TRANSMED HR / Labour Conference 04- -05 October 2007 05 October - - PowerPoint PPT Presentation

TRANSMED HR / Labour Conference 04 04-

• 05 October 2007

05 October 2007

Content Content

• Company Profile
• Market Orientation
• Managed Care Services
• Network Management
• Client Liaison Services
• Benefit Design

Ownership Structure

Network Healthcare Holdings Limited Network Healthcare Holdings Limited Medicross Healthcare Group (Pty) Ltd Medicross Healthcare Group (Pty) Ltd Prime Cure Holdings (Pty) Ltd Prime Cure Holdings (Pty) Ltd

100% 100% 100%

Prime Cure Occupational Health (Pty) Ltd Prime Cure Occupational Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Managemnt Services (Pty)Ltd Prime Cure Managemnt Services (Pty)Ltd

100% 100%

Network Healthcare Holdings Limited Network Healthcare Holdings Limited Medicross Healthcare Group (Pty) Ltd Medicross Healthcare Group (Pty) Ltd Prime Cure Holdings (Pty) Ltd Prime Cure Holdings (Pty) Ltd

100% 100% 100%

Prime Cure Occupational Health (Pty) Ltd Prime Cure Occupational Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Managemnt Services (Pty)Ltd Prime Cure Managemnt Services (Pty)Ltd

100% 100%

Accreditation & Empowerdex Rating

• Accredited Managed Care Organisation

– Unconditional Accreditation – 08 November 2006 to 08 November 2008

• Management of Prime Cure and Medicross managed care /

network products

• Empowered organisation:

– “A” rating by EmpowerDEX

Target Market Segmentation

Living Standards Measure & Approximate Monthly Household Income LSM 10 R15,000 + LSM 8 – 9 R7,500-R15,000 LSM 5 – 7 R2,000-R7,500 LSM 3 – 4 R1,000 – 2,000 LSM 1 – 2 R800 – R1,000

Fee for service

Medicross Network Prime Cure Network Emerging Market Indigent Group

Managed Care Target Market

Insured (7 Insured (7-

• million)

million) Uninsured Uninsured Formally employed Formally employed (7 (7 – – 10 million) 10 million) Uninsured Uninsured Unemployed Unemployed (25 (25 – – 28 million) 28 million)

Managed Care

• A Managed Care Provider of affordable, integrated managed healthcare
• 35 Medical Scheme options
• > 180,000 beneficiaries under management
• Growth of 4,000 new beneficiaries per month over 18 months
• Innovative, risk-sharing partnership with schemes

Integrated Business Model

• Prime Cure evolved from a Primary

Care network model to a sophisticated full service, full risk accredited managed care

• rganisation
• Focus to ensure patient access to a

continuum of appropriate, affordable health care services

• Enhancement of health status &

quality of life with reduction in health care costs

• Savings of up to 50% of traditional

fee-for-service medical aid premiums

Managed Care Client List

Anglo Health Bestmed Camaf Day One Health Eyethumed Furnmed GEMS Global Health Ingwe Laundry Bargaining Council Medisense Minemed Momentum Nimas Purehealth ProSano Protea Telemed Thebemed Topmed Transmed Umvuzo

Stakeholder Relationships

Medical Scheme Service Providers Administrator

Primary Contracting Parties Seamless Integration Managed Care Services

• Prime Cure contracts directly with Medical

Scheme

• Seamless integration with administrator
• Services provided within the contracted DSP

service provider network

The managed healthcare services provided by Prime Cure and its alliance partners are seamlessly integrated into one affordable offering.

100%

TRANSMED

Accredited Managed Care Organisation

Providers

Mediscor PBM Mediscor PBM

Integrated Managed Care Services

Comprehensive Managed Care Infrastructure

• 24-hour Call Centre and Advice Line
• Claims Administration & Provider Reimbursement
• Pre-authorisation procedures & Case Management
• Chronic Disease Management
• HIV/AIDS Disease Benefit Programme
• Medicine Formulary & Chronic Medicine Management
• Marketing & Client Support Services

– Member & Provider education

• Network Management Infrastructure

– Dedicated team of 12 regional Relationship Managers

• Intellectual Capital

– Specialist medical, legal, financial & actuarial experts

• Dedicated forensics unit

Out-of-hospital

• High frequency and high

cost GP procedures

• All Specialist referrals
• All Allied Provider referrals
• Chronic medicines
• PMB conditions
• High cost investigations

(radiology & pathology) Hospital Admissions

• All admissions
• Based on protocols with

financial guidelines

• ICD-10 and CPT coding

Pre-Authorisation

Pre-authorisation is usually obtained by the referring doctor

Evidence-Based Clinical Pathways

Network Risk Management

• Prime Cure ensures access by geo-mapping members to providers:

– Appointment of providers to match the needs of members

• Providers are accredited according to:

– Practice infrastructure – Administrative and operational efficiency – Compliance with protocols & medicine formulary – Wellness promotion and preventative care

• Reimbursement of providers is performance-based

– Reward for compliance and cost-effective outcomes

• Profiling and practice audit
• Patient / member satisfaction surveys
• Customer (medical scheme) satisfaction surveys

Patients are not restricted to one provider, and can choose any provider on the network

Prime Cure National Provider Footprint

General Practitioners Optometrists Dentists

Prime Cure DSP Network: 17-Sept-07

AREA MEDI CENTRES DOCTORS DENTIST OPTOMETRISTS

EC

3 214 65 65

FS

2 172 52 47

GAUTENG

7 566 259 269

KZN

7 454 156 156

LESOTHO

10 5 2

LIMPOPO

153 50 55

MPUMALANGA

2 188 58 73

NC

59 19 29

NW

152 40 52

Swaziland

1 1 3

WP

2 307 151 121

TOTALS:

23 2276 856 872

GP, Dental & Optometry Networks

GROWTH IN GP, DENTAL & OPTOMETRY NETWORKS

350 850 1,350 1,850 2,350 2,850

GPs Dentists Optometrists GPs 1227 1385 1704 1850 2153 2243 2276 Dentists 395 424 634 705 809 842 856 Optometrists 364 450 656 681 782 832 872 Mar-06 Jun-06 Sep-06 Nov-06 Apr-07 Jul-07 Sep-07 Number of Providers

DSP Network Stability: 2007 (YTD)

• The Prime Cure Network continues to show stability over time

CHANGES DENTISTS DOCTORS OPTOMETRISTS Totals 18 (2.1%) 72 (3.1%) 27 (3.09%)

Client Support

Marketing Union negotiations Retailing Education Ongoing support Provider Management

Prime Cure will provide a medical scheme with value-added services crucial to developing the emerging market and growing membership

Benefit Design

State Plus Network

DSP Netw ork: General Practitioner visits ( Prim e Cure Centres & Netw ork) All clinically necessary visits No co-paym ents Medication Unlim ited based on Prim e Cure Form ulary

• Acute Medication
• Chronic Medication
• “OTC” Self- m edication benefit

Pathology X-Rays and Ultrasound Em ergency visits & Out-of-Area 2 4 -hour Medical Advice Line

Basic Primary Care ► General Practitioners ► Medication ► X-rays ► Pathology

Primary Care

Comprehensive Primary Care ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► HIV Cover

DSP Netw ork: Unlim ited Essential Dentistry Preventative care Fillings Extractions Optom etry Annual eye exam ination One set of spectacles every 2 4 m onths ( single vision or bifocal lenses)

Dental & Optometry

Comprehensive Primary Care ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► HIV Cover

DSP Netw ork: Unlim ited Essential Dentistry Preventative care Fillings Extractions Optom etry Annual eye exam ination One set of spectacles every 2 4 m onths ( single vision or bifocal lenses)

Dental & Optometry

Consultations and office procedures

• Lim ited to R1 ,6 0 0 per

beneficiary or R2 ,2 0 0 per fam ily per annum

• Unlim ited for PMBs

Primary Care and Specialists ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► HIV Cover

Out-of-Hospital Specialist Cover

Benefit Design

Ubuntu

Sim ilar to State Plus Netw ork, except:

• Optom etry:
• 4 boxes of disposal

contact lenses / One pair perm anent contact lenses lim ited to R7 4 9 every second year

Primary Care and Specialists ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► HIV Cover

Out-of-Hospital Services

Primary Care, Specialists & Allied Professionals ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► HIV Cover ► Allied

Physiotherapy and Occupational Therapy: PMB Conditions unlim ited, provided referral obtained from DSP & preauthorisation Non-PMB: All Services – com bined lim it of R1 ,1 0 0 per beneficiary or R1 ,6 0 0 per fam ily per annum

Allied Provider Benefits

Primary Care, Specialists & PMB Cover including Hospitals ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► HIV Cover ► EMS

Em ergency Medical Services, including:

• Road & Air Transport
• I nter-hospital Transport

from non-DSP to DSP

• Netcare 9 1 1 DSP only

Emergency Medical Services

Full Risk Cover - Private Hospitals (including Public Facilities) ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► PMB ► Hospitals ►Allied Professionals

Lim ited to R5 5 0 ,0 0 0 private hospital cover per annum ( non PMB, and unlim ited ( PMB)

• Planned Hospital Care

( including m aternity) at DSP

• nly
• Unplanned and Em ergencies at

any hospital. Transfer m ay be arranged once the patient is stable to a DSP facility

• Various sub-lim its for non-PMB

conditions

• Certain conditions in State

Hospitals only

Private Hospital Cover

Thank you