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

Transmed Managed Care Services Presentation to Transnet Human Resources and Labour Representative Conference

4th October 2007

Contents

Qualsa Overview Managed Care Services 2008

Metropolitan

Asset Managers

Metropolitan Unit Trusts Metropolitan Employee Benefits Metropolitan Properties Corporate business Metropolitan Life Metropolitan Odyssey Metropolitan Direct Metropolitan

Group Schemes

Metropolitan Advisory &

Retail Services

Retail business Metropolitan Namibia Metropolitan Botswana International business

METROPOLITAN

Qualsa Overview

Vision The company people trust to manage health and promote wellness. Mission To be the partner of choice in healthcare management that

• Focuses on People
• Empowers Providers
• Embraces Technology
• 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
• Managing known risks
• Managing high cost events
• Specific benefit management
• Focus on ageing population
• Provider management

Qualsa Care Management Services for Transmed

• Clinical Advisory Services
• Chronic Illness Management
• Prescribed Minimum Benefit Management
• Hospital Event Management
• Major Medical Event Management

Qualsa Care Management Services for Transmed

continued

• Oncology Management
• Maternity Management
• HIV / AIDS Disease Management
• Elder Care Programme

Clinical Advisory Services

Clinical and Specialist support to all programmes

Specialist Services

• General practitioners
• Radiologist + Oncologist
• Dental Advisors
• Specialist Academic Consultant Panel
• Drug and Therapeutics Committee

Clinical Advisory Services

continued Clinical Advisor role

• Liaise with
• health care professionals
• service providers
• patients and family
• Assess complex and involved cases
• Assess appropriateness of medical interventions
• Clinical Governance
• Forensic referrals

Chronic Medicine Management

Promote cost-efficient prescribing without compromising quality or outcomes Transmed Chronic Medicine Benefit

• Full compliance to PMB medicine legislation
• 26 Chronic Disease List conditions
• 24 Chronic Disease Treatment Pairs
• Additional Chronic Conditions

Chronic Medicine Management

continued Formularies

• 2 Formularies customised for fund’s risk profile
• Drug and Therapeutics Committee

Pharmacist on Line

• On line pre-authorisation
• Pro-active intervention process

Integration facilitates immediate access to

• Prescribed Minimum Benefit Care Plan
• Disease Risk Management Support

• Chronic Medicine Management

continued

Essential Formulary Standard Formulary

• SATS
• Private Cover plus Savings
• PMB CDL conditions
• PMB CDL conditions
• PMB DTP conditions
• PMB DTP conditions
• 6 Additional chronic conditions
• 27 Additional chronic conditions

Benefit for PMB conditions

• 100% Benefit for PMB medicines o 100% Benefit for PMB medicines

no co-payment applies no co-payment applies (CDL + DTP)

• Reference Pricing is applied
• Reference Pricing is applied
• 80% Benefit for non-PMB medicines
• 80% Benefit for non-PMB medicines

20% co-payment applies 20% co-payment applies

• Reference Pricing is applied
• Reference Pricing is applied

Applicable Benefit Options

• State + Own Choice

Conditions covered Benefit for Additional chronic conditions

Pharmaceutical Benefit Management

Online real-time 24-hour claims adjudication validating member and benefit eligibility

• Real-time access to Medicine Benefit
• Chronic and Acute Medicine
• Member informed of claim status at pharmacy
• Electronic Benefit Management
• Pricing validation
• Scheme rules
• Clinical rules
• Utilisation rules
• Flexible exception process

Prescribed Minimum Benefits

Disease Specific Care Plans

• Structured, controlled access to benefit
• Transparent Benefit
• Developed by a panel of specialists
• Compliant with legislative guidelines
• Customised to level of care
• Includes information on medication authorisation
• Authorisation of additional services for high risk

patients

Pro-active benefit assisting members to manage their chronic conditions

Prescribed Minimum Benefits

continued Automated enrolment and Automated Claims payment for disease-specific Care Plans

• Automatic enrolment via Medicine Risk Program
• Claim payment is ICD10 code / Tariff code driven

Prescribed Minimum Benefits

Manage non-pharmaceutical Care of 26 Life- Threatening Conditions (as per Medical Schemes Act)

• Addison’s Disease
• Asthma
• Bipolar Mood Disorder
• Bronchiectasis
• Cardiac Failure
• Cardiomyopathy Disease
• Chronic Renal Disease
• Coronary Artery Disease
• Chronic Obstructive Lung Disease
• Crohn’s Disease
• Diabetes Insipidus
• Diabetes Mellitus Type 1
• Diabetes Mellitus Type 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple Sclerosis
• Parkinson’s Disease
• Rheumatoid Arthritis
• Schizophrenia
• Systemic Lupus Erythematosus
• Ulcerative Colitis

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 Management Process

Disease Risk Management

continued

• Outcomes achieved
• Improved understanding of disease
• Improved treatment compliance
• Decrease in complications and

emergency admissions

• Improved quality of life
• Additional benefit management
• Health days
• Member brochure
• Care pack

Hospital Risk Management

Manage Hospital expenditure

• Manage length of stay
• Concurrent review of all cases
• Intensive management of high cost cases
• Procedures performed in alternative facilities

in lieu of hospitalization

• Doctor’s room
• Specialised facilities
• Step-down and Rehabilitation facilities
• Home wound care management

Effective management of acute, trauma, high cost or high risk episodes

Hospital Risk Management

continued

Services to Members

• SMS notification to member when authorisation

requested

• Education material regarding procedure available

website, self-help fax service or call centre

• Telephonic interaction with family in high risk and

complicated cases

• Information Care Pack provided for high risk and

complicated cases

Hospital Risk Management

continued Manage hospital access for State Option Members

• Emergency admissions
• State inaccessibility
• Voluntary admissions

Retrospective hospital account review

• Analyse and audit hospital accounts
• Manage inappropriate billing practices
• Confirm negotiated discounts

Psychiatry Management

Challenges

• Sensitivity
• Psychiatric admissions are always emergencies
• Ineffective treatment – relapse

Patient management and support

• Ensure multi-disciplinary management in-

hospital

• Additional benefits often requested
• Followed up after discharge
• Patient & family education & support (crisis

referral)

Psychiatry Management

continued Cost Management

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

Oncology Management

Challenges

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

Oncology Management

continued Patient management and support

• Emotional support
• Understanding disease, treatment, side effects
• Ensure appropriate evidence based treatment
• Treatment options negotiated on behalf of

member

Cost Management

• Treatment plan intervention
• Collaboration with Specialised Oncology Panel
• Oncology network

Maternity Management

Patient management and support

• Identification of all pregnant mothers
• Contact for enrollment
• Risk assessment
• Maternity information pack
• Health information
• High risk members assigned to dedicated

case manager

HIV Management

Optimal management of HIV-positive members

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

• Registration form completed by

treating doctor and assessed

• I llness is staged and needs identified
• According to stage of illness
• Antiretroviral therapy (ART)
• Prophylaxis for opportunistic infections
• Education needs assessed and

applicable information given

• Counseling conducted (especially with

regard to medication compliance)

• Response to treatment monitored

according to guidelines (e.g. CD4 count, Viral Load estimation)

• All information analysed to assess

response to management programme Application for Registration Treatment Authorized Education and Support Monitoring Outcomes Measurements

HIV Disease Management

I f change of treatment necessary

Eldercare Programme

Member support

• Dedicated call centre to assist the elderly
• Educational information regarding healthy

ageing

• Website and newsletter
• Clinical support
• Social support

Thank you