Problems experienced by role players w ithin the managed healthcare context in Gauteng

Role players within the context of managed healthcare in Gauteng experience problems in the delivery of healthcare, which negatively affect their working relationships. This is turn, affects the quality of care provided to patients. The purpose of this study is to explore and describe the problem experienced by different role players within the context of managed healthcare in Gauteng, as well as the suggested solutions to counteract these problems. These results will be utilised as the basis of a conceptual framework to formulate a strategy to enhance the working relationships amongst these role players. The strategy will not be discussed in this article as the focus is on the problems experienced by the role players in the delivery of healthcare, as well as suggested solutions in the counteraction thereof. A qualitative, exploratory, descriptive and contextual study was followed to explore and describe the problems, as well as the suggested solutions to counteract these problems. Focus group interviews were conducted to collect data from three private hospitals, three managed care organisations and four general medical practitioners in Gauteng. The participants were purposively and conveniently selected. Content analysis as described by Tesch (1990) was followed to analyse the data. The main problems experienced were related to inadequate communication, inadequate staff competence, cost saving versus quality care, procedural complexity, perceived loss of power by doctors and patients and the system of accounts payment. The suggested solutions focused mainly on empowerment and standardisation of procedures. It is recommended that replication studies of this nature be conducted in other provinces and that ethical standards are formulated within the managed healthcare context.


Introduction
M anaged healthcare is a system of healthcare delivery that ensures that cost effective quality care is provided to pa tients, who are members of medical aid schemes within the managed healthcare context.Various role players are involved in the delivery of healthcare within the managed healthcare context.According to Anderson (in HASA 1998:170).there are three main role players in managed healthcare,-namefy.-the professional service providers, the funders and the members.Professional service providers are responsible for the provision of qual ity healthcare to patients.Funders, rep resented by m anaged care organisa tions, are responsible for paying for the healthcare services provided to patients by the professional service providers and to m onitor the quality of care provided.In this context, professional service pro viders are represeriTed b y tfr e privaté h ospitalsáhdT hê'aoctbrspróvïdïngpíivate healtcare services within the~managed healthcare context in Gaute ng .Members are responsible for the pay ment of their monthly premiums to their m am cjed care organisations.Medical aid schemes in South Africa, represent ing 15 to 20% of all patients (HASA, 1998:160), started introducing managed h ea lthca re in an a tte m p t to reduce healthcare costs, which was increasing '_at a high rate for the past few years, par ticularly so in the private healthcare in dustry.
According to T.W.I.G Inform (1998:6), m anaged healthcare was introduced four years ago in South Africa, and since then, an estimated 95% of local medical aids have introduced a form of cost sav ings orientated to the philosophy of man aged healthcare.During the process of healthcare delivery, role players experi ence problems which negatively affects their working relationships and in turn, affect the quality of care provided to pa tients (Barr, 1997:4;Gallows and Lee, 1997:246).As managed healthcare is fairly new in South Africa, little is known about these problems.As a result, there Curationis June 2000 are no guidelines for the formulation of a strategy to enhance positive working relationships among the role players' Exploration and description of the prob lems experienced by the role players and the suggested solutions to counter act these problems, within the context of managed healthcare, should provide guidelines for the researcher to formu late a strategy to enhance positive work ing relationships among the role play ers in the delivery of healthcare.This in turn, should impact upon the quality of care provided to patients.The study fo cuses on the problems experienced by the professional service providers and the funders.The follow ing research question is relevant: "What are the prob lems experienced by the role players within the managed healthcare context in Gauteng and how can these problems; bejsolyed?The specific objective of the study is to e x p lo rtfa n d describe the problems experienced by .therole play ers and the suggested solutions to coun teract these problems, within the context of managed healthcare in Gauteng.These results will form the basis for the development of the strategy to enhance positive working relationship among the role players within the context of man aged healthcare in Gauteng.

Terminology
M anaged liealtlioare M anaged healthcare is a system of healthcare delivery that influences the utilisation and cost of services to facili tate cost effective quality care to the m em ber of the m edical aid schem e within the managed healthcare context.

R ole players
Role players in this study refer to the pro fe ssio n a l service p ro vid e rs and the fu n d e rs in the co n te xt of m anaged healthcare in Gauteng.

N ursin g service m anager
The nursing service manager is a regis tered nurse/midwife in charge of a nurs ing service and is responsible for the fa cilitation of quality nursing care in a cost effective manner within the m anaged healthcare context.

nit m anager
A unit manager is a registered nurse/ midwife in charge of a clinical medical ward/unit within the managed healthcare context where he/she acts as the opera tional manager of nursing care.

H o spital ease m anager
Hospital case manager refers to a regis tered nurse em ployed by the private hospital to liase with the managed care organisations and ensures that the hos pital is getting paid for the services ren dered to the patients, who are members of the managed care organisations.
M anaged care ease m anagers Managed care case managers refer to registered nurses employed by m an aged care organisations to monitor the quality of care provided to their members by the service providers and to approve paym ent for such services.Managed care case managers ensure that profes sional service providers provide cost ef fective quality care to their members.

Problem s
Problems refer to negative experiences by the role players within the managed healthcare context in the d elivery of healthcare.

Solutions
The suggested strategies to counteract the problem.

Research Design
A qualitative, exploratory, descriptive and_.conïexïïjáf design was follow ed to ex plore the problems experienced by th_e_ role-players within tlïe context of man aged healthcare in Gauteng, as well as the suggested ^solutions to counteract these problems.Fqcus group interviews were conducted to explore and describe theproblem s and the solutionsTcfcounteract these problems (Krueger, 1988).Focus groups were conducted with three private hospitals, three managed care organisations and four general medical practitionersjn Gauteng^ All role players arfVd participantsHwërê' purposively arid corivënteTTtÍy'seíected according to the s i r inclusion criteria: • The hospital had a medical unit/ward, nursing service manager and a hospital case manager.
• A nursing service manager with one year experience as a nursing service ' manager in a private hospital.
• Medical ward unit manager to have at least one year experience as a medical ward unit manager in a private hospital.
• Hospital case manager with at least one year experience as a case manager.
• Managed care organisation must be in existence for a year.
• Managed care case managers with one year experience working as a man aged care case manager.
• Doctors must have been in private practice for at least a year.The researcher used the principles of focus group interviews (Krueger, 1988) 38 C urationis June 2000 to encourage the participants to actively participate.The following principles are relevant: • Only information rich participants who are willing to participant were selected • The researcher used a group small enough to allow every member to par ticipate and big enough to generate in formation • Although they had com m on back ground, participants were not familiar with each other as this could influence the information they generate • Focus group interviews took place in a place designed for the focus group interviews.
• Discussion took place in a series to allow all participants to actively partici pate.
The follow ing research question was asked: "What are the problems experi enced by the role players within the con text of managed healthcare in Gauteng and what solutions do you suggest to counteract these problems?" .To facili tate data storage and retrieval, the re s e a rc h e r o p e n e d th re e (De Vos, 1998:334).Comprehensive field notes were also written by the researcher to capture external factors that could have influenced the inform ation generated and the researcher's experiences.Con tent analysis as suggested by Tesch (1990) was conducted and an independ ent coder approved by the researcher's supervisor was used.To facilitate the trustworthiness of the study, the princi ples of Lincoln and Guba (1985:290) were employed by the researcher.As the researcher is not experienced in con ducting focus group interviews and due to the sensitivity of the topic, the re s e a rc h e r e m p lo y e d a p ro fe s s io n a l facilitator.To ensure the quality of the research, the researcher adhered to the ethical standards set by the Democratic Nursing O rganisation of South Africa (1998) in this regard.

Results
Six themes emerged from the identified problems and they are related to com m unication, inadequate staff com pe tence, cost saving versus quality care, procedural complexity, perceived loss of power by doctors and patients and ac count payment.Problems related to communication were grouped into infor mation flow and poor relationship be tween the private hospitals and man aged care organisations.Managed care organisations (n = 3 ), private hospital (n=9) and general medical practitioners (n=4) are experiencing difficulties ob taining information from each other to review the conditions of patients and for the managed care organisations to au f) When phoning the hospitals, there is always insufficient information for managed care case managers to do updates.
a) Lack of information from managed care organisations to the patients on managed healthcare.
b) There is no information flow from managed care organisations to serv ice providers thorise payment of services provided to patients, who are their members (see tables one and two).Doctors refuse to provide necessary in form ation required by m anaged care organisations to hospital case manag ers to authorise payment of services pro vided to patients because they feel like they are being checked upon by medi c a lly u n q u a lifie d p e o p le .HASA (1999:100) confirms this situation: "Why should a nursing sister be allowed to challenge the opinion of an orthopedic surgeon that that an operation is not necessary?Should someone who is not m edically qualified have the power to decide that the patient has stay enough in hospital?"As a result, managed care case manag ers refuse to update the accounts or authorise services provided.Two partici pants (n= 2 ) confirm ed the problem : "You know, doctors don't want to give us information required by these man aged care people, and in this case, man aged care people don't want to update our accounts...when they don't get this information..." ; "This is frustrating, doc tors feel like they are being checked upon by these people who are not medi cally trained" .Managed care case man agers (n=3) also share this problem with the private h ospitals in that doctors refuse to give them necessary informa tion to update the conditions of patients as they perceive managed healthcare as being there for managed care organisa tions to make money at their expense: " The whole myth that managed health care is there to save money and make profit you know, makes doctors to refuse to give us necessary information to up date conditions of patients..." .Managed care organisations do not edu cate their members on the requirements of managed healthcare.As a result pa tients go to hospitals without knowing what they are getting admitted for, and without authorisation numbers.Hospital case managers (n=3) experience frus tration as they find themselves in situa tions where they phone doctors for pa tie n ts' diagnoses and m anaged care organisations concerned for authorisa tion numbers: "Managed care organisa tions d on 't even inform their members on the e x p e c ta tio n s o f m anaged care.You find patients coming to hospi tals without knowing what they are get ting admitted for, and without authorisa tion numbers" .This problem is also ex perienced by general medical practition ers (n=4).As a result they find them selves in a situation of educating patients on the requirements of their managed care organisations rather than treating them: "The most serious problem is that they are busy dictating to us, but they are failing to educate their members whom they are claiming to protect..., that is why members themselves don't know what their managed care organisations expect of them, and I think this is a seri ous problem, because we as doctors are finding ourselves in a situation whereby we educate patients on the rules of their medical aids and this is irritating" .Man aged care organisations are experienc ing a problem of the hospitals and doc tors not accepting information on man aged healthcare because of their resist ance to change, as confirmed by the fol lowing quotation: "You can give informa tion and education to people, but if they are not willing, if they shut to it..., I think there are doctors and hospitals that un derstand it, but are not accepting it be ca use o f...a n d th e ir re s is ta n c e to change" .Doctors provide insufficient or incorrect inform ation about the conditions and treatment of patients to managed care case managers, hoping that treatment and conditions that are normally not cov ered will be paid: " ...I mean giving us in sufficient information, this is frustrating and th e y a lso g ive us in c o rre c t information...when you receive the ac count, the information is not the same as what he told you when he phone, they think that this will make us pay for what we n o rm a lly d o n 't pay fo r " .HASA Cost saving versus quality X X care Procedural complexity X Perceived loss of power by X doctors and patients Account payment X iX indicates the response group (1999:27) confirms these problems and emphasised that the information needed by managed care decisions is, in most cases, no known to the patient, the rela tive and other team members; there is no understanding among the medical aid beneficiaries as to how managed care w orks and how to access care within that system.The lack of educa tion in managed healthcare is supported by Gallaway and Lee (1997:23), T.W.I.G Inform (1998:12).Table one summa rises the information related problems as experienced by different role players.
Building meaningful relationships was experienced as a problem between the private hospitals and managed care or ganisations because of the lack of spe cific reliable contacts.Three participants emphasised the problem and the follow ing d ire ct q uo tations a rticulated the problem : "A nother problem , another problem is making contacts with neces sary people at the managed care organi sations" ; You also find that there are no reliable people to talk to for updates, because they still don't have case man agers you know ..." .
Another source of the problems is the limited or no medical knowledge to cer tain people doing updates from other role players.All role players are experi encing a problem of talking to people with limited or no medical knowledge from the other two, which makes it diffi cult to update conditions of patients.This problem was emphasised by eight par ticipants and the following selected di rect quotations were used to emphasise the problem: " People that we talk to on the other side of medical aids don't have necessary medical knowledge.. .trying to explain to them the condition of the pa tient is oh...difficult, because the only thing that guide them are pro toco ls" ; "What about talking to the hospital con firmation clerks with those hospitals who don't have case managers?, it is difficult b eca u se th e y are not m e d ic a lly trained..." ; "And eh...and also dictating to us as to how to operate, how to treat the patient, eh., meanwhile these dicta tors don't even have medical knowledge, or in most cases, with managed care organisations are nurses, who come with unethical decisions...and not having an idea of the im plications of their d eci sions" .
Procedures followed by managed care organisations are perceived by private hospitals as rigid, and they are often not known to them, leading to frustration and resentment.This appears to be a mani festation of lack of standardisation in managed care industry.There is a strict adherence to protocols by m anaged care organisations without due consid eration: " From the managed care organi sations' side, protocols are a problem, protocols as opposed to what we do at the hospital" ; " Rules differ from man aged care organisation to managed care organisation you know, it is so amazing because eh..eh..they all expect us to adhere to all these rules" .
Role players are experiencing a dilemma in balancing the provision of quality care, on the one hand, with the cost of provid ing the care to the member: "Another thing is that medical aids are desperate to save cost, rather than the quality of care provided to members, yet they are claim ing to protect these m em bers" ; " ...When you are in managed health care, you must prove your existance that you m ake a d iffe re n c e in an 40 Curationis June 2000 organisation...We are forced into a situ ation where we have to say we have saved so much to prove our existance" ; "A n o th e r p ro b le m is the preauthorisation, we still have...a lot of preauthorisation requests when patients are b e in g at th e d o o r being adm itted...and in that way, you cannot make an impact on the saving" .General medical practitioners feel that managed care organisations are taking over their power to decide on how and where the patient must be treated, and even dictating to patients as to who and where they m ust be treated: " I think these managed care organisations want to employ us and be in control of us, desperate to make profit..." .This con cern is supported by HASA (1999:49) : How can a protocol distinguish whether a headache needs an aspirin or whether it is related to a tum or?" Doctor's accounts are paid late or not paid at all.Managed care organisations demand quality of care to their members from the service providers, yet they don't want to pay for it: "Accounts are not paid in time or not paid at all, this is frustrat ing as they expect us to provide quality care , yet they don't want to pay for this quality that they demand from us" ; " I think they try and look for a good rea son for not paying the account, and if they pay, they do not pay in tim e" .International data triangulation indicates that the USA also experienced these problems in the implementation of man aged healthcare by different role play ers.Not all role players experienced all problems, similarly, some problems were experienced by m ore than one role player.Table two provides a summary of the problems as experienced by differ ent role players.
Solutions are suggested by the partici pants themselves to counteract the ex perienced problems.Suggested solu tions revolved around the standardisa tion of methods, procedures and sys tems followed in the managed health care industry, involvement of all role play ers in the formulation of the guidelines and standards, role players education on managed healthcare, recruitm ent and employment of medically qualified staff to be case managers by both the private hospitals and managed care organiza tions, employment of doctors by man aged care organizations to make medi cal decisions and member education.These solutions were seen by role play ers as important for enhancing positive working relationship in the delivery of healthcare within the managed health care context in Gauteng.

Conclusions And Recommendations
The following conclusions are made: Problems experienced by the role play ers within the managed healthcare con text in Gauteng were related to commu nication, staff competence, cost saving versus quality care, procedural complex ity, perceived loss of power by doctors and patients and accounts payment.
• Com m unication problems relate to difficulty in the flow of information among the role players and difficulty in building meaningful relationship.
• All role players experience a problem of talking to people with limited or no medical knowledge from the other two.
• Managed care case managers need to prove their existance to their organi sations by saving costs and as a result, the care provided to patients is compro mised.
• Managed care organisations expect other role players to work according to their procedures rather than what is best for the patients.
• Managed care organisations dictate to other role players.
• Managed care organisations don't pay the d o cto rs' accounts in time or they don't pay them at all.
• All role players suggested solutions to counteract the problem s and solu tions revolved around the standardisa tion of m anaged healthcare m ethods across managed health care industry, role player involvement in standards and guidelines formulation, role player em powerment and member education and formation of independent practitioners' association by doctors.From the identified problems and sug gested solutions, the following recom mendations were made: • Replication studies to be conducted in other provinces of South Africa.
• Problems experienced by the patients within the context of managed health care in Gauteng to be explored and de scribed.
• Ethical standards to be formulated for the role players in the provision of health care.
• The roles of different role players in the provision of healthcare within the context of m anaged healthcare to be clarified.
• A clear job description of a case man ager to be formulated.
• A clear inservice training programme for a case managers to be formulated.

^imitations
The sensitive nature of the topic could have influenced the process and the content of data collection.Participants were interviewed in different venues, which could have influenced the nature of the results.The professional facilitator was not probing enough inform ation from the participants, which could have influenced the nature of the results.

Concluding Remarks
Problems experienced by the role play ers w ith in the c o n te x t of m anaged healthcare have a negative effect on their relationship, which in turn affect the qual ity of care provided to patients.As man aged healthcare is a new concept in South Africa, little was known about the problems.Exploration and description of such problems lead to their better un derstanding and the research results were used as guidelines for the formu lation of the strategy to enhance posi tive working relationship among the role players within the managed healthcare context in Gauteng.
T a b le 1: S u m m a ry o f in fo rm a tio n -re la te d p ro b lem s H ospitals Managed care organisation Doctors a) Doctors refuse to give information required by managed care organisa tions to hospital case managers.b) Doctors refuse to write motivation letters required by managed care or ganisations to do updates.c) Patients come to hospitals for ad m ission not know ing what they are being admitted for.d) Patients come to the hospitals with out authorisaion numbers.a) Doctors refuse to give necessary inform ation to m anaged care case managers to do updates.b) Doctors and hospitals do not ac cept information on managed health care because of their resistance to change.c) Doctors refuse to talk to managed care case managers because they are nurses and prefer to talk to doctors.d) Patients phone managed care or ganisations for authorisation numbers without necessary information to grant such authorisation.e) Doctors sometimes provide insuffi cient or incorrect information regard ing the diagnosis or treatment of the patient.