Afrocentric

MEDSCHEME SOUTH AFRICA

Medscheme focuses on enhancing its operational systems to coordinate care and build partnerships between patients and healthcare providers.

OVERVIEW

Medscheme is the largest manager of medical schemes in South Africa, managing approximately 3.6 million lives. It now offers the most advanced and comprehensive fraud, waste and abuse management service available to medical schemes in South Africa.

• OUR NETWORK
  CONSISTS OF
  MORE THAN:

• 7 000 FAMILY PRACTITIONERS;
  4 500 SPECIALISTS;
  2 500 PHARMACIES; AND
  2 000 DENTISTS AND 70 ORTHOPAEDIC SURGEONS

Medscheme is a specialised, integrated health administration and managed healthcare organisation. It addresses unsustainable health costs through innovative technology and managed care solutions in a complex operational and regulatory environment. Our dedicated and resilient team secures new contracts and finds new solutions in the procurement and funding of healthcare. Our awards are a testimony to their hard work.

Through our Integrated Chronic Care Mode ("ICCM"), we deliver the highest standards of care to our clients' members. We view client relationships as partnerships that provide beneficiaries with the most cost-efficient and high-quality clinical care. The healthcare value chain is a continuum, and each contact point along the chain is an opportunity to improve health outcomes.

Regular liaisons with family practitioners encourage coordinated care that treats patients, not diseases. Medscheme ensures ongoing consultation with hospitals and healthcare providers to gather clinical data that improves results monitoring. In this way, we are able to measure the cost-efficiency of interventions and the quality of healthcare funding.

Schemes are managed in separate business units, and clients' 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 that our dedicated, knowledgeable employees are tailored to their business. Medscheme collaborates with the other Group companies to deliver an appropriate package of care services that may be tailored to the client and the individual scheme member.

We are thought leaders who pioneer new technologies and better ways of doing business. Through these, we make a measurable difference in the healthcare industry, and offer our customers more flexibility and efficiency.

Medscheme has the necessary infrastructure and IT platforms 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, member surveys and claim turnaround times.

PERFORMANCE SUMMARY

• Successful amalgamation of the Bonitas Medical Fund and LMS Medical Fund in October 2016 and the integration of the two medical schemes' benefits in January 2017
• Expanding the emerging risk, mental health and spinal programmes to existing scheme clients
• Opened new branches in Klerksdorp and Bellville, Cape Town
• Achieved ISO 9001 accreditation in 2012

Titanium Awards Recognising Excellence in Healthcare in:

• Service Excellence – Administrators – Medscheme; and
• Service to membership (closed medical schemes) – Nedgroup Medical Aid Scheme.

STRATEGY

We deliver an Integrated Chronic Care Model that brings together the pillars of effective active disease management.

Medscheme's strategy is to facilitate the most efficient and effective healthcare that will achieve the best possible outcomes including the best medical care at an affordable cost. We integrate a variety of services that are applied across the healthcare value chain to optimise cost efficiency, rate effectiveness and service delivery to our clients.

AFROCENTRIC STRATEGIC OBJECTIVES			MEDSCHEME’S ALIGNMENT TO THESE
	Enhance shareholder value		The strategic composition of our client base has enabled us to grow our earnings. We have an established market share in the private medical scheme industry, which we are well equipped to sustain with human and intellectual capital.
	Maximise growth opportunities		Medscheme is exploring innovation through thought leadership. We are looking to design and implement new healthcare procurement solutions which will grow our business and the Group.
	Improve efficiencies through cost consciousness		Through re-engineered business processes, automation and other integration tools such as decision modelling and integrated data management, we are containing and driving down non-healthcare costs. We are measuring the quality of our services through regular member surveys, ensuring that clients receive an efficient service.
	Promote transformation		Medscheme is prioritising employment equity at all levels; we aid transformation by mentoring and up-skilling through our recently established training academy.
	Diversify revenue sources		Medscheme is looking to provide new services into new markets and international countries. Our partnership with Sanlam creates opportunities to enter the financial services market, and to cross-sell core products to a broader customer database. We are well positioned to strategically procure healthcare services, and Medscheme is working towards implementing risk sharing models with funders. We are leveraging our existing capabilities and technical solutions to support and enable the management of NHI.
	Deliver exceptional client service		Our key focus is to deliver exceptional service, retain our clients, and constantly monitor and evaluate their perception of our services. We also continually evaluate the value of our managed care services in order to respond to the constant rise in healthcare costs by redesigning managed care solutions and managing the health risks within our schemes.
	Reduce the cost of healthcare		We have redesigned managed care solutions to manage health risks; examples include the ICCM, the redesign of hospital benefit management, and the focus on strategically procuring healthcare services. The expansion of the emerging risk, mental health and spinal programmes has focused on areas of disproportionate scheme cost escalation by increasing focus on quality of care, as well as further empowering patients to manage their own conditions. In the year under review, Medscheme intensified its fraud, wastage and abuse detection activities, increasing recoveries of scheme funds.
	Uplift our people		Medscheme is passionately employee-centric as it is through our committed employees that we exceed the needs and requirements of our customers and members. Our committed and passionate employees have the knowledge and skills to play a crucial role in streamlining processes and product innovation. Medscheme further focuses on cultivating the intangible leadership qualities that enable greater competitiveness.

OPPORTUNITIES AND CHALLENGES

Medscheme has the ability to influence behaviour and make structural changes to the system that smaller administrators are not able to emulate.

The weakness of the Rand is driving the cost of medicines and equipment upwards and medical fraud impedes the sustainability of private healthcare, as fraudulent claims lead to healthcare cost increases across the industry. Medscheme is vigorously addressing fraud, waste and abuse. We have expanded the Medscheme Forensic Medical Scheme Department and further rolled out IFM fraud modules.

The amalgamation of Bonitas and LMS Medical Fund ("Liberty") added approximately 125 000 lives under our care. The growth of the scheme allows this volume to be more effectively leveraged in terms of negotiating rates from healthcare professionals and, in particular, hospitals.

The challenging environment requires us to integrate the healthcare value chain and find innovative solutions to address the rising costs without compromising quality. Consolidation has placed us in a perfect position to expand our market share, and we have introduced innovative solutions such as the ICCM and Hospital Benefit Management Model (Acute Care Model) which have been instrumental in addressing the costs.

We are engaging Sanlam to re-engineer the Sanlam Reality loyalty programme to be more competitive for Medscheme members. Our partnership with Sanlam is pivotal, both to a cohesive and integrated financial services offering that integrates with medical scheme products, and to exploring solutions for the low-income market.

The NHI poses a risk to our member retention within our current funder base. Through our expertise, we are exploring methods of facilitating the design of solutions for both the providers of healthcare and the government.

Skilled resources are highly sought after in the industry. It is vital for us to continue attracting and retaining critical and scarce skills.

OUTLOOK

Medscheme will continue focusing on quality, innovation, fraud management and operational efficiency. We aim to implement the IFM Facilities and Pharmaceutical forensic modules which will enable us to recover at least R100 million by December 2017.

The business is also optimistic about the implementation of:

• the ICCM for Bonitas as part of the diabetes management roll-out;
• the Nexus IT Programme system enhancements;
• a new hospital benefit utilisation model to address the high incidence of unnecessary admissions due to provider fraud, waste and abuse; and
• at least two Robotic Process Automation models into the operational business.

Visit the Medscheme website, http://www.medscheme.com/