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Alliance-Midmed Medical Scheme
2019 Budgets and Planning
Rumours and National Health
• NHI - Government provide / pay for healthcare provider and payer for all citizens – and some
• Medical schemes – supplementary benefits
• All medical schemes will be affected
• RUMOUR - AM will close down - NHI consolidation plan?
• NHI timeframe, cost and stakeholders
• Many stakeholder groups – members, business, trade unions, civil society, healthcare professionals, employers, etc.
• Ownership questions asked by members
• Alliance-Midmed – Private Health Administrators is a private company now 60% held by Medscheme and 40% by private individuals
• Sizwe - Sechaba – NUMSA owns 60% of Sechaba and a group of doctors owns 40%
2019 Budget assumptionsand decisions
Contribution increase 10.7%
2019 Scheme contributions compared
2 0 1 9 C O N T R I B U T I O N S % I N C R E A S E N E W R AT E S
Most expensive Medical Scheme Option 10.70% 20 940
Comparable benefit option 9.20% 15 578
Comparable benefit option 10.70% 15 379
Comparable benefit option 9.20% 12 585
Option with ~0% less benefits at same rate 8.50% 7 569
____ more affordable care – significantly less benefits 6.10% 8 426
____ fuller benefit option – comparable benefits 6.10% 12 364
Alliance - Midmed (highest income bracket) 10.70% 7 729
Family of four in highest income bracket
Alliance-Midmed 2019 increases -The Rand Value impact
New monthly premium Additional monthly contribution (before subsidy)
Monthly income
Member Adult Child *2 Total Member Adult Child *2 Total
R5 000 2 119 1 927 1258 5 304 204 178 74 456
R10 000 2 844 2 589 1702 7 135 275 250 164 689
R20 000 3 081 2 804 1844 7 729 298 271 178 747
Additional monthly premium (after subsidy)
Member Adult Child *2 Total
82 71 30 182110 100 66 276119 108 71 299
Scheme positioning
Description BenefitMonthly
ContrExample
66-Star,
hotel-likeChoice and exclusivity
R20,954Most expensive and fuller benefit option
6
5 5Alliance-Midmed
4 4
3Alliance-Midmed
3
2 2
1Hospital
Plan
Limited choice and
benefitR3,228
Cheapest hospital plan
1
Private room Designer drugsMeals and
alcoholPrivate nursing
Visitors at any time
No limitsEntertainment
suite
Reasonable Access
(availability, turnaround time, efficiency)
Quality Healthcare
(Accurate diagnosis and treatment, competent and efficient care, reduced risk and downside of intervention)
Affordable price
(Cost of optimal diagnosis, treatment and care, administration, turnaround, wastage prevention, skills, etc.)
INCREASES – 1999 to 2017
-10.00%
-5.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Industry AM CPI M-CPI
0%
32 – 70%
Scheme operational statistics – Dec 2017
Alliance-Midmed Industry
Number of members at the end of the year 1 855 Number of beneficiaries at the end of the year 4 413 Average age of beneficiaries for the year 31.24 Pensioner ratio (beneficiaries > 65 years) 6.03%
Healthcare expense as a percentage of gross contributions 90.52%
Aver non-healthcare expenditure per beneficiary per month R 113
Non-health expenses as a % of gross contributions 6.33% 11.89%
Ave accumulated funds per member at year-end R 26 429Net member movement trend: Last 3-5 years 26Contribution increases (%): Last 3-5 years 7.17%Health care expenditure - 2017 R 85.604mCurrent solvency 34.60%Solvency changes over last 3-5 years (5.74%)% of contribution subsidised by employer 60%
Replaced Deloitte with BDO as Scheme auditor from Oct 18
The industry and why things go
wrong and right?
• Basic processes, procedures (and) checklists
• Skills and exposure
• Level of care
• Coordination
• Transparency
• Ownership
• Profit
• Referral systems
• Permission to fail
• Preferential treatment
• Rule and regulation
• Patient involvement and wishes
Most healthcare professionals want to excel…
Level of Care
Why does it matter?
Surgeons book patients overnight into high care post-surgery because they are concerned about the level of care in general wards
=
R5 507 per day
Level of care Cost Emergency consult at hospital R970
- Plus wound care R370
Medical and Surgical Wards R3,092
Pediatric Ward R3,677
Maternity – Caesarean 1st Day R19,950
- Cesearian – subsequent days R4,244
High Care R8,607
Intensive Care R14,050
www.alliancemidmed.co.za | Tel 087-740-2815 | Call Centre 0860-002-101 | Emergency Number 0860-255-426
Generic medicines• Generic vs sub-standard manufacturing
• Bio-equivalent vs biosimilar
• Counterfeit (fake) meds • Developed world - 8%, developing world 13%, Africa – 19%, and South Africa 8.9%• World Health Organisation (WHO)
• Surveillance and AlertSystem for Counterfeit Medicines• Medicines quality assurance task force
• Popular counterfeit targets• Malaria, diabetes, hypertension erectile dysfunction, cancer medicines, HIV/AIDS• Antibiotics and corticosteroids
• AM is affected BUT less • Mediscor monitor and check and we deal with known pharmacies….
• In high-risk/ precision dosages – extra cautious - Neurology and children under 6 years
• Buy only from known and legitimate pharmacies and avoid street vendors and internet
Always consult a medical practitioner when you change your treatment
www.alliancemidmed.co.za• >benefits• >chronic medicines
which are covered• http://www.mediscor.
net/Midmed_Formulary_Lookup.html
Always consult a medical practitioner when you change your treatment
Cost per
tablet
Cost for 30-day
supply
0.57 17.11
2.19 65.81
Aspirin 300mg
Count = 17
informed and participative patient decisions, together with your healthcare professional
Saving
__Some insulin pen - 3ml, 100
unit ml___818.07 341.89
476.18__Its
generic_____
Original
Generic
Saving___Some Antibiotic_______ 133.27 24.58 108.69 __Its generic_____
___Some Antibiotic_______ 161.38 50.53 110.85 __Its generic_____
___Some antibiotic - pediatric_ 95.81 32.74 63.07 __Its generic_____
____Some other anti-biotic__ 132.46 -2.83 135.29 __Its generic_____
Original Generic
Adherence Ratio
<41% 1.7%
50% 6.8%
75% 16.8%
80% 44.9%
100% 29.7%
Total 2 196
Hypertension
Cholesterol
Thyroid disease
Asthma
Depression
Non-insulin dependent
diabetes
Ischaemic heart disease
Epilepsy
Bipolar mood disorder
Menopause
Chronic medicines adherence
How often members collect
their prescriptions from the
pharmacy for these conditions
Indicative costs
CostPer one event
for all lives
No of lives 4 413
Cost per GP Consult 485 2 140 305
Cost per GP consult and meds 851 3 753 344
Per visit / test (ZAR)
Doctor visit R485
Medicine (average acute script) R366
Specialist visit R970 - R3 400
Black and white x-ray – arm R627
Colonoscopy R1 923
Gastroscopy R1 020
Sinus scan R860
One day hospital visit R10 436
Three day hospital visit R15 257
Blood test – sugar R65
Blood test – lipogram (cholesterol) R387
Blood test – allergies R339
A day in intensive care R14 818
An hour in theatre R11 838
Lifestyle and cost impact – the power of team work
Members Lives
1 844 4 415
R2,4m R108.50/ month R45.33/ month
R2,7m R122.00/ month R51 .00 /month
2.8% to 3.1% of contributions
It is possible to reduce hospital expenses (+-30% of the total) and medicine expenditure @5% of the total by R.2.7m and that equates to the savings indicated above.
Our health management risk strategy
Age Chronic condition/s
Family history and
illness profile
Prevention, treatment
compliance
Current health profile
Lifestyle indicators
Cost profile
R7m or R321,28 per member per month
Know Your Numbers
Body mass index (height and weight)
Blood pressure
Blood glucose
Cholesterol
Health risk questionnaire
Solutions
www.alliancemidmed.co.za
Tel 087-740-2815
Call Centre 0860-002-101
Emergency 0860-255-426
Challenges
FraudAbuseOver-servicingIncompetenceSelf-harmPreventable use
• The system
• Fraud
• Abuse
• Waste
• Skills and training
• Under-staffed
• Over-pricing and over-charging
• Charging for unnecessary services
• Calling patients back unnecessarily
• Hospital acquired infections
• Duplicate services
• Non-essential use of expensive drugs/ treatment
• Inaccurate diagnosis
• Ineffective prescription
• Lifestyle (diet, exercise, smoking, alcohol and drugs)
• Non-compliance to treatment plans
• Dependence
• “Locking into the system”
• Doctor-hopping
• Abuse
• Cash for claims
• Beneficiary not registered (substitute)
• Incomplete information
The system The “players”
Connect with us…
Emergency 0860-255-426After hours nursing staff and doctor on call
0860-255-426
Middelburg office (08H00 - 16H00) 087 740 2815 [email protected]
The cell phone app
Address SEVEN@DOLERITE or (7 Dolerite)
Mediscor Chroniline 0860-119-553 [email protected]
Denis Call Centre 0860-000-702 [email protected]
Fraud Hotline 0860-040-040 [email protected]
www.alliancemidmed.co.za
Alliance-Midmed
app
www.alliancemidmed.co.za | Tel 087-740-2815 | Call Centre 0860-002-101 | Emergency Number 0860-255-426
Collect emergency stickers at Ronelle
and member card in cubby hole
Questions so far…• GP consults
• Optical benefits
• Out-of-area
• Preferential treatment
• Alliance-Midmed versus Midmed Hospital
• The vulnerable groups
• Gym membership
• Multivitamins
• Monthly updates
• J Hartzenberg – 0828013323/ [email protected]
QUESTIONS?
Brand names and generics
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150029/
• http://scienceblogs.com/deanscorner/2011/12/20/generic-lipitor-the-same-and-n/
• https://www.cadth.ca/generic-drugs/similarities-and-differences-between-brand-name-and-generic-drugs
• https://www.cadth.ca/generic-drugs/similarities-and-differences-between-brand-name-and-generic-drugs
• https://www.rxlist.com/script/main/hp.asp
• http://www.who.int/medicines/areas/policy/monitoring/empmedmon/en/
Some things that we do differently and well
• Claims processing speed
• Query answering speed
• After-the-pay-run audit
• Non-healthcare cost as % of contributions
• Medical care as % of pay.
• Cost and benefit
www.alliancemidmed.co.za | Tel 087-740-2815 | Call Centre 0860-002-101 | Emergency Number 0860-255-426
Life stages and cost
Medical expenses rise as we grow older – if the expense for all or most groups rise, the scheme becomes financially stressed
2 832
1 854
5 212
10 700
3 824
-
2 000
4 000
6 000
8 000
10 000
12 000
14 000
16 000
18 000
Up to 6 7 - 20 21 25 30 35 40 45 50 55 60 65 >65
In this example the average cost changed from R4 960 to R7 787 and reserves and member
contributions will be affected
Pharma context
• World pharma market – USD 1.1Trillion
• USA constitutes ~70 of that amount.
• RSA pharma market - R1.2 Trillion (USD 1/ZAR 14.55) • USD R82 Billion.