Uncovering value for money

01 November 2007 Stephen Maasch, Liberty Medical Scheme

Everyday, brokers face clients who want the same thing: value for money. Knowing what questions to ask, brokers can uncover a health plan’s value-for-money proposition and ensure their clients get the best advice.

While almost all clients realise they cannot do without appropriate medical aid cover, there is no reason why the value offered by individual plans should not be tested by the broker before the client makes a choice. Here are the questions brokers should pose to prospective medical schemes.

* How does the scheme help clients stay well? Prevention is not only better than cure, it’s cheaper, too. What wellness and educational programmes are in place to help clients manage their health?

* What in-hospital cover is offered? Specialist skills are costly and may become more so as skill shortages grow. When your clients are sick in hospital, they are in no position to haggle about prices. Many specialists charge twice if not three times the tariff rate. How much above-tariff cover will the scheme offer when specialists go over the top?

* Will the out-of-hospital benefit leave clients out of pocket? Even if clients avoid hospitalisation, they might have to undergo MRI and CT scans. Costs can be as much as R5 000. Does the out-of-hospital benefit have enough depth to cover this or will clients have to pay from their medical savings account?

* Does the scheme offer flexibility or a straitjacket? When clients get older or when their financial status changes, can they move easily to another plan that suits their new situation? Clients may have limited ability to flit between medical aids later in life and have to be assured of mobility across the scheme’s range of plan options – some with savings accounts attached – should their state of health change in future.

* What back-up does the scheme have? Industry consolidation continues. If a scheme is a small independent, it could be taken over by big players later on, with a resulting change in culture and service. If a scheme has strong backing from well-resourced partners or group companies, it can probably offer continuity and quality assurance.

* What national coverage does the scheme offer? A voice from a distant call centre is no substitute for physical presence close to home. A scheme with a widespread national presence can offer hands-on help when needed.

* How financially efficient is the scheme? The key test is claims-paying efficiency in which at least 85% of the scheme income goes into claims. A scheme should be lean, efficient, responsive and claims-focused.

* How does the scheme help clients identify value? Clients and brokers don’t have the time or expertise to compare the prices of healthcare providers. And if price is the only guide, the client could receive inferior care. Does the scheme offer smart databases that track value-for-money providers and alert clients to quality care at affordable rates? Does the scheme communicate regularly with members and alert them to trends and opportunities?

* What sort of corporate support is available? How strong is the scheme’s corporate support? If a client works for a large employer, there should be a close co-operation between the scheme and the employer to ensure a corporate standard of service.

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