A STRATEGY TO ENHANCE POSITIVE WORKWG RELATIONSHIPS AMONG THE ROLE PLAYERS WITHIN THE MANAGED NEALTHCARE CONTEXT IN GAUTENG

Tlze iiztroductioiz of iizaizaged lzealtlzcare in Soutli Afiica ivas airned at tlzr reduction of rizedical costs, wlzich wei-e iizcreusiizg at a lziglz ratefor tlze past,few years, particularly so iiz a private lzealtlicui-e irzdusti-y. Maizaged lzealtlzcare is a systenz of healrlzcare delivery, ivlziclz eizsuirs that cost eff'ective quali/y care is provided to parieizu. A positive working relatioizslzi1~ is izecessaty aiizoizg tlze I-ole players in tlze provision of cost effective qualif); care witlziiz flze iiiaizaged lzealtlicure conrext. Role players experierzce probleiizs in tlze deliveiy of lzealtlzcare, aSfectiizg their workiizg relationslz&, which iiz tc11.1~ afects flze qualiQ of care provided to patieizts. Because nznizaged lzealtlzcare iis a fail%): izew corzcepr iiz Soutlz Afiica, little is kizowrz about tlzeprobleiiis. As u I-rsult, there are no guideliizes for the foriizulation of a strategy to eizhaizcepositive workir~g r-elatiorz.slzii,s aiizorzg tlze I-ole player-s ii.vitlziiz tlze corztext ofnzanaged lzealtlicare. Uizdei-.standirzg of tlze problenis ex11erierzced 0)) tlze role players will provide a baseliize to tlze researclzer ro fonizulate a strategy to eizlzaizce positive working I-elatiorzshi11.s. Tlze overall purpose of tlze study is to,fo7-i?zulate a strategy to eizlzaizce a positive working relatioizslii1~ ariiorzg tlze role players witlziii tlie iizaizaged healtl?care context iiz Gauteizg. Tlze probleiizs ex1Jerieizced 0)' the role playei-s iiz tlzis regard, as well as suggested solutiorzs to couizteract tlzese probleiizs, were l?re.seizted iiz a separate ai-ticle. Tlzis is t / !e , fol lo~-up article that aiiiis at descrihirzg tlze strateg): to eizhance a positive woi-king relarionslii~~ behveeiz rlze role p1u):ei-s. A qualitative, exploi-atoiy, descriptive and coiztexrual design ivas fbllowed to answer tlze research questioizs. Focus gi-oup ii~rerviews were conducted to collect data aizd a coizteizt aiialysis was corzducted as described by Tesch (lYYO), folloiverl 1,). tlze developiizeizt of u strategy to erihance a positive ivorkiizg relatioiislzi~~ aiizong tlze role plu)~er.s, based on role plrzyer eii?powemzeizt, staff develo~~nzerzt, recruiti?zerit aizd selectioiz, use of advariced ii7jofbnlzatioii teclznolog): and starzdardisatioiz o f iizetlzods across iizaizaged healtlzcare ii~dristiy Tlze researcher elil,rllo)~ed Liiicoln aizd Cuba S (1985t290) prirzciples o f t~ushvortliiizes aizd tlze ethical staizdards as set by DENOSA (1998) were adl~ered to l ~ y tlze ~esearclzer to facilitute tlze qualif)! of rlze study. It was reconznzeizded tlzat tlze strategy be iiiipleii!eizted aizd evaluated forits efectiverzess by evaluatiizg tlie quality ofworkiiig relation.shi11s aiiioizg tlze role players and tlzat etliical standards be foriiiulr1ted in iiiaizaged healtlzcure.


INTRODUCTION
Managed healthcare is a system of healthcare delivery which is aimed at ensuring that cost effective quality healthcare is provided to patients, who are members of medical aid schemes within the context of managed healthcare.Various role players are involved in the delivery of healthcare within the managed healthcare context.According to Anderson (HASA, 1998:170); there are three main role players namely, the service provider, the funder and the member.For the purpose of this study, the member was excluded and role players consisted of the service providers and funders.Service providers are represented by the private hospitals and doctors, and funders are represented by managed care organisations.Private hospitals are represented by the nursing service manager, responsible for ensuring that quality care is provided in a cost effective manner in a nursing service, the unit manager, responsible for ensuring that cost effective quality care is provided in a medical unit, and the hospital case manager who liase with the managed care organisations and ensuring that the hospital gets paid for the services rendered.Managed Managed healthcare is a system of healthcare delivery that influences the utilisation of health services and the cost of these services resulting in performance measurement (Veliotes, Magennis an.ndBrown, 1993:37).

Role players
A role player refers to the professional service providers and funders within the managed healthcare context in Gauteng.

Professional service providers
Professional service providers refer to private hospitals and general medical practitioners within the managed healthcare context in Gauteug.

Funders
Funders are medical aid schemes, a fonn of medical insurance that pay for the services received by the members from a practitioner of their choice (MASA, 1993:16), within the managed healthcare context in Gauteng.

Quality care
Quality care refers to the compliance to predetermined standards in relation to healthcare delivery within the managed health care context.

Working relationship
Working relationship refers to a positive interpersonal working relationship among the role players during service delivery within the context of managed healthcare in Gauteng.

Problems
Refers to the negative experiences by the role players within the context of managed healthcare during the delivery of healthcare in Gauteng, which affect their working relationship in the delivery of healthcare.

Strategy
A strategy refers to the written guidelineslstandards to enhance a positive working relationship among the role players within the managed healthcare context in Gauteng.

RESEARCH DESIGN
A qualitative, exploratory, descriptive and contextual design was conducted with selected private hospitals, managed care organisations and general medical practitioners in Gauteng.Focus group interviews were conducted with the nursing service managers, unit managers of medical wards and hospital case managers from three private hospitals, three case maxagers representing managed care organisations each and four general medical practitioners.A purposive and convenient sampling was used in the selection of the participants qualified to participate in accordance with the set inclusion criteria which relates to the following: Private hospital with amedical ward, nursing service manager and a hospital case manager.
Nursing service manager with at least one year of experience as anursing service manager in a private hospital.
Medical ward unit manager with at least one year of experience as a unit manager in a medical ward in a private hospital.
Hospital case manager with at least one year of experience as a hospital case manager.
Managed care case manager with at least one year of experience as a case manager in a managed care organisation.
General medical practitioner involved in providing private healthcare services within the managed healthcare context for at least one year.
Managed care organisations must be in existence at least for a year.
The researcher used focus group interviews for data collection as it encourages interaction between the s o u p members (Krueger, 1988).This in turn enabled the researcher to do an in depth exploration of the problems

Managed healthcare
Managed healthcare is a system of healthcare delively that influences the utilisation of health services and the cost of these services resulting in performance ~neasurement (Veliotes, Magennis and Brown, 1993:37).

Role players
A role player refers to the professional service providers and iiinders within the managed healthcare context in Gauteng.

Professional service providers
Professional service providers refer to private hospitals and general medical practitioners within the managed healthcal-e context in Gauteng.

Funders
Funders are medical aid schemes, a form of medical ilisurance that pay fol-the services received by the rneillbers fro111 a practitioner of their choice (MASA, 1993: 16).within the managed liealthcare context in Gauteng.

Quality care
Quality care refers to the complial~ce to pre-deterulined standards in relation to healthcat-e delivery within the managed health care context.

Working relationship
Working relationship refers to a positive interpersonal wolking relationship among the role players during service delivery within the context of managed healtbcare in Gauteng.

Problems
Refel-s to the negative experiences by the role players within the context of managed healthcare during the delivery of healthcare in Gauteng.which affect their working relationship in the delivery of healthcare.

Strategy
A strategy refers to the written guidelineslstandards to enhance a positive working relationship among the role players within the managed healthcare context in Gauteng.

RESEARCH DESIGN
A qualitative, exploratoryl descriptive and contextual design was conducted with selected private hospitals.
managed ca-e organisations and general medical practitioners in Gauteng.Focus group interviews were conducted with the nursing service managers, unit managers of inedical wards and hospital case rumagers from three private hospitals, three case managers representing managed care orga~isations each and four general medical practitioners.A purposive and convenient sampling was used in the selection of the participants qualified to participate in accordance with the set illclusion criteria which relates to the following: . Private hospital with a medical ward, nursing sel-vice llianager and a hospital case manager.
Nursing service manager with at least one year of experience as a uursing service mallages in a private hospital. .Medical ward unit manager with at least one year of experience as a unit manager in a medical ward in a private hospital. .Hospital case manager with at least one year of experience as a hospital case manager.
. Managed cal-e case malager with at least one year of experience as a case manager in a managed care organisation.
. General medical practitioner involved in providing private healthcare services within the managed healthcare context for at least one year. .Managed care organisations must be in existence at least for a year.
The researcher used focus group interviews for data collection as it encourages interaction between the group me~nbei~s ((Krueger, 1988).This in turn enabled the researcher to do an in depth exploration of the problems expel-ienced by the role players.Focus group interviews were conducted based on the principles discussed by Krueger (1988), making provision for the following: .Only infonnation rich participants who were willing to participate were selected.
. The researcher used a group small enough to allow every group member to participate and big enough to generate information. .Although they had common background, all group members were not familiar with each other, as this could influence the information they generate. .To ensure that people attend focus group interviews, transpoa and snacks were provided. .Interviews were conducted in a series to ensure that all participants have a chance to speak.
The following questions were asked during the focus and the experiences of the researcher.Content analysis as described by Tesch (1990) was applied to analyse the data.The principles of trustworthiness as described by Lincoln and Guba (1985:290) which relate to credibility, confirmability, dependability, and transferability were applied by the researcher to cnsure the tlvstworthiness of the study: . To avoid making own interpretations, especially because the researcher is involved in the industry, member checking was conducted, where the participants were asked to confirm the veracity of the statements in the third focus group, which was designed for a follow-up session.
Although four focus group interviews were conducted, the same professional facilitator and questions were used to maintain consistency throughout the research process.
All the diskettes, together with the transcriptions were given to the University for storage in the archives as a way of enhancing the credibility of the findings through referential adequacy.
Sufficient audit trail will be kept for later critiques and evaluation.
Each focus group discussion was preceded by an informal discussion in an attempt to "break the ice" and hopefully build the relationship of trust.
The results were exposed to a literature control and an international data triangulation during a visit to the USA by the researcher.
The researcher employed a professional facilitator as the researcher is not experienced in conducting focus groups and because of the sensitive nature of the topic.
To facilitate the quality of the study, the researcher adhered to the ethical standards set by DENOSA (1998).

RESULTS
The sample realisation is presented, followed by a summary of the problems experienced by the role players.A strategy to enhance a positive working relationship between the different role players is finally presented.

Problems experienced by the role players
Problenls experienced by the role players within the context of managed healthcal-e in Gauteng arc related to communication, inadequate staff competence, procedural complexity.cost saving versus quality care, perceived loss of power by doctors and patients and the system of accounts payment."Rules differ from managed care organisation to managed care organisation, it is so amusing because they expect us to adhere to all these rules'' your existence that you make a difference in an organisation by saving cost"

Cortzwzunicatiorz
"Another probleln is the pre-authorisation.. .We still get a lot of pre-authorisation requests when patients are being at the door being admitted, or even retrospectively.
Tn this way you cannot make an impact on the savings"

Perceived loss of power by doctors arzdpatieizts
Doctors feel that managed care organisations are taking

Procedural cor~tplexity
over their power to decide how and where the patient The main problem is that the pr-ocedures followed by must be treated and also dictating to patients as to who lnanaged care organisations are being perceived by the and where they must be treated.The following selected hospitals (n=9) as colnplex and rigid, and are often not direct quotations confinn the problem: known to them, leading to frustration and resentment.This appears to be a manifestatiot~ of a lack of standardisation across managed healthcare industry.
There is too much reliance oil the protocols by managed care organisations without due considerations.This is also confirmed by HASA (1999:49): "How can a protocol distinguish whether a headache needs an aspirin or whether it is related to a tumor?" "Another problem we are facing is that these managed case organisations are dictating to doctors and patients as to which hospitals to be u s e d "I think these managed care organisations want to employ us and be in control of us"

Accourtts paynzerzt Cost saviizg versus qualify care
Doctors feel that lnanaged care 01-gnisations denland Role players are experiencing a dilelnnla in balancing quality care to their members, but they don't want to the provision of quality care on the one hand, with the pay for it.This was stressed by the following quotations cost of providing care to the member.Private hospitals from the transcriptions by four participants: (n=9) feel that the quality of care provided to patients is being cornpromised because managed care organisations are desperate to save costs and nlake profit.Three participants confirlned the problenl.Managed care case managers (n=3) experience a problem of being expected to prove their existence to their organisations by saving costs.Tlveepa~ticipants confilmed the problem.Patients also get admitted to hospitals for planned admissions without informing their managed care organisations, which make it difficult for managed care case managers to save cost by stopping unnecessary admissions (n=3), the following quotations emphasise the problem: "Another thing is that medical aids are desperate to save cost rather than the quality of care provided to patients" I "When you are in managed care organisations, you prove I "Accounts a-e not paid in time or not paid at all.This is frustrating as they expect us to provide quality care, yet they don't want to pay for this quality cave which they demand from us" "I think they look for a good reason for not paying the accounts" These probletns are confirmed by HASA (1999:27; 49).
The lack of education in managed healthcare is also supported by Gallaway aid Lee (1997:23) and by TWIG Infonn (1998:12).Similarl]: some problems were experienced by more than one role player.Table three is a summary of all problems as experienced by different role players.

Context
The context of the strategy is within the private hospitals, managed cal-e organisations and doctors providiilg private medical services.All these role players are practicing in Gauteng.

Purpose
The purpose of the strategy is to enhance positive working relationship anlong the role players within the managed healthcare context in Gauteng, so as to improve the quality of care provided by implementing a strategy for resolving all identified problems, which relates to inadequate communication, inadequate staff coinpetence, cost saving versus quality care, procedural complexity, perceived loss of power by the doctors and patients and account payment.

Elnpowerinent of tlze role players
Managed care organisations must invite all role players to clarify the concept of managed healthcare.as it is a relatively new concept in South Africa.Expectations fi-om different role players in the delivery of healthcare can be discussed, as well as ideas and guidelines on the protocols being followed can be exchanged among the role players.This strategic theme resolves problems related to conununication, account payment, procedural complexity, perceived loss of power by doctors and patients and the collflict between cost saving and quality care.

Greater use of infor~natiow techtzology
By making the gl-eater use of information technology by all role players, e.g.extranet and the timelines.
accuracy and reliability of information will be enhanced.

LIMITATIONS
The sensitive nature of the topic could have influenced the process and the content of data collection.Participants were interviewed in diRerent venues, which could have influenced the nature of the results.The professional facilitator did not probe enough information from the participants, which could also have influenced the nature of the results.

CONCLUDING REMARKS
Problems experienced by the role players witl~in the context of managed healthcare have a negative effect on their relationship, which in turn affect the quality of care provided to patients.As managed healthcare is a new concept in South Africa, little was known about the problems.Exploration and description of such problenis led to their better understanding and the research results were used as guidelines for the fonnulation of the strategy to enhance positive working relationship anlong the role players within the managed healthcare context in Gauteng.
care organisations are represented by the managed care case managers, responsible for monitoring the quality of care provided to their members by the senrice providers and authorising payment for such services.Problems experienced by the role players are related to com-munication, staff competence.cost saving versus quality care, procedural complexity, perceived loss of power by doctors and patients and accounts payment.These problems have a negative effect on the working relationships between the different role players, which could in turn affect the quality of care provided to patients.The relevant research questions are as follows: What are the problems experienced by the role players within the managed healthcare context in Gauteng, and what are the recommended solutions to counteract these problems?What strategy can be formulated to enhance positive working relationship among the role players within the managed healthcare context in Gauteng?The aim of the study is to formulate a strategy to enhance positive working relationship among the role players within the managed healthcare context in Gauteng.The specific objective is to explore and describe the problems experienced by the role players within the managed healthcare context in Gauteng and their suggested solutions.The results of the study are used for the development of a strategy to enhance apositive working relationship and the strategy relates to role player empowerment, staff development, standardisation of methods across managed healthcare industry, recruitment and selection, as well as the use of advanced information technology.
group interviews: ~~l z a t proble~~zs do you experience witlzirz tlze coiztext of managed Izealth carp and what solutions do you suggest to counteract tlzese problems?Interviews were video recorded with the permission of all participants.Information was confirmed with the participants in a follow-up session.The appropriate code was written on each cassette and was locked at the researcher's home in a steel cabinet.Comprehensive field notes were written by the researcher to capture external factors that might have influence on the results Comnlunication problems a1-e grouped into information flow and poor relationships.Managed care organisations (n=3), private hospitals (n=9) and general nledical practitioners (11=4) are experiencing difficulties in obtaining information from each other to review the conditions of patients and for the managed care organisations to authovise payiiient of services provided to patients who al-e their niembers.Doctors refuse to provide necessary inibrn~ation required by managed care organisations to hospital case managers to authorise payment of services provided to patients.As a result.managed care case managers refuse to update the accounts or authorise payment of services provided.Two hospital case manage!-s raised this problem.Managed care olganisations do not educate their members on the requirements of managed healthcare.As aresult_ patients go to hospitals for adniissions without knowing what they are admitted for and without autborisation numbers fro111 their ~nanaged care organisations.Hospitals experience frustrations because they find themselves in situations where they have to phone doctors to find out patients' admission diagnosis and the managed care n~anaged care organisations to make money at their expense.Two managed care case managers emphasised the problem.Doctors and private hospitals are not ope11 to info~nlation on managed healthcare because of their resistance to change and they see managed healthcare as interfering with their relationships with their patients and this problem was stressed by one respondent.Doctors also refuse to talk to case managers because they are just nurses and they would prefer to talk to other doctors regarding the treatment of their patients.One participant articulated the problem.Managed care case managers (n=3) are also experiencing a problem with doctors providing insufficient or incorrect infol-nlation on the conditions and treatment of patients because they think managed care organisations will pay for tlie services that they normally don't pay for.One managed care case managers corroborated the problem.Doctors find theniselves in a situation of educating patients on the rules of their illanaged care organisations and expectations on managed healthcare rather than treating them, because of the lack of member education fro111 managed care organisations.Two participants articulated tlie problem.Doctors are experiencing frustrations of not being inforrued on their roles and expectatiol~s of inanaged healthcare by managed care orgmisations, yet they are expected to comply with the rules being followed by managed care organisations.Two participants emphasised this problem.Managed care organisations (n=3) experience problems in that doctors do not inform patients on what they are being admitted fou when they send them to hospitals for admissions.and as a result, patients phone for autborisation numbers without knowing what they are going to be adnlitted for.Two participants emphasised the problem.The following selected direct quotations are used to emphasise the infor~nation related proble~ns as experienced by the role players: HEALTH SA GESONDHEID V01.5 N0.
International data triangulation indicates that the USA also experienced problems in the implementation of HEALTH SA GESONDHEID Voi.5 No.3 -2000 managed healthcare and these problems are not discussed in this article as the focus of this article is on tlie problems experienced by the role players in Gauteng and the strategy to enhance positive working relationship ainong them.All problen~s identified in the USA confirmed problems identified by the focus group interviews in Gauteng Not all role players experienced all tlie problems.
the problem being experienced by the different role players) the role players to counteract identified problems revolved around the standardisation of methods, procedures and systems across managed healthcare industry, involve~nent of all role players in the formulation of guidelines and standards, education of role players on managed healthcare, recruitment and employment of medically qualified people and member education.All role players are of the opinion that standardisation of managed healthcase principles by all managed care organisations across the managed healthcare industly will eliminate most of the problems related to information flow as it will be easy for the service providers to follow these principles.Role play-of power by doclors and 1 X ers are also of the opinion that involvement of all role players by managed care organisations in standards and guidelines forn~ulation in managed healthcare will enhance the acceptance of managed healthcare by the professional service providers.All role players see the employment of medically qualified people as case managers by both managed care organisations and private hospitals as going to r e ~o l \ ~e the problen~s of inadequate staff competence and information flow.Role players also see member education by their managed care organisations as ai~other strategy to enhance information flow among the role players.It was also suggested by all role players that role player education on managed healthcare by the managed care organisations will resolve a lot of coinmunication problems as all role players will be aware of their roles and expectations in the context of managed healthcare.Doctors are of an opinion of the formation of the independent practitioners' associations for peer review and to fight managed care organisations as a group of their unfair expectations from them.palienls Account payment International data triangulation indicates that the USA role players used a combination of the identified solutions in the focus group interviews to resolve their problems.!Introduction Managed healthcare is the control of cost in healthcare delivery without jeopardising quality of case provided to patients.It is a system of healthcare delivery that ensures cost effective quality care to patients.Various role players are involved in mallaged healthcare.Various problems identified in focus group interviews are expe-10 HEALTH SA GESONDHEID V01.5 N0.3 -2000 rienced by the role players during healthcare delivel-y, which have a negative effect on their working relationship, which in turn affect the cost-effective quality of care provided to the patient.A strategy to enhance positive working relationship among the role players was fol-mulated, based on the research results and the relevant literature control.A visual presentation on the conceptual framework of the strategy to enhance positive working relationship among the role players in the context of managed healthcare is provided in figure one.According to Anderson in HASA (1998:170), there are three main role players involved in managed healthcare.
Guidelines to enhance positive working relationship among the role playersA strategy for enhancing positive working relationship among the role players consist of five strategic themes, namely_ einpowerrnent of the role players.staff development, standardisation, use of advanced infonnation technology: and recruitment and selection.The strategy is based on the research results and relevant literature conducted.Each strategic theme resolve specific problems experienced by the role players as will be discussed.
FIGURE 1: CONCEPTUAL FRAMEWORK the role players within the managed healthcare context in Gauteng were related to communication, staff competence, cost saving versus quality care, procedural complexity, perceived loss of power by doctors and patients and accounts payment.Comulunication problems relate to difficulty in the flow of information among the role players and difficulty in building meaningful relationships.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 existence to their organisations by saving costs and as a result, the care provided to patients is compromised.Managed case organisations expect other role players to work according to their procedures rather than what is best for the patients.12 HEALTH SA GESONDHEID Vo1.5 No.3 -2000 Managed care organisations dictate to other role players. .Managed care organisations don't pay the doctors' accounts in time or they don't pay them at all. .All role players suggested solutions to counteract the problems and solutions revolved around the standardisation of managed healthcare methods, role player involvenlent in standards and guidelines formulation, and formation of independent practitioners' associations by doctors.From the identified problems and suggested solutions the following recomnendations are made: .The strategy should be implemented and evaluated for its effectiveness by evaluating the quality of the working relationship among the role players in Gauteng.Ethical standards should be fonllulated in managed healthcare, in healthcare delivery.Replication studies should be couducted in other provinces in South Africa to confirm the findings.Probleins experienced by patients in managed healthcare should be explored. .The following hypotheses are stated for testing: a) A positive working relationship among the role players within the inanaged healthcare context improves the quality of care provided to patients.b) There is a relationship between the quality of the working relationship among the role players in ~iianaged healthcare and the quality of care provided to patients.c) Problems experienced by the vole playel-s within the managed healthcare context in the delivery of healthcare have a negative effect on their working relationship.

TABLE 1 : SAMPLE REALISATION , ANALYSIS OF PARTICIPANTS
HEALTH SA GESONDHEID Vo1.5 No.3 -2000 i Four focus group interviews were conducted in the study.01-ganisations concerned for the authorisation numbers.The first focus group interview composed of three One case manager confirmed this problem.Doctors private hospitals represented by the nursing service refuse to provide necessary information to managed care

TABLE 4 : ROLE PLAYERS AND THEIR RESPONSI- BILITIES
Table four summarises three main role players and their responsibilities.

Managed Healthcare Cmt-cffefti,e qualit! cntx
are employed.Table five summarises problems resolved by the strategic themes to enhance positive working relationship anong the role players within the context of managed healthcase.This in turn has the positive impact on the cost-effective quality care provided to the patient as depicted in figure one.