Globally, day surgery hospitals have changed the experience of patients by offering an alternative to acute/conventional hospital surgery.
Hospital costs the highest expense
In South Africa, the concept of day hospitals is also gaining popularity – particularly as a result of high hospital costs. Lee Callakoppen, Principal Officer of Bonitas Medical Fund, says, ‘Using our hospital dashboard for the full 2019 year, direct hospital costs were 43% of the total scheme expenditure. These excluded doctor and allied services while a patient was in-hospital.
The increase in the use of day hospitals
Internationally there is a trend in increased day surgery for multiple reasons including:
- Improved anaesthesia (with quicker recovery period)
- Improved pain control (anaesthetic blocks and improved medication)
- Instrumentation and procedures (keyhole surgery).
Cost saving initiatives
Private medical aids are struggling to keep up with rising healthcare costs, which usually outpace inflation by 3+%. They are continually looking for ways of reducing costs and keeping premium increases as low as possible without prejudicing the quality of healthcare or financial stability of the fund.
‘We negotiate special rates through our hospital networks and Designated Service Providers (DSPs) and encouraging members to use our Managed Care initiatives. Encouraging members to use day hospitals is another way in which we can save on costs. That said, the strategy amongst acute hospitals is to reduce the tariffs for day surgery to the level of day clinics to prevent a market shift away from their facilities. For the Scheme and members this is a win-win as it still translates to cost savings.
Examples of price differences
‘There remains a difference in costs between day and acute hospitals,’ says Callakoppen. The table below represents savings across some of the most prevalent surgeries.
| Procedure | Difference in Case-Mix Adjusted Hospital Cost per Event (Acute Hospital Base) |
| Corneal, Scleral And Conjunctival rocedures | -6.3% |
| Eyelid Procedures | -28.1% |
| Circumcision | -13.9% |
| Tonsillectomy And/Or Adenoidectomy (Child) | -13.0% |
| Tonsillectomy And/Or Adenoidectomy (Adult) | -11.7% |
| Myringotomy (grommets) | -15.5% |
|
Colonoscopy
| -15.4% |
Other advantages of day hospitals
- Patient satisfaction
- No overnight stay – patients are admitted, operated on and discharged on the same day
- Child-friendly wards and facilities – day hospitals are the ideal alternative for children requiring same day surgery as the trauma of overnight stays are eliminated
- Lower risk of infection – due to the fact that patients return home on the same day, the risks of cross infection are reduced, which results in a shorter recovery
- Mortality and major morbidity is extremely low (<1%)*
- Improved surgery scheduling – decrease in waiting lists
Why is take up not higher?
- Day hospitals clearly have marked advantages but the reason take-up is not that high, is there are some perceived disadvantages of using them. One which is the geographical access – specifically in areas like the Eastern Cape.
- There is concern around procedure complications and the need for a patient to have advanced care. But legislation is strict around day hospitals and they have to be located within five kilometres of an acute hospital for exactly this reason.’
- The issue of doctor access is another factor inhibiting the rapid increase in use. Many doctors have their consulting rooms close to an acute hospital and are unwilling to travel further. Equipment may be limited in day hospitals but the increasing list of procedures which can be performed in day hospitals speaks to this challenge being overcome.
This is probably why the percentage of day cases, split between acute hospitals and day hospitals, is still biased toward acute hospitals. Currently the split of day cases being done in acute hospitals is 74% and 26% in day hospitals. This implies that 74% of all procedures which could be performed in a day hospital are currently performed in acute facilities.
Safety is foremost
Not all patients can go to day hospitals. Callakoppen says, “It should be noted that this percentage will be lower as some patients would have anaesthetic and comorbidity risks and from a safety perspective may rather have the procedure performed in an acute hospital where overnight facilities are available. Additionally, not all day clinics are adequately equipped to do some procedures and, as such, the true percentage will be lower.’
Day hospital options for 2021
Bonitas currently has 68 day hospitals on the BonCap network and 30 day clinics on the Select options. According to Callakoppen, ‘This will be enhanced in 2021 when we implement a day surgery network across all options. A comprehensive list of procedures that should be done as day procedures has been collated for our members. If any of these procedures need to be done then members must use a facility on the day surgery network, or alternatively pay a co-payment. While the day surgery network will be comprised mainly of day clinics, it should be noted that certain acute (conventional) hospitals will need to be included on the network where there are areas of access constraint to them.”
Will day hospital use be enforced?
The Day Hospital Association of South Africa has proposed that medical aid enforce day hospital use in the future but also caution that there are some cases which cannot be carried out in day hospitals.
He says, “The Scheme is in agreement with the concept. Although we do promote the use of day hospitals, we must bear in mind that there are some procedures for which this is not suitable. High risk patients who require more intensive post-surgery care would require acute/conventional hospitals. But the benefits of day hospitals should definitely be considered by all patients when undergoing a procedure.”
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