Value Based Hip & Knee Arthroplasty Surgical Product (Care ExpertHip and Knee Arthroplasty)

By Mediclinic South Africa

The Care Expert Hip and Knee Arthroplasty product innovatively addressed the cost and quality
variability in the service line by introducing a global fee, risk sharing Alternative Reimburement Model
(ARM) into a traditionally Fee-for-Service market.

The global fee includes the hospital component (and prosthesis) as well as the orthopaedic surgeon’s fee
(and assistant’s fee). No additional fees are incurred, except for Take Home Medication; Private charges
and Scheme benefit design exclusions. These cases attract no co-payments. Modifiers can be applied for
patient risk factors, e.g. Age, BMI, Hypertension, Diabeties Mellitus and Coronary Artery Disease. For the
Funders, the global fee model offers budget predictability and cost advantages, to its members.
Additionally, Mediclinic shares in the risk with Funders, with a stop loss limit to manage unexpected
events, carving out the hospital account to fee-for-service should the stop loss limit be breached.

The Anaesthetists, physiotherapists, pathology and radiology are contracted separately through a fixed
fee arrangement with the individual Funders. Importantly, Doctor autonomy is maintained, and patients
actively engage in decision-making with Care Expert Navigator (CEN) support.

Collaboration among practitioners, hospitals, and services is facilitated, by the CEN through aligning
hospital and clinical practices. Capturing of the surgeons pathway into an outcomes database, enables the
CEN to demonstrate compliance with the surgical pathway. The model encourages behavior change
through outcome reviews shared with participating doctors and hospitals. At inception, and still relevant
today, is that hospitals and specialists maintain regulatory independence but collaborate and co-create
the desired outcomes. Patients excluded from participating include those requiring bilateral procedures,
trauma cases, additional theatre procedures (unrelated to), revision surgery, haemophilia and private
paying patients.

Following a successful pilot in 2015, the model expanded and to date, 35 hospitals and 120 surgeons are
actively participating in the Care Expert Hip and Knee Arthroplasty model, which accounts for 42% of all
hip and knee arthroplasty performed in Mediclinic Southern Africa.

In 2021, the model integrated robotic-assisted surgery, with a rapid adoption rate from 3% to 20% in
2023. Ongoing enhancements introduced in 2023, include Mediclinic addressing additional risk for 30
day readmissions (per Mediclinic eligibility criteria) solidifying the model’s competitiveness in the
greater arthroplasty ARM market and the addition of a performer tier (reserved for surgeons
exemplifying effectiveness in both cost containment while improving overall quality outcomes).

To date 16 549 cases have been performed.