The Value of Managed Care. Lagoon Hotel Cape Town Lagoon Beach Road, Milnerton. Friday, 1 March Programme

Transcription

1 2 ND CMS INDABA The Value of Managed Care Lagoon Hotel Cape Town Lagoon Beach Road, Milnerton Friday, 1 March 2013 RSVP: forums@medicalschemes.com Join us in gaining valuable information from well-recognised CMS and industry speakers; we encourage you to participate in the panel discussion. This second Indaba of the CMS aims to explore the meaning and value of managed care in the context of the South African medical schemes industry. How does managed care benefit schemes and beneficiaries alike? 09:00 Tea Programme 10:00 Welcome Dr Elsabé Conradie 11:00 Topic to be confirmed Dr Stan Moloabi Acting Principal Officer (GEMS) 12:00 Topic to be confirmed Metropolitan Health 13:00 Lunch 14:00 Managed Care: South African Context Danie Kolver Head: Accreditation, CMS 15:00 The limitations of determining the value of Panel discussion managed healthcare using the rand value 16:00 Closure Dr Monwabisi Gantsho

2 Trends in financial performance of medical schemes Tebogo Maziya Head Financial Supervision

3 Trends in number of schemes and beneficiaries Millions Open schemes Restricted schemes Beneficiaries -

4 Trends in age of beneficiaries Average age ( ysrs) Open schemes Restricted schemes Restricted schemes (excl GEMS) Consolidated

5 Claims costs pbpm: 2011 prices pbpm (R) 1, private hospitals specialists Capitated primary care Other benefits Ex gratia payments Supplementary and allied health professionals Medicines Private hospitals Provincial hospitals Dental specialists Dentists Medical specialists General practitioners

6 Risk claims ratio : 2011 prices 1, % 1, % 88.0% 86.5% 86.9% 89.3% 87.3% 86.5% 90.0% 88.0% % 82.1% 84.1% 86.0% 84.0% % % 78.6% 80.0% 78.0% % 74.0% 0 Year Risk contributions Risk claims Risk claims ratio 72.0%

7 Non healthcare expenditure : 2011 prices 2,000 1,800 1,600 1,400 1,200 1, Administration (Risk+Savings) Managed care: management services Broker fees and distribution costs Nett reinsurance Impaired receivables

8 Cost trends pbpa : 2011 prices MSA outside CMS control Total NHE Net relevant helathcare expenditure

9 Net healthcare results Million (R) , , , , , , , , , , , , , , , , Year -2, , Net healthcare result Net surplus/(deficit)

10 Solvency Solvency ratio (%) Prescribed solvency Level Industry average (all) Linear (Industry average (all))

11 Trends in financial performance of medical schemes Tebogo Maziya Head Financial Supervision

12 Trends in number of schemes and beneficiaries Millions Open schemes Restricted schemes Beneficiaries -

13 Trends in age of beneficiaries Average age ( ysrs) Open schemes Restricted schemes Restricted schemes (excl GEMS) Consolidated

14 Claims costs pbpm: 2011 prices pbpm (R) private hospitals specialists Capitated primary care Other benefits Ex gratia payments Supplementary and allied health professionals Medicines Private hospitals Provincial hospitals Dental specialists Dentists Medical specialists General practitioners

15 Risk claims ratio : 2011 prices % % 88.0% 86.5% 86.9% 89.3% 87.3% 86.5% 90.0% 88.0% % 82.1% 84.1% 86.0% 84.0% % % 78.6% 80.0% 78.0% % 74.0% 0 Year Risk contributions Risk claims Risk claims ratio 72.0%

16 Non healthcare expenditure : 2011 prices Administration (Risk+Savings) Managed care: management services Broker fees and distribution costs Nett reinsurance Impaired receivables

17 Cost trends pbpa: 2011 prices MSA outside CMS control Total NHE Net relevant helathcare expenditure

18 Net healthcare results Million (R) Year Net healthcare result Net surplus/(deficit)

19 Solvency Solvency ratio (%) Prescribed solvency Level Industry average (all) Linear (Industry average (all))

20 Healthcare brokers Where are we and whereto from here CMS INDABA KOPANONG 2012 Danie Kolver Head of Accreditation Council for Medical Schemes

21 Presentation Outline Brokers: current status Some undesirable practices emerged Broker fees and membership What does the future hold? The role of the broker Broker conduct in perspective Managed care matters

22 Brokers: current status There are currently 8334 individual health care brokers and 2237 broker organisations accredited All members pay currently for broker services in unfair manner not scheme expense Analysis of FAIS regulatory exam results may change numbers as those who fail become not fit and proper and accordingly fail accreditation No accreditation to business or family trusts incapable of functioning as legal entities Recent trends: Indicate large influx of apprentice brokers associated with major corporations Market penetration by trade union linked broker organisations Insignificant organic growth in new members being brokered in open schemes Therefore mismatch between broker fees and members enrolled

23 Some undesirable practices emerged Inability of broker fraternity to market scheme cover to uncovered Churning of members and battle for market share amongst brokers as a result has become general practice Increased emphasis on selling unlawful insurance products (hospital cash plans and gap cover) Commercial gain for brokers playing in that environment with much higher income stream cited as main reason

24 Some undesirable practices emerged Independence of brokers is often questioned as their advice is influenced by other financial and non-financial incentives attached to the products they sell Increase in purported marketing, distribution, survey and related activities by brokers to secure misplaced loyalty Gives rise to questionable income stream for brokers, real value for members with adverse effect on cost structures for members Overall, competition is driven along inappropriate business culture

25 Some undesirable practices emerged Conduct of certain individuals tarnish good name of bona fide brokers Scheme members allocated to favoured brokers without services being rendered by such brokers Brokers expose themselves by false promises wrt waiver of waiting periods and clients failing to disclose material information

26 Million (R) BROKER FEES AND MEMBERSHIP Millions Broker fees Average members

27 What does the future hold? In general terms, aligning health brokers with financial services industry. Consideration given to strengthen environment by means of legislative amendments. Ensure independence of advice to consumers seeking this service No urging priority to dispense with dual licensing and accreditation. Fit and proper requirements and measures to deal with unacceptable behaviour by two regulators will continue. Compliance based regulation to focus on distribution channel arrangements.

28 The Role of the broker Unlike other investments, clients approach intermediaries to facilitate appropriate coverage to ensure access to necessary health care, not to create wealth Health intermediaries should see themselves first and foremost as advisors taking into account analysing the client s health care needs and match with relevant insured benefits their means to pay for needed coverage effect of transferring clients to another scheme on waiting periods and late joiner penalties that might be imposed Individual vs group transfer and effect thereof on all clients retirees to join group transferred to new scheme transfer within meaning of scheme rules - no person can have more rights than another

29 Maintain high standards of professionalism and integrity Comply timeously with regulatory requirements Stay up to date with regulatory developments (CMS website for circulars & FSB licensing F&P requirements) Keep regulator informed of unlawful conduct Investigate complaints; suspend & terminate accreditation Broker conduct in perspective Compliance based regulation = ad hoc evaluation of contracts & conduct to assess fitness and propriety misleading practices & undertakings re admission Advanced training towards obtaining required licensing credits needed

30 Managed care matters On-site evaluations on track following success with administrators Progressing with research towards measuring impact of managed care interventions Continued initiative to address value proposition provided ito quality of care and health outcomes IPA s and direct providers of care not required to be accredited

31 THANK YOU