MEDSCHEME SOUTH AFRICA
Medscheme is a medical scheme administrator and health risk manager with interests extending into our neighbouring countries. Medscheme is contributing to the control of unsustainable medical inflation and improving access to quality of care.
OVERVIEW
Medscheme is the largest manager of medical schemes with approximately 3.7 million lives under our management. Medscheme has 19 offices in Southern Africa, with a network of more than 6 800 family practitioners, 4 100 specialists, 2 100 pharmacies, 2 000 dentists and 30 orthopaedic surgeons. 3 542 employees look after 16 leading medical schemes in South Africa and the Southern African Development Community (“SADC”) region.
Medscheme is committed to service excellence and collaborates with clients to assist them in delivering the highest standards of care to their members. We view the client relationship as a partnership designed to maximise value to beneficiaries in terms of cost efficiency and delivery of clinical care. The healthcare value chain is a continuum, with each contact point along the chain representing an opportunity to improve health outcomes.
Regular liaison with family practitioners encourages co-ordination of care and promotes a patient-centred approach that treats people, not diseases. Medscheme is engaged in an ongoing consultation process with hospitals and healthcare providers to extract clinical data that enables enhanced results monitoring. In this way, we are able to measure the cost-effectiveness of interventions and the quality of healthcare funding.
Schemes are managed in separate business units, and client needs are considered in constructing the business processes and resources for each unit. The client service team is unique to each scheme, so clients and their members are always assured of dedicated, knowledgeable employees taking care of their business. Medscheme collaborates with the other Group companies to deliver an appropriate package of care services that can be tailored to the client and the individual scheme member.
In a complex industry, Medscheme provides thought leadership, pioneering new technologies and improved ways of doing business whereby we can make a measurable difference in the healthcare industry.
Medscheme has the infrastructure and IT platforms in place to process high volumes and pays out a significant Rand value in claims each year. Service quality is assessed using a range of indicators, such as call response time, query resolution and claim turnaround times.
STRATEGY
Medscheme’s strategy is to facilitate the most efficient and effective healthcare that will achieve the best possible outcomes and the best quality care of beneficiaries at an affordable cost.
The strategy is operationalised via eight strategic focus areas:
| Strategic focus areas | Why this is important | Link to Group strategy |
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| Growth in South Africa, Africa and international markets |
Membership growth of existing schemes is far less and in some cases reversing, as younger members opt for cheaper, reduced-cover options or exit the schemes altogether. Medscheme must gain new business, outright and through amalgamation of smaller schemes. International opportunities can enhance the growth trajectory with the South African market experiencing pressure on margins and stagnation. |
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| Client retention | Client retention is critical for sustainability. Investment in business processes, unique to each scheme, needs to be maximised for optimal client service delivery and shareholder value. Existing clients, with brand-loyal members, provide a rich cross-selling opportunity for new products (i.e. Sanlam). |
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| Cost consciousness | Reducing the cost of doing business, through re-engineered business processes and automation, contributes to containing and driving down healthcare costs, the vision of the Group and Medscheme. Effective cost management, internally and in the healthcare market through managed care solutions, keeps clients satisfied that they are receiving an efficient service (aiding client retention) thus reducing scheme membership attrition. |
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| Fraud, waste and abuse | Fraud, waste and abuse in the medical scheme environment is a critical matter and a source of escalating costs. The Insurance Fraud Manager system from FICO will identify aberrant claims and unusual claim trends to enable client schemes to address this matter. |
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| Drive innovation through technology |
Technology is the backbone of the business and represents a high fixed cost. Technological innovation can reduce costs and improve the overall customer experience. An example would be interactive devices and communication channels. The enhanced Fusion IT platform will be more flexible and customisable, allowing greater tailoring of the service offering to each client scheme. |
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| Employee retention and attractio |
Critical skills in the business are in short supply in the country, and there is tough competition for them within the healthcare market, and between private and public sectors. This competition drives up remuneration costs, particularly for skilled employees such as actuaries and professionals with scarce skills such as pharmacists. Employees are also part of the intellectual property of Medscheme, a repository of institutional knowledge that is critical to preserve. |
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| Population health management/health risk management solutions |
Alternative reimbursement models offer a mechanism to address challenges within the healthcare system which is currently fragmented and inefficient. Medscheme’s predictive modelling and data analytics capabilities allow for the identification of both high-risk beneficiaries and the profiling of healthcare service providers. High risk beneficiaries are cared for by a team of care managers. This controls the cost and provides more compassionate customer care. Provider relationship and management team use profiling in their engagement with healthcare professionals and to guide the creation of preferred provider arrangements. Effectiveness is measured in terms of clinical outcomes, cost reduction and behavioural changes. |
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| Optimisation of partnerships |
Our partnership with Sanlam creates opportunities to enter the financial services market, and to cross-sell core products to a broader customer database. Sanlam has a strong presence in other African countries and represents opportunities for geographical expansion and extension of product range. This contributes to diversification of revenue sources and growth ambitions for the Group. |
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OPPORTUNITIES AND CHALLENGES
Medscheme operates in a challenging environment. The complexity of healthcare makes it difficult to balance cost against quality. Skilled resources are in demand across the industry. Attracting and retaining critical and scarce skils in an ongoing concern. The weakness of the Rand is driving up the cost of medicines and equipment; and medical fraud impends the sustainability of private healthcare as fraudulent claims leads to healthcare costs increases across the industry.
The current economic climate combined with hyperinflation in medical costs is consequentially the membership base across all claims, reducing claims in a healthcare market undergoing consolidation, size does matter. Medscheme has the ability to influence behaviour and make structural changes to the system that smaller administrators can not emulate.
Helios holds the distribution licence for the FICO Insurance Fraud Manager South Africa. This provides Medscheme with the capability to combat fraud, waste and abuse within schemes and to generate revenue by selling the tool on to other administrators and to client schemes.
Medscheme has yet to fully optimise the Sanlam investment in AfroCentric Group and is exploring the brand and product extensions the partnership offers.
PERFORMANCE OVERVIEW AND OUTLOOK
The performance highlight was the introduction of the Polmed medical scheme on 1 January 2016. This increased the number of beneficiaries under Medscheme’s care by nearly 500 000, making it the second largest closed scheme under management.
Numerous innovative initiatives were fine-tuned and incorporated into the value proposition, such as the introduction of LiveChat for members. Other highlights include the enhancement of disease management and an increased focus on measuring quality of healthcare.
Medscheme also developed a model that predicts emerging risk with accuracy and segments the population. This enables Medscheme to engage with those most in need of immediate high-cost disease care or wellness interventions to avert future illness, and to deliver the right care at the right cost to each cohort. This model achieved international recognition and was purchased by Johns Hopkins University in the United States for distribution to the American market.
The relationship with government is established through the GEMS contract, and is further strengthened by the successful Polmed tender.
The year ahead will focus on quality, innovation and operational efficiency, in a continued quest to ensure that high-quality healthcare is made affordable and accessible to all Medscheme beneficiaries.
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