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Health Risk Management

Medscheme’s health risk management offering is differentiated by our visionCreating a World of Sustainable Healthcare. Our insight into sustainable healthcare allows us to develop customised programmes that achieve better solutions and deliver enhanced healthcare value.

Our approach is built on informed decisions, which prioritise the use of sustainable healthcare resources. Without this healthy, disciplined approach, health risk management is reduced to random cost-cutting, which ultimately results in inferior health outcomes and unsustainability.

Medscheme is committed to:

  • Focussing on quality and cost through interventions geared towards improving the value of affordable healthcare
  • Adopt a structured approach to health risk management based on secure value judgments in partnership with healthcare providers and medical aids
  • Measure quality and costs incurred at all levels of care to support ongoing refinement of tiered reimbursement models. This leads to increasingly meaningful funder-provider partnerships
  • Encourage the informed participation of medical aid beneficiaries in managing their own health

Medscheme’s approach to health risk management

Create healthcare intelligence

Strategic decision-making in the context of sustainability depends heavily on the ability to access and analyse data intelligently.

Medscheme’s Health Intelligence Unit has developed robust data management systems and analytical models that manage data intelligently in order to generate insightful information and identify trends. The data is then used to interpret and understand the value of healthcare provision and to focus interventions on enhancing healthcare value.

Develop and manage healthcare funding policies

Crucial elements to planning a structured health risk management approach include:

  • Understanding the potential clinical benefits of medical diagnostic and therapeutic care
  • Understanding the financial implications for third-party funders

Medscheme’s Health Policy Unit continually reviews health risk management protocols and scheme benefit design in line with the latest scientific evidence. This process takes into account cost-effectiveness, real-life practices, as well as affordability, where appropriate.

Develop reimbursement models that actively encourage competition between healthcare providers

Enhanced healthcare value and sustainability can be achieved with better co-ordination of care as well as appropriate and cost-effective use of diagnostics and treatment in primary and secondary disease prevention.

Medscheme’s improvements in the quality and value of healthcare are achieved through active collaboration with leadership forums, professional societies and hospital groups. Alternative reimbursement models that feature performance-based tiered payments encourage competition between healthcare providers and are a part of this model.

Support individual beneficiaries and beneficiary groups to limit prevalence and severity of disease

We use predictive modelling to accurately identify and engage with beneficiaries who represent a risk of incurring high healthcare costs. This approach is aimed at encouraging beneficiaries to improve their own health by consulting with healthcare professionals of their choice.

Integrate provider network and beneficiary support initiatives

Ideally, provider network and beneficiary support should be integrated. Only healthcare professionals (not funders) can assume responsibility for the diagnosis and treatment of disease. As such, only healthcare professionals can perform appropriate and cost-effective preventative and curative healthcare at primary and secondary preventative levels.

Medscheme facilitates the value management process to support healthcare professionals.

Manage healthcare utilisation and price

The management of utilisation and price to ensure access to appropriate levels of quality in affordable healthcare is an important part of Medscheme’s product offering. Medscheme is continuously evolving these techniques to become more focused and user friendly.

Price negotiations are part of on-going, structured provider relationships. Medscheme actively pursues appropriate alternative reimbursement models, to fee for service models, based on the results of price and utilisation analyses.

Perform healthcare actuarial analyses and provide reports

Medscheme’s specialist healthcare actuaries produce quarterly healthcare funder-specific risk management reports to describe benchmarked demographic and cost trends. These reports, in conjunction with standard actuarial analyses, allow Medscheme to fulfil an invaluable client-specific support and product development role.

Promote healthcare “Information Communication Technology” solutions

The goal of sustainable healthcare will be increasingly supported by information-sharing. The latest communication technologies are used to support this trend. Medscheme’s ultimate accomplishment lies in our ability to demonstrate a measurable improvement in healthcare outcomes for each component of our health risk management suite of products.

For two consecutive years Medscheme’s Managed Care Division has been awarded PMR.africa’s top accolades for excellence in managed care and disease management.

Contact Medscheme

+27 11 671 2000

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