Mediclinic Care Expert lightens the load for patients – and clinicians

Being hospitalised is stressful enough, but it’s even worse when you are responsible for making sure your medical aid will cover the costs of all service providers involved in your procedure.

“To put this [situation] in perspective, the team involved in a joint replacement may include the referring GP, the orthopaedic surgeon, a physician to help you manage other conditions before the surgery, and a dietitian to provide nutritional advice for optimal healing,” says Dr Johan Charilaou, a specialist arthroplasty and orthopaedic trauma surgeon at Mediclinic Cape Gate.

“Then there’s the orthotist who provides prosthetics if you need it, the ward staff, ICU staff, and perhaps staff within a step-down facility if you don’t have the resources to access proper care at home. Not to mention the pharmacist who dispenses medication, physiotherapists, pathology labs, the anaesthetist, and the theatre team.”

It’s a long list – which is why Care Expert, a bundled billing product for hip and knee replacements, makes sense. Dr Charilaou explains that the package is available to patients on certain medical aids and plans, irrespective of underlying medical expense codes. “In other words, the bundled payment covers the hospital, prosthetic, surgeon, and assistant’s fees,” he assures. The anaesthetist and physiotherapy fees need to be approved by the patient’s medical aid, and the other referrals, such as the physician, are covered in the usual fee-for-service way.

Convenient service

You can’t underestimate the convenience of this service, says Ida van Dolderen, a nurse who made use of Care Expert when she had a hip replacement in January 2023. She explains that her Care Expert journey started with a visit to a surgeon after she experienced severe pain in her groin. “Although we initially thought the condition could be treated conservatively, an MRI showed I had no cartilage left on the head of the femur. Now, following the surgery, I have no pain at all. I can’t believe I’ve had a replacement.”

As a nurse, Van Dolderen knew how important it was to establish ahead of time if the surgery would be covered by her medical benefits. She was pleased to find out that because her service providers were part of Care Expert, significant costs would be taken care of. In addition, she received follow-up care provided by a Care Navigator, who supported her during her recovery. “I felt very looked after,” she says.

Dr Charilaou explains that the Care Expert Navigator is also the patient’s point of reference before and during their procedure, helping them as they work through the processes of admission and pre-theatre workup.

Care Expert Navigators are also involved in the scoring that is a key part of Care Expert. All surgeons are required to load a score onto the package’s Amplitude software that represents the patient’s level of comfort before and after the surgical event. These scores are used to evaluate the surgeons, effectively reviewing them against their peers within the same hospital as well as other surgeons around the country. This makes it easier for hospitals to uphold standards of excellence.

The doctor’s score is especially important for those working in academia, as it points to their credibility. At the same time, a doctor whose score reflects high proficiency and an ability to use resources cost effectively can earn incentives from their hospital – while reaping the rewards of an excellent reputation.

Streamlined and holistic

There are other benefits for doctors, too, says Dr Charilaou. For a start, Care Expert streamlines admin since the practice is reimbursed by the hospital rather than a medical aid. The system also provides access to a holistic set of data providing information about patient recovery, making it easier to conduct further investigation if improvement does not take place as expected.

An added benefit for the orthopaedic surgeon is that Care Expert requires them to log the implants used on the National Joint Replacement Registry, so any complications and the longevity of the prostheses can be evaluated. This is in line with international trends, making it possible to pick up abnormalities and make informed decisions on management pathways and implant selection

“The goal is to understand and meet my patients’ needs. I want to restore function, mobility, lifestyle, and independence,” Dr Charilaou says. “Care Expert helps us to achieve this to everyone’s benefit.”