BHF 360 into Healthcare

healthcare in Southern Africa p. 5

COVER: BHF's Lamees Scholtz and Dr. Nomalungelo Nyathi of Medscheme p. 20 & 28

SEPTEMBER 2014

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S E P T E M B E R 2 0 1 4

FOREWORD

BOARD O f HEALTHCARE fUNDERS O f SOUTHERN AfR ICA 1

From the EDITOR'S DESKWelcome to the first edition of BHF360° – into healthcare. This initia-

tive heralds in exciting times at BHF. The launch of BHF360° is in the spirit of our renewed value proposition, which commits to – among other things – provide stewardship and facilitate thought leadership exchange on industry issues.

This issue focuses on different views from key role players in healthcare – on the future of healthcare locally and beyond our borders – zooming in on the current changes and challenges. We also cover highlights from the 15th Annual BHF conference programme and included a listing of our sponsors and exhibitors. I sincerely hope you find it of value.

I’d also like to extend a warm welcome to all delegates, representing more than 300 organisations, to the 15th Annual BHF Southern African Conference. To our partners, sponsors and speakers – thank you for your contribution and support of what has come to be known as the “premier event of the year” – which provides another excellent platform for you to learn, connect and collaborate. May you all find the oceans of opportunity that are being brought about by the current waves of change, as our international and local subject matter experts share their insights and experience with you.

l would like to take this opportunity to thank our members for support-ing BHF and would like to assure you of our commitment to represent member interests at all times, in this dynamic environment.

Zola MtshiyaHeads up the Marketing and Branding Department

Editor in Chief: Zola MtshiyaSub-editor: Fay HumphriesDesign & Layout: Mariette du Plessis

CoverTaken on location at 54 on Bath AvenueChris Wessels Photography

Advertisingt. 011 5370236e. [email protected]

Editorial e. [email protected]

Published by the Board of Healthcare Funders of Southern Africa

Non-Profit Company Registration no. 2001/003387/08

Lower Ground Floor, South Tower1Sixty Jan Smuts AvenueCnr Tyrwhitt AveRosebank, Johannesburg

P O Box 2324, Parklands, 2121

Tel: +27 11 537-0200Fax: +27 11 880-8798Client Services: 0861 30 20 10e-mail: [email protected]: www.bhfglobal.com

in to hea l thcareBHF360°

BOARD O f HEALTHCARE fUNDERS O f SOUTHERN AfR ICA

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

IN THIS ISSUE

2

» p.5

5 THE FUTURE OF HEALTHCARE

It is almost certain, given the way the healthcare system is structured in both the public and private sectors in South Africa, that its viability and sustainability is threatened. – Dr HZ Zokufa, MD, Board of Healthcare Funders of Southern Africa

7 CO-ORDINATION OF CARE

Improved co-ordination of care is one of the many innovative opportunities relating to healthcare funding and delivery that must be explored. – Kevin Aron, CEO, Medscheme

10 HEALTHCARE INSIGHTS

Liberty Medical Scheme . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SAMWUMED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Metropolitan Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Old Mutual Investment Group. . . . . . . . . . . . . . . . . . . . . . 16

Council for Medical Schemes. . . . . . . . . . . . . . . . . . . . . . . 18

KPMG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 EXECUTIVE Q&A

BHF360° spent some time with key industry executives to explore changes, challenges and issues close to their hearts.

Dr. Nomalungelo Nyathi, Executive Manager: GEMS Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Lamees Scholtz, Executive Coordinator: MD Offices, PCNS & Knowledge Management . . . . . . . . 28

CONTENTS

» p.7

» p.20 » p.28

» p.10 » p.19

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

IN THIS ISSUE


Momentum Asset Management . . . . . . . . . . IFC

BHF Southern Africa . . . . . . . . . . . . . . . . . . . . . .4

Medscheme . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Metropolitan Health . . . . . . . . . . . . . . . . . . . . .14

Old Mutual Investment Group . . . . . . . . . . . .17

Preferred Provider Negotiators (PPN) . . . . . 22

Merck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Mediscor Medicines Review 2013 . . . . . . . . . 30

Mediscor Medicines Review 2013 . . . . . . . . . .31

Netcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Insight Actuaries & Consultants . . . . . . . . . . .51

KZN Children's Hospital . . . . . . . . . . . . . . . . 58

Private Health Administrators (PHA) . . . . . . .IBC

Clicks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OBC

ADVERTISER INDEX

23 BHF INSIGHTS

Protect against and prevent healthcare fraud . . . . . . . . 23

Competition in healthcare not the only answer . . . . . . . 26

32 15th ANNUAL BHF CONFERENCE

Collective activism in health. . . . . . . . . . . . . . . . . . . . . . . . 32

Leadership in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Mobile health – just what the doctor ordered! . . . . . . . . 36

What’s the alternative to alternative dispute resolution? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Listing of sponsors & exhibitors . . . . . . . . . . . . . . . . . . . . 39

52 REGIONAL UPDATES

Botswana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Lesotho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Mozambique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Zimbabwe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Namibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

59 BHF MEMBERS

South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

SADC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

» p.32

» p.34 » p.37

» p.53 » p.54

Lobbying and advocating policy position on behalf of our membersAssist members with regulatory complianceProvide legal advice to membership on industry issuesAssist in containing healthcare costsIdentify and monitor trends impacting our membersProtect the image of the industry

Represent Member Interests1

Promote unity and collaboration by creating platforms that enable our members to engage with BHF and participate in industry issuesCreate networking opportunitiesEngage and develop relationships with key stakeholders

Create Platforms for Member Engagement2

Promote best practice in the healthcare funding industryPromote healthcare qualityIdentify and recognise key role players in the industry

Develop Industry Standards3

Provide stewardship and facilitate thought leadership exchange on industry issuesEnhance skills and knowledge within our membershipProvide guidanceProgress tracking reports on industry issuesPromote stakeholder, consumer awareness and medical scheme member education

Facilitate Education and Training4

Identify opportunities to drive transformation in the industryGraduate programme development

Transformation through Development5

Profile our members and our industryProvide and Identify Opportunities6

V A L U E PR

OP

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ITION

WWW.BHFGLOBAL.COM

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HEALTHCARE 360º


By Dr HZ Zokufa, MD

BHF SOUTHERN AFRICA

The current healthcare services, and what the future of these services in Southern Africa will look like, is a deep

concern for every citizen living in this region because: An inadequate healthcare system

threatens citizens’ survival and dignity. To deepen the democracy so painfully

earned, the health of citizens must be restored, guaranteed and taken good care of on an ongoing basis.

The economic growth of the country and foreign direct investment, will be better assured if the healthcare system is robust enough to take care of its people.

For us to guarantee the rendering of healthcare services in the future, it is an imperative that a major intervention has to occur at systemic level.

It is almost certain, that given the way the healthcare system is structured in both the public and private sectors in South Africa, its viability and sustainability is threatened. The following are some of the factors that have contributed to this state of affairs: A two-tiered healthcare system that is

fragmented in both tiers. This compro-mises and frustrates the resource gains which can be obtained, humanly and financially.

An inadequately funded public sector, battling to render quality services to 84% of the population, and a well funded private sector rendering services to 16% of the population, but highly fragmented.

A fee for service reimbursement model in the private sector, without guaranteed quality health outcomes and value for money. This incentivises

THE FUTURE OFhealthcare in Southern Africa

increasing healthcare costs on the provision side without a corresponding increase in value and/or quality. This threatens the viability and sustainability of the funding industry.

An inadequately regulated private healthcare system, especially on the provision side, and the assertion that free market principles and competition must be allowed to operate. It is questionable whether this works or not, given the current failures in healthcare services, with those principles in place.

All of the above occur to greater or lesser extent in other Southern Africa countries as well; namely Zimbabwe, Namibia, Lesotho and Botswana.

For us to guarantee the rendering of healthcare services in the future, it is imperative that a major intervention has to occur at systemic level. There has to be a major redesign of the healthcare system with a clear end point in mind.

In South Africa the provision of healthcare services is the responsibility of the State. The State has an obligation to intervene and redesign the frame-work of healthcare services, both in the private and public sector, so that it responds to the delivery of universal healthcare on an ongo-ing basis. Failure to do so will be an abdication and dereliction of duty by the State.

The State in South Africa has reflected on these issues, and came up with the Policy on National Health Insurance gazetted on the 12 August 2011. This policy clearly states the objectives, the end point and how the intervention will be done. Done properly and judiciously, it is very possible that the current irksome systemic issues in healthcare ser-vices will be rectified. This rectification and redesign of the healthcare system will inevitably provide a platform and usher in sustainable, viable and quality healthcare services. The future of healthcare in South Africa depends on this.

It is therefore very important for all the players in the health-care environment to: Embrace the principles in the Policy on the National

Health Insurance. Embrace the clear end point of the policy, and posi-

tion themselves to play a constructive role in its implementation.

Actively build bridges to connect both the private and public healthcare sector. This will allow for a pooling of resources, and unlock them to the benefit of all South Africans.

Provide expertise on how healthcare finances can be rudently managed, to gain service efficiencies, strategic purchase and reimbursement of healthcare services.

It is my optimistic view that if all of the above occurs, there is a sustained and viable future for healthcare services in South Africa and other countries in Southern Africa.

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HEALTHCARE 360º

Dr HZ Zokufa is MD of the Board of Healthcare Funders of Southern Africa6

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HEALTHCARE 360º


By Kevin Aron, CEO MEDSCHEME

Similar to other countries, South Africa is grappling with a healthcare system that is becoming increasingly complex.

Evolution of modern medicine, financing reform, political developments, advances in technology and legal and regulatory changes are impacting the delivery of healthcare.

Unsustainable cost increases are running parallel to such transformations. Yet, the South African private healthcare system remains functional against the background of a public healthcare system that is grappling to provide quality primary, secondary and tertiary care to the larger population. This presents a significant opportunity for responsible private sector stakeholders, in collaboration with Government.

In this context a significant “hidden” cost driver within the local system is the fragmentation of healthcare delivery.

There are many definitions of the term but

CO-ORDINATION OF CARE

essentially fragmentation involves multiple decision-makers making healthcare decisions in isolation. "This has an impact on the efficiency of healthcare delivery, affecting cost and quality outcomes negatively," explains Kevin Aron, CEO of Medscheme.

He believes that improved co-ordination of care is one of the many innovative opportunities relating to healthcare funding and delivery that must be explored.

Medscheme, according to Aron, supports the definition of co-ordination of care used by the National Committee for Quality Assurance: "Care co-ordination is the deliberate organisation of patient care activities between two or more participants (including the patient) involved in a patient's care, to facilitate the appropriate and cost-effective delivery of healthcare services. Organising care involves the marshalling of personnel and other resources needed to carry out all required patient care activities (without duplication) and is often managed by the exchange of information among participants responsible for different aspects of care."

One of the goals to achieve sustainable healthcare

Improved co-ordination of care is one of the many innovative opportunities relating to healthcare funding and delivery that must be explored.

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HEALTHCARE 360º

8

He maintains the co-ordination of beneficiary-centric medical scheme care ideally requires adherence to four high-level guiding principles:

1 Supporting the beneficiary and the beneficiary’s family through education and information sharing which gives them the knowledge of what should be achieved through coordinated, quality, cost-effective and affordable healthcare.

2 Supporting and contractually obliging co-ordinated quality, cost-effective healthcare service delivery by providers of care, within the constraints of available resources.

3 Setting financial incentives and establishing agreed care pathways to ensure provider adherence and accountability for quality, cost-effective and affordable care.

4 Establishing a relevant electronic information sharing framework.

According to Aron, it is safe to say that no country will ever be in a position to raise adequate funds to provide for all the quality healthcare services its citizens may need.

"It is incumbent on our country’s healthcare leaders, many of whom are participating in the BHF conference, to ensure that limited resources can be stretched as far as possible," Aron concludes.

Kevin Aron is CEO of Medscheme

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Innovation and expertise underpin our progressive approach

to health risk management to bring about meaningful cost

containment without sacrificing quality. This, coupled with

our relentless drive towards operational efficiency ensures

improved access to quality, affordable healthcare.

The key to sustainable healthcare

www.medscheme.com


B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

LIBERTY MEDICAL SCHEME PERSPECTIVE

10

With the price of medical cover eating into a big part of your

salary, it’s tempting to think that buying cheaper health insurance, rather than joining a medical scheme, will cost you less. “But health insurance products will often only cover a fraction of the costs if you are admitted to a private hospital and you could be left just one heart attack away from financial disaster,” says Executive Principal Officer of Liberty Medical Scheme, Andrew Edwards.

Edwards says understanding the difference between health insurance products and medical scheme cover – whether it be a hospital plan or comprehensive cover – is vital in making the decision on how best to protect your family’s health.

CHEAP, BUT LIMITEDHealth insurance can be bought from as little as R86 a month, typically from a large life insurer.

Health insurance products usually pay out a flat rate per day you are in hospital – it is not dependent on what condition or procedure you have.

Instead of paying the provider, the insurance company pays you directly and you are then responsible for set-tling the bill. Typical payouts on health insurance products range between R2 500 to R5 000 a day.

“That sounds like a lot, but in reality, it is unlikely to come close to cover-ing the costs of doctors, specialists and medical procedures such as sur-gery while in hospital,” says Edwards. “The daily rate for booking a bed in a general ward is around R2 500 per day alone.”

According to Liberty Medical Scheme research, Edwards points out, an average hospital bill is around R150 000, depending on the condi-tion that the patient has. The average length of stay in hospital is three days. “Some insurance products only pay

out from day three of being in hospi-tal,” he adds.

Another factor to consider is that if you try to use your insurance as a guarantee of payment to be admitted to a private hospital, you’re likely to be turned away. “Most private hospi-tals will not view insurance products as credible cover and will request an upfront cash deposit – which can be as much as R40 000 – before you are even admitted.”

However, if you don’t buy insurance, you are taking the risk of self-insuring. “You need to weigh up the option of putting what you would be paying in insurance contributions into a high interest earning account or invest-ment that could build up a good-sized emergency medical fund over time should you need it.”

By choosing medical scheme cover which is tailored to suit your needs and budget, you will not be caught short when it comes to taking care of your health.

Beware: you could be left out of pocket by health insurance products

Choosing a reputable medical scheme

that gives you value for money for your contribution

can mean the difference between getting access

to quality private medical care or not.

““

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LIBERTY MEDICAL SCHEME PERSPECTIVE


MEDICAL SCHEME COVERIn contrast to health insurance, you can buy (for an individual) a hospital plan from a medical scheme for around R839 a month and comprehensive medical scheme cover from between R2 000 to R3 800 a month. “The difference is that you get much better cover if you are a member of a medical scheme if you experience a serious health episode or are involved in an accident,” says Edwards.

He adds: “Choosing a reputable medi-cal scheme that gives you value for money for your contribution can mean the difference between getting access to quality private medical care or not.” Because medical schemes are registered with the Council of Medical Schemes (CMS), they have to cover certain conditions and emergencies – called Prescribed Minimum Benefits (PMBs) – in full, regardless of the plan you are on. Insurance products do not fall under the same regulations and therefore offer limited cover.

It’s also important to note that while medical scheme contributions are tax deductible, health insurance contri-butions aren’t. For the 2015 tax year, the medical tax credit available is R257 per month each for the taxpayer and the first dependant, and R172 per month for every additional dependant for contributions made to medical schemes.

Hospital plans cover all the costs related to your treatment in hospital – no matter how long you are hospitalised or how severe your condition. This means that whether you need surgery or are admitted to ICU, you don’t need to worry about your funds running out.

Of course the best way to avoid incurring the high costs associated with hospitalisation is to avoid being admitted in the first place. If you are on a comprehensive plan, find out what preventative care benefits your medical scheme offers – such as cholesterol and insulin blood tests, diabetes management, screens and scans.

“Your plan should cover these types of costs from the risk portion of your medical scheme and not out of your medical savings,” says Edwards. “Choose a scheme that knows how to make the most of your health when you are well, as well as take care of you when you are ill.”

By choosing medical scheme cover which is tailored to suit your needs and budget, you will be making sure you’re not caught short when it comes to taking care of your health.

LIBERTY MEDICAL SCHEMEAndrew Edwards

Executive Principal Officer


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SAMWUMED PERSPECTIVE

12

According to the July 2013 edition of the Statistics South

Africa Fieldworker summary report, the average life expectancy of a South African is 59.6 years. The grim reality of these findings is the fact that a huge percentage of the country’s population still does not have access to equal healthcare, either in the public or private sector.

Our constitution enshrines the rights and freedom to quality healthcare

for all, and Government is actively advocating for a National Health Insurance Plan, which is premised on the same ideology. How is this to be realised in increasingly fragmenting public and private health sectors?

Notwithstanding that 16% of South Africans have access to private healthcare via medical schemes; we are still being challenged by many issues which include an increase in the burden of disease, the cost of private health services, the de-regulation of costs and the need for negotiated deals between funders and healthcare service providers – all resulting in exorbitantly high medical aid premiums.

Smaller and lower-cost medical schemes are at the mercy of this tug of war where they are expected to provide the same healthcare inter-ventions, regardless of how low their contributions per member may be.

This is exacerbated by the denial of care for seriously chronic patients in state hospitals for medical aid members, where treatment was sought for very expensive PMB conditions by low income schemes as a buffer against the interpretation of PMB legislation.

This constitutes a human rights issue, as the State may not turn away any patient, regardless of their income status – albeit at a higher cost (increas-ing revenue for destitute patients).

The average cost of care per medical aid patient is indicative of an unsus-tainable system: Between 2007 and 2013 the average hospital cost per beneficiary per annum (pbpa) in SAMWUMED increased by about 180%. This was at a designated service provider hospital network – the number is much higher at non-designated providers, where no deals exist.

Funders and service providers must engage to ensure progression from a curative health model to a preventative health model – within a regulated regime.

SAMWUMEDNeil NairNair is the Principal Officer of SAMWUMED and the opinions expressed are shared by SAMWUMED.

How to reduce the burden and cost of medical aid...

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SAMWUMED PERSPECTIVE


Why is patient care so significantly on the rise? The answer lies in the de-regulation of cost and an increased burden of disease often detected very late.

What can be done to stop this run-away train? The answer rests in tariff regulation and of course creating a progressive, preventative healthcare system.

As an industry we have pronounced much on the former and I would wish to exercise our voice on the latter.

PREVENTATIVE SOLUTIONSPreventative healthcare solutions are often touted, but more often than not, never implemented as a complete strategy. If we can con-trol disease we can better manage health costs. Medical schemes play a significant role in the health process and must use their strategic advantage to ensure healthier members by facilitating and indeed rewarding prevention strategies.

Medical schemes do employ interven-tion strategies to better manage the risk pool, such as co-payments and benefit risk strategies via managed care. We must recognise that the solution does not simply rest with benefit cut-backs and certainly NOT with co-payments as these deal a double blow to the member.

It rests with the progressive realisa-tion of better preventative strategies, for example by employing benefits for vaccinations, screenings, healthcare assessments, vitamins, contraception,

circumcision, etc. as a means to better manage quality health outcomes which would ultimately result in lower medical aid premiums.

Easily diagnosed and treatable chronic conditions such as hypertension and diabetes are often left undiagnosed; contributing heavily to the health cost burden. The statistics in the table below are extracted from the Health Quality Assessment (HQA) Report and reveal frightening facts.

members, given that there is no competition between these schemes?

According to the 2013 HQA Report which is produced annually, it is the responsibility of the health industry to ensure: “The right diagnoses, followed by the right treatment in the right setting, at the right time, at the right price, delivering the right outcome, every time”. This is why measuring clinical quality is a cornerstone of an effective healthcare system.

SAMWUMED INDUSTRYHypertension 15.5 12.7

Diabetes 6.6 3.9

Asthma 5.5 4.7

HIV 2.5 1.8

The same report further supports the notion that the objective of preventative care and health screen-ing initiatives is to detect illnesses early, prevent future illness, and to minimise the complications and costs that could be associated with such illness, particularly with respect to those who are at higher risk.

South Africa is one of many countries with a two-tier health system that is challenged with dire healthcare needs. Until medical aid schemes are better protected and indeed incen-tivised to implement preventative health treatment, the issues will only worsen.

The expected result of better quality of care in the primary health-care setting would be that patients would be healthier while enjoying lower medical aid premiums.

PRICE INEQUALITYIf one considers the care pro-vided for in-hospital costs for these conditions – it would indicate that the rate of prevalence is much higher and has remained undetected and thus inappropriately treated – causing considerable down-stream costs.

What is even more startling is that we have witnessed an average increase in the cost pbpa of approximately 18% between 2008 and 2013. This is about three times the average annual infla-tion. In the private healthcare sector networks exist, however, in bilateral vacuums for competitive purposes which far too often limit the poten-tial for the economies of scale that would serve to lower medical aid premiums.

Why shouldn’t SAMWUMED mem-bers enjoy the same rates as GEMS

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METROPOLITAN HEALTH PERSPECTIVE


The status quo for South African healthcare is not an option.

Creating a far more inclusive system is essential. Dylan Garnett, CEO of Metropolitan Health, outlines key aspects of a future system that gives all South Africans equitable access to affordable, quality healthcare.

Addressing current inefficiencies and inequities takes place against a backdrop of serious resource constraints. The evolving system will need to address the heavy triple burden of infectious diseases, non-communicable diseases (NCDs)

and injuries. Alongside this is the paradox that successfully managing high levels of infectious diseases accelerates the increase of NCDs, as greater longevity increases the risk of developing a chronic condition.

National Health Insurance (NHI) is no panacea. In essence, NHI is a finan-cing mechanism. The future healthcare dispensation has to address systemic cost drivers and delivery issues.

Primary and preventative health-care needs to become the fulcrum for delivery. Provider networks and clinics, including in-pharmacy clinics, will become the first point of entry in the future health value chain.

The focus will shift to out-of-hospital solutions, such as home-based care; however seamless coordination between in-hospital and out-of-hospi-tal care is vital.

Supported by integrated technology, the coordination of care across the care continuum will be vital in unlock-ing efficiencies, reducing costs and improving health outcomes. Smart

technology and predictive modeling should be leveraged to enable early detection and proactive intervention.

While more efficient provider remuneration models and, possibly, some form of price regulation, may generate supply-side efficiencies, addressing demand-side dynamics is also essential. A ‘fix-me’ attitude and blind reliance on benefits, whether funded by a medical scheme or NHI, is no basis for sustainability. Patient advocacy and mHealth innovations will transform patients from passive recipients to active, co-producers of their own health.

“Successfully transforming the South African healthcare system will require a co-creation mindset and genuine collaboration across all stakeholders,” Garnett concludes.

The coordination of care across the care continuum will be vital in unlocking efficiencies.

The future healthcare dispensation has to address systemic cost drivers and delivery issues.

Primary and preventative healthcare needs to become the fulcrum for delivery.

The focus will shift to out-of-hospital solutions, such as home-based care.

AT A GLANCE

METROPOLITAN HEALTHDylan Garnett, CEO

Co-creation essential forinclusive healthcare


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OLD MUTUAL INVESTMENT GROUP PERSPECTIVE

16

The South African healthcare sector can be broken down into two

parts, namely pharmaceuticals and hospitals. In the pharmaceutical sector, we’ve already had regulation with the introduction of Single Exit Pricing (SEP), which caps the annual increase in the manufactured price of drugs. In addition, we’ve also seen a cap on the increases a pharmacy can add to the retail price of drugs in the form of a dispensing fee.

What has been mentioned, but is yet to be introduced, is regulation of the fees

The effects of regulation/legislation on the healthcare sector

charged for the distribution of phar-maceuticals and, more importantly, international benchmark pricing. The latter aims to ensure that drugs in SA are competitively priced compared to drug prices in other countries. In short, regulation will ensure better prices for consumers.

From an investment perspective, this regulation needn’t have a completely adverse effect on local pharmaceuti-cal company share prices, as it could force participants to look elsewhere for growth. Consider the case of Aspen, the share price of which had a stellar run when it diversified its geographical foot-print to become a truly global player.

In the private hospital sector it gets a bit trickier. The Competition Com-mission has established an inquiry into the private healthcare sector with the primary aim of increasing competition, which will hopefully result in decreased prices.

The focus areas of the inquiry are:

1 To change the way hospital licenses are granted: Generally, one geographical zone gets one hospital licence. This gives the hospital a catch-ment area and, effectively, a monopoly in that area.

2 To take a closer look at the broker model: Currently, medical scheme agents or brokers align themselves with one medical scheme, as medical schemes remunerate them through commissions. This process does not promote the need for the insured individual to shop around and look for a better deal, a state of affairs which may artificially keep scheme prices high. An alternative model may be for the consumer to pay a flat fee to the broker instead.

The result? Competition should benefit the consumer. However, for the hospi-tals to negate the effects of increased competition and sustain or increase profit levels, they will need to continue to increase efficiencies and patient volumes.

To negate the effects of increased competition, hospitals will need to continue to increase

efficiencies and patient volumes if they are to sustain or increase profit levels.

OLD MUTUALPhilip Short Analyst at Old Mutual Equities, Old Mutual Investment Group

Old Mutual Investment Group (Pty) Limited is a licensed financial services provider, FSP 604, approved by the Registrar of Financial Services Providers (www.fsb.co.za) to provide intermediary services and advice in terms of the Financial Advisory and Intermediary Services Act 37 of 2002. Old Mutual Investment Group is a wholly owned subsidiary of Old Mutual (South Africa) Limited. Reg No 1993/003023/07.

The investment portfolios are market linked. Products may either be policy based or unitised in collective investment schemes. Investors’ rights and obligations are set out in the relevant contracts. Market fluctuations and changes in rates of exchange or taxation may have an effect on the value, price or income of investments. Since the performance of financial markets fluctuates, an investor may not get back the full amount invested. Past performance is not necessarily a guide to future investment performance.

MACROSOLUTIONS

INVEST WITH PERSPECTIVE

Medical aid PORTFOLIO

MacroSolutions Medical aid Portfolio• Target: CPI + 4% per annum • Objectives:

o Stable capital growth ando Capital protection over rolling 18-month periods

• Active asset allocation• Regulation 30 compliant• Expected to beat money market returns over the medium term

0

100

200

300

400

500

600

700

800Money Market*

CPI

CPI + 4%

MacroSolutions Medical Aid Portfolio

Jul-9

9

Dec

-99

May

-00

Oct

-00

Mar

-01

Aug

-02

Jan-

02

Jun-

02

Nov

-02

Apr

-03

Sep-

03

Feb-

04

Jul-0

4

Dec

-04

May

-05

Oct

-05

Mar

-06

Aug

-06

Jan-

07

Jun-

07

Nov

-07

Apr

-08

Sep-

08

Feb-

09

Jul-0

9

Dec

-09

May

-10

Oct

-10

Mar

-11

Aug

-11

Jan-

12

Jun-

12

Nov

-12

Apr

-13

Sep-

13

Feb-

14

Jul-1

4

Source: MacroSolutions

MacroSolutions Medical aid Solution vs Money Market & cPi + 4%

(15 years to June 2014)

* STeFI

Expose your medical scheme to international and local asset classes − actively managed across regions, sectors and economies − in line with regulatory requirements.

The challengeTime horizon: Medical scheme funds are long-term investors with short-term solvency measurement. This means that they are forced to shorten their time horizons. In doing so, they trade off potential investment returns, which introduces risk to their long-term prosperity.

Limited exposure to growth: Regulation 30 of the Medical Schemes Act:

• No exposure to foreign equity • 40% exposure to local equity

Your SolutionAn actively managed and a diversified portfolio We move freely between asset classes to gain exposure to investment opportunities that offer inflation-beating returns while avoiding exposure to risk.

Risk and return profileTo deliver inflation-beating returns, we go beyond an ultra-conservative cash/money market portfolio by using an appropriate mix of assets. This is a vital element of making medical aid schemes more sustainable, as better returns in the long run will enable lower contributions and/or improved benefits for members

Our experience• We manage R1.5bn in medical aid portfolios.• We have been managing these portfolios for 19 years.

Portfolio managers

PeTeR BROOKEHead of MacroSolutions

URVeSH DESAIPortfolio Manager & Strategist

CONTACT USwww.macrosolutions.co.za | [email protected]

Capital Preservation SuccessOver rolling 18-month periods capital has been protected 97% of the time and the maximum loss has been 1.3%.


B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

HEALTHCARE INSIGHT

18

Healthcare and a healthcare system are

major contributing factors of economic growth and social development in any country. The global call for countries to provide uni-versal access to healthcare is also embraced by South Africa in the form of the National Health Insurance (NHI).

The reform from the exist-ing health system to a NHI system refers, in essence, to the reform of healthcare financing in South Africa in order to improve access to affordable, quality health-care services regardless of socio-economic status.

The private sector plays an important role in improving access to healthcare and

Towards innovative healthcare in South Africa

reducing the burden for the public sector. However, only 8,7 million people of the total population of around 53 million are beneficiaries of private healthcare, i.e. medical schemes.

It is estimated that about 21% of the population, not on medical aid, prefer to use private doctors and pharmacies, paying on an out-of-pocket basis. They rely almost entirely on public sector specialists and hospitals, while the remain-ing 60% of the population are completely dependent on the public sector for all their healthcare services.

Innovation to enhance the future of healthcare should include mandatory partici-pation in medical schemes’

membership for people in formal employment and increasing income cross-subsidisation among members.

Income cross-subsidies are required to ensure that medical scheme mem-bership is affordable for lower-income households. Currently, wealthier house-holds spend a far lower proportion of their income on medical scheme contributions.

In an environment of open enrolment and community-rating without mandatory medical scheme member-ship, it is unavoidable that the healthy will opt out while the sick will opt in.

By implication, the preva-lence of the prescribed minimum benefits (PMB) conditions will increase, ultimately resulting in an increase in the average cost of benefits, of which PMBs

Failure to regulate the supply side of the market will erode social solidarity and financial protection

will represent a large pro-portion. Furthermore, there is a dire need to establish a statutory pricing authority to regulate price setting by private hospitals, day clinics, private primary healthcare centers and specialists.

The adverse impact of vertical relationships between specialists and private hospitals needs to be addressed. Failure to regulate the supply side of the market will erode social solidarity and financial pro-tection within the industry.

Therefore, a healthcare environment of financial stability is urgently required within which the medical scheme industry can thrive while promoting quality, accessible healthcare for all South Africans.

R E G U L A T O R Y

By Dr Elsabé ConradieCouncil for Medical Schemes

Dr Elsabé Conradie is Head: Stakeholder Relations at the Council for Medical Schemes

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

HEALTHCARE INSIGHT

Gone are the days where the transferring of

knowledge was seen as a one-way process.

These days we all have something to teach and something to learn.

Today, healthcare systems around the world are expe-riencing an era of rapid and dramatic changes as they struggle to cope with aging populations, technological advances, rising expecta-tions and spiralling costs.

In the South African

Innovate and elevate healthcare systemscontext, these challenges pose an opportunity to make private healthcare more accessible and of higher quality for all citizens.

Auditing and professional services company, KPMG, sees four major opportuni-ties of reshaping healthcare today:

1 Payers are becoming ‘activist payers’ by pay-ing for value delivered to patients, reshaping patient behaviour and moving care to other settings.

2 Providers are respond-ing to ‘activist payers’ by either delaying trans-formational change or using the opportunity to transform themselves into 'health systems' and by taking on risk and/or accountability for out-comes.

3 Patients are becoming active partners in their

Healthcare systems around the world are experiencing an era of rapid and dramatic changes

care, rather than pas-sive recipients. This is changing the clinician’s role from ‘God to guide’, as one physician put it.

4 ‘High-growth healthcare systems’ in Africa, South American and Asia are a hot bed of innovation. Private equity is a big driver in this.

A D V I S O R YS E R V I C E S

By Dr Anuschka Coovadia KPMG

We have moved!

We have moved!

We have

moved!

Lower Ground FloorSouth Tower

1Sixty Jan Smuts AvenueCnr Tyrwhitt Ave

Rosebank, Johannesburg


B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

EXECUTIVE Q&A

20

BHF360° sat down with Dr Nomalungelo Nyathi to find out why she is so passionate about healthcare administration, and what other issues are close to her heart.

GettinG to know Dr. Nomalungelo Nyathi

Do you still practice?

A No, I don’t. I made the decision not to get into clinical work on a permanent basis while I was still a student. Medicine is about so much more than hands-on patient care, and I pre-

fer to work in the fields of healthcare systems, administration and management. Medscheme offered me an opportunity to do so in the private sector, and I feel more fulfilled than ever in my current role.

You’re Executive Director at Aid for Aids. What is the connection here with Medscheme?

A Afrocentric Health is a group of healthcare companies in the private healthcare industry, which includes Medscheme – which specialises in medical scheme administration and

managed care provision. The group owns other companies such as Aid for Aids – which specialises in HIV management, both for schemes as well as for corporates and, to a certain degree, public funders.

How often are you in Johannesburg?

A I live in Cape Town, but many of my clients are based in Jo-hannesburg, so I travel between the two cities every two weeks or so.

Executive Manager: GEMS Managed Care

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

EXECUTIVE Q&A


The conversations have

moved towards staying healthy

and leading a productive

life, having access to

medication and access to life

insurance, and not being

stigmatised at work.

““What are some of your key contributions at Medscheme?

A Medscheme is a for-profit organisation so driving revenues through providing top-quality service to clients is obviously key. I add value for clients by

advising on strategy and current market trends, by leading and managing a business unit of around 520 employees, and by developing new business.

Do you think the level of HIV/Aids awareness is high enough?

A I think we are moving to an era where no one is sticking their head in the sand anymore. Also, the stigma related to being HIV positive is abating now,

which means the conversation has moved towards staying as healthy as possible, leading a productive life, and having access to medication and to life insurance. We’re currently interacting with people who have been in treatment for up to a decade, so our focus with them is on how the treat-ment has changed their lives, what the side effects are, and other related issues. We are also continuously investigating how all business role players can get meaningfully involved. Corporates are taking a keen interest in HIV management for their employees because it affects productivity. So the conversation here has expanded to include these role play-ers and new approaches to the prevention and manage-ment of the disease.

What are you currently reading?

A I ‘m busy reading texts on value-based leader-ship, and – as I’m a religious person, I also enjoy reading some church leadership literature as well.

I also thoroughly enjoy historical fiction. Walter Beats, Michael Porter, and Francine Rivers are on my list of favourite authors.

Tell us about your family

A I am married and have two children.

How has motherhood changed you?

A I am a bit of a workaholic and tend to treat every-thing in my life as a ‘project’, so initially mother-hood was something I tried to fit into all the other

things I do and like. However, since becoming a parent I’ve found myself soften as a person – I’m now more patient, my EQ has definitely gone up, and I’m much less ‘task orien-tated’ and more ‘people focused’ than I used to be.

What do you do to unwind?

A I do all kinds of dance from salsa to ballroom to clubbing - depending who I am hanging out with. I co-run poetry cafes in Cape Town where differ-

ent poets share their work, which we sometimes expand to include musicians as well.

What are some of the teachings from your upbringing that you still carry with you?

A The main lesson I carry with me, from my mother, is to ‘Finish well and strong’. When still in medical school, I realised that I did not want to practice

clinical medicine. But I completed my studies regardless. This lesson continues to be one I strive to live by, as finish-ing well is still important to me..

Contact Chantell Giulietti on: 041 506 5900 | [email protected] | www.ppn.co.za

Preferred Provider Negoti ators | B-BBEE level 2

The future of healthcarein the optometry space

Aft er 20 years’ experience in managed care PPN believes that the future of healthcare in the optometry space will be linked to:

Raising the clinical and service experience of the consultati onOur comprehensive consultati on includes a refracti on, tonometry and visual fi eld screening plus the screening for Blood glucose, Blood pressure and Cholesterol. PPN together with our network providers will be off ering a second benefi t warranty for those members who break, damage or lose their spectacles

Bett er Lens PricingClear lens prices will not be increased for 2015 and lens enhancements will be reduced by 15%

Lower Non Healthcare CostsWe have dropped our management fee on all capitated products to 5%.

Introducing Biometrics:PPN has developed a Biometric platf orm over the last 2 years and has started rolling out Biometrics to our network providers. We see Biometrics playing 2 important roles going forward: (1) members can personally control their opti cal data and electronic record card; and (2)reliance on the Biometric reading will eliminate the need for medical aid cards and associated fraud through card swopping.

Focusing on Forensic controlsMore emphasis will be placed on practi ce profi les to detect deviati on from the norm in terms of fraud and benefi t design. PPN has the unique ability through the profi les developed over the past 20 years and the volume of 2.7 million lives to access the most sophisti cated practi ce profi les in the optometry space. Our forensic unit uses these profi les to detect abnormal claiming patt erns for both current and new schemes joining PPN. They also make use of a hotline and mystery shopping as well as conduct interviews with medical aid members. Additi onal sophisti cati on developed by PPN to control fraud is: (1) ValidateIT where we collect informati on from 80% of all laboratories that validate that both Bifocal and Multi focal lenses ordered, have been manufactured. Providers when claiming have to quote the laboratory used and the order number which allows us to validate that the claim matches the lens order;

(2) NVS frame tagging system which is designed to develop over ti me a control methodology for the mark up value applied to spectacle frames

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

BHF PERSPECTIVES

By Lynette Swanepoel

BHF HFMU

When it comes to address-ing healthcare fraud head-on, tough sentencing is not

enough. The crime has been com-mitted, and the money is gone. We need to focus more on prevention, says Lynette Swanepoel, manager of the Healthcare Forensic Management Unit (HFMU) at the Board of Health-care Funders of Southern Africa.

Healthcare fraud is a persistent problem within the industry, with an increasing level of sophistication being demonstrated by the culprits.

"With the multiplicity of skills, sys-tems and expertise that already exist in the private funding sector,"

23

PROTECT AGAINSTand prevent healthcare fraud

Much can be done to guard against the creation of medical aid ‘scams’

says Swanepoel, "it would make sense, moving into a National Health Insurance (NHI) environment, to form a public- private healthcare fraud prevention and enforcement action team."

Swanepoel says other possible solutions aimed at preventing healthcare fraud



B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

BHF PERSPECTIVES

24

could include encouraging healthcare funders to exchange anti-fraud infor-mation, best practices, and trends, both nationally and internationally.

“This kind of information transfer could also be extended into the public sector,” she says. The use of predictive analytics to pick up trends, a greater emphasis on doing background checks on new healthcare providers, tougher enforcement of rules and regulations by the relevant statutory councils, and centralising drug pro-curement could also prove effective deterrents to healthcare fraud, she adds.

Among the more novel approaches suggested is the establishment of ‘senior patrols’, involving the formation of groups of trained senior citizen volunteers. These could teach others about healthcare fraud, identify protection, how to read medical aid claims statements and avoid being scammed; and educate

medical scheme members to protect against, detect and report fraudulent activities.

Other suggestions put forward for consideration included the following: The development of engaging

public awareness campaigns aimed at creating increased

AHFoZ

Bonitas Medical Scheme

De Beers Benefit Society

Denis

Keyhealth

Liberty Health

Medihelp

Medscheme

Metropolitan Health

Momentum Health

PHA

Providence

Polmed

PMSA

PPN

PPS

RAF

Rand Water Medical Scheme

Regent insurers

Resolution Health

Samwumed

Sanlamhealth

Sechaba Medical Solutions

Standard Bank Forensics

Thebemed

Universal Healthcare

Veripath/Verirad

HFMU MEMBERS

EHFCN

CHCAA

HICFG

NHCAA

GHCAN

MarisIT

Pluritone

Qhubeka Forensic Services

HFMU PARTNERS

Big cases may require big investments

Listen to your whistle-blowers

The law requires you to report fraud

Essential elements of fraud are unlawfulness, misrepresentation, prejudice and intention

FAST FRAUD FACTSawareness around identity theft and common healthcare fraud scams

A look at the Obama Administra-tion's strategies for preventing and combating healthcare fraud to ascertain whether these could be effective in combatting fraud in South Africa and other Southern Africa countries

Enhancing the current local legis-lation around healthcare, in line with the Patient Protection and Affordable Care Act in the United States

Introducing fraud awareness training programmes for medical students about to graduate

However, perhaps one of the most effective measures is when ordinary citizens make the effort to get involved and report their suspicions, says Swanepoel. She urged those aware of fraudulent activities to report these to the HFMU tip-offs line on 080 TIP HFMU / 080 847 4368.

Merck takes its corporate responsibility seriously and has

worked especially hard over time to entrench a culture of

giving throughout the organisation.

Locally, Merck’s responsibility projects include the Alexandra Health Centre and University Clinic, iThemba Labantu, the Tomorrow Trust and Stop Hunger Now Southern Africa.

Alexandra Health Centre and University Clinic is a community health centre serving approximately 800,000 people. Merck assists the clinic through financial donations and practical support.

iThemba Labantu, a care centre in the Western Cape, provides medical and psychological support to the community; more specifically to people affected by and living with HIV and AIDS. Merck has adopted this centre and provides it with financial assistance.

Merck – Living its Responsibility The Tomorrow Trust is a South African based non-profit organization supporting orphaned and vulnerable youth to achieve their educational goals. Merck sponsors post-secondary students by giving them an opportunity to gain hands-on experience working at Merck’s office.

Stop Hunger Now Southern Africa is a volunteer-based meal packaging and results-orientated nutrition program proudly supported by Merck. Their vision is a Southern Africa without hunger and their mission is transformation through education.

Globally, Merck has consolidated its resources into two main projects, namely the Merck Praziquantel Donation Program and the Global Pharma Health Fund (GPHF).

Merck supports the World Health Organisation (WHO) in combating schistosomiasis, a widespread tropical worm disease, with tablets comprising of praziquantel – an effective treatment for this debilitating disease. These tablets will make it possible to treat 27 million children for schistosomiasis in the most severely affected countries of Africa. Counterfeit medicines are a serious threat to healthcare and the World Health Organization (WHO) estimates that 10-30% of all medicines worldwide are either counterfeit or of inferior quality. The Global Pharma Health Fund (GPHF) is a Merck-funded initiative that provides assistance in combating counterfeit medicines.

Merck is an organisation that cares and as such can appreciate and understand just how important it is that its communities remain supported during their times of need.

Ruth Field, Head: Market Acccess and Pricing

(South East Africa), Merck Serono

ADVERTORIALB H F 3 6 0 ° | S E P T E M B E R 2 0 1 4


B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

BHF PERSPECTIVES

26

Edited by Fay Humphries

Freelance Journalist

The primary principle on which BHF’s response is based is that Section 27 of the Constitu-

tion guarantees access to healthcare service as a human right. As such, healthcare services, irrespective of whether these are delivered in the public or the private sector, must be seen as a “public good”.

In this context, it concerns BHF that the focus of the terms of reference in the Competition Commissioner’s draft statement is on harm to competition,

Dr Rajesh Patel, Head: Benefits and Risk at BHF, and Dr Debbie Pearmain, independent legal consultant, developed a joint response on behalf of BHF, on the Competition Commission’s draft statement of issues, dated 30 May. The main points contained in this BHF response are summarised here.

COMPETITION in healthcare not the only answer

and not on how strengthening compe-tition can assist in achieving improved access to healthcare services.

Competition is not an end in itself but a means to an end. In the healthcare context, that end must always be the progressive realisation of the right of access to healthcare services.

If competition interferes with or impedes access to healthcare ser-vices, even within the private health sector, or interventions or recom-mendations by the Competition Commission have the same result, then BHF maintains that such action is inconsistent with the Constitution.

The state has an obligation to respect, protect, promote and fulfil the rights in the Bill of Rights. This includes the right to have access to healthcare services.

BHF is of the view that regulatory intervention, and not strong competi-tion, within the private health sector is a prerequisite for the realisation of the right of access to healthcare services. Government must imple-ment regulated pricing for healthcare services in pursuit of the constitutional mandate rather than as a response to any market failures.

While BHF acknowledges and respects

the fact that the role and function of the Competition Commission is to promote competition, this role must be fulfilled within the broader context of the South African constitutional framework and the Bill of Rights. The market inquiry into private healthcare by the Competition Commission, while investigating the general state of com-petition in the market, must not lose sight of the weaknesses of competi-tion as far as this particular market is concerned.

There will be factors other than com-petition which have a bearing on the market inquiry and which operate in conjunction with market principles and competition to influence the state of the private healthcare environment.

BHF regards the notion of competition as inherently flawed as a mechanism for ensuring equitable and ideal dis-tribution of healthcare goods and services. At best competition is only one of a number of tools that must be used to promote access to healthcare services by consumers in the private health sector.

BHF believes that treating the pri-vate healthcare sector as just

another market for commodities and services is not justifiable in consti-tutional terms. The harm this does to consumers has been amply dem-onstrated by the fallout from the Competition Commission’s previous interventions in the private health sector. A previous Competition Com-missioner told doctors they could charge what they like for their ser-vices. They took his advice with the resulting increases in healthcare expenditure and prices to which the TOR now refers.

By confining itself to theories of harm to competition, BHF is concerned that the Competition Commissioner may lose sight of the bigger picture, and that there is a danger that its find-ings and recommendations will be geared more towards the strength-ening of competition in the private health sector and not necessarily the realisation of the right of access to healthcare services by consumers.

While there are certainly factors that may adversely affect competition in a market and competition may to some extent be healthy in the private health sector, BHF believes that competition alone cannot yield the desired results.


Other considerations raised by BHF

There is a need to evaluate and include the content of the prescribed minimum benefits (PMB), its associated regulation and the manner in which these are enforced by the regulator as drivers of inflated healthcare pricing and expenditure.

The total costs in healthcare need to be evaluated – not just prices, expenditure and costs – and a root cause analysis needs to be done, to promote an understanding of the various factors that have resulted in increases in the private health sector.

Many people have access to membership of a medical scheme by virtue of their employment and employment benefits. The options of which scheme to join are often limited by who they work for. The extent to which medical scheme membership is a corporate decision taken by an employer for its employees needs to be factored into the Competition Commissioner’s investigations into consumers.

The Competition Commissioner should also implement an inquiry into the pricing determination, and its public listing, by suppliers for medical devices and medical consumables other than pharmaceuticals and the market structure in the area of consumables, taking specific note of previous publicity related to the perverse practice of rebates.

HEALTHCARE 360º

BHF is of the view that regulatory

intervention, and not strong competition,

within the private health sector is a

prerequisite for the realisation of the right

of access to healthcare services.

““


B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

EXECUTIVE Q&A

28

BHF360° spent some time with Lamees Scholtz to chat about upcoming changes, challenges and her contribution.

GettinG to know Lamees Scholtz

What do you do at the BHF?

A I am responsible for three portfolios. The biggest and most challenging of these is the management of the Practice Code Numbering System (PCNS). The unique practice number is

generated through the BHF system which is used to facilitate pay-ment between service providers and medical schemes.

The system has been around for a long time and was originally adopted from an in-house system. Since its humble beginnings, it has evolved and we are currently going through an exciting meta-morphosis. This transformation is in response to the ever-changing healthcare environment and the introduction of NHI. The way every-one in the healthcare industry operates will change in this country and we will have to change in order to remain relevant. I am excited about the imminent changes. The PCNS unit has been aligning its processes to the changing legislative environment and we are becoming more tech-savvy, bringing the BHF systems into the 21st century. The manual validations which lead to errors at time are now being automated, ensuring that the data is credible.

Which brings me to my relatively new portfolio – the Knowledge Management (KM) unit. The concept of KM has been a key strategic issue for BHF since its inception. As a representative body our constituents rely on us to be informed and keep them informed. I am tasked with redesigning and implementing this core offering.

Executive Coordinator: MD Offices, PCNS & Knowledge Management

B H F 3 6 0 ° | S E P T E M B E R 2 0 1 4

EXECUTIVE Q&A


The way everyone in the

healthcare industry operates will change

in this country and we will have to change

in order to remain relevant.

““Last but not least, my third portfolio relates to the management of the MD’s Office operations and admin-istration activities with the assistance of an executive administrator.

Who do you regard as role models / mentors?

A It’s a privilege to work in an environment such as BHF, as we get to look at the industry from a bird’s eye view, whilst representing a diverse group

of members. I am influenced directly and indirectly by the BHF Board of Directors and individuals such as Dr Clarence Mini and Mr Neil Nair. All have had a profound impact on my thinking, not just in business but personally and some have challenged me to really think out of the box. Key role models are Mr Grant Newton from Sechaba Medical Solutions, Dr Mangaliso Mahlaba from Thebe Ya Bophelo Healthcare Administrators and Dr Johan Pretorius from Universal Health Administrators, who come from key organisations that are innovative, knowledgeable and well respected. However, my principal mentor and barometer is our managing director, Dr Humphrey Zokufa, who has taught me that a ‘negative mind will never give you a positive life, to be patient – people are individuals and will arrive at things at different times. To listen, to understand, and not just to reply’. These are just some of the great life lessons I will take with me wherever I go.

Do you have any rituals that you do before your work day starts?

A Before I go home at the end of a working day, I usually document the events of the day and prioritise what I need to get done the following day.

My morning ritual involves sitting in my car for ten minutes or so to meditate and get myself focused for the day ahead. Once I leave the car, I literally hit the ground running. Critical issues are always kept in my notepad on my phone. I really appreciate the fact that I have an awesome and supportive team, as they all make my job much easier.

Who is your personal role model and why?

A My mother is definitely my personal role model. Despite all the struggles she faced during her life, she’s managed to remain humble, dignified and

very nurturing. She has led by example by remaining faith-ful to her beliefs, which encourages me to do the same. She has also taught me that family should be one of my top priorities.

What would you say your greatest achievement has been?

A While I have set out goals to achieve, I’ve come to realise that what you achieve is not as important as what you learn and share. It humbled me to

discover that I am on a continual learning and growth curve.

What, in your opinion, was the one opportunity denied to you that helped you, in hindsight?

A We tend to be our own worst critiques. I discov-ered that I was the only person who denied me opportunities and when I started believing in

myself and pursuing the things that I was passionate about, doors opened up for me.

What would you say was a turning point in your life?

A I think the real turning point in my life was when I got married and had children. Everything I thought was important, was not as important

anymore. I am blessed with an amazing husband and two beautiful children.

Mediscor Medicines Review 2013 Twenty-five years ago, in a little office in Pretoria, Mediscor was established. While initially only servicing 50 000 medical scheme members, the company now manages the pharmaceutical benefits of 1.7 million members who are affiliated with more than 40 clients. Mediscor, an accredited managed care organisation with the Council for Medical Schemes, include all South African pharmacies and dispensing doctors in the Mediscor service provider database and process more than 150 000 real-time transactions each day. Each year, the medicine claims data submitted by pharmacies, doctors and patients to Mediscor are analysed, and the most relevant findings are collated in the Mediscor Medicines Review. For the 2013 edition, only fee-for-service schemes, on behalf of which claims processing was performed for the total period under review, were included, which can roughly be equated to a representation of one million beneficiaries. Key trends in 2013 For the first time since 2011, medicine expenditure, measured as the cost per beneficiary per annum, increased. The increase of 1.9% was the result of a 2% increase in cost per item, but was offset by a 0.1% reduction in the utilisation of items per beneficiary. The changes in total expenditure, item cost and utilisation from 2012 to 2013 are summarised in Table 1. Table 1: Change in key expenditure indicators: 2012 vs. 2013

Key indicator Change (%)

Total expenditure Cost per beneficiary 1.9

Cost component Cost per item 2.0

Utilisation component Number of items per beneficiary 0.1

The impact of single exit price In 2013, the Department of Health permitted a maximum single exit price (SEP) increase of 5.8%. An SEP increase was not permitted in 2011, while a maximum increase of only 2.14% was gazetted in 2014. From January to May 2013, 42.2% of manufacturers, representing 85.3% of products, took an SEP increase of 4% or more. The actual increase in the same representative basket of medicines was only 1.2% in 2012 and 3.9% in 2013.

New chemical entities New chemical entities (NCEs), defined as innovator medicines launched within the preceding five-year period, are potentially major drivers of medicine expenditure. This is because these products are still under patent and have no generic equivalents. The average cost an NCE is R747, which is 5.5 times greater than that of an established medicine. However, this large cost differential is offset by the fact that only 0.3% of all medicines claimed are NCEs. Expenditure per benefit type In terms of expenditure per benefit type, the landscape remained largely unchanged. The greatest proportion was spent on acute medicine, at 40% of total rand value and 49.8% of item volume. Medicines for the treatment of prescribed minimum benefit (PMB) conditions made up the next most popular grouping, with 22.4% of beneficiaries claiming on average 24 items per patient per year. The contribution to total expenditure and claim volume per benefit type are illustrated in Figures 1 and 2. Figure 1: Expenditure distribution per benefit category for 2013

Figure 2: Volume distribution per benefit category for 2013

40.0%

5.2%2.5%9.4%

4.5%

4.5%

33.9%

Acute

Non-CDL chronic

HIV/AIDS

Oncology

Other

OTC

PMB

49.8%

4.1%1.2%0.8%

3.1%

10.4%

30.7%Acute

Non-CDL chronic

HIV/AIDS

Oncology

Other

OTC

PMB

Generic utilisation Once again, the generic utilisation rate increased, from 53.4% in 2012 to 54.5% in 2013. The vast majority (74.8%) of all products claimed were genericised items, and in 72.8% of instances where a generic equivalent was available, the generic was used. However, almost 20% of overall expenditure was on original products with expired patents. The generic utilisation rate per benefit type is summarised in Table 2. Table 2: Generic utilisation rate per benefit category for 2013

Benefit category Generic

utilisation rate (%)

Acute 53.8 Non-CDL chronic 57.4 HIV/AIDS 78.2 Oncology 56.1 OTC 39.6 Other 38.7 PMB 60.8

The top therapeutic groups It is always interesting to note the prescription trends of the top 25 therapeutic groups according to expenditure. These products represent 72.3% of overall expenditure, and 64.5% of item volume. In 2013, the top 25 products remained virtually unchanged, and there were no new additions to this list. The top five therapeutic groups, ranked according to contribution to total expenditure, were antihypertensive (11.0%), cytostatic (6.3%), antidiabetic (5.8%), antidepressant (4.4%) and gastric acid-reducing (4.3%) agents. The latter group displaced hypolipidaemic agents from the top five, which is not surprising now that generic versions of all the statins are available. Specialty medicines As medical technology advances, new and improved therapies become available, many for conditions for which there previously was no safe and effective treatment. Many of these NCEs are so-called speciality medicines. These are agents, often biologicals, which target rare or orphan diseases, require special storage or administration measures, and must be accompanied by intensive educational initiatives to ensure safe and effective treatment. In addition, these are, without exception, costly medicines. Treating complex conditions with biological medicines places an ever-increasing financial burden on both members and schemes. It is thus important to ensure that the correct speciality medicine is used in the correct manner by the individual that is most likely to benefit from it. Managed care organisations like Mediscor have already put in place measures to ensure the appropriate use of speciality medicines.

The member experience Medical schemes are expected to strike a balance between member satisfaction and adequate financial performance. This year’s report noted an increase in medicine expenditure, which is placing strain on funders of health care in this time of soaring medical inflation. It is imperative to maintain control over costs by employing managed care initiatives, like adopting medicine formularies and encouraging the use of generic medicines. However, this cannot be done at the expense of the medical scheme member. Effective benefit design should enable all stakeholders to choose appropriate and cost-effective medicines without transferring the risk to members in the form of co-payments. Designated service providers may, therefore, be contracted to protect the member against this practice, by applying fees that have been negotiated and agreed upon with the scheme. However, to ensure that the member is protected, the scheme should monitor the adoption of these measures by providers. The Patient Experience Monitor, a Mediscor analytical tool, measures the financial experience of members at point of sale, comparing pharmacy networks and individual pharmacies. Compliance with generic substitution measures, negotiated fees and co-payment application rules can be quantified and trends measured. Mediscor is as committed now as we ever have been to providing guidance and services that will enable our clients to successfully navigate the potentially turbulent times ahead. We want to ensure that, over the next 25 years, there will be even more satisfied members, providers and schemes. For more information or the full report, visit www.mediscor.net or e-mail to [email protected].

finance the nation's health system and the people’s wellbeing. The state of individual and population health depends, inter alia, on access to and provision of the social determinants of health such as suitable housing, clean water, sanitation, and electricity and education. Income, employment and clean air are also essential.

It can easily be shown globally that the level of GDP, with certain critical


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ANNUAL BHF CONFERENCE

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The case for bringing together many different sources of

information and activities for the public good has already been convincingly made numerous times.

There are fundamental philo-sophical reasons confirming to the superiority of collective, rather than individual, action from authors CP Snow`s “Two Cultures” (humani-ties and the sciences) to EO Wilson s

Collective activism in health

“Consilience”, which reflect advice, suggestion, wisdom, plan, purpose, and judgment, and derive mean-ing from a collective understanding of many diverse fields of human endeavour, including health.

Health is the product of a multipli-city of interacting political, social, economic, climatic, cultural, and inter-national forces. It is self-evident that we need a functioning economy to

SPEAKER OPENING CEREMONY: Professor Hoosen (Jerry) Coovadia, M.D.

PROFESSOR HOOSEN (JERRY) COOVADIAProfessor Hoosen (Jerry) Coovadia is an Emeritus Professor of Paediatrics and Child Health, and Emeritus Victor Daitz Professor of HIV/Aids research at the University of KwaZulu-Natal. He is also Commissioner for the National Planning Commissioner for the Presidency of the Republic of South Africa, and Director for the Health System Strengthening division at MatCH (Maternal, Adolescent and Child Health), a division of the University of the Witwatersrand.

Hon Dr Michael Harry Armitage

Dr Armitage is the Chief Executive Officer of Private Healthcare Australia (formerly AHIA), the peak body representing health funds in Australia.

Dr Armitage was a Member of the South Australian Parliament from 1989 to 2002, and a Minister from 1993 to 2002. In particular, he held the Health portfolio from 1993 to 1997.

Before entering Parliament, Dr Armitage was in private practice after serving as Paediatric Registrar in Adelaide Children’s Hospital, and as House Surgeon for Invercargill New Zealand.

Since leaving Parliament, he was involved in the Super Computer industry, as the Director – Sciences (ANZ) for Silicon Graphics (SGI), before joining Private Healthcare Australia as CEO in November 2005.

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qualifications, influences the health of the nation. Equitable distribution of resources is essential. The effects of economic growth are most clearly evident up to a point in a curve balancing money spent per person against gains in health. After such a point no further benefits accrue from rising GDP.

Nearly all of the social determinants can be shown to affect the health of people. Most important are housing, water, sanitation and regular availab-ility of food. However, controlled trials, which many would argue are neither necessary nor ethical to show cause and effect for these factors, are often difficult to prove the hypothesis.

Let us take the question of food secu-rity in South Africa, as more than half the population in the country is at risk of hunger and food insecurity. This requires more effective legislation, land restitution, education, train-ing, skills development, support to the newly transformed farmers with seeds, equipment and technology markets, distribution networks, bank-ing, financial know-how, gender equity etc.

Can we even begin such a lifesaving programme without ridding ourselves

of the curses of corruption and racism? I will avoid a step-by-step analysis of all the very wide range of sectors, from the legislature to land banks to corporations to educational institu-tions and agriculture, which have to be mobilised to achieve this goal. This does not cover family food security which has its own imperatives, not the least being sufficient income, decent employment and access to affordable foods.

What about the political, social, cul-tural and economic engagement required for confronting, managing and driving back the unprecedented HIV epidemic?

COLLECTIVE ACTIONSIt’s too large a question to answer here except to state that South Africa has made great progress. The rela-tively straight-forward prevention of mother-to-child transmission of HIV demands numerous participating groups and institutions. This did not come through individual but collec-tive actions, including state, local and global philanthropic contributions.

For this audience we each need to ask what is within our capacity and capabilities to contribute to the health of the most distant and deprived men and women, the wellbeing of the poorest family, and the most affected communities?

At its most demanding, we should aim to wipe clean the anguish and suffer-ing and hunger from each and every parent, child, family and community, by 2030.

KEYNOTE SPEAKER

KEYNOTE: SESSION ONE

Monday, 25 August 2014

09h30-10h15: Session One

The Power of Collective Activism


Health is about all of us – and everyone has a role to play.

Health is about health professionals – in all their variety of professions and specialities – about government policies, about hospital managers and commercial organisations, about insurance schemes and about what people do for themselves, about neighbours and families and commu-nities, about public services and local facilities, about food and education and much more.

Leadership in health

Africa has the greatest health needs in the world, both in volume and range of needs. South Africa alone faces four major epidemics – of communicable disease, non-communicable disease, maternal mortality and trauma – while elsewhere there are neglected tropical diseases, environmental problems and conflict.

These two sets of statements reveal much about what is needed for leader-ship in health. I will concentrate on five simple points here:

1 The first is the point that leaps out of the first paragraph. There is a need to have many leaders from different backgrounds who can work together to improve health. Individual leaders, such as doctors, politicians and members of civil societies, for example, can do a certain amount by

SPEAKER: Lord Nigel Crisp

Real progress comes when there is an alignment between goals and shared leadership

LORD NIGEL CRISPLord Nigel Crisp is an independent crossbench member of the House of Lords and works mainly on international development and global health. From 2000 to 2006, he was both Chief Executive of the NHS, the largest health organisation in the world, and Permanent Secretary of the UK Department of Health, and led major reforms in the British health system.


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themselves, but real progress comes when there is an align-ment between goals and shared leadership.

As Chief Executive of the biggest health organisation in the world, I deliberately built coalitions of leadership at different levels in the organisa-tion to lead and embed change, with different leaders bringing in different constituencies as well as different perspectives and ideas. During our most successful period of reform in the NHS there were nine people in our guiding coalition, including Tony Blair as Prime Minister and myself as Chief Executive. Together we could move the system, individually we struggled – with the problems and with each other.

2 The second point is that there needs to be a clear strategic vision behind which the different parties can align. It must be bold and ambitious, and based on values. It must also generate a sense of urgency and be energising. It needs to be supported by a strategic plan which shows how everyone involved can contrib-ute. It is the leaders’ responsibility to create the vision, and plan and mobilise public and political support behind it.

3 Leadership, however, needs to be firm and clear. Coali-tions of leadership and shared vision are not a recipe for fudging issues and working to the lowest common denominator. Not everyone will be able or willing to participate in this shared leadership, but everyone needs to be offered the chance to contribute. Lead-ers need to be tough about breaches of values and adopt a 'no tolerance' policy to quality failures. Lead-ers need to be seen to have values and integrity – and to stick to them.

4 Leaders also need to enable and support others. They provide the direction but need others to deliver. Accordingly, they need to appoint the best people, create the systems, and facilitate the development which will allow them to succeed.

5 Finally, leadership is about context, culture and authenticity. Leaders need to understand how to get things done within the local context, working with the flow of culture and local experience. People with the greatest technical expertise and the best technical answers to every problem cannot be leaders unless they have the skills, and the contextual knowledge, to be able to persuade and influence others.

SPEAKER HIGHLIGHTS

Gunvant has been the Principal Officer of the Government Employees Medical Scheme (GEMS) since 2013. A qualified medical practitioner, he has an extensive public and private healthcare background spanning nearly three decades, across medical, marketing, sales and general management. He has extensive executive experience having led AstraZeneca South Africa, a multinational pharmaceutical company for close on ten years. During this period, AstraZeneca was one of the fastest growing pharmaceutical companies in South Africa with the introduction of leading medicines including Nexiam, Symbicord, Atacand, and Crestor. In addition, from 2008 to 2013, he led the expansion of AstraZeneca into Sub-Saharan Africa, with a particular focus on Nigeria, Ghana, Kenya and Angola.

Dr Gunvant Goolab

Linda has been the Principal Officer of the Cellmed Health Medical Fund in Zimbabwe, since it was founded in 2010. Cellmed is recognised as a major medical funder in Zimbabwe. Linda has more than 15 years of experience in the financial services sector; banking; and insurance industry. She sits on the board of a ZSE listed company and of the leading micro finance institutions in Zimbabwe. Linda also has an MBA from Nottingham Trent University (UK) and fellowship of the Insurance Institute of South Africa.

Linda Mukusha

SPEAKER: SESSION THREE

Monday, 25 August 2014

11h30-12h15: Leadership in health

Lord Nigel Crisp, Member of the House of Lords (UK)

35


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While mobile technology contrib-utes to the current generation’s

inactive, high-stress, never switch-off lifestyle, instead of condemning them, mobile devices can be used as 24-hour lifestyle management tools.

Generally the lifestyle led by the “Digital Age” generation of poor diet, low physi-cal activity, smoking, high stress-levels and excessive alcohol intake aggra-vates the risk of non-communicable diseases (NCDs). These destructive health-habits are brought about by a culture which makes it dangerously convenient to make unhealthy choices.

Mobile health – just what the doctor ordered!

Patients typically take too long to seek medical advice, arriving in healthcare facilities, be it doctors' rooms, clinics or hospitals too far along the continuum, making medical intervention more expensive than it would have been had the problem been diagnosed earlier.

Empowering them with tools – such as mobile apps and strategic social media – will help create ‘early symp-tomatic awareness’ so they can assess their health and lifestyle in a way that channels them towards diagnosis and managed care significantly earlier. This prospective, rather than retrospective, view translates into prevention – which is far more cost-efficient than cure.

CHALLENGE #1Changing behaviour is only made possible by meaningfully connecting with and empowering members, within their reality, to make health-conscious choices.

In this day and age, information is readily available everywhere, virtually overloading the consumer with data and opinions that consumers need to make a call on. Due to this there is ‘decision fatigue’ that sets in – the

By Celynn Erasmus RD (SA), NewCel Mobile Technologies

more choices we are forced to make, the more the quality of the decision deteriorates, and thoroughness is sacrificed in favour of convenience.

AN (APP)LE A DAYMobile applications leverage the need for convenience by removing the chaos of choice and providing simpli-fied, useful information. Apps offer an opportunity to position a brand as a trusted provider of relevant, valuable information.

A well-designed app provides key feedback about the frequency of usage and diagnostic trends, allowing schemes to proactively push relevant information to their members, thereby managing potential health risks and trends. Apps also contribute dynami-cally to the health and profitability of funds because members are equipped with the tools to proactively manage their own health.

Apps are the perfect opportunity for schemes to re-connect with current members and attract new ones – showing that they really do care about their members’ health – and about making their health even better.

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Commercial mediation is a voluntary process through which

a mutually acceptable third party helps the parties in a dispute try and reach an agreed settlement. It is a form of dispute resolution which has gained significant traction inter-nationally in recent years by offering benefits not typically associated with litigation or arbitration.

WIN-WIN OUTCOMESMediation offers the parties control over the process and outcome, and it is expedient and cost effective. It results in the maintenance of long-term relationships and occasionally results in innovative resolutions that go beyond losses, delivering a win-win outcome on terms not anticipated by either party from the outset.

The Centre for Effective Dispute Resolution (CEDR) in the UK estimates that out of approximately 3 000 civil disputes mediated in London each year 70–80% are settled within one or two days and a further 10–15% within a few weeks. Such speedy res-olutions will obviously go a long way in decreasing non-healthcare related expenditure often hiked up by the

What’s the alternative to alternative dispute resolution?

amount spent annually by medical schemes on legal fees.

Mediation is typically recommended in the context of disputes that involve a need for rapid resolution, that are characterised by reputational sensi-tivity and that arise between parties

David Geral, Practice Manager, Pensions & Healthcare, Bowman Gilfillan Africa Group

who are dependent on one another in the sense that a typical penalty driven, or clean break and damages ‘solution’ is not feasible.

These factors are typical of medical schemes’ relationships with their administrators, brokers, their members, participating employers, and also to a large extent with their designated service providers.

The medical schemes environment is characterised by intimate and long-term contractual relationships, a relatively low number of available administration service providers for the bigger schemes, and a lengthy prescribed internal complaint and appeals process before parties can approach a court for relief.

If the trustees of a medical scheme could resolve a multi-million rand dispute affecting the scheme’s repu-tation, in a cost effective, confidential, expedited process, while maintaining and possibly improving the scheme’s operational relationship with the other disputant, be it the administrator, the main employer or a practitioners’ association, why wouldn’t they?

You’re in safe hands

Prostatectomies using advanced da Vinci robotic technology to treat prostate cancer were recently performed for the first time in Johannesburg at Netcare Waterfall City Hospital and in Cape Town at Netcare Christiaan Barnard Memorial Hospital.

“The state-of-the-art da Vinci Si technology is a major investment by Netcare in South African medicine and is driven by our commitment to continue creating an environment at our hospitals where specialists can offer patients cutting-edge treatment that has been proven internationally to enhance outcomes,” says Jacques du Plessis, managing director of Netcare’s hospital division.

This robotic technology is internationally regarded as a huge step forward over the current surgical gold standard for the treatment of localised prostate cancer as it enables surgeons to perform highly intricate, minimally invasive prostatectomies with more precision. Some 80% of these procedures in United States are now being performed robotically, and the number of procedures completed worldwide using such technology is increasing significantly year-on-year.

The da Vinci technology effectively allows the practiced surgeon to operate within finer margins, which means there is less chance of leaving any cancerous tissue behind. Studies have shown that in the hands of a well-trained surgeon, da Vinci robotic surgery delivers consistently good outcomes in treating localised prostate cancer compared to the more traditional forms of surgery, and also results in fewer complications.

Seven local urologists have undergone extensive training locally as well as in an accredited wet laboratory in Belgium in the use of the system, and are now performing procedures at Netcare Waterfall City and Netcare Christiaan Barnard Memorial hospitals.

Dr Marius Conradie, a urologist based at Netcare Waterfall City Hospital, and the President of the Southern African Endourology Society, performed the first robotic assisted surgery at the hospital at the end of June under the watchful eye of a proctor from the UK. “This technology provides the specialist with far superior three-dimensional, high-definition visualisation of the prostate, surrounding tissue and neurovascular bundles than is possible with open or laparoscopic surgery. It also allows a steadier ‘hand’ and excellent control in a wide range of motions when performing the procedure as the system translates the surgeon’s hand movements on the instruments of the console into corresponding movements of the robotic arm instruments inside the patient,” says Dr Conradie.

Urologist, Dr Dave Bowden, who performed the first procedure at Netcare Christiaan Barnard Memorial Hospital, says the technology gives surgeons the ability to perform more accurate nerve-sparing prostatectomies, ensuring that the nerves that control erectile function and urinary continence are better preserved. “This results in a faster return to normal erectile function. Studies have also shown that patients have improved early outcomes in urinary continence,” he adds.

Dr Conradie says the technology offers a number of other advantages over both open and laparoscopic surgery. “It is a much less invasive form of surgery than open surgery, resulting in a shorter hospital stay and quicker recovery time. There is less need for blood transfusion as patients lose less blood during surgery, while post-operative pain is also reduced as smaller incisions are required. In addition there is a lower risk of wound infection.”

R botic technology for prostate cancer surgery

now available in Johannesburg and

Cape Town

Netcare VCD 7352 | 07.2014

Waves of Change Oceans of Opportunity

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CONFERENCE SPONSORS


2CANA SOLUTIONS South Africa’s undisputed leader in providing ICT business solutions to the insurance sector, 2Cana Solutions, brings broad experience and deep exper-tise to clients in Medical Aid Administration, life and short term insurance and risk management.

2Cana Solutions has long been regarded as provider of highly sought after services and solutions to the insurance sector. Customer success stories include TopMed Medical Scheme, PHA, Momentum Health, MMSA, Metropolitan International, Symphony Health, CellMed, iWyze, MiWay & Old Mutual.

HIP is a modern, innovative and integrated platform for efficient and reliable administration of medical schemes. The HIP Solution enables you to dynamically and rapidly adapt to the changing market conditions and compliance require-ments with innovative products and superior service levels.

2Cana Solutions is an Oracle Gold Partner, a Microsoft Gold Partner, has a BBB EmpowerDex rating and has been the winner of multiple awards.

Come and see us at BHF2014 in Durban to find how you can get HiP!

Allegra A strong health system ensures that people and insti-tutions in the healthcare industry; effectively undertake core functions to improve health outcomes through the coordina-tion of care. It protects citizens from catastrophic financial loss and impoverishment resulting from illness or injury, and ensures consumer satisfaction, in an equitable, efficient and sustainable manner. Allegra’s software solutions are built around the philosophy of TOTAL PATIENT CARE. Allegra provides one integrated effective customised business pro-cess solution that enables the healthcare provider to adapt to current and future customer care challenges. The Allegra solution allows integration between healthcare stakeholders such as medical aids, insurance companies and healthcare providers. This results in the opportunity of one shared patient health record across the Southern African healthcare network for those who are a part of the Allegra Healthcare community. The Allegra Healthcare Management Solution product suite, that will assist the healthcare community in this task of TOTAL PATIENT CARE consists of: AllegraCon-nect a Financial and Biometric data switch, WellScreen a Preventative Health Assessment Solution;ClinicPro a Clinic Solution;CarePro – Pharmacy management solution and Allegra eCademy-Training to healthcare professionals.

15th Annual ConferenceSponsors & Exhibitors


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40

Cadiz Asset Management (CAM) is an independent, award winning asset management company focused on enriching lives through sustainable investment excellence. CAM has been managing investments on behalf of investors since 1996 and has R29bn assets under management. We offer a premier range of products to a variety of clients.

CareCross Health has brought affordable healthcare to lower and middle-income South Africans through long-term, trusted partnerships with their local providers for over 16 years. It was established in response to esca-lating medical costs, with the objective of providing affordable primary health-care cover to the emerging market.

Today, CareCross Health offers sustainable, low-cost healthcare to this market through an extensive network of 2 000 general practitioners and 6 000 associated healthcare pro-fessionals throughout Southern Africa.

CareCross Health has built trusted relationships with a number of medi-cal schemes and administers. It is able to offer operating models to meet the needs of the medical scheme from basic primary care to integrated models including specialists for the middle-income market. Our nation-wide network team regularly consults with the contracted healthcare profes-sionals to ensure real compliance with treatment standards and protocols.

CareCross members select a Care-Cross GP, whose participation ensures unlimited primary care, inclusive of consultations and medications plus radiology and pathology services. All CareCross facilities are positioned to ensure delivery of well-defined quality healthcare at the most affordable cost.

Carodine Solutions brings you innovative member communication platforms, from the most basic inter-actions to high level apps and other multimedia solutions. Current solutions include PillTime a Mobile Medication Reminder service and MAcK Member Access Kiosks, where members can login and review benefits, interact with their providers, get authorisations and service provider listings by area. This technology has been developed by Tru Blu Media a firm of specialist interac-tive developers.

Clicks is the country’s largest retail pharmacy chain with a national foot-print comprising of over 335 in-store dispensaries and over 135 in-store clinics. Through our central patient database, members can collect their medication from any Clicks pharmacy across the country, while our courier pharmacy service, Clicks Direct Medi-cines, offers free nationwide delivery.

Clicks pharmacies are focused on the optimisation of member benefits through low prices on prescription and self-medication, the offering of generic medicine alternatives to reduce cost of treatment, no co-pay-ments or levies on approved chronic medication, and assistance with chronic benefit application processes, helping both schemes and members to save money. Through our free com-pliance and adherence programme featuring telephonic patient remind-ers, a dedicated repeat prescription service and targeted generic switching based on scheme formulary require-ments, Clicks pharmacies ensure that patients take their medication on time and so improving health outcomes.

We believe in the promotion of phar-macy as a primary healthcare centre of excellence, visible through our in-store Clinic offering which includes a wide range of cost-effective primary healthcare services.

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The Council for Medical Schemes (CMS) believes that a healthy private health financing industry, guided and protected by an empowered regulator, contributes to the goal of achieving universal access to quality healthcare which is in line with South Africa’s National Development Plan.

The CMS oversees the R113-billion medical schemes industry by ensur-ing that members of medical schemes are protected and informed of their rights. Furthermore, the CMS ensures that medical schemes comply with the Medical Schemes Act of 1998, by keeping an eye on schemes’ financial performance which is the cornerstone of CMS’ existence.

Staying true to its mission of ensuring that members' complaints are handled appropriately and speedily, the CMS has in the past financial year, resolved close to 6 000 complaints. This is an average of 17 complaints handled per day. Not bad for a regulator with a staff compliment of less than 100!

CMS’ commitment to being a fair custodian of equitable access to medical schemes is illustrated in a set of strategic goals guiding it to achievement. As an effective and efficient organisation, the CMS conti-nues to abide to its obligation of staying responsive to the needs of the medical schemes environment.

The Day Hospital Association represents registered private day hospitals throughout South Africa.

Day hospitals offer distinct qual-ity, comfort and cost advantages to patients, medical practitioners and medical funders, being designed, equipped and staffed for specific specialities. Some 60% of surgical procedures can be safely performed in a day hospital.

City of Durban EThekwini Mu-nicipality is a Category A municipality found in the South African province of KwaZulu-Natal. eThekwini is the larg-est City in this province and the third largest city in the country. It is a so-phisticated cosmopolitan city of over 3 442 398 people (as per 2011 Census). It is known as the home of Africa's best-managed, busiest port and is also a major centre of tourism because of the city's warm subtropical climate and extensive beaches.

Our Vision: By 2030 eThekwini Munici-pality will enjoy the reputation of being Africa’s most caring and liveable City, where all citizens live in harmony.

DLA GROUP provides comprehen-sive maternity & toddler healthcare programmes to medical schemes in South Africa and across border. We are proud to launch our Maternity & Toddler healthcare applications for Android & iOS phones for 2015!

OverviewWe offer detailed pregnancy & baby care information through; • Regular telephonic & member email

communications• Smart phone applications• Scheme-branded fully packed diaper

bags & vouchers• 24 hour pregnancy advice line• Pregnancy & birth books• Linking with doulas and midwives

countrywide• Toddler’s pack for 0 to 4 years!

We allow for customisation to your Scheme brand. We also provide COM-PETITIVE pricing on packed diaper bags AND countrywide DISPATCH!

Crucial sections • Identifying pregnancy risk prior to

birth for proactive case manage-ment.

• Chronic disease articles relating to pregnancy.

• Information on stages of pregnancy, common ailments, birthing options, pain relief, nutrition & breastfeeding.

• Immunisation programme, informa-tion on childhood diseases & toddler development stages.


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EOH is one of the largest ICT ser-vice providers in Africa and a leader in technology and business services. Our Business Process Outsourcing (BPO) operation currently serves over 2,5 million people throughout Africa with a range of consulting, benefit risk management, ICT, workplace health, learning and development, legal and Human Capital competencies.

EOH Health, a division of EOH BPO, specialises in providing employers, medical schemes and administrators with a variety of services including wearable and medical device tech-nologies, electronic patient records, hospital, dental and primary care ben-efit risk management and network services. It also offers a comprehensive range of workplace health, wellness and intermediary services. We’re connected to an extensive provider network across Africa, allowing us to offer an essential risk management resource to local and international insurance carriers operating across the continent.

With this range of competencies, and our dedicated public and private sector consultancies, EOH Health is also well placed to participate in public private collaborative initiatives that strengthen the country’s healthcare delivery system and improve overall resource utilisation.

Healthi Choices is a subsidiary of Europ Assistance Holdings (a global leader in assistance services). Healthi Choices provides comprehensive and integrated wellbeing services to affinity groups, healthcare organisations and employers. The wellbeing solutions are designed to improve:

• Wellbeing engagement and influ-ence

• The wellbeing status of populations and individuals

• A reduction of healthcare and human factor risks

Wellbeing solutions include:• Concierge services to provide

convenient access to the world of wellbeing

• Screenings and tracking, goal setting and intervention programmes to facilitate desired behaviour change

• Affordable access to wellbeing and lifestyle partners and rewards to sustain a healthy lifestyle

For more information, please contact:Terra Nyati Mobile : +27 (0) 83 624 8700Email: [email protected]

a Europ Assistance group company

First Care Courier Pharmacy aspires to relentlessly improve cus-tomer service and operational excellence and so ensure its position as one of the leading providers of HIV medication in South Africa.

Our service focuses on the patient’s individual medication management needs in an environment of strict patient confidentiality. Because of our unwavering commitment we can unlock additional value for patients without compromising their integ-rity. We will address patients’ unmet needs and provide them with access and assistance in healthcare wher-ever and whenever they may need it.

The vast experience and knowledge that we have gained through the years has allowed us to mature in our approach to all challenges presented by the schemes to whom we provide a service.

In January 2011, First Care broadened its service offering by establish-ing a partnership with the We Care Pharmacy Network, an initiative of the Computassist Group of compa-nies. We Care comprises 700 well distributed community pharmacies throughout the country.

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At FNB Business we are com-mitted to providing you with innovative, efficient and relevant banking solutions. FNB Healthcare provides solutions tailored for your business and clients to help you get more and do more with our business banking solutions. 1. Business Banking Solutions • Transactional Banking Enterprise™:

secure electronic banking option that lets you bank 24/7.

• Investment Solutions: Optimise yield on reserves and surplus funds that is easily accessible via electronic bank-ing. Direct access to Investment Spe-cialists and Treasury Desk for ease of dealing

• Commercial Property Funding • Lending solutions • Forex services: Set up orders in com-

pliance with regulations and protect against the risks and challenges of international trade. Use eForex to make online payments to offshore suppliers and purchase forex online

• Merchant Services • eWallet-pro: Card solution to mange

staff or client payments in a closed-loop system

2. Private Banking • Transactional and Online Banking • SLOW lounge Access (Domestic and

International)• eBucks rewards eBucks Lifestyle

Desk to help with your travel• Structured Finance and Lending

Solutions Fiduciary Services • Forex order online at no extra charge EMAIL: [email protected]

HPCSA The Health Professions Council of South Africa (HPCSA) is a statutory body and is committed to protecting the public and guiding the professions. The mission of the HPCSA is quality healthcare standards for all.

The Council is mandated to regu-late the health professions in the country in aspects pertaining to registration, education and train-ing, professional conduct and ethical behaviour, ensuring continuing Professional Development (CPD), and fostering compliance with healthcare standards.

There are 12 Professional Boards under the auspices of the HPCSA. The Professional Boards are the coordi-nating bodies for all the healthcare practitioners registered and deal with any matters relating to a specific profession.

The 12 Professional Boards are: Dental Therapy and Oral Hygiene; Dietetics and Nutrition; Emergency Care; Environmental Health; Medi-cal and Dental; Medical Technology; Occupational Therapy, Medical Orthotics and Prosthetics and Arts Therapy; Optometry and Dispensing Opticians; Physiotherapy, Podiatry and Biokinetics; Psychology; Radiography and Clinical Technology; and Speech Language and Hearing.

Helios IT Solutions Effective management of medical schemes is an extremely complex undertak-ing which involves the processing of massive transaction volumes coupled with the integration of the full spectrum of diverse processes and electronic communication mediums.

A sophisticated information and communications technology (ICT) platform developed by experts who have an intimate understanding of the complexities of the healthcare indus-try is therefore central to the success of any leading medical scheme.

Helios IT Solutions is an independent ICT company that specialises in deliv-ering innovative technology solutions which focus on creating efficiencies within the healthcare industry.

We have extensive experience in this field and have been instrumental in developing industry-leading, inte-grated medical scheme administration and managed care systems including Nexus.


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KPMG is committed to working with system partners and our clients to shift the focus from short-term goals to long-term ambitions. We are dedi-cated to working on the biggest chal-lenges to reduce their risk and com-plexity.

Want to learn more about how we cut through the complexity of change? Visit us at www.kpmg.co.za

MediRite Pharmacy With 150 stores nationwide and still growing, MediRite Pharmacy is fast becoming a pharmacy of choice for millions of South African consumers. Our unique location allows us to be a one-stop shop for affordable, convenient and trusted healthcare, thereby fulfilling a growing need within the African land-scape.

ISO LESO is a national provider network of optometrists that adminis-ters optical benefits for over 500,000 beneficiaries in South Africa. The administration office and Call Centre is based in Northcliff, Johannesburg and has ample capacity and experience to deliver all the requirements needed by any healthcare funder.

Once you make the choice to switch to Iso Leso as your optometric partner, you will be assured of a pro-vider relationship that promotes successful delivery, sophisticated management structures and a holis-tic approach to optical benefits for funder/provider relationships that ensures stability in the market.

For information call 011 340 9000 or 0860 10 30 50 / 60 or send an email to [email protected].

HEALTHCARE A publication offering an in-depth look at the state of the public and private healthcare sectors, innovative new products and services in South Africa has been the missing piece in the mainstream of healthcare communications. HEALTHCARE… just the facts, is a new publication which launched in July 2014 in print and digital formats.

Insight Actuaries & Consultants Three specialist consultancies – the Health Monitor Company, CareGauge and Lighthouse Actuarial Consult-ing, recently merged to form Insight Actuaries and Consultants, a mar-ket leading actuarial and consulting services company that is uniquely positioned to operate across the health, insurance and employer sectors. Our core purpose is to assist our clients to identify and mitigate their risks; and to reveal and take advantage of key opportunities. By leveraging our unique expertise and desire to innovate, we are able to unlock intellectual capital, helping our clients solve complex problems and achieve excellence.

www.insight.co.za

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MediKredit With its proud 73-year track record and acknowledged global expertise MediKredit has carved a niche for itself in the field of provider network management and connec-tivity. Known as a healthcare benefit management force to be reckoned with MediKredit not only pioneered on-line real time claims processing within the South African healthcare industry but is also the custodian of the Nappi® Price File and the industry expert in clinical database management.

At present the locally developed, flexible internationally patented IT systems of MediKredit touches the lives of more than 6.4 million South Africans. The fully integrated end-to-end MediKredit service is used by more than 2 700 pharmacies, 150 private hospitals, 3 000 doctor practices, 80 medical schemes as well as 121 public sector hospitals in five provinces.

As the only electronic benefit manage-ment company with its own switch MediKredit can guarantee its clients 99.9% real time provider connectivity and flexible information technology systems that cross boundaries with the aid of smart switching. MediKredit affords its clients customised tech-nological solutions with a uniquely patented rule stacking capability.

Medipost Pharmacy With 23 years experience, Medipost Pharmacy is the leading national pharmacy in the country and is currently dispensing and delivering an average of 400 000 prescriptions per month to satisfied medication users throughout South Africa.

Medipost is an affordable, convenient and reliable medication provider of chronic, HIV, oncology, renal and oth-er specialized medication. The corner-stones of Medipost’s success are our advanced IT technology and systems, tried and tested processes, highly skilled personnel and a high technol-ogy help desk rendering service in all 11 national languages.

Medipost also provides comprehen-sive reporting to Medical Schemes which include findings and trends re-lating to data analysis of operational, clinical and financial statistics linked to the performance of the organization. As part of our patient-centric service offering, we provide personal tele-phonic clinical consultations through our friendly and qualified pharmacists and pharmacists’ assistants. Delivery is free of charge to any destination of choice.

eMail: [email protected], Tel: + 27 12 426 4007, Web: www.medipost.co.za

Medscheme Driven by our vision of Creating a World of Sustainable Healthcare, Medscheme has consis-tently delivered innovative, quality medical scheme administration and health risk management products and services to our clients in South Africa, Africa and internationally for 43 years.

Today Medscheme is South Africa’s largest health risk management ser-vice providers and the second larg-est medical scheme administrator and we touch the lives of over three million people through our network of branches conveniently located throughout the territories in which we operate.

Our unmatched combination of client centricity and expertise is founded on proven excellence in corporate gov-ernance and world-class information technology.

This positions Medscheme as the ideal business partner for corporate clients and medical schemes seek-ing to offer products and services of exceptional quality to their members and employees.

MIP is the world's only software com-pany to deliver solutions across the financial service verticals. Our systems are diversified to accommodate the specialised administration needs of medical aids; employee benefits; life insurance; treasury; lending; collec-tive investments; wealth management and short-term maintenance and warranty.

Also unique to MIP is our billing model. There is no upfront capital outlay for MIP's financial administration sys-tems, and no hidden billing. Instead, we share your risk while helping you to grow your business. By creating part-nerships with our clients, your success is in our best interest, which is why some companies have been with MIP for over 21 years.

Because MIP understands the busi-ness of financial administration, we offer more than technical knowledge to our clients. Our services include over two decades of experience, inge-nuity, perception and a distinctive way of dealing with your individual needs.

Our roots in emerging markets give us the advantage of delivering cost-effec-tive solutions that meet the current financial conditions across the globe.

Momentum Asset Management manages funds for many leading South African institutions, including parastatals, retirement funds, medi-cal aids, educational institutions and corporates. It offers a diverse range of collective investments cater-ing for investor needs and wealth accumulation.

Momentum Asset Management is a wholly-owned subsidiary of MMI Holdings Limited. Its investment capa-bilities include Core Strategies, Fixed Income Strategies, Unconstrained Strategies, Frontier Strategies and Beta Strategies, which cater for varied client requirements.

Metropolitan Health, a sub-sidiary of JSE-listed MMI Holdings, manages benefits for 3 million beneficiaries in open and restricted membership medical schemes and employers. Economies of scale, robust technology and integrated health risk management are successfully leveraged to contain healthcare and non-healthcare costs.

Metropolitan Health Risk Manage-ment, a wholly owned subsidiary of Metropolitan Health, offers a total health risk management model that seamlessly integrates healthcare services across a coordinated network of service providers. State-of-the-art technology supports holistic, patient-centric health management shaped by industry leading clinical, actuarial and wellness experts. Delivery seeks to reduce unnecessary complex-ity, streamline processes, overcome fragmentation and create a superior service experience. The result: appro-priate cost savings, improved health outcomes and optimal value creation.

Metropolitan Health creates smart solutions that expand healthcare access and bridge the gap between private and public healthcare. A good example is a venture with Alpha Pharm to establish a national network of pharmacy-based clinics offering preventative and primary healthcare to all South Africans – the insured and uninsured.

BOARD O f HEALTHCARE fUNDERS O f SOUTHERN AfR ICA46

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Merck is a leading company for inno-vative and top-quality high-tech prod-ucts in the pharmaceutical and chemi-cal sectors. Around 38,000 employees work in 66 countries to improve the quality of life for patients, to further the success of our customers and to help meet global challenges. Merck is the world's oldest pharmaceutical and chemical company.

Netcare operates the largest private hospital, emergency medical service and primary healthcare networks in South Africa. There are 54 Netcare owned or managed hospitals, with emergency medical services offered through Netcare 911, primary health-care through Medicross and Prime Cure, retail pharmacy services through Netcare pharmacies, and private dial-ysis services through a joint venture, National Renal Care.

Old Mutual Corporate Consul-tants was established at the beginning of 2014 following the amalgamation of Acsis, Symmetry and Old Mutual Actuaries & Consultants with a view to provide superior, relationship-based advice to institutions.

Built on Old Mutual’s well-established reputation for service excellence, brand leadership and client cen-tricity, we offer institutional clients access to world-class advice on mat-ters including treasury management, investment, communication, actuarial and employee benefits, supported by state-of-of-the-art technical platforms and in-depth research.

Old Mutual Corporate Consultants is able to offer a comprehensive, end-to-end consulting and advice solution including highly efficient cash/liquidity management solutions to help medi-cal schemes, institutions, corporates, retirement funds and trusts meet their investment objectives.

Newcel brings your wellness needs together with interactive mobile appli-cations. From diet and exercise to chronic disease management, NewCel puts your members’ individual health screening and wellness needs right where they need them, at their finger-tips, where and whenever.

NewCel’s clinically supported pre-diagnostic mobile solutions create platforms for ‘early symptomatic awareness’ resulting in improved health risk outcomes and cost savings. It’s not just about technology, it is about… empowerment, support and behaviour change – Healthier living. Made easier. At your fingertips.

Website: www.newcel.co.za Email: [email protected]

Netcare 911 Our purpose is simple: Helping care for the health of human-kind. We care about the dignity of our patients and all members of the Netcare family. We care about the participation of our people and our partners in everything we do. We care about truth in all our actions. We are passionate about quality care and pro-fessional excellence.

Netcare 911 is the wholly-owned pre-hospital risk management and emergency assistance subsidiary of Netcare Ltd. Since its inception in 1998, Netcare 911 has invested extensively in infrastructural resources and capabili-ties and can demand a high standard of performance accountability.

As a premier provider of private emergency medical service in South Africa, Netcare 911 prides itself on offering fully integrated and efficient turnkey solutions to patients in crisis situations. Our core competence encompasses world-class emergency medical assistance, evacuation by road or air, telephonic medical advi-sory services and a range of innovative products coupled with extensive man-agement expertise.

In addition to a fleet of more than 230 response vehicles and ambulances - the latter equipped in accordance with first world standards - a helicopter and fixed wing aircraft are also available to patients in need.


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Optipharm This year Optipharm, national specialist courier pharmacy celebrates 10 years in business. Optipharm was established in 2004 with a specific focus on dispensing and distribution of anti-retroviral therapy to patients living with HIV and AIDS. In this environment the impor-tance of timeous delivery, no matter what the circumstances was instilled as part of our culture.

Once we diversified into general chronic medication several years later, this philosophy of supporting patients’ health allowed us to expand our ser-vice offering to specialist disease areas such as oncology and diabetes.

Optipharm celebrates with:

• The award of two the Department of Health’s (DoH) pilot districts for medicine distribution. This project is the beginning of what we hope will be a long and mutually benefi-cial relationship with the DoH.

• The commissioning of our new ROWA dispensing robot. The robot unit has the ability to dispense 3 000 patient prescriptions within an 8-hour cycle and went live in April this year.

PPN, established in 1994, is the Optometry Network that our opposi-tion chooses to talk about more than we do! We continue to "Innovate – Integrate – Eradicate" ensuring that we stay at the forefront of Optical Ben-efit design and management for our contracted schemes.

• Innovate through continuous improvements and savings initia-tives ie laboratory ordering system to facilitate lens cost savings, cata-ract management, stream lined tariff system, online benefit and claims administration system and member portals.

• Integrate with multi facetted sys-tems of all our medical schemes and their administrators.

• Eradicate fraud through our Forensic team, System analysis, Partnerships, Biometrics and Vali-date IT initiative on Bifocal and Multifocal lenses.

We currently have 2.7 million lives contracted to us through 22 schemes and 2 406 Optometrists contracted to our network which accounts for 98% of all practicing Optometrists in South Africa.

We guarantee that we will not increase our management fees above inflation or CPI for 2015 whichever is the lower.

Old Mutual Investment Group Investing with the Old Mutual Invest-ment Group means that as Africa’s largest asset manager you get access to the depth and reach of its unparalleled range of listed and unlisted multi-spe-cialist investment capabilities. Based on this, and our 169-year heritage, our customers have entrusted us with R562bn to manage on their behalf.

At the heart of our investment propo-sition is the fact that our investment professionals are business owners and thus invest alongside their cli-ents. To ensure they are able to give their 100% focus to investing, Old Mutual Investment Group takes care of all their non-investment operational responsibilities.

Through this investment partnership, we are committed to delivering mar-ket-beating returns across our African active and passively managed listed funds, as well as our sizeable portfolio of unlisted assets.

Our strong transformation agenda ensures that we have a vibrant, socially-relevant and demographi-cally representative staff complement. We are currently a Level 2 BBBEE contributor.

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Private Health Administrators (PHA) is a fully independent managed care and medical scheme administra-tor. Established more than 20 years ago, PHA currently provides adminis-tration services to a number of open and restricted medical schemes. PHA has successfully developed and imple-mented a concept known as “Demand Management” utilising our experience in the healthcare industry as well as the clinical knowledge and insights gained. The concept adds to the underlying PHA business model by cre-ating a unique member informed and clinically appropriate consumer driven healthcare delivery approach ensuring a high level of patient advocacy. This dimension is a registered trademark and methodology exclusive to PHA.

This approach is implemented through our nursed–based member interaction program, supported by our centralised Health Risk Management System that identifies and targets those members with the highest burden of disease and need for intervention and thereby pre-senting the highest potential risk to the scheme and employer. This concept is exceptionally useful in a corporate environment where the opportunity to integrate this approach with Human resources strategies, Corporate Occu-pational and Primary Health offerings ensures the synergies of an Organisa-tional Health strategy is realised and issues such as absenteeism is reduced.

SAMWUMED is a national accredit-ed, self-administered medical scheme. The Scheme's underlying principles support the view that all South Africans are entitled to quality health-care at a fair cost and that society must unite to ensure its adequate funding. We commit ourselves to service excellence by providing the most affordable, member-friendly, accessible and accountable scheme and administration.

Sechaba Medical Solutions’ success spans more than 35 years of service excellence as a medical scheme administrator. Sechaba was formed in 1978 and offers a fully integrated, seamless package of both administration and managed care services to clients.

Sechaba’s focus on technological innovations offers its stakeholders highly effective healthcare delivery solutions, positioning it as key player in the current healthcare industry.

A determination and resoluteness... borne from a history of doing good business with resolve and deeprooted ‘vasberadenheid’. With a legacy of ‘safe hands’, Sanlam chooses functional over fancy and is concerned with doing things right with the proper dedication.

As healthcare administrator, our unique and customized products come with tried and tested systems on an integrated IT platform. Our clients and members enjoy easy access to information, regular updates, as well as Sanlam’s vast knowledge in wealth and health management underpinned by a well-structured rewards programme.

As a managed healthcare provider, Sanlam’s fully integrated managed healthcare service ensures that opti-mal attention is given to medical expenses as a means to ensure mem-bers’ peace of mind and personal wellbeing in the long term.

Sanlam’s investment solutions for medical schemes include two funds that are Regulation 30 compliant: • SIM Medical Aid Domestic Absolute Return Fund• SIM Enhanced Cash Medical Fund

Continuous recognition of our invest-ment credentials is testimony to the fact that you can trust us with the prudent investment of your scheme’s funds.


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Universal Healthcare It is the Universal Factor that positions South Africa’s fourth largest healthcare management company in a league of its own. It is this special quality that has helped us perfect the balance between cost, access and excellence of care.

Known as the ‘personal bankers’ of the healthcare funding sector we have earned our reputation for excellence. Steeped in a culture of innovation Universal Healthcare has built a last-ing DNA with care management as our cornerstone.

Medical scheme members under our management benefit from care that is not just cost efficient, but appropriate, effective and compassionate. Patient care is at all times guided by a com-bination of personalised medicine and evidence-based protocols. One of the largest individually contracted pro-vider networks in South Africa ensures that we have buy-in from every one of our healthcare providers.

By paying close attention to every aspect of the healthcare delivery chain we are able to offer unparal-leled healthcare funding solutions to medical schemes, employer groups, scheme members and providers.

Strata Healthcare Management offers an integrated administration and managed healthcare solution to medical schemes who require excel-lent service and real value.

Strata was established by separating the administration and healthcare management components from Medi-help Medical Scheme. We can now offer our considerable expertise and tested integrated model to offer clients product sustainability and organic growth aligned with their strategic objectives, effective risk management and responsive managed healthcare programmes.

Strata’s client-centric approach enables medical schemes to provide their members with what they need: preventive care to help them maintain their health, private healthcare cover with the option to manage subscrip-tions through established networks of providers, active engagement on vari-ous forums to ensure they’re informed and enabled, and outstanding service.

To exceed expectations, we apply busi-ness intelligence and match research results to market trends to enhance our clients’ experience, streamline processes and develop innovative products and services to add value. This comes with the assurance that risks are efficiently managed in the interest of continued sustainability.

SAMA The South African Medical Association (SAMA) is a non-statutory, professional association for public and private sector medical practitioners. Registered as an independent, non-profit company SAMA acts as a Trade Union for its public sector members and as a champion for doctors and patients.

On behalf of its members, the Association strives for a healthcare dispensation that will best serve their needs.

SAMA membership is voluntary, with some 70% of public and private sector doctors in South Africa currently registered as members of SAMA.

Our VisionTo be the representative Associa-tion for the South African Medical Profession.

Our Mission Empowering Doctors to bring health to the Nation.


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Botswana has a pluralistic healthcare system in which the public system caters for about 83% of the popula-tion while the private sector looks after the remaining 17%.

Government remains the major healthcare financier and accounts for about 68% of the annual health expenditure. Medical aid schemes and external donors account for about 20% and 12% respectively.

While HIV/AIDS remains a concern, other key chal-lenges facing Botswana’s healthcare system include the following:i) An increasing burden

of non-communicable diseases (NCDs).

ii) Shortages of skilled manpower.

iii) Service delivery challenges.

iv) Weak supply chain man-agement systems.

v) Weak health information management.

After revising the National Health Policy, the Minis-try of Health (MOH) has

developed an integrated health services plan (IHSP) which identifies prior-ity areas to be addressed going towards 2020. Key to this plan is an essential health services package (EHSP) which aims to offer universal coverage of a high quality package of essential services to the population in an equal and integrated manner.

Various options of fund-ing the EHSP are still being explored, one of them being a national health insurance scheme which may allow participation of medical aid schemes.

By the end of 2014 Botswana will have com-missioned its first teaching hospital, which is expected to uplift medical educa-tion, clinical training and research.

KEY INDICATORSLife expectancy is esti-mated at 62 years (CSO 2011) with crude birth and death rates per 1 000 being 29.7 and 11.2 respectively. Both <5 mortality rates and

maternal mortality ratios remain a concern at 53 per 1 000 live births and 170 per 100 000 live births respec-tively (CSO 2011). HIV prevalence has dropped to 16.9% (BAIS 2013), with adjusted incidence at 1.35%. TB remains a challenge despite a reduc-tion in notification rates and improved treatment outcomes.

The incidence of malaria has also dropped down to 0.23% (MOH 2013). The prevalence of NCDs is on the rise and these diseases are estimated to account for approximately 31% of all deaths (MOH 2013).

PRIVATE HEALTHCAREThe industry is relatively small with nine medical aid schemes, about 350 independent medical prac-titioners, 220 allied health professionals and two main private hospitals, all servic-ing a membership base of about 350 000 lives.

Key challenges include sluggish formal employ-ment, a saturating market,

The future of healthcare in Botswanaincreasing cost of private healthcare, limited special-ist care within the country, limited PPP opportunities for the private sector, a lack of regulatory framework for medical aid schemes and the unfortunate treatment of healthcare as a commodity.

The latter, being the advent of the Competition Act, has brought challenges such as pricing disputes between funders and pro-viders, leaving consumers vulnerable to ‘balance billing’ practises applied by certain providers.

BOTSWANA

Pula Medical Aid Fund (PULA)+267 [email protected]

Botswana Public Officers Medical Aid Scheme (BPOMAS)+267 [email protected]

Botswana Medical Aid Society (BOMaid)+267 [email protected]

BHF MEMBERS

The private healthcare industry is relatively small with nine medical aid schemes

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The Lesotho healthcare system is funded through a combination of domestic government and interna-tional donor funds.

The government is the major source of health funds and has increased its contributions to health spending over the past decade.

The total expenditure on health for public and private in percentage is estimated at 76% and 24% respectively, with private expenditure being almost entirely out-of-pocket and covered by medical aid schemes, according to Thato Moshoeshoe, Managing Director of Mamoth Health Plan.

The distribution of hos-pitals is mainly in the public sector (57%), with non-profit and for-profit private sectors repre-senting 38% and 5% respectively.

Since 2007, the Christian Hospital Association of Lesotho (CHAL) has been financed primarily by the government but still pri-vately owned.

Each of the country's 10 districts has a hospital providing primary health-care and some secondary services.

There is also a network of primary healthcare centres and local clinics.

In the public health-care system there are 11 government hospitals, five private hospitals and lastly five CHAL Hospitals. Lesotho has 94 doctors registered with BHF.

Private healthcare is accessed by people on medical aid and by high income earners.

Most of the public health-care subsidies from the government are used by

Healthcare in LesothoLESOTHO

Mamoth Health+26622322383 (tel)+266 6232 2383 (mob)[email protected]

BHF MEMBERS

Government remains the major source of health funds and has increased its contributions to health spending over the past decade

Thato Moshoeshoe, Managing Director, Mamoth Health Plan

the public and lower income earners.

Lesotho still refers most of its complicated healthcare cases in health to neighbouring, South Africa.


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The state of medical facili-ties in Mozambique is becoming more and more impressive. It is no longer necessary to leave the country to get proper medi-cal care.

Ten years ago there were no trustworthy doctors or medical facilities in

Mozambique, and nobody trusted the healthcare system.

Times have changed and the country is developing well. New private clinics and practices have sprung up all over the country and the standard of care is increasing steadily as the demand for quality is being taken seriously.

The country’s healthcare administration is a long way behind that of South Africa and even further behind those of first world countries.

There is no legislation gov-erning ethical practise or pricing on healthcare treat-ment at non-governmental facilities, no practise num-bers to identify service providers and certainly no tariff code structure.

This has posed a daunting task for those bold enough to venture into the business of healthcare insurance.

However, Rick Palermo, CEO of Mediplus Mozam-bique, has done the impossible. He has made a success of an unlikely opportunity and gone where many others feared to tread.

Palermo is the pioneer of medical aid in Mozambique. Others have attempted to follow in his footsteps, but only a small minority have succeeded. He obviously made it look easy, but the reality is very hard work, dedication and serious trust building.

“A hospital in South Africa can sometimes demand a deposit of R 500 000 or more. It is not possible to get that kind of money out of Mozambique at a moment’s notice. That’s why it is so important to establish good, trusting relationships with both hospitals and doctors so they will recognise the medical aid card and accept it at face value,” Palermo

explains. He adds that one of the problems they are trying to tackle at the moment is the recognition of his medical aid by South African schemes.

According to Palermo, there are hundreds of South African citizens living and working in Mozam-bique who have to remain on Mediplus once they move back to South Africa because the SA schemes are imposing late joiner penalties and waiting periods.

He believes there is a solu-tion to this problem. “We are currently discussing the issue with SA Council of Medical Schemes to try and determine a way around this," says Palermo. "We are hoping that one of the SA schemes will come forward to say YES, we will take your members, we accept that they have been on a valid medical aid scheme,” he concludes.

Conquering medical aid challenges The standard of care is increasing steadily as the demand for quality is being taken seriously

MOZAMBIQUE

Rick Palermo, CEO of Mediplus, Mozambique

BHF MEMBERS ON PAGE 60

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Following ultra-hyper-inflation, the Government of Zimbabwe introduced multi-currencies in Feb-ruary 2009. The decision created a major dilemma for funders in determining sus-tainable subscription rates and tariffs. Funders fixed their subscriptions at levels that they thought were more likely to be affordable for their members. Yet, ser-vice providers had already been collecting money in US currency (US$). As a result, a discrepancy between con-tributions and claims costs existed from the start. For example, some members’ contributions were fixed at say $1 while general prac-titioner consultation fees ranged between $20 -$50.

Healthcare funders literally had to start afresh at the onset of the use of multi-currencies as they had no reserves, yet could not impose waiting periods on

their existing members. The discrepancy between claim costs and subscriptions has continued to exist and has impacted on the funders’ ability to meet the statutory reserve requirements and absorb any increases.

In 2013, doctors requested a fee review including a 75% increase in GP fees. Medical aid members could not absorb this increase due to the macro-economic fac-tors prevailing in the country. Then, in May 2014, the Minister of Health gazetted fees in terms of the Medical Services Act. These included a GP consultation fee of $35. This further pushed up costs of healthcare which had already seen an increase in outward bound medical tourism as patients faced huge shortfalls on surgery. This had also seen increased usage of medical aid owned healthcare facili-ties. The increase cannot be

The Zimbabwean dilemma on subscriptions and tariffs

ZIMBABWE

absorbed without increas-ing subscriptions but the latter is likely to force many members to come off medical aid.

It is imperative that all key stakeholders engage in order to find a sustainable solution, taking cognizance

Mrs Shylet Sanyanga, CEO, AHFoZ

It is imperative that all key stakeholders engage in order to find a sustainable solution

of the macro-economic fundamentals so that the system continues to work. Currently 90% of service providers’ income comes from private medical aid societies. There is a dire need to review the current reimbursement model of Fee for Service.

BHF MEMBERS LISTING ON PAGE 60

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Namibians can and should be proud of the quality of their private healthcare, which is funded by medi-cal aid schemes and insurers, and delivered by healthcare profession-als who offer value and a high level of care, says Callie Schafer, CEO at Cor-porate Prosperity Group in Namibia.

However, he adds, afford-ability and accessibility remain a challenge for the population at large, and finding sustainable solu-tions here will mean that the relevant stakeholders will have to work together.

“Private healthcare stake-holders need to become part of the government’s

Challenges lie ahead for the Namibian healthcare industryWhile certain parts of the healthcare sector are operating well, much is still needed to improve the overall affordability and accessibility of services

healthcare reform initiative. Closer working relation-ships between healthcare funders and healthcare pro-fessionals will lead to better understanding and trust from healthcare consumers. Constructive engagement is critical for the future of pri-vate healthcare and it calls for a demonstration from all of us of solid and committed leadership.

“The need to turn Namibia’s Vision 2030 into a reality is yet another reason why the private healthcare sector needs to engage and work with the government.”

The private medical aid industry, which includes members of the Public Ser-vice Employee Medical Aid Scheme, covers 15% to 18% of Namibians – about half of the country’s employed people. The number of uninsured Namibians is increasing, creating an extra

financial burden for the public health sector, says Schafer.

Much also needs to be done with regards to educat-ing the ‘man in the street’, members of medical aids, insurance policy holders, the uninsured and patients, so as to raise the level of awareness around the delivery of healthcare ser-vices delivery and medical aid offerings.

"Consumers of medical services have to accept co-responsibility, and act as gatekeepers when it comes to managing their medical aid/insurance benefits and the impact of costs for ser-vices being acquired,” he states.

On the upside, progress is being made. The Universal Health Coverage Advisory Committee (UHCAN ) has been formed to provide

NAMIBIA

Callie Schafer, CEO, Corporate Prosperity Group

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Closer working relationships are required between the public and private sectors

Less than 20% of Namibians are covered by private medical aid schemes

The general level of knowledge around what medical aids offer is relatively low

Alternative funding options need to be seriously considered

FAST FACTS

NAMIBIA COMPETITION COMMISSIONER PROBING FEE FIXING ALLEGATIONS The Namibia Competition Commissioner is currently considering a complaint that was laid against the Namibian Association of Medical Aid Funds (NAMAF) and the private medical aid funds for alleged collusion in setting fees payable to health professionals and other service

providers. “The case dates back for some years. It seems it will come to a close in the foreseeable future. Whether there will be winners or losers or whether it will contribute to a better healthcare system in the country, only time will tell. If we look at similar experiences of other countries in the region it seems that the industry may go through the same learning curves and experiences,” says Schafer.

FINANCIAL INSTITUTIONS MARKET BILL (FIM BILL)The Namibia Financial Institutions Supervisory Authority (NAMFISA) has embarked on the formation of an Omni Bill covering all sectors of the Namibian financial markets. The draft Bill has been passed and currently they are busy preparing the prudential standards, for sharing with the respective sectors for comments during 2015.

Current legal and legislative issues

advice and guidance to the Ministry of Health and Social Services on the development of systems and policies for universal health cover in Namibia. It is expected to be a long-term structure that contrib-utes to the establishment of relevant, new systems and policies in Namibia, and the achievement of health-related Millennium Development Goals.

According to Schafer, the country has also experi-enced an increase in the investment into new private healthcare facilities and new technology equipment over the last year or two. A number of new private hospitals, oncology cen-tres and day theatres have recently been established or are in the process of being built or planned. These will

make a positive contribu-tion towards ensuring the country can continue to deliver first-class healthcare services. This could, how-ever, be a double-edged sword.

“Due to the unique-ness of our industry, this new investment will not necessarily introduce com-petition within the industry or control or reduce costs,” says Schafer. “It may, in fact increase utilisation and admission and thus drive the overall healthcare costs up."

He is of the opinion that the interest of all parties will be best addressed if alterna-tive reimbursement models can be negotiated than the current “fee for service” model and that in fact will complement the interest

of all stakeholders and offer the expected returns to the investors and balance the impact and costs of the funders.

“The Namibian healthcare sector is at a crossroads. If open medical aid funds and the insurers fail to attract members from among the uninsured work-force, alternative funding models will have to be con-sidered. It is critical that a

primary healthcare service delivery model is also looked at. With good member and patient education and buy-in, this could be a viable option,” he says.

“It is early days and we believe that constructive engagement involving all the relevant stakeholders is crucial as we seek to find solutions for the healthcare challenges in the country,” he concludes.

REGIONAL UPDATE

BHF MEMBERS LISTING ON PAGE 60

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Addington Children’s hospital on Durban’s beachfront was built in 1928 and was the first hospital for children on the African continent. In 1984, at the peak of the huge combined internal and international struggle against Apartheid, the Hospital was closed by the government of the time because it offered services to children of all races. The hospital remained closed for 28 years and deteriorated into a state of disrepair and dilapidation.

THE KWAZULU-NATAL CHILDREN’S HOSPITAL TRUST, a non-profit, public benefit Trust is re-establishing the Children’s Hospital in partnership with the KZN Department of Health as a world-class children’s hospital provincial Children’s Hospital that is cost–effective, green, patient and caregiver-friendly and that will provide for all the children of the province regardless of socio-economic background or social-standing.

The beneficiaries of the KZN Children’s Hospital potentially include approximately 3 million children and adolescents aged 18 years or younger that reside in the province i.e. 22% of all children in South Africa.

Re-Establishing Africa’s first Children's Hospital

Phase 1 of the Infrastructural work at KZN Children’s Hospital commenced in February, 2012 and was completed in mid-2013.

The re-establishment of the Children’s Hospital is expected to be in the region of 5 years, depending on resource availability. Renovations will occur in a phased manner. It is the intention to restore the entire city block indicated above, building by building. Each building will become operational on completion. A further R450 million is required for completion of renovations. We continue to seek corporate and individual support for this.

The new construction offers many opportunities to increase name recognition by contributing to the building effort. A range of options exist for sponsorship of naming rights.

For further information please contact:

Dr Arthi Ramkissoon

[email protected]

Tel: +27 82 4105709

www.kznchildrenshospital.org.za

Renovated Outpatient’s building Waiting area in renovated outpatient buidling

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MEDICAL SCHEMESAlliance Midmed Medical Scheme

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Malcor Medical Aid Scheme

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Massmart Health Plan

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Old Mutual Staff Medical Aid Scheme

Opmed

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Spectramed

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Thebemed

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Topmed Medical Scheme (merged with Pharos)

Umvuzo Health Medical Scheme

University of Witwatersrand Medical Scheme

Witbank Coalfields Medical Aid Scheme

Wooltru Healthcare Fund

ADMINISTRATORSSanlam Health Administrators

Private Health Administrators

Sechaba Medical Solutions

Thebe Ya Bophelo Healthcare Administrators

Medscheme Holding (Pty) Ltd

Metropolitan Health

Universal Health Administrators

MembersSouth Africa


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BOTSWANAPula Medical Aid Fund (PULA)

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LESOTHOMamoth Health

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NAMIBIANamdeb

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ZIMBABWEAHFoZ

Altfin Medical Aid Scheme

Blanket Mine Medical Aid Society

Calm Health Medical Scheme

Cellmed Health Medical Fund

Cimas Medical Aid Society

EMF Medical Aid Society

Fidelity Life Medical Aid Society

First Mutual Health

Galaxy Medical Aid Society

Generation Health Medical Fund

Grainmed Agricultural Medical Aid Society (GAMAS)

Harare Municipality Medical Aid Society (HMMAS)

Heritage Health Fund

Kwekwe City Council Medical Aid Society

Liberty Health Medical Aid Society

Masvingo Municipal Medical Aid Society

Medical Aid Society Of Central Africa (MASCA)

Municipality Of Bulawayo Medical Aid Society

National Social Security Authority (NSSA)

Northern Medical Aid Society

Premier Service Medical Aid Society (PSMAS)

Railmed

Regency Employees Medical Fund

TN Medical Benefit Fund

Ultracorporate Medical Aid

Varichem Limited Medical Fund

Zenith Medical Benefit Society

Zimpapers Medical Aid Society

MembersSADC

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