Metropolitan Health Group provides tailor-made healthcare solutions
Ben Rootman; the Star
FOR most people medical aid is something that is deducted on their payslips and which they don't worry about - until they or their family members fall ill.
But for the Metropolitan Health Group, the responsibility for the health of over 1,2 million South Africans to whom they provide medical cover is a daily priority.
"Meeting the challenges of administering medical schemes of the magnitude of the Metropolitan Health Group, to best benefit its members, is what we do best:' says Chief Executive Officer Blum Khan.
In terms of price the group's models are well below the industry average. As far as technology is concerned it has an information technology system that ensures easy access for clients across the entire healthcare industry, specifically in the processing and payment of claims.
The group offers customised solutions, providing exactly the kind of medical cover that clients need.
"We have the backing of highly qualified professionals across various speciality areas, including doctors, nurses, dental advisors and radiology consultants.
'The combined input of these professionals contributes to our managed care protocols, but also to the quality of care plans that we promote, which means clients get the best quality care at the best price," he says.
Metropolitan Health Group, a subsidiary of JSE-listed Metropolitan Holdings, provides world-class medical scheme administration and cost-effective, managed healthcare solutions to more than 1,2 million people on 20 South African medical schemes.
Its client list includes four of the country's biggest restricted schemes - the South African Police Services Medical Scheme, the Transmed Medical Fund, the Government Employees' Medical Scheme and Bankmed.
Each ranges between 75 000 and 150 000 principal members.
Among its blue-chip corporate clients are BP South Africa, British American Tobacco, the Cape Town City Council, the Foschini Group, Pick 'n Pay and Woolworths.
Both the group and its wholly owned subsidiary, Qualsa, received an AA rating in the 2006 EmpowerDEX survey.
Qualsa specialises in independent health-risk management, making quality healthcare both accessible and affordable. It has considerable capacity in the key areas of health that concern South Africans today, including wellness, HIV/AIDS, disease, medicine, and hospital and clinical risk management.
"Being South Africa's biggest administrator of closed medical schemes has given us a unique insight and by working very closely with employers we ensure that the product fits the client.
"This has allowed us to align the healthcare benefits with the workplace programmes offered by the employer.
"However, medical aids have to operate within the broad challenges currently facing the country's healthcare industry, perhaps the most important of which is affordability into the future.
"Costs keep escalating year on year, and this places a great burden on the patients who are directly affected by cost increases.
"Managing costs through regulatory changes is simply not going to be enough, so we need to rethink how and by whom the various services can be delivered. This means examining the regulations governing the licensing of medical service providers and hospitals.
"For medical schemes to be sustainable they must meet the significant challenge of providing comprehensive healthcare benefits, within a set budget," he says.
Qualsa's Executive Manager Leighton McDonald says hospital costs, lack of preventative measures for curable conditions, inappropriate rationing of care, HIV/AIDS, and the fact that South Africans are living longer are some of the major obstacles.
"While the pensioner ratio is increasing, with their medical needs which cost schemes significantly, younger people increasingly only insure for catastrophic cover. The result is a loss of cross-subsidisation which is needed to assure funding sustainability"
The group also plays a significant role in growing the industry in general. It is able to licence its administration systems to new players and has already helped smaller schemes improve their technology platforms.
In the field of BEE, the group is an over-achiever.
Khan says, "We understand that having the right BEE credentials is not negotiable, and we have demonstrated that we can meet the requirements at shareholder, employee and management level.
"Stronger alliances with other players to tackle issues like over-servicing and fraud, is another imperative.
"But ultimately the focus must be on keeping down the costs of hospitalisation," he says.
The launch of Gems, the government employees' medical scheme, which is one of the group's biggest clients and which is expected to provide medical cover to more than 300 000 families by next year, is a perfect example of how innovative solutions can work.
"Gems will set the trend for medical schemes and as it grows, it will enjoy enormous negotiating power which I predict will lead a new dispensation in purchasing discussions with service providers," says Khan.
Obviously, the lessons learnt along the way will benefit everyone covered by the group.
Faranani Health Solutions does just what the customers want
Ben Rootman: The Star
LET the core people of your business - in our case medical doctors - drive the core business of your company, says Faranani Health Solutions Chief Executive Officer Dr Kabs Makaba.
"We are demand driven and we take care to focus on exactly what our customers need."
Focusing on the lower end of the healthcare market, the company's competitive edge is offering an innovative reimbursement model to doctors that incentivises them to keep members in optimum health.
Chief Operating Officer Dr Kenosi Mosalakae says because they are a doctor-initiated healthcare delivery network company, they understand the balance between patients' needs and resource availability.
"Our major focus is on providing solutions to the challenges of affordability and accessibility of quality healthcare, particularly for the massive population currently outside the medical aid industry in South Africa," says Mosalakae.
The company currently offers the affordable options of Bonitas, Momentum, Ingwe and Sizwe medical schemes and provides primary care for Day 1 Health and Joburg City Parks.
Members of these options would not otherwise afford medical aid.
It also features in the recruitment drive of the South African Police Services, and provides HIV/AIDS management in a joint venture with Aurum Health.
The company also provides occupational healthcare to companies through a joint venture with Life Occupational Health, contracted to the COEGA project in the Eastern Cape and to Bloemfontein Prisons.
The advent of managed care - perceived as a threat to doctors - in the early 1990's led black doctors in the townships to form themselves into localised independent practitioners' associations with the aim to protect the independence of doctors' clinical discretion in the practice of their profession.
By the end of the 90's these associations came together to form the National Health Providers Group that co-operated across the borders of town-ships across the country.
In the interest of doctors and patients alike, the group took a strategic commercial approach in defining the role of doctors in the healthcare industry. After all, they can because they understand the business of healthcare.
A functional business entity, owned by doctors, it plays and competes in the same terrain as the commercial interest entities. At the same time its aim was to promote access to quality healthcare for most of the population, thus placing patient care at the forefront of the healthcare industry.
Founded in 2001, Faranani Health Solutions is a truly black enterprise that is doctor initiated and funded, and 100 percent black-owned.
"We provide a core network of about 1 117 doctors, spread throughout the country. Contractual arrangements with other doctor groups total over 3 000 doctors rendering healthcare services, even outside the core group, anywhere in South Africa. These doctors are highly experienced in managing healthcare delivery within the means of low income or poor people.
"All of this assists us in rendering accessible, cost effective and high quality healthcare services," says Mosalakae.
What makes your medical fund work?
Ben Rootman: The Star
PEOPLE belonging to healthcare providers or medical funds often talk about, for example, the benefits, the cost structure and the loyalty programmes on offer - particularly in a highly competitive industry where medical inflation outstrips normal inflation by far.
For the government, primary healthcare is a priority to transform the health services in South Africa. An integrated package of essential primary healthcare services available to the entire population will provide the solid foundations of a single, unified health system.
Acting Minister of Health, Jeff Radebe recently said at the World Health Organisation in Geneva that the Southern African region continues to battle with high morbidity and mortality from preventable childhood diseases, diseases of poverty as well as limited access to healthcare services.
"The ultimate goals are poverty eradication, improvement of the standard and quality of life of the people of the region and accelerated and sustained economic development."
This, however, does not mean that sophisticated medical services are not available, albeit at a price. Affordability of such services can be enhanced by joining a healthcare provider, many of whom offer a myriad of different options to suit clients' needs and pockets.
Managing one's healthcare needs is as important as managing one's financial affairs. It is essential to know who, for example, provides your healthcare provider's information technology services, administration back-up, ambulance services and dental services, as all of these have a marked influence on the eventual pricing structure offered to clients. Thanks to abundant information available, prospective healthcare users can make informed choices.
Denis keeps medical fund members smiling
Ben Rootman: The Star
TEN South African medical funds use Dental Information Systems (Denis) to administer dental care for their members, ensuring sustainability and affordability of dental benefits in a healthcare climate where oral health is often seen as non-essential.
"Rapid growth in healthcare technology and diagnostics, not to mention drugs, is resulting in parallel escalation in health insurance premiums in many parts of the world," says Dr Gareth Hayton, Managing Director of Risk Management at Denis.
"Since this is not sustainable, other models simply must be found.
"A great concern for private dental practices in South Africa for a number of years has been the possibility that health funders may choose not to fund dentistry at all. This would merely be following international trends where 'dental' is often seen as a supplementary healthcare requirement and therefore not critical"
As margins are squeezed by increasing hospital and medicine costs, areas such as dentistry that are seen as 'contingencies' end up losing out.
Hayton says other factors adding to this problem are the fact that dentistry can be expensive and that many medical funds don't know how to fund dentistry effectively.
"Denis was established in 1996, bringing essential expertise to the business of making dental healthcare funding sustainable. We contain runaway expenditure, but in a way that continues to provide access to essential treatment for the 1,3 million lives we are responsible for via South African medical funds," he says.
