Dave van der Berg is pictured with some of the nurses who work at Pharos Medical Aid, from left to right Eleana Bloem, Nzo Ngcobo and Tanya James.
Private Health Care Administrators (PHA), which not only manages the respected Pharos open medical scheme but provides managed care for Pick ‘n Pay medical scheme and provides occupational and primary healthcare services for major corporates, has been the
According to PHA’s chief operations officer, David van der Berg, medical scheme system migrations are often fraught with problems and in the South African healthcare industry there have been some casualties and failed projects in recent years. “Many administrators rely on systems that are outdated and utilise legacy technologies restricting their ability to adapt to client needs and market changes. Several local medical aid administrators rely on systems that are over 10 or 20 years old, which have become patchworks of separate systems and databases. Making matters worse is that these systems were typically designed around the requirements of a specific medical scheme. HiP is one of the first that has been designed and architected as a product with modern technology and best practice as a starting point.
He says HiP, developed by Durban-based insurance IT solution specialist 2CANA Solutions, offered a modern and user-friendly, yet sophisticated solution. The first scheme to be migrated onto HiP was Alliance Midmed, which represents Africa’s largest stainless steel producer, Columbus Steel. The HiP solution has been successfully implemented for managed care programmes and medical aid administration in over 7 African countries.
2CANA’s Business Development Director, Charles Cowan, said the transition whilst not without its challenges but had been successful and completely seamless from a member point of view.
“For example, from day one when the system went live in January this year, claims from pharmacies across the country were being processed in a matter of milliseconds. The level of integration in system is paramount to service delivery. All aspects of the business are always up to date in real-time.” He explains for example, when a medicine claim is processed by a pharmacist while the member is standing at his counter – the claim switches through our business partner Mediscor’s systems and then back to HiP where all the processing and checking happens, including clinical, membership and financial. The finance module shows the credit for the payment now due and the contact centre’s has easy access to all this information through one interface”
There’s nothing new about processing transactions fast, many systems can do that but it’s all about intelligent and integrated processing to glean valuable information from the data and to direct clinical intervention where it’s most needed. For example the system provides automated protocol based treatment plans which factor in the patients specific profile; automated adherence monitoring and flagging of high risk patients for active management programs and regular health assessments. This enables targeted and timely interventions and is in the best interests of the patient and the scheme.
The second scheme to migrate to HiP will be the 15 000 member TopMed Medical Scheme. It is due to go live on June 1.
“Alliance Midmed now enjoys the unique combined benefit of PHA’s approach / philosophy and a state-of-the-art system that is fully compliant for the South African healthcare environment,” van der Berg explained.
Cowan said that his team at 2CANA worked tirelessly over the past year months to “localize” HIP so that it is not only compatible with South Africa’s rigorous legislative requirements but also meets the high market expectations. The end result is a platform that complies with South African legislation and accepts the standard coding for different diagnostic procedures used by the industry. Key to this appointment was the fact that 2CANA is an Oracle Gold and Microsoft Gold certified partner.
According to van der Berg, HIP underpins all four drivers within the PHA business model - its robust flexible system, strong managed care protocols, efficient administration system and trademarked Demand Management service.
PHA is the only administrator that uses a nurse-based administrative approach, providing a key differentiator in a highly competitive market. However, he stresses, the quality of managed care and the ability for professional nurses to appraise appraisal of members’ claims, assessment of crucial danger signs such as high blood pressure, sugar and cholesterol levels and one-on-one communication are totally dependent on the quality and accessibility of vital data.
The end result is a combined value proposition that connects clinicians with state-of-the-art technology and takes managed care to another level. “PHA’s Demand Management approach aims to put the member at the heart of decision making, promotes long term focus on health improvement and preventative strategies, encourages innovation to ensure quality of care whilst increasing cost efficiency. At the heart of Demand Management is engagement with members, clinicians and service providers to work out how best to deliver the services that meet our members’ healthcare needs,” explains van der Berg.
He believes the use of HiP has positioned PHA to grow existing clients and accommodate new ones. “The core of our system has been designed to be flexible, scalable, robust and reliable. It has been designed to successfully manage both traditional and new generation plans with or without medical saving options. Due to our partnership with 2CANA and the flexible architecture of our data base, it is possible for us to rapidly implement solutions that meet our clients’ requirements.”
2CANA intends making HiP world class and competing on a global level. Cowan says that the company not only plans to market HiP in South Africa but also to roll it out across Africa where medical aid is much needed but IT skills are in short supply.