Achieving value in the face of rising healthcare costs

Managing medical scheme funds effectively on behalf of members is a delicate balancing act between offering maximum cover for quality private healthcare and maintaining affordability in light of medical expenses routinely outstripping inflation.

Mark Arnold, principal officer of Resolution Health Medical Scheme, notes that in the most recent Council for Medical Schemes (CMS) Annual Report, Chairman of the Council, Professor Emeritus Yosuf Veriava, highlights the role of managed care in securing value for members.

“The framework adopted to address risk management and managed care for each medical scheme has a direct bearing on the benefits and quality of service members receive in return for their contribution fees. Members rely on us to ensure that their funds are being managed prudently to ensure the best possible healthcare access for their money, and the design of a scheme’s managed care is key to optimising value,” Arnold explains.

“The integrated approach to managed care and risk management principles implemented by Agility Health, Resolution Health’s administrator and managed care provider, goes an additional step further, however, by empowering our members with an advanced claims management system that actively checks patients’ treatment and conditions for contraindications and potential health risk using finely attuned clinical protocols.”

Where the system identifies problematic claims, a team of clinical professionals review the details and engage with the patient and the medical practitioner to establish the clinical and procedural validity of the prescribed treatment and claim.

“This system is highly adept at weeding out potentially harmful treatment combinations, as well as eliminating wasteful expenditure and abuse of scheme resources. Value is achieved through ensuring claims are legitimate and therefore make the best possible use of our members’ funds, while providing an additional layer of protection for members through confirming adherence with clinical protocols,” he observes.

Resolution Health also has a unique and fact-driven approach to product enhancement and richness, which ensures that members enjoy more of the benefits they use the most, as opposed to benefits they will never use.

“Our benefit design process is highly technical and driven by industry and option specific data that informs which benefits members who fall within the demographic of an option are utilising most. Through this ‘most benefits for most members’ approach, we can then ensure that we enrich our options in line with their intended demographic. This ultimately means more relevant value for money for members,” Arnold adds.

“The good health of our members is central to our philosophy as a medical scheme, and the measures incorporated into our approach of providing healthcare cover for members reflects our commitment to provide true value at every opportunity while ensuring they have access to the most appropriate care at all times,” Arnold concludes.

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