Transmed Managed Care Services Presentation to Transnet Human - PowerPoint PPT Presentation

Transmed Managed Care Services Presentation to Transnet Human Resources and Labour Representative Conference 4 th October 2007

Contents � Qualsa Overview � Managed Care Services 2008

METROPOLITAN Corporate Retail International business business business Metropolitan Metropolitan Metropolitan Metropolitan Metropolitan Metropolitan Life Asset Managers Unit Trusts Odyssey Namibia Botswana Metropolitan Metropolitan Metropolitan Metropolitan Group Schemes Employee Properties Direct Benefits Metropolitan Advisory & Retail Services

Qualsa Overview Vision The company people trust to manage health and promote wellness. Mission To be the partner of choice in healthcare management that o Focuses on People o Empowers Providers o Embraces Technology o Promotes Treatment Excellence

Medical Scheme Profile

Employer Group Profile

Healthcare Cost Drivers • Ageing population - Chronic Illness • New technology - Hospital expenditure - High cost procedures • HIV and AIDS • Curative Healthcare Model • Legislation

Role of Managed Healthcare Qualsa manages health care cost while improving health outcomes through appropriate intervention and support programmes to promote member wellness and to ensure financial viability of fund

Role of Managed Healthcare This is achieved by: Prevention and education o Managing known risks o Managing high cost events o Specific benefit management o Focus on ageing population o Provider management o

Qualsa Care Management Services for Transmed Clinical Advisory Services o Chronic Illness Management o Prescribed Minimum Benefit Management o Hospital Event Management o Major Medical Event Management o

Qualsa Care Management Services for Transmed continued Oncology Management o Maternity Management o HIV / AIDS Disease Management o Elder Care Programme o

Clinical Advisory Services Clinical and Specialist support to all programmes Specialist Services o General practitioners o Radiologist + Oncologist o Dental Advisors o Specialist Academic Consultant Panel o Drug and Therapeutics Committee

Clinical Advisory Services continued Clinical Advisor role o Liaise with o health care professionals o service providers o patients and family o Assess complex and involved cases o Assess appropriateness of medical interventions o Clinical Governance o Forensic referrals

Chronic Medicine Management Promote cost-efficient prescribing without compromising quality or outcomes Transmed Chronic Medicine Benefit o Full compliance to PMB medicine legislation o 26 Chronic Disease List conditions o 24 Chronic Disease Treatment Pairs o Additional Chronic Conditions

Chronic Medicine Management continued Formularies o 2 Formularies customised for fund’s risk profile o Drug and Therapeutics Committee Pharmacist on Line o On line pre-authorisation o Pro-active intervention process Integration facilitates immediate access to o Prescribed Minimum Benefit Care Plan o Disease Risk Management Support

Chronic Medicine Management continued Essential Formulary Standard Formulary Applicable Benefit Options o State + Own Choice o SATS o Private Cover plus Savings Conditions covered o PMB CDL conditions o PMB CDL conditions o PMB DTP conditions o PMB DTP conditions o 6 Additional chronic conditions o 27 Additional chronic conditions • Benefit for PMB conditions o 100% Benefit for PMB medicines o 100% Benefit for PMB medicines no co-payment applies no co-payment applies (CDL + DTP) o Reference Pricing is applied o Reference Pricing is applied Benefit for Additional o 80% Benefit for non-PMB medicines o 80% Benefit for non-PMB medicines chronic conditions 20% co-payment applies 20% co-payment applies o Reference Pricing is applied o Reference Pricing is applied

Pharmaceutical Benefit Management Online real-time 24-hour claims adjudication validating member and benefit eligibility o Real-time access to Medicine Benefit o Chronic and Acute Medicine o Member informed of claim status at pharmacy Electronic Benefit Management o o Pricing validation o Scheme rules o Clinical rules o Utilisation rules Flexible exception process o

Prescribed Minimum Benefits Pro-active benefit assisting members to manage their chronic conditions Disease Specific Care Plans Structured, controlled access to benefit o o Transparent Benefit o Developed by a panel of specialists o Compliant with legislative guidelines o Customised to level of care Includes information on medication authorisation o Authorisation of additional services for high risk o patients

Prescribed Minimum Benefits continued Automated enrolment and Automated Claims payment for disease-specific Care Plans Automatic enrolment via Medicine Risk Program o Claim payment is ICD10 code / Tariff code driven o

Prescribed Minimum Benefits Manage non-pharmaceutical Care of 26 Life- Threatening Conditions (as per Medical Schemes Act) • Addison’s Disease • Dysrhythmias • Asthma • Epilepsy • Bipolar Mood Disorder • Glaucoma • Bronchiectasis • Haemophilia • Cardiac Failure • Hyperlipidaemia • Cardiomyopathy Disease • Hypertension • Chronic Renal Disease • Hypothyroidism • Coronary Artery Disease • Multiple Sclerosis • Chronic Obstructive Lung Disease • Parkinson’s Disease • Crohn’s Disease • Rheumatoid Arthritis • Diabetes Insipidus • Schizophrenia • Diabetes Mellitus Type 1 • Systemic Lupus Erythematosus • Diabetes Mellitus Type 2 • Ulcerative Colitis

Disease Management Process Identification of Disease Risk Assessment of clinical status and health Risk rating Treatment Plan Care Pack Education, support, lifestyle management Ongoing monitoring Outcomes measurement

Disease Risk Management continued Outcomes achieved o Improved understanding of disease o Improved treatment compliance o Decrease in complications and o emergency admissions Improved quality of life o Additional benefit management o Health days o Member brochure o Care pack o

Hospital Risk Management Effective management of acute, trauma, high cost or high risk episodes Manage Hospital expenditure o Manage length of stay o Concurrent review of all cases o Intensive management of high cost cases o Procedures performed in alternative facilities in lieu of hospitalization o Doctor’s room o Specialised facilities o Step-down and Rehabilitation facilities o Home wound care management

Hospital Risk Management continued Services to Members SMS notification to member when authorisation o requested Education material regarding procedure available o website, self-help fax service or call centre Telephonic interaction with family in high risk and o complicated cases Information Care Pack provided for high risk and o complicated cases

Hospital Risk Management continued Manage hospital access for State Option Members Emergency admissions o State inaccessibility o Voluntary admissions o Retrospective hospital account review Analyse and audit hospital accounts o Manage inappropriate billing practices o Confirm negotiated discounts o

Psychiatry Management Challenges Sensitivity o Psychiatric admissions are always emergencies o Ineffective treatment – relapse o Patient management and support Ensure multi-disciplinary management in- o hospital Additional benefits often requested o Followed up after discharge o Patient & family education & support (crisis o referral)

Psychiatry Management continued Cost Management Negotiated rates with preferred providers o Weekend leave + out patient programmes o Referral to State facilities for long term treatment o Referral to non-profit organisations o SANCA + AA o FAMSA o EAP o

Oncology Management Challenges Emotional time o Oncology benefit managed to SA guidelines o Rising costs associated with: o Technology (new drugs) o Unregistered treatment o Consumer expectation o

Oncology Management continued Patient management and support Emotional support o Understanding disease, treatment, side effects o Ensure appropriate evidence based treatment o Treatment options negotiated on behalf of o member Cost Management Treatment plan intervention o Collaboration with Specialised Oncology Panel o Oncology network o

Maternity Management Patient management and support Identification of all pregnant mothers o Contact for enrollment o Risk assessment o Maternity information pack o Health information o High risk members assigned to dedicated o case manager

HIV Management Optimal management of HIV-positive members Benefit for : o HIV positive o AIDS sick o PMTCT o Post exposure prophylaxis o Provides benefit for spouses and children o Ensure appropriate treatment o Disease education and support o Medication compliance o Non-pharmaceutical management o Positive member attitude and approach to disease o Constructive relationships with doctors o