Medscheme focuses on strategic purchasing or activist paying of healthcare services, which aims to maximise the overall health gain from available resources. Strategic purchasing underpins our approach to building and maintaining sustainable healthcare provider networks as well as the implementation of different payment systems and contractual mechanisms. Fundamental to strategic purchasing is the ability to accurately profile healthcare provider services from a cost efficiency and quality perspective. Medscheme uses risk-adjusted Diagnosis Related Groups (DRGs) to allow comparison between different providers. Similarly the quality of service is measured to allow comparison across facilities and to track trends.
Medscheme has the largest contracted Family Practitioner Network in South Africa with over 5500 participants that:
- agree to charge the medical scheme tariff and not levy co-payments
- are measured against practice specific quality and cost targets
- receive an enhanced fee for being a ‘top’ performer (pay-for performance)
- ensures exceptional access and coverage for all members
- agree to enter a peer management process for ‘poor’ performance.
Our Family Practitioner profiling tool (REPI2) measures practice-specific cost and quality metrics, and our Family Practitioner Peer Management infrastructure are both considered to be the industry-leading standard in South Africa.
Medscheme’s Specialist Network includes over 3 600 contracted Specialists across all disciplines (including Anaesthetists). Existing funding models and network agreements focus on addressing specific Specialist costs, e.g. joint replacements.
Where the Prescribed Minimum Benefit (PMB) risk for member Specialist claims is high, Medscheme is able to contract a Specialist Network to mitigate this risk. We can also assist Scheme’s in taking a collaborative approach with Specialists by developing centres of excellence for the treatment of Scheme members.
Our unique, dedicated and well established engagement structures/forums address Family Practitioner and Specialist related issues, as well as assist in creating joint partnering strategies to address fragmentation and wastage in the healthcare system through structured co-ordination of care initiatives.
Medscheme has implemented and manages several different Hospital Networks, customised to suit our Scheme’s needs. Quality standards, access and cost efficiency drivers are contractually enforced, monitored and managed within our networks to ensure that the strategic objectives are met. The participation criteria for hospitals/hospital groups in the Hospital Network include a commitment to quality of care and standards of care. Risk transfer for poor quality is addressed as hospitals are required at a minimum to take financial responsibility for ‘never events’ such as wrong side surgery and falls.
We also contract and manage a large Pharmacy Network of approximately 1 800 pharmacies that include corporate groups, independent pharmacies and courier pharmacies. These pharmacies are contracted to charge a set dispensing fee in order to eliminate overcharged member dispensing fees. These pharmacies are also committed to offering generic alternatives to ensure that the member does not incur any out-of-pocket expenses.
Medscheme also manages a Dental Network via a contracted supplier who contracts dentists according to set Scheme tariffs and Medscheme formulary. In this way co-payments to members are eliminated.
Our Optometry management programme ensures the delivery of clinically appropriate and cost effective eye-care within the parameters of each of our Scheme’s optometry benefit design. This programme incorporates automated processes and manual intervention for specific cases.
Medscheme also focuses on managing utilisation risk and quality, rather than on tariffs (fees) alone as we see it as the true instrument to ensure sustainability of private healthcare. This is why our network and contracting model incorporates the management of high risk members – those members who are most vulnerable and account for a disproportionately large proportion of Scheme spend. For these members, the contracted Family Practitioner ensures that their member’s health care is optimally co-ordinated.