for patients who were being treated by ICON doctors. Of those who were hospitalised, they were admitted fewer times and the total stay per admission was shorter.

“In fact, every single metric related to hospitalisation was more favourable,” said Izzett.

“Values-based medicine prioritises outcomes over cost – so that means that we are looking for ways not just to reduce or cap cost but to improve the experience of patients and hospitalisation a key proxy of this,” said Dr Marais.

According to Dr Marais, this collaboration is part of ICON’s on-going efforts to improve healthcare in South Africa by finding alternative reimbursement models that share risk. He believes that it is crucial that South Africa moves away from a narrow fee-for-service model and that this case study provides new evidence of why this is necessary.

“Our approach incentivises quality outcomes in healthcare by engaging in risk transfer models between funders and providers of clinical services,” he commented.

The potential for this kind of shift is enormous – he believes.

“If we managed to achieve 13% saving on oncology bills on direct oncology costs for low-cost medical scheme options – imagine the difference we could make on higher levels and in other specialities?”