TRANSMED HR / Labour Conference 04- -05 October 2007 05 October 2007 04
Content Content • Company Profile • Market Orientation • Managed Care Services • Network Management • Client Liaison Services • Benefit Design
Ownership Structure Network Healthcare Holdings Limited Network Healthcare Holdings Limited Network Healthcare Holdings Limited Network Healthcare Holdings Limited 100% 100% Medicross Healthcare Group (Pty) Ltd Medicross Healthcare Group (Pty) Ltd Medicross Healthcare Group (Pty) Ltd Medicross Healthcare Group (Pty) Ltd 100% 100% Prime Cure Holdings (Pty) Ltd Prime Cure Holdings (Pty) Ltd Prime Cure Holdings (Pty) Ltd Prime Cure Holdings (Pty) Ltd 100% 100% 100% 100% 100% 100% Prime Cure Occupational Health (Pty) Ltd Prime Cure Occupational Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Managemnt Services (Pty)Ltd Prime Cure Managemnt Services (Pty)Ltd Prime Cure Occupational Health (Pty) Ltd Prime Cure Occupational Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Health (Pty) Ltd Prime Cure Managemnt Services (Pty)Ltd Prime Cure Managemnt Services (Pty)Ltd
Accreditation & Empowerdex Rating • Accredited Managed Care Organisation – Unconditional Accreditation – 08 November 2006 to 08 November 2008 • Management of Prime Cure and Medicross managed care / network products • Empowered organisation: – “A” rating by EmpowerDEX
Target Market Segmentation Living Standards Measure & Approximate Monthly Household Fee Insured (7- - Insured (7 for Income LSM 10 service million) million) R15,000 + LSM 8 – 9 Managed Medicross R7,500-R15,000 Network Care Target LSM 5 – 7 Market Prime Cure Network R2,000-R7,500 Uninsured Uninsured Formally employed Formally employed LSM 3 – 4 (7 – (7 – 10 million) 10 million) Emerging Market R1,000 – 2,000 Uninsured Uninsured LSM 1 – 2 Indigent Group Unemployed Unemployed R800 – R1,000 (25 (25 – – 28 million) 28 million)
Managed Care • A Managed Care Provider of affordable, integrated managed healthcare • 35 Medical Scheme options • > 180,000 beneficiaries under management • Growth of 4,000 new beneficiaries per month over 18 months • Innovative, risk-sharing partnership with schemes
Integrated Business Model • Prime Cure evolved from a Primary Care network model to a sophisticated full service, full risk accredited managed care organisation • Focus to ensure patient access to a continuum of appropriate, affordable health care services • Enhancement of health status & quality of life with reduction in health care costs • Savings of up to 50% of traditional fee-for-service medical aid premiums
Managed Care Client List � Anglo Health � Minemed � Bestmed � Momentum � Camaf � Nimas � Day One Health � Purehealth � Eyethumed � ProSano � Furnmed � Protea � GEMS � Telemed � Global Health � Thebemed � Ingwe � Topmed � Laundry Bargaining Council � Transmed � Medisense � Umvuzo
Stakeholder Relationships • Prime Cure contracts directly with Medical Scheme • Seamless integration with administrator Medical Scheme • Services provided within the contracted DSP service provider network Primary Contracting Parties Seamless Administrator Integration Managed Care Services Service Providers
Integrated Managed Care Services The managed healthcare services provided by Prime Cure and its alliance partners are seamlessly integrated into one affordable offering. TRANSMED 100% Accredited Managed Care Organisation Mediscor PBM Mediscor PBM Providers
Comprehensive Managed Care Infrastructure • 24-hour Call Centre and Advice Line • Claims Administration & Provider Reimbursement • Pre-authorisation procedures & Case Management • Chronic Disease Management • HIV/AIDS Disease Benefit Programme • Medicine Formulary & Chronic Medicine Management • Marketing & Client Support Services – Member & Provider education • Network Management Infrastructure – Dedicated team of 12 regional Relationship Managers • Intellectual Capital – Specialist medical, legal, financial & actuarial experts • Dedicated forensics unit
Pre-Authorisation Pre-authorisation is usually obtained by the referring doctor Out-of-hospital Hospital Admissions • High frequency and high • All admissions cost GP procedures • Based on protocols with • All Specialist referrals financial guidelines • All Allied Provider referrals • ICD-10 and CPT coding • Chronic medicines • PMB conditions • High cost investigations (radiology & pathology)
Evidence-Based Clinical Pathways
Network Risk Management Patients are not restricted to one provider, and can choose any provider on the network • Prime Cure ensures access by geo-mapping members to providers: – Appointment of providers to match the needs of members • Providers are accredited according to: – Practice infrastructure – Administrative and operational efficiency – Compliance with protocols & medicine formulary – Wellness promotion and preventative care • Reimbursement of providers is performance-based – Reward for compliance and cost-effective outcomes • Profiling and practice audit • Patient / member satisfaction surveys • Customer (medical scheme) satisfaction surveys
Prime Cure National Provider Footprint General Practitioners Optometrists Dentists
Prime Cure DSP Network: 17-Sept-07 AREA MEDI CENTRES DOCTORS DENTIST OPTOMETRISTS 3 214 65 65 EC 2 172 52 47 FS 7 566 259 269 GAUTENG 7 454 156 156 KZN 0 10 5 2 LESOTHO 0 153 50 55 LIMPOPO 2 188 58 73 MPUMALANGA 0 59 19 29 NC 0 152 40 52 NW 0 1 1 3 Swaziland 2 307 151 121 WP 23 2276 856 872 TOTALS:
GP, Dental & Optometry Networks GROWTH IN GP, DENTAL & OPTOMETRY NETWORKS Optometrists GPs Dentists 2,850 2,350 Number of Providers 1,850 1,350 850 350 Mar-06 Jun-06 Sep-06 Nov-06 Apr-07 Jul-07 Sep-07 1227 1385 1704 1850 2153 2243 2276 GPs Dentists 395 424 634 705 809 842 856 364 450 656 681 782 832 872 Optometrists
DSP Network Stability: 2007 (YTD) • The Prime Cure Network continues to show stability over time CHANGES DENTISTS DOCTORS OPTOMETRISTS Totals 18 (2.1%) 72 (3.1%) 27 (3.09%)
Client Support Marketing Prime Cure Union negotiations will provide a medical scheme with Retailing value-added services crucial to Education developing the emerging market and growing Ongoing support membership Provider Management
Benefit Design State Plus Network
Primary Care DSP Netw ork: General Practitioner visits ( Prim e Cure Centres & Netw ork) Basic Primary Care All clinically necessary visits No co-paym ents ► General Practitioners Medication Unlim ited based on ► Medication Prim e Cure Form ulary ► X-rays • Acute Medication • Chronic Medication ► Pathology • “OTC” Self- m edication benefit Pathology X-Rays and Ultrasound Em ergency visits & Out-of-Area 2 4 -hour Medical Advice Line
Dental & Optometry DSP Netw ork: Comprehensive Primary Unlim ited Essential Dentistry Care Preventative care ► General Practitioners Fillings Extractions ► Medication Optom etry Annual eye exam ination ► X-rays One set of spectacles every 2 4 m onths ( single ► Pathology vision or bifocal lenses) ► Optometry ► Dentistry ► HIV Cover
Dental & Optometry DSP Netw ork: Comprehensive Primary Unlim ited Essential Dentistry Care Preventative care ► General Practitioners Fillings Extractions ► Medication Optom etry Annual eye exam ination ► X-rays One set of spectacles every 2 4 m onths ( single ► Pathology vision or bifocal lenses) ► Optometry ► Dentistry ► HIV Cover
Out-of-Hospital Specialist Cover Primary Care and Consultations and office procedures Specialists • Lim ited to R1 ,6 0 0 per beneficiary or R2 ,2 0 0 per ► General Practitioners fam ily per annum • Unlim ited for PMBs ► Medication ► X-rays ► Pathology ► Optometry ► Dentistry ► Specialists ► HIV Cover
Benefit Design Ubuntu
Out-of-Hospital Services Primary Care and Specialists ► General Practitioners Sim ilar to State Plus ► Medication Netw ork, except: • Optom etry: ► X-rays • 4 boxes of disposal ► Pathology contact lenses / One pair perm anent contact lenses lim ited to R7 4 9 ► Optometry every second year ► Dentistry ► Specialists ► HIV Cover
Allied Provider Benefits Primary Care, Specialists & Allied Professionals ► General Practitioners ► Medication ► X-rays ► Pathology ► Optometry Physiotherapy and ► Dentistry Occupational Therapy: PMB Conditions unlim ited, ► Specialists provided referral obtained from DSP & preauthorisation ► HIV Cover Non-PMB: All Services – com bined lim it of R1 ,1 0 0 ► Allied per beneficiary or R1 ,6 0 0 per fam ily per annum
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