The pulse of investment by medical schemes in sophisticated IT systems has been quickening for several years and the result is improved administration and slightly reduced costs of health care.
Most private medical scheme members would agree they are reimbursed sooner than they were a few years ago. But not everyone is convinced.
Board of Healthcare Funders research and advocacy executive Vishal Brijlal says not all schemes have improved, though there has been an overall improvement in management information and electronic claims processing.
"We still get poor data from some medical schemes. The investment in IT development is not generating all it promised," he says.
Ten years ago, 100% of medical claims were paper-based and administrators aimed for a turnaround time of 20 days . Claim forms had to be filled in, mailed, captured on the administrator's system, adjudicated and then paid. And that's the way it still works today for the 25% of claims that are not submitted electronically.
Today, about 75% of claims involve electronic submission of invoices, an electronic adjudication process, which takes seconds, and electronic payment of three to six days.
Yet technology in health care is a mixed blessing, pulling medical inflation in opposing directions.
Though IT is reducing costs of administration, costly improvements in medical technology are the cause of the cost spiral in health care. Many illnesses, which 10 years ago were untreatable, can today be easily treated thanks to technology.
SA is one of only a handful of countries that has a free market health-care system, but the lack of regulation has allowed for the over-treatment of patients.
Here too, information management is making it possible to control over-treatment and unnecessary expenditure on treatment, medication and hospitalisation. This is what managed health care promised 10 years ago, but it lacked the systems to effect change. The systems underpinning managed health care have finally been rolled out over the past two years.
Most countries have state-run health-care services with protocols for treatments, making administration relatively simple. In SA each claim has to be closely interrogated for over-treatment and fraud. IT systems now interrogate claims against the scheme rules and previous claims.
IT in health care is driving down the cost of administration by about a third, but administration makes up only 10% of the total cost of health care .
Technological breakthroughs have so far been in the processing of huge volumes of transactions. There are about 7,2m medical scheme members who claim on average three times a month for a staggering 21m claims a month.
It is a business that feeds on critical mass and has brought about considerable consolidation among administrators and medical practices as they join forces to spread the cost of the sophisticated and expensive systems.
Few of the 7,2m medical scheme members in SA know exactly what their benefits are at point. Now, most medical schemes have their members' details online and those 75% of medical practices that are also online can verify member details such as medical history, allergies and who is responsible for the account.
Medical schemes such as Discovery Health and Old Mutual's Oxygen offer an online self-service facility. About 40% of Discovery Health members are connected online and can access and amend their personal data, change their plans, track claims and self-administer their policy.
Medscheme chief information officer Kevin Wright says the public is happier with the level of service compared with 10 years ago. "But their expectations have also risen and their tolerance for failure is lower."
Facilitating the electronic claims process is a number of systems that have been installed around the country: Healthbridge is a switching company that links general practitioners to the back offices of administrators and MediCredit does the same for pharmacies. This enables their systems to talk directly with each other.
But about 25% of medical suppliers are not yet connected . For the one-man practice, the cost of infrastructure is an obstacle. Not all medical disciplines are yet catered for - a module allowing dentists to connect is under development and optometrists were only recently connected.
