THE CDE: ‘Revovational Transformation’ Underpins CDE Stability

The age of digitisation in healthcare is here. Where retail, real estate, travel, hospitality, finance, and more have been disrupted by technology and digitisation, healthcare is following. This transformation is both welcomed and feared by those active in the industry as it brings waves of change which require upskilling and learning, but outcomes can result in vast improvements for patients.

Unfortunately, the benefits that come with a technological transformation have not been quick to materialise in healthcare, and according to McKinsey & Company the reason for this differs by region but is usually not because of the technology itself. Rather, culture change is a barrier which struggles to be hurdled.

For sufferers of chronic conditions, digital transformation can provide major leaps in terms of care quality and, ultimately, treatment outcomes. Diabetes provides a clear example. Global healthcare company Abbott launched a glucose monitoring system through which users can gain large amounts of data, and timely readings of their current level using a smartphone or digital reader to scan a sensor which is attached to the arm through a pain free adhesive. The system is designed to remove the need for finger pricking, which is uncomfortable and inconvenient, and only gives a snapshot of the overall picture. For many, this innovation has changed the way diabetes is managed, and resulted in clinicians being able to provide much more precise guidance.

As the company has learnt more, the sensors have become smaller, stronger and more sensitive, and the information has been incomparable to previous regimes. By using technology in this way, people in healthcare have been empowered.

This is the vision of Grant Newton, CEO of the Centre for Diabetes and Endocrinology (the CDE), South Africa’s leading provider of specialist diabetes care, spanning all related conditions, and known as a ground-breaking organisation in terms of its business model.

His long-held idea is to blend the expert humanity already present in healthcare with novel and exciting tech that is emerging as part of the fourth industrial revolution. Operating with 204 centres of excellence around the country, alongside 508 highly upskilled family practitioner, diabetology cardiovascular centres around the country, the CDE is positioned strongly to drive this revolution and deliver a unique integrated care model which incorporates multidisciplinary teams that can deal with all cardiovascular care.

REVOVATIONAL TRANSFORMATION

“I coined the phrase revovational transformation. When we were starting this process of digitisation, we were in innovation. Then we realised that the fourth industrial revolution was not about innovation but about disruption and revolution,” he says. 

In this fast-moving environment, where the end goal is less about profit but more about life and improving health, a digital transformation is no easy task – especially across a business and industry with such reach.

“Moving out of the dynamics of historic, legacy ways of dealing with healthcare, towards health 4.0, digital and AI, and things that are going to change the way that they do business through the flux that is going on around the globe at the moment, is what we need to do,” says Newton.

But South Africa faces a number of significant challenges that feed into the bigger problem. Connectivity, affordability, and perhaps most troubling but at the same time conducing for a digital revolt, trust.

“Because of the continuous onslaught onto private and public healthcare clinicians, there is a retreat. In the current environment, there is a fear to treat and fear to be treated,” admits Newton, who has been involved in the healthcare space for more than two decades. “There is a disconnect, and from a business perspective that is the worst thing that can happen as the customer is disconnecting from the provider. The bottom line is that people are getting less healthy because they have lost contact with a formal clinical environment. It’s our job to bring that back together. Using technology is what we consider as the critical pivot to achieve that.”

Currently, growing levels of diabetes diagnosis is considered a global healthcare crisis. In South Africa, it is cited as a leading cause of death with some estimates suggesting up to 15% of the population could suffer the condition. By 2045, the International Diabetes Federation (IDF) expects 47 million people in the sub-Saharan region will have diabetes. But the condition is manageable and the CDE offers significant support. The challenge for the company is bringing the population into a formal clinician environment.

“Extending clinicians, putting them together with, and presenting them digitally to individuals, and then working on bringing in data that we’ve never had before – from a tracking device for example, where there is more information than you could ever glean in a consultation – and utilising that data for effective cost reduction of healthcare and increased access to quality healthcare – that is our problem statement,” confirms Newton.

By employing digital technologies including cloud-based big data management, AI organisation, video-based interaction, IoT collaboration, telemedicine, blockchain electronic health records, 5G powered wearable devices and much more, the process of developing a long-standing but adaptable treatment plan becomes more affordable, more detailed, and more measurable. But at the heart of the system remains a skilled clinician.

“Our approach is to grab the jewels of history, and there are some extraordinary jewels,” smiles Newton. “You can’t lose humanity in the transfer. What was in healthcare, which has unfortunately waned radically, is the humanity. There are still doctors and nurses in healthcare who have a vocation when they come into healthcare, and we don’t want to lose that humanity. In our minds, the trick is about integrating humanity and digitisation – not replacing humanity with digitisation. My philosophy is if I can replicate humanity in digitisation and still hold a thread to the humanity, that is a far more effective and efficient outcome than trying to replace humanity with digitisation – therein lays the disruption.”

WAKE UP DOCTORS

The CDE started out in 1994, working for those with diabetes who had been underserved for many years. Medical schemes did not fund care for the condition correctly, and it was grouped in with general health conditions. Suboptimal care was the standard. The establishment of the CDE saw a specialist programme developed by Professor Larry Distiller, a world-renowned Endocrinologist. From here, diabetes care in South Africa, and the idea of managed healthcare for a singular condition, grew significantly. The first medical aid scheme to participate was the Tafelberg medical aid scheme. The provision of specialist advice and expert management programmes helped patients achieve results, and the company grew, expanding the number of excellence centres around the country.

Now, the fourth industrial revolution – described by President Ramaphosa as key in challenges around health, poverty, unemployment and inequality – is a driver of the CDE’s ambition as it adapts again.

“We have had to say, ‘wake up doctors in business, your patients/consumers have sought a new doctor, and all of a sudden doctor Google is doing home visits and you don’t do that anymore’. How can we get you back into creating home visits? That is the structure of our business,” says Newton, discussing closing the chasmic disconnect between clinicians and patients.

“AI is a fundamental part of what we’re doing. When it comes to diabetic retinopathy screening, we are linking ourselves to the entire ecosystem of AI fundus cameras across the country. We are setting up high value nutrition management programmes, we are working on physical management and wellness programmes, and we want to become not only the destination for the unwell but also for those who want to ensure they don’t become unwell.

“We believe that we are addressing the problem through empowering clinicians with digital, AI and telemedicine healthcare, replacing stethoscopes and warm body pulse taking with digital tools. The technology is there. How can we marry the legacy paternal hierarchical individual who came from a very positive medical school environment with the daily life of people who have moved on – those who go to doctor Google first, before going to their GP?

“In the research, the fourth industrial revolution and healthcare 4.0 was our driver initially. We realised that the trending patterns of health consumers was different and changing quickly. The access to far more information, the increase in curiosity amongst health consumers, and the ability for doctor Google to meet a lot of those needs changes the way we think. That was the initial inspiration for revovational transformation, but it was expedited very quickly when it became a critical business need rather than a necessary business need.”

COVID CRISIS

Operating a healthcare business as the Covid-19 pandemic roared through economies was and is a major undertaking, and requires careful but speedy decision making. For the CDE, providing care and advice to patients was essential as those with diabetes were quickly identified as being at high risk from serious complications thanks to a compromised immune system.

Continuing to deliver important services while shifting strategy to become Covid-secure was a challenge.

“Frankly, if we had not reacted like we did, we would have found ourselves in a very bad space,” admits Newton. “We reacted by realising and accepting that there was going to be, and is, fear. The pandemic was a disruptor and business as usual was halted. Family practitioners and specialists were sitting and waiting for patients in their consulting rooms, but everyone was staying away. There was the fear to treat, the fear to be treated, and now a fear to be treated differently. The opportunity there was that we could introduce digitisation much quicker. Finding a reason for disruption is much easier than disrupting for the sake of disrupting. We began empowering clinicians with telemedicine, ability to connect digitally with patients, and simple things like incorporating booking reminders and the establishments of call centres to create a connection point between us as a catalyst between clinicians and healthcare consumers.”

This uncomfortable jolt towards its longer-term vision was unwelcome, the CDE was thankfully prepared. Digitisation in healthcare is not all new. Many innovations have been used for decades, and much of the modern technology now being trialled is already active in other industries, but for Newton progress has been too slow and Covid kicked up the speed of an overhaul. The internal strategy and culture of the CDE was also challenged as clinicians close the edge of exhaustion required support.

“These people may have been trained as soldiers rather than clinicians as they are the infantry on the frontline in this battle, and giving them support is a privilege,” confirms Newton.

“Whilst there was devastation, and the ongoing impact of the mental health fallout with what we’ve been through, as well as clinician burnout, we have had to adapt as a business to be prepared.

“We are now engaging to ensure we build the personal resilience of clinicians, helping them to understand their own personal environment. Personal mastery is something we have to be introducing through clinical practice. Clinical practice has never had the advantage of corporate practice where you have these programs and training mechanisms – that doesn’t happen in private clinical practice, let alone public clinical practice. We support those clinicians and help them revive and reconstitute their business in a completely different way. This is where we believe we have a multipronged approach towards the necessity for change.”

With more than 2500 clinicians around the country, supporting hundreds of thousands of patients, across multiple centres of excellence, total breakdown was not an option. “The CDE was founded by clinicians and not business people,” reminds Newton. This internal obstacle further embedded the need for a revamp in the industry.

“By changing our philosophy and engaging in healthcare 4.0 or the fourth industrial revolution, we continue to ask: how can we radicalise and disrupt? It is my intention to disintermediate the current legacy health insurance market. We want to work with the industry, but we intend to disrupt,” he says.

ALL NEW COMPETITION

The CDE stands apart from others in the industry thanks to its strategic and concentrated focus, as well as its model which sees it partner across the value chain and through both private and public channels. In the future, Newton is keen to partner with medical schemes, insurers, payers as well as managed care organisations and other relevant bodies to ensure proper diabetes care is administered. Stats suggest that many in the country who live with the condition are not aware of it and are therefore unaware of improvements that could be made to their life with the correct management plan. But a collaborative approach to business is more difficult to arrange in a sector that has been traditionally focused on profit.

“We have found that the economics have driven a new dynamic. Previously, the market was flush with cash and the growth was strong,” explains Newton. “But there was heavy tightening in the regulatory environment and that increased the cost of access to healthcare and restricted the growth for big administrators. The medical scheme environment in South Africa was a community-led environment and there was no competition on price. What they appreciated was that their market was not growing but they had to continue to feed their big shareholders. There was a large consolidation into three big cohorts in the market. We moved from more than 100 medical schemes to just 63 in that consolidation process, and we have moved from 20 or so administration managed care organisations to less than 12. The market didn’t grow, consolidation happened, and the shareholders ended up coming down into value chain to ensure they continued to earn.”

This situation sees increased competition in the market, but for many the CDE remains a premier choice because of its emphasis on real healthcare outcomes for patients. Corporate businesses, individual patients, and clinicians within the organisation appreciate the drive towards patient care excellence rather complementing a healthy balance sheet rather than the other way around.

“Historically, we never saw the administrators or managed care organisations as competitors in the value chain. Subsequently, all of the big competitors have realised that the only way they are going to feed the share price is to gain more of the wallet in the value chain, more of the wallet in the medical schemes, and the specialisation of dealing with managed care diabetes with designated service providers and integrated care models etc. That has been usurped by big, listed conglomerates who have come down and started to acquire clinical practices in the value chain. That has left the clinical practices scurrying, and there are not many like ourselves – clinician driven managed care organisations – that are not driven by consolidated insurers,” details Newton.

This forced home the realisation that some administrators are now directly competing with the CDE – and competing with strength. The nature of administrators means they have deep insight into their clients’ full financials and full intimate back office. This makes constructing products to compete with the delivery service partners in the market easy.

“We now have to look at our three-to-five-year plan,” says Newton. “Do we end up competing with our clients because they are closer to the administrator and we are just clinicians? Are we at the point where we convert our services to business-to-consumer rather than business-to-business? We are looking at all options.”

ALWAYS GROWING

In what is clearly a dynamic environment, changing regularly but on the cusp of a major metamorphosis, a growth strategy is hard to pen. And market predictions – especially in South Africa where economic stability has been absent for some time – are equally tough to prescribe. But the CDE is working to formulate for what certainties are already clear. The result is a flourishing business, helping more people across a range of disciplines.

“We are absolutely expanding,” assures Newton. “That’s expansion of our own product lines rather than being a price taker, and expanding by formalising more people in care onto annuity revenue streams rather than being this third party interaction.

“72% of diabetic patients have anxiety and depression and mental health is something we cannot ignore. If we want effective outcomes based on diabetes, we have to address the mental health side – we are bulking up those teams to support mental health now too.”

Currently only active in South Africa, the CDE will be opening centres in Botswana, Zimbabwe, Kenya, Mauritius and, potentially, the Middle East. The idea here is to provide a ready-made offering for the market that comes with 25 years of workflows, protocols, structures and processes so that clinicians can get the best outcomes associated with patients living with cardiovascular chronic care, and now including mental health – appropriately labelled ‘CDE in a box’. 

Locally, the company is preparing for the country’s National Health Plan by registering as a designated national service provider in the national health environment. The CDE is 90% black-owned with shareholders from government pension funds and the PIC. “We are positioned very nicely for externalising and internalising our business as the shift happens from private to a hybrid of public-private healthcare,” says Newton.

For patients, the CDE provides unrivalled care. For corporate clients, the company absorbs high levels of risk. “We want the least healthy people because we know we can make a difference,” insists Newton. “Whether you’re a life insurer, corporate, a medical scheme or a man in the street, give us your bad risk and we’ll help you through it – that is our value proposition rather than just providing a service.”

For almost 30 years, the CDE has been promoting a leading diabetes management programme, and as the seriousness and volume of cases continues to grow in sub-Saharan Africa and around the world, now is the time for all involved in the government, medical and healthcare spheres to do whatever is necessary to combat and mitigate the ill effects of a killer condition which should not be as destructive as it is. If this means adopting and accelerating entry to tech-drive digital healthcare sooner, then the CDE will be ready.

“When people think about diabetes, they don’t think about the cardiovascular issues, or the mental health issues. So, what we’re trying to do is get people living with diabetes, opposed to patients who have diabetes (an important nuance), living a better quality life.

“There has been an evolution from a family business to an organisation that can now extend the philosophy and legacy of that family – those founding people – into creating extended care, bringing more quality care to more people. We aim to become a gentle part of the life of every person living with a chronic care disease.”

Unfortunately, the adoption of value-adding innovation is not possible without sizeable investments from those with spending power. Fortunately, digitising healthcare is showing signs of ROI like in the case of Abbott and the Freestyle Libre sensor which has been onboarded by major healthcare programmes in the UK, USA, Canada, India, and more.

The CDE is at the forefront of digitisation and technological transformation, and that should bring positivity to South Africans with diabetes and related chronic cardiovascular conditions.

“The global mindset of moving healthcare towards a merge of humanity and digitisation. There are now new opportunities and we need to think through these opportunities, and be curios, to create new offerings. If that’s a blending of humanity and digitisation, that would be great. Revovational transformation is necessary, and if we are to face what is to come at us from digital, Covid etc, we are going to have to do things differently and quickly,” concludes Newton.