Understanding our integrated model


We developed our integrated model to address our most material matters. The model focuses on the rising cost of healthcare. For most, medical cover has simply become unaffordable. Our mission is to innovate a new integrated model of sustainable healthcare that measurably improves access to quality healthcare. Recognising that we have the scale (with 3.8 million lives under management) and the capability necessary to transform the delivery of healthcare, we set about doing just that.

Over the past few years, the Group has invested significant intellectual capital into analysing the full healthcare spend, analysing the challenges and risk environment and developing or acquiring the necessary assets and capabilities to deliver the right solutions to achieve our mission.

Aim Value-adding activity Outcomes – How we’re increasing
the value of the healthcare spend
PRIMARY CARE Shifting the
focus of
healthcare
delivery to
primary care and
prevention or
early detection to
increase access
to sustainable,
affordable and
quality healthcare.
At the core of AfroCentric's offering is Medscheme, who:
  • Coordinates care to expand primary care and reduce reliance on specialist care when not clinically indicated
  • Primary care providers (GPs) are incentivised to expand their care of high-risk patients to more effectively manage their chronic conditions
  • Applies various reimbursement models for healthcare providers and health facilities (including sharing risk in different ways) to incentivise cost optimisation
2.4% of scheme lives are responsible for 16% of scheme claims. Effective management of the care and lifestyle factors of these people is core to our strategy.Medscheme managed care pilots conducted by multi-disciplinary clinical teams for integrated chronic care, healthcare outcomes and value-linked reimbursement, resulted in:
  • Better clinical outcomes
  • Fewer hospital admissions
  • Less costly complications
  Allegra leverages technology to reduce cost and improve patient experience with:
  • Telemedicine (VirtualCareTM) and e-scripting software
  • Primary care clinic software for health screenings, consultations with nurses, family planning, immunisations and maternal and child visits
  • A single system and integrated health information exchange that integrates financial data, primary healthcare, practice management and wellness management
Allegra's cost-saving healthcare technology has:
  • Reduced healthcare providers' costs by up to 30%
  • Enabled greater access to care to thousands of patients through VirtualCareTM
  EssentialMed provides medical insurance focused on primary care that widens the range of affordable products available to employees and scheme members. EssentialMed's products and services retain members who would otherwise not be able to afford medical aid.
  AfroCentric Integrated Corporate Solutions delivers integrated health and wellness solutions for the workplace. Value delivered includes:
  • Client services that demonstrate value to the employer, employees and scheme members
  • Managed care that delivers on agreed clinical and financial outcomes to the benefit of schemes and their members while providing a positive impact on the employer's health investment
  • Employee wellness solutions that boost productivity, reduce absenteeism, tend to physical welfare and effectively revitalise employees' mental and financial wellbeing
Aim Value-adding activity Outcomes – How we’re increasing
the value of the healthcare spend
MEDICINE AND MEDICAL PRODUCTS
Participating
throughout the
pharmaceutical
value chain
to reduce
medicine and
related costs.
MMed eliminates the need for third-party suppliers to hospitals.
  • MMed's model saves costs for high-volume member usage of pharmaceutical, surgical and medical products
  • Increased access to chronic medicine has improved treatment compliance, as demonstrated by a reduction in hospital admissions by:
    • 8.5% for diabetes patients
  • Increased use of generics reduces the cost of oncology medicine (33% of oncology medicines have generics)
  • Active generic substitution has been 99% on antiretrovirals (ARVs) and 92% on other chronic medication where generic equivalents are available, resulting in wallet-free member experience, free courier delivery and competitive dispensing fees
  • Medscheme Pharmacy Network Management has negotiated R263.4 million in reduced dispensing fees
Activo Health acquires the rights to distribute affordable generic medicine for managing chronic and acute conditions.
Pharmacy Direct increases access to healthcare and alleviates congestion in public hospitals and clinics by distributing chronic medicine to provincial hospitals countrywide (80% of public sector work). As a courier pharmacy, Pharmacy Direct also distributes chronic medication to medical scheme members.
Curasana plays a pivotal role in managing the pharmaceutical value chain by ensuring that stock demands are met for its clients to ensure the continuation of chronic treatment for patients.
Scriptpharm delivers a unique chronic medicine capitation solution through a network of over 2 000 retail pharmacies and has diversified into oncology and acute medicine where it reduces costs by increasing the use of generic medicine.
SPECIALIST CARE AND HOSPITALISATION Negotiating
strategic
purchasing
arrangements
to eliminate
inefficiency and
contain hospital
costs.Negotiating arrangements to reduce the length of hospital stays and improve cost-efficiency of treatment, while ensuring quality patient care and appropriate remuneration for specialists.
Medscheme improves healthcare providers' efficiencies and reduces costs with:
  • Risk-based targeted interventions
  • Alternative pricing and payment models
  • Medicine cost management at all levels of the value chain
  • Clinical pathways, especially for non-communicable or chronic diseases, re-engineering the supply side of healthcare
Containing the hospital costs by reducing the elements that drive costs (fewer people coming into hospital, staying in hospitals briefly and managing post-discharge care to prevent readmissions)
2020
%
  2019
%
  2018
%
 
Admission rate per 1 000 lives -11.7   -1.6   +6.8  
Average length of stay +0.6   +2.0   +0.9  
Average cost
per event
+3.2   +8.5   +7.3  
Hospitalisation as % of total healthcare costs 30.8   34.3   38.2  
Klinnika’s DBC for musculoskeletal disorders helps insurance providers and employers to make informed choices when evaluating scheme members with back and neck pain, reducing the cost of care by limiting unnecessary hospitalisation and surgery.
Aid for AIDS’s clinical guidelines achieve effective viral load suppression, resulting in fewer hospital admissions.  


Aim Value-adding activity Outcomes – How we’re increasing
the value of the healthcare spend
ACROSS THE ENTIRE CARE CYCLE Curbing FWA
with analytics.
Leveraging
digital
technology to
enhance client
experience.
Medscheme applies a fraud risk management system with sophisticated analytical measures to identify and curb unethical behaviour and reinforce the principles of ethical billing and claims behaviour in the provision of services to medical scheme members. These include:
  • Raising awareness about FWA of scheme members' benefits
  • Applying abuse prevention tactics
  • Using analytical software to identify outlier behaviour
  • Employing forensic resources to engage with outliers, conduct investigations if necessary, and manage fraud cases
FWA prevention as at 30 June 2020:
  • R228 million in FWA quantified
  • R1.5 billion saved in claims reduction
  • R141 million recovered
  Digital priorities for the Group include:
  • Customer journeys and process automation
  • Member, broker and corporate portals
  • Business intelligence and analysis
  • Reduce the cost of healthcare
  • Create a functionally more simplified platform
  • Enhance member experience
  • Improve operational efficiencies