Partnerships add value to medical scheme members

Affordable contribution increases are among the key components to ensure the future sustainability of medical schemes. This can only be achieved through a combination of financial management and better health outcomes.

Peter Jordaan, Acting Principal Officer of Fedhealth, says members are looking at schemes to provide them with the assurance of predictable and affordable contribution increases into the future. They are also demanding quality and value for money healthcare.

From reactive to proactive

This requires that healthcare management transitions from the reactive control of price and utilization through benefit management and pre-authorisation programmes, to pro-active holistic management of members’ health conditions.

“At Fedhealth we have adopted a genuine partnership model with a shared focus on improving health outcomes and providing our members with better value for money benefits,” he says. By working together the scheme and its partners limit out of pocket expenditure (such as excesses on dispensing fees) and extend the range of insurable benefits to which members have access. Members are the real beneficiaries as each role player is focused on the quality of care available to members! The innovative partnerships include general practitioners, dentists, optometrists and pharmacies.

Minimising co-payments

In an attempt to further reduce out-of-pocket expenses the medical scheme has extended partnerships to include medical specialists. “The primary objective is to ensure that members are able to access meaningful benefits without having to resort to co-payments on fees charged,” says Jordaan. Over the long term a scheme can leverage partnerships to the benefit of both the scheme and its members by providing improved health outcomes and lowering the cost curve! Partnerships arrangements also enable schemes to provide a private designated service provider (DSP) for the treatment of the Prescribed Minimum Benefits (PMBs).

PMBs are a set of defined benefits to ensure that all medical scheme members have access to minimum health services, regardless of the benefit option they have selected. The aim is to provide members with continuous care to improve their health and well-being and to make healthcare more affordable. At present PMBs include an emergency condition, a limited set of 270 medical conditions and 26 chronic conditions. Although well-intentioned and positively received by industry stakeholders, the provision of PMB services has put many schemes on the back foot from a cost perspective.

A 2 000-strong specialist network

The specialist initiative has been met with overwhelmingly positive response by both members and healthcare professionals. In Fedhealth’s case the specialist partnership is already approaching 1 500 specialists across all disciplines and by 2012 the scheme anticipates more than 2 000 specialists will have signed up!

Jordaan says the specialist partnership model assists in containing healthcare expenditure, thereby ensuring more predictable future rate increases: “We believe true partnerships will ultimately also ensure quality healthcare and better health outcomes for members.”

An emphasis on primary care

At present, medical care is very fragmented and we believe both the private and public sector through NHI need to be encouraged to focus more on primary care. “Similarly, a focus on performance-based monitoring and recognition will add real value to our total healthcare system,” says Jordaan. “It is encouraging to see so many schemes starting to offer network options and partnerships with medical professionals which embrace primary and preventative care.”

One of the greatest challenges for schemes moving forward will be how to attract young healthy members into the scheme to ensure sustainability. Jordaan concludes: “Obviously member education is critical as well as a suitable range of entry level products which are more affordable for the younger set. Supplementary products such as Gap Cover are also, by necessity, becoming a norm in the industry to protect against any shortfalls.”