Medical aid administration, risk management and technology

 

AfroCentric primarily operates in administration and health risk management through Medscheme. We provide efficient, client-centric administration services to leading medical schemes in Southern Africa. Furthermore, by identifying and managing clinical and financial risks for our client schemes, we are able to reduce the cost of healthcare, decrease the cost of scheme contributions and improve the health of scheme members.

Highlights		Challenges
As a response to the COVID-19 pandemic, over 85% of staff moved to a work-from-home environment. This shift has enabled Medscheme to re-examine its working model altogether, which will enable the business to accelerate its progress towards a 4IR future		Changes in access to healthcare due to the COVID-19 pandemic The full macroeconomic impact of COVID-19 is unknown, and the unemployment rate will likely rise dramatically in response to the challenges businesses have faced, impacting scheme membership
Over R3.2 billion in claims costs were saved for our schemes due to managed care programmes
The hospital-at-home product was launched - a critical development for eldercare during the ongoing COVID-19 pandemic

Revenue (R’m)	Operating costs (R’m)	Operating profit (R’m)

Overview

In recent years, much has changed in the healthcare environment, both locally and globally. Increasingly, the healthcare sector has recognised the value of focusing on preventative and primary care as a critical strategy to temper the unsustainable escalation of healthcare costs.

In the South African context, medical schemes have moved from being primarily claims administrators to actively managing the health of their members. Moreover, how members and healthcare professionals expect to interact with medical schemes is now heavily influenced by the convenience offered by the technology that is part of our daily lives.

While these changes continue to influence and shape our medical aid administration, risk management and technology cluster, the COVID-19 pandemic has rapidly reshaped lives across the globe. This unprecedented global health crisis showed how quickly the healthcare environment can change and demonstrated the critical requirement for healthcare systems to be able to adapt and to do so rapidly.

Unpacking our performance

The changes to our operating environment described above are significant and require a response that disrupts the status quo, delivering creative, impactful and sustainable solutions. By leveraging our Group-wide capabilities through our integrated model, Medscheme was able to provide innovative solutions that meet critical needs while increasing healthcare savings, assisting both medical scheme members and employers during the COVID-19 pandemic, and will be to their benefit in its aftermath.

The focus for the administration business, in particular, is to improve the operational delivery of our services. In this regard, we utilised technology to improve the channels members and providers used to engage with us, including online and mobile technologies for their day-to-day administrative requirements. We also escalated the use of automation solutions, as well as machine learning and AI to refine our operational business model.

One such impactful innovation in light of the current crisis was the development of a new Hospital Benefit Management (HBM) system that enables digital engagement with providers and members seeking hospital authorisations. The new HBM system is being implemented in phases, in collaboration with the medical scheme clients' Boards of Trustees. As part of the HBM system, providers were able to use web services better to request authorisations and a new decision engine is going live in Q3 of 2020, which will ensure over 40% of our authorisations can be processed immediately, regardless of the channel used. This system leverages the latest technology in decisioning and, when integrated with the claims decision engine, will make the hospital admission and claims process almost immediate at first submission. This groundbreaking initiative will enable providers to reduce the cost of running their practices. The HBM system will also deliver a better service experience and swifter turnaround times, as well as a more intuitive and robust protocol implementation.

Furthermore, an enhanced electronic health record will be added to the member app by the first quarter of 2021 to empower beneficiaries to engage and take greater accountability of their health status and outcomes. This will be further aligned with any rewards programme, as agreed.

COVID-19 has also fast-tracked the development and roll-out of our VirtualCare^TM application, which enables members to consult a GP more conveniently and cost-effectively on their cellphones. This app achieved the following since its launch:

• Week 1: Number one free mobile app
• Week 2: Still in top five trending apps, with
  17 563 downloads
• In the first two weeks: 728 consultations, 48 GPs signed up and 70 prescriptions successfully sent to patients

VirtualCare^TM demonstrated the thirst for digital solutions. We have, therefore, accelerated our development cycle, and launched various digital innovations to enhance the employer and member service experience and quality of life.

For managed care, the focus in this financial year was on the supply side of healthcare, that is, how healthcare is delivered. In previous years, we concentrated our efforts on the beneficiary - their health status and the way they buy healthcare, as well as the risk factors posed by those who need to access healthcare. By focusing on how healthcare is delivered, including the costs related to the way it is provided, how providers work, individually and collectively, how it is billed and the quality of healthcare provided, we are able to support more efficient delivery for the benefit of members and schemes.

We spent time strengthening the relationships Medscheme has with healthcare professionals and their associations, as strategic partners in the healthcare delivery continuum, to support greater transparency, co-creation, agility, flexibility and adaptability.

Significantly, we are the first managed care organisation to intentionally rebuild and share our protocols with healthcare providers regarding who and how hospital admissions need to be managed. This will ensure the cost of hospital admissions are vastly reduced from 2021.

We are tackling variation and inefficiency in care delivery as a priority. We collaborated with healthcare provider associations and societies in dealing with this through data sharing in the form of practice profiles.

We took a view that the re-engineering of the reimbursement models used in healthcare will be an ongoing journey and we are working to build more alternative reimbursement models. Our experience in joint replacement alternative reimbursement models is a testament that these initiatives create savings, which benefit member funds, but also improve the quality of healthcare and enhance doctor sentiment.

To reduce costs and increase innovation in the dental treatment offerings to all South African medical schemes and their members, the Group acquired 100% of DENIS.

Outlook

Looking ahead, the sharp decline in the rand, as well as likely challenges faced with regard to the access and availability of products and raw materials, may see a significant increase in the cost of surgical and medical consumables and devices.

Furthermore, the healthcare industry's private sector segment may face challenges as spending contracts due to poor economic conditions and COVID-19's impact.

To reduce the cost of care, we will maintain focus on supporting our members' health, with a greater emphasis on lifestyle risk management and mental wellbeing. We will also ramp up our work on the delivery of care. We are working on leveraging the lessons learnt during the COVID-19 pandemic to create more efficient and affordable digital models of care.

From an administration perspective, our focus is on customer service models that are excellent and equally leverage the accelerated digital transformation at this stage.

For 2021, we are also focusing on the correct setting of care, having launched hospital-at-home and home-based care strategies, as well as mental health and day surgery networks.