MEDICAL schemes services are viewed by the majority of prospective lower-income members as a luxury rather than a necessity. Making it even more difficult to reach this market are the dramatic increases in medical aid rates, which are consistently above that of consumer inflation, so says Dr Johan Pretorius, CEO of Universal Healthcare.

According to Pretorius, costs in the medical scheme industry have been driven particularly by hospital admission, which currently comprises 37 percent of the medical aid spend.

"This can be attributed to the so-called 'technology creep', where new procedures and technology offer more accurate diagnosis and more effective treatment, but always at an additional cost. Other contributing factors to increased medical costs include fraud where members and providers are partners in crime in abusing medical funds, and an ageing population."

However, Pretorious says that one of the biggest barriers to affordable healthcare is the cost of treatment for Prescribed Minimum Benefits (PMBs). These currently include any emergency medical condition, 271 diseases and 26 chronic conditions. By law medical schemes are obliged to cover all in full, irrespective of the amount charged.

"PMB codes are therefore open to abuse by unscrupulous healthcare practitioners who manipulate the codes in order to charge higher fees than necessary resulting in massive additional costs, " he explains.

In order to survive, healthcare administrators are under pressure to find better, more affordable ways to provide health care cover. Pretorius believes that one of the most effective ways of doing this is by networking providers and gainfully engaging them.

"In the case of network products, providers are incentivised to keep patients healthy, as opposed to simply treating diseases. Where members are kept healthy, and where the costs are kept within predefined parameters, the practitioners are rewarded for good health outcomes."

CompCare Wellness Medical Scheme, an affordable open medical scheme administered by Universal Healthcare, has experienced strong interest in its Networx option, says Pretorius

Loraine Tulleken: Business Report, 28 May 2010

THE introduction of Cheiron Health Technologies into the Sechaba Medical Solutions stable last April has greatly strengthened the medical aid administrator's arm, according to CEO Thokozani Magwaza.

He says "It allowed us to leverage off .synergies between administration and managed care functionalities and has also significantly broadened our product base to clients."

It is a relationship that has matured since Cheiron first introduced the unique internationally acclaimed state-of-the-art Epic system, which has been specifically customised to meet the needs of the complex South African healthcare environment.

The system, which provides healthcare software solutions for more than 110-million lives worldwide, is designed to manage integrated delivery systems, managed care organisations, medical groups and hospitals with large ambulatory care environments.

It is essentially a capitation system with adaptations and conversion capabilities to a fee-for-service.
Sechaba was quick to invest in the system and the subsequent synergies between the two companies made a merger inevitable, says Magwaza.

The country's first 100 percent black medical aid administrator is now well positioned to play a significant role in offering healthcare service delivery across the board, according to its CEO.

"We incorporate modern clinical intelligence into relevant care processes within the administration system. It ensures continuous efficiencies and provides a beneficiary-centric approach as opposed to a programme or disease management one.

"This assists in continuously improving efficiencies and identifying and proactively managing clinical and financial risks of identifiable health risks.

"The net result - balanced healthcare costs, improved general wellness, and proactively managed health risks makes us one of South Africa's best medical aid administrators."

Magwaza adds, "Sechaba is particularly well placed to adapt to a changing marketplace."

Loraine Tulleken: Business Report, 28 May 2010

THE country has the knowledge, skills and capacity across all sectors, public and private, to make universal quality healthcare a reality, says Blum Khan, CEO of the Metropolitan Health Group.

He warns, however, of the need to design the NHI (National Health Insurance) model correctly. "We must also concentrate on collaboration and partnership, rather than elimination and division, if we want to make a real difference to the life of all South Africans."

He says the private medical scheme industry has anticipated and supported a NHI over the past few years and adds, "I believe there is room in South Africa both for a national health insurance scheme and for private medical schemes."

Khan elaborates on his idea for a NHI model that would deliver far improved healthcare for the nation and save the state hundreds of millions of rands. This, in turn, could be used to improve delivery in vital areas such as in the treatment of HIV and TB.

"In addition to these improvements, people who have become accustomed to acquiring optional benefits beyond the basic minimum level of service will be allowed to continue doing so. This includes a private hospital room or access to cosmetic medical procedures.

"In my model, the strengths of the public and private healthcare sectors will be combined and the weaknesses substantially reduced. I strongly subscribe to the notion that we should strive to transform our society and infrastructure and make it more relevant for the South Africa we now service.

"For me there seems little value in destroying what we have and more so in a world where scarcity of skill and limited resources remains a reality"

Among several suggestion he makes is the need for public and private sector partnerships and for all working South Africans and foreigners to contribute between 1,75 percent and 2,5 percent of their taxable income to NHI.

"These contributions would fund a network of NHI hospitals to which any contributing South African could go and would be assured of a reasonable level of healthcare. The unemployed could be catered for through a network of specific hospitals in each area that ensure access, quality of care and dignity for all. A hospital like Groote Schuur in Cape Town might be categorised in this way.

"With private hospitals also in play there would be fewer bottlenecks as people are channeled to hospitals appropriate to their situation and needs."

While conceding that those who opt for private care will also have to contribute to the NHI and will probably lose their tax subsidies, he says their preferences will still be catered for.

He suggests that NHI hospitals should be run and administered by private contractors and that this should be put to tender.

"To ensure that the state inherits an efficient, smooth-running operation, back-office administration should be tendered out for 15 to 20 years to crack down on corruption and false claims. Taking a large number of hospitals off the state's books for 20 years should immediately result in the saving of tens of millions of rands."

Khan also believes that only way to attract medical skills from overseas and retain our own would be to change the way professional bodies allow people to qualify. "Incentives would bring people on short-term contracts and doctors in rural areas should be paid more and enjoy greater benefits and perks than their urban counterparts."

Private sector general practitioners would serve as providers, conforming to the clinical protocols and guidelines set by NHI, which will see an estimated seven million new patients nationally.

"We also need to review tilt manner in which licenses are held and re-issue or issue additional licenses to enable more competition to prevail in the industry."

In conclusion, he says it is in evitable that the private system, will undergo fairly serious restructuring and change. However, the inclusion of private sector skills, facilities and administrators in a new NHI network will offer a range of nevi opportunities and possibilities.

"Medical schemes and their management will have to be flexible and efficient," he warns.

Loraine Tulleken: Business Report, 28 May 2010

PEOPLE throughout the world are facing lifestyle-related illnesses on an unprecedented scale with as much as 56 percent of South African medical scheme members displaying at least one or more healthcare risk factors.

This is according to Mike Collier, CEO of Agility Global Healthcare Solutions, who warns that as many as 20 percent could be at high risk from chronic disease.

"Effective management of risk in healthcare funding is not a series of point solutions but rather the application of a holistic framework of interventions. With the landscape of healthcare constantly changing, it has become increasingly important for medical schemes and their administrative risk managers to think 'out of the box'.

"They have to establish new and innovative ways for addressing the challenges of managing risk while still providing world-class care to their members."

Agility GHS is an international healthcare player and administrator to several global health insurers.

In December last year it assumed the role of new administrator and risk manager to Resolution Health Medical Scheme, an open scheme which has experienced tumultuous times in recent years.

Collier says, "We focus on alternative thinking when it comes to managed healthcare practices and pride ourselves in being the first administrator in the country to apply a 'more care, less risk' rationale to our administrative practices.

"We believe that the future of managed healthcare lies within proactive interventions. To this end we have developed a Patient Driven Care programme which has rewritten the rules of disease management."

At its heart, he explains is a proactive, fully integrated healthcare campaign. It focuses on keeping members with high risk profiles healthier by making available the appropriate benefits for their specific condition in a structured, timely fashion.

"This proactive allocative framework ensures optimal buy-in from providers and patients who are not frustrated by tedious applications and paperwork. All this is done online and approvals can be updated real-time and mostly without the need for human intervention," he says.

By monitoring compliance and disease severity to establish treatment protocols within the benefits made available, the administrator reduces the onset of acute episodes, hospitalisation, disability and relapse.

"Although this means an initial greater expenditure in medical costs, this is completely offset by a significant reduction in event rates for most serious chronic conditions. Healthier members translate directly into lower healthcare costs", says Collier.

Online, real-time services are also a key focal point according to the CEO. "Highly automated systems feature an unprecedented amount of embedded business and clinical knowledge. Most pre-authorisation requests are handled online in real time through an easy to use portal accessible by members and providers."

Agility is currently phasing in real-time claims capability for optical and dental service providers using terminal technology. Outpatient claims are also handled online in real-time where the provider knows exactly what will be paid, all whilst the member is present at the point of care.

"While these automated, real time processes provide for more efficient administration and an improved member and service provider experience, they also create more accurate and complete data. This, in turn, allows for better risk management."

Loraine Tulleken: Business Report, 28 May 2010

LIBERTY Health continues to grow locally and is making significant strides towards being the leading Pan-African health insurance company, according to its CEO Peter Botha.

He explains that the company is focused on providing innovative and cost effective healthcare solutions through investment in technology-based administration capabilities, solid back-office support for front-office services and strategic partnerships with leading medical schemes.

"With a firm footprint in South Africa, we provide systems and administration support to scheme clients, with more than a million lives. We do so through wholly-owned technology and administration affiliates, Neil Harvey and Associates and V-Med."

The affiliates, he says, give Liberty Health a unique advantage in the healthcare industry by providing in-house technology-enabled administration capabilities.

This makes it possible to provide simple and cost effective solutions for the administration and support of medical schemes.

He elaborates, "Our technology-enabled administrative system allows for the provision of superior and cost effective support to clients. This strengthens our offering of efficient scheme and member administration. And, in turn, empowers members and intermediaries by enabling the scheme to provide them with self-service system capabilities that are easy to customise for individual use."

Botha reports that over the past year, Liberty has successfully taken on the administration of Liberty Medical Scheme, Medicover and Spectramed.

These are key milestones in a strategic move towards the consolidation of scheme administration, translating into significant cutting of costs, greater uniformity and efficiencies.

They also minimise the risk to schemes the company has taken on board.

He says, "We have a substantial presence in South Africa and over the past 12 months we have experienced steady growth in the number of members and dependent lives receiving administration and IT services.

"This growth gives us the economies of scale that are key to success in medical scheme administration.

"Our strategic alliances and partnerships bring value for both our members and the industry as a whole. "Our partnership model allows us to bring the best of health management solutions to our clients."

Liberty, he adds, remains committed to strategic investments in technology.

The company acquired NHA in the second half of 2008 to provide the technology needed to support the company's target operating model and growth strategy.

It is the largest independent technology vendor in Africa and also serves as the administrative backbone to V-Med, an accredited administrator based in Cape Town.

"V-Med offers a unique and comprehensive administration support system using world class communications technology.

"The model is based on full back-office functionality and concentrated client-facing front-office functionality through which an integrated approach to administration and managed care services is provided to the client.

"This provides back-office efficiencies through scale and improved customer service through focused front-offices," says Botha.

Loraine Tulleken: Business Report, 28 May 2010

MEDICAL aid administration has reached unprecedented levels of sophistication and administrators place their clients at risk when they fail to consistently raise the bar in terms of service delivery," says Kevin Aron, managing director of Medscheme Health.

"Gone are the days when an administrator can invest in the best technology and sit back complacently.

"There's a minefield of legislation with which principal offers and boards of trustees must comply and there is ever-increasing pressure to ensure that the medical scheme remains relevant and competitive.

"Of course, there's the often-overlooked principle that an administrator's own house must also be in order. Every aspect of its operational systems impact its clients", he says.

Industry surveys have repeatedly shown that after value-for-money healthcare benefits, efficient, quality administration is next on a medical scheme member's priority list.

Aron adds, "While the Board of Trustees is responsible for designing and marketing the benefit offerings, it is the, medical scheme administrator that provides the network and transaction processing-power to keep the medical scheme operating efficiently.

"A brilliant benefit structure cannot compensate for poor administration - which is why the selection of the right medical scheme administrator is such a crucial decision for the trustees to make."

He makes the point that the development of quality administration begins with listening to the members.

"It is all too easy to make assumptions about member's needs - but that can be a costly mistake. Voice of the customer surveys are essential to develop the insight necessary to makes the difference between merely competent and market-leading administration."

To achieve this insight Medscheme has embarked upon the implementation of ISO 9001:2008 across the business. It has already achieved certification within its largest business unit and is currently rolling out the project across the rest.

Aron explains that, while continuous improvement philosophies such as Toyota's famed "keizan" focus on incremental process improvements, what differentiates the ISO 9001:2008 standard is its particularly strong focus on the customer.

"While the objective of the ISO certification is to promote a culture of continuous business improvement, the process begins with understanding the customer.

"Those insights should align management systems, processes and services to not only meet but exceed customer expectations.

"The ISO 9001:2008 standard provides a tried and tested framework for taking a systematic approach to managing the organisation's processes so that they consistently turn out a product that satisfies customers' expectations."

The standard also provides guidance on, among other things, record-keeping, controlling documents, processes, controlling and monitoring the effectiveness of the quality management systems in determining gaps between actual performance and client requirements.

However, this is only part of the equation. The other is a sophisticated information technology platform.

Aron explains that successful medical scheme administration also involves an extensive national network of healthcare providers including hospitals, clinics, healthcare professionals as well as dispensing pharmacies.

"The administration system that underpins the medical scheme must have the capacity to manage this network, while processing massive transaction volumes and integrating seamlessly with databases housing members' particulars and clinical history.

"In addition the system must have the ability to intelligently analyse data and identify trends at a micro and macro level. All these factors must integrate effectively to eliminate any wastage in the healthcare system and ultimately to deliver a cost effective, quality service experience to the member whenever he or she has any interaction with the medical scheme", he says.

This strong focus on the customer and quality has paid handsome dividends.

PMR Africa conducts an annual survey of the healthcare industry and for the last two consecutive years both Medscheme Health and Medscheme Health Risk Solutions have received the highest overall scores for excellence in administration and managed care respectively.

Medscheme Health received a Golden Arrow Award for the highest overall score of all accredited administrators measured across 24 relevant service indicators. Similarly, Medscheme Health Risk Solutions received Diamond, Gold and Silver Arrow awards across all 14 managed care service categories as well as a Diamond Arrow award for excellence in HIV/AIDS disease management.
Medscheme's open scheme clients have also benefitted with one being awarded the prestigious Orange IndexTM and another thinkmoney.co.za subscriber's survey for the best medical scheme in South Africa.

Aron says that while the results of these independent surveys are gratifying, it is important to engender a culture of creative dissatisfaction within the organisation.

"When an organisation touches the lives of 2,6million South Africans, even an error rate of less than one percent translates into thousands of less than happy customers.

"There is always room for further improvement", he concludes.

Loraine Tulleken: Business Report, 28 May 2010

THE US government has launched the distribution of R900 million of antiretrovirals in South Africa while denying reports it was decreasing funding for the management of the disease. Ambassador Donald Gips said the money would buy enough drugs to meet one-third of that needed by the country for the next 18 to 24 months. Cabinet approved a 33 percent increase in the budget for the prevention, treatment and management of HIV/AIDS in March to R8 billion - the biggest increase any department received. However, Health Minister Aaron Motsoaledi said that if these kinds of increases continued and targets to reduce the spread of the disease were not reached, Treasury would collapse. The R900 million was an additional pledge made out of the US President's Emergency Plan for AIDS Relief (Pepfar). It followed an earlier contribution towards antiretrovirals (ARVs) made on World AIDS Day in December. Meanwhile, Medecins sans Frontières (MSF) said that donor funding towards HIV/AIDS programmes was shrinking and this could lead to deaths. MSF health policy analyst Dr Mit Phillips said international donors were "flat-lining" and direct funds for AIDS treatment was being affected. Phillips said that US President Barack Obama's Pepfar reduced its budget for ARV treatment in 2009. In 2010 it froze its overall HIV/AIDS budget. However, a subsequent statement by the US government denied this, saying their funding had actually increased. They said US funding for Pepfar had risen from nearly US2.3 billion in 2004 (for bilateral HIV/AIDS programmes, the Global Fund, and bilateral tuberculosis programmes) to US6.8 billion in 2010. For the financial year 2011, Obama had requested nearly US7 billion, including US5.74 billion for bilateral HIV/AIDS programmes, US1 billion for the Global Fund, and US251 million for bilateral tuberculosis programmes. Motsoaledi said recently South Africa was treating 920 000 people for HIV/AIDS at state hospitals, with 400 000 of those treated funded by the Global Fund. The number of people needing treatment was expected to increase as a result of the government's programme to test 15 million people for the HIV virus by 2011, and its goal of providing ARVs to 80 percent of the people who have the virus. In terms of the new plan, all HIV-positive children under one year old would get treatment. In addition, all patients with both TB and HIV would get treatment if their CD4 count was 350 or less. Gips said the drugs bought with the additional R900 million over the planned period would be sourced from local South African vendors and would be in line with the registration and regulation requirements of the Medicines Control Council and the US's Food and Drug Administration. He said the cost savings realised through focused and efficient procurements were critical for the long-term sustainability of the South African HIV programme. Gips said the initiative for expanding treatment access to more people in need meant that South Africa was serving as a true leader to its own people and as a demonstrated example of commitment for the rest of the continent. Figures vary on South Africa's infection rate but South Africa counts for only 0.7 percent of the world's population, yet carries 17 percent of the global HIV burden.

SAPA, 28 May 2010

MEDICAL aid costs and general medical expenses are fairly extensively tax deductible and hard pressed consumers should not act too hastily when it comes to cancelling or downgrading their medical aid cover.

Medical aid cover is not merely a nice to have and that, while cancelling or reducing that cover may bring temporary relief to the household budget, it's in fact "false economy" that exposes you to potentially huge medical expense risk.

Retain your medical aid cover if it's at all financially feasible to do so.

While this obviously affects cash flow in the short term, a large proportion of medical expenses is deductible in a given tax year and it's far preferable to remain covered for medical costs until those deductions begin to filter through.

The tax benefits for medical aid contributions and medical expenditure are straightforward and can quite easily be explained.

The tax free allowance granted by the receiver toward medical aid contributions during a given tax year, now amounts to R670 per month for the member and the first dependant and R410 per month for every other dependant.

This works out at a substantial R2 160 deduction pm (R25 920 pa) for a family of four, applicable after Finance Minister Pravin Gordhan announced some welcome relief on the tax front for medical contributions in his Budget speech.

In addition to that, the Receiver allows against tax, your contribution that exceeds this total, together with the unclaimed portion of your general medical expenses (the amount not paid by your medical aid) where the total of those amounts exceeds 7.5 % of your taxable earnings.

Also, taxpayers over the age of 65 enjoy a full deduction for qualifying medical aid contributions and expenses while tax payers under 65 may claim all qualifying medical expenses where the taxpayer or the taxpayer's spouse or child is disabled. So taken as a whole, these deductions and potential deductions can be substantial.

It should be kept in mind however that any contribution made by the employer on behalf of the employee toward his medical aid contribution, either by way of a subsidy or a salary sacrifice is regarded as income in the hands of the employee and this has to be taken into account in your tax calculations.

The exception to this rule is where a company subsidises low income staff medical cover in which case that contribution is still 100% tax deductible for the employee, resulting in a ‘zero effect', tax wise for the employee.

Other tax free exceptions apply where contributions are made by a company on behalf of pensioners, or dependants of deceased pensioners.

The fundamental fact is that medical expenses for individuals are already substantially tax deductible and maintaining your medical aid membership is crucially important against the background of rising medical costs and the alternative of being reliant upon the State health system.

The Citizen, 17 May 2010

MICHAEL Flemming claims the stress of preparing for the listing of Life Healthcare on June 8 is killing him. "I don't get paid to do this," he says. It's the volatility of the JSE that is causing frayed nerves.

The planned initial public offering is the biggest in the JSE's history and could raise as much as R8bn. It is unlikely to be derailed by volatility.

The hospital group, which has a 27% share of SA's private healthcare market, was bought from Afrox and taken private in 2005 by a consortium led by Brimstone and Mvelaphanda, together with Life's senior management. This was after a hostile bid from Medi-Clinic was stymied by the competition authorities.

It was Mvelaphanda's desire to unbundle part of its shareholding that was the catalyst for the listing.

In the five years "under the radar" the 120-strong leadership team, all with "skin in the game" (their stake cost them R150m at the time), have achieved impressive growth.

The group has grown from a R4,1bn company into one, at current projections, that will achieve a market capitalisation of R15bn-R19bn on listing.

"We've closed underperforming assets and worked hard on our efficiencies," says Flemming. "Occupancies have grown by 6% to a 70% average, "which means we are sweating our assets better".

During the 2007, 2008 and 2009 financial years Life recorded adjusted Ebitda of R1,4bn, R1,7bn and R1,89bn respectively, with a compound annual growth rate over the period of 14,2%. The company has also grown margins aggressively, achieving the highest in the industry.

Its ability to sustain that growth at those margins will be under scrutiny.

Flemming believes there is room for more growth in the local market. To achieve this, Life plans to increase its bed numbers by about 10,7% (800 beds) over the next two to three years. It also plans to expand in areas in which the group has established a niche, such as its mental health, renal dialysis, acute rehabilitation and frail care lines. Three new acute care hospitals and an additional mental health facility will be built within two to three years, while another three acute care hospitals, a rehabilitation facility and two mental health facilities are acquisition targets.

SA's heavily regulated healthcare environment and proposed national health insurance are listed as risks in the prospectus. However, it is precisely this imbalance between the public and private health-care sectors that Flemming sees as an opportunity.

"There are about 4,5m people who earn above the tax threshold but do not belong to medical schemes," he says. "We [the industry] have to take some of the healthcare burden off the shoulders of government. We need to develop affordable funding models for these 4,5m people."

The advantage Life has is that it already has experience in partnerships with government, says Old Mutual Investment Group analyst Jonathan Larcombe. "They operate the country's largest public-private partnership business in Life Esidimeni, which is profitable."

One risk the prospectus does not dwell on is what happens to the 120 executives who will be able to pay down their debt plus more after the listing. Will they stick around? Flemming shakes his head. "Some people will leave. But we see that as an opportunity to advance other bright people in the organisation."

One area of differentiation, says Mark Ansley, a portfolio manager at Cadiz Asset Management, is the underlying ownership of the group's hospitals — its major assets. Life doctors have direct interest in these hospitals, together with a 7,2% shareholding in the group. "That ensures a certain loyalty, which could help drive procedures through its hospitals," he says.

Like Netcare and Medi-Clinic, Life also has an offshore expansion plan, though it will focus on emerging markets like India and Turkey, while its competitors have ventured - at huge expense -into developed markets.

"These markets are not heavily regulated," says Flemming. "Private health insurance is expanding, the private hospital sector is growing fast but is highly fragmented and there is a good supply of medical professionals and personnel."

Ansley says: "All you can value is what is in front of you - and that is the SA operation. At this point we cannot get excited about the offshore strategy. That can only happen when we know exactly what will be paid for new assets."

Life is relatively ungeared, with R2,4bn debt on its balance sheet. In comparison, Medi-Clinic and Netcare, which have ventured offshore, have about R25bn of debt on their respective balance sheets. In Medi-Clinic's case, R3bn of that debt is in SA; R4bn in the case of Netcare.

"This leaves Life with plenty of opportunity to expand further, and with little likelihood that it will return to shareholders for funding," says Larcombe.

Sasha Planting: The Financial Mail, 28 May 2010

THE dynamics of healthcare funding in Europe is changing. As governments review their options to meet growing healthcare demands with limited resources, the potential to combine cost reduction with new funding sources will gain support in many countries. Reimbursement decisions in the public sector are becoming increasingly tougher for pharmaceutical and diagnostic manufacturers; the private market offers a potential alternative route to gaining market access. Private insurers currently play differing roles in European national healthcare systems. A new report, "The private health insurance market in Europe: Future trends, emerging opportunities and key players", reviews their role in the major European markets and provides an insight into trends in their coverage of health benefits and products. It highlights selected product areas where private insurance could fill the gaps in public reimbursement. An insight into the European private insurance industry, including overall trends and profiles of leading insurers, provides an indication of future developments within the sector and highlights potential opportunities for pharmaceutical and diagnostic companies to work with private insurers. Key findings from the report are: there are over 84 million Europeans with some form of private health insurance. Germans account for the largest proportion of the privately insured population, with 22.3 million, followed by the Dutch with 16.2 million; healthcare benefits paid by private insurers account for eight percent of total European healthcare expenditure, a share that is on course to increase as public payors redefine their benefits package; the cost of medicines accounts for a significant proportion of private insurers costs in most markets. Around 93 percent of the French population has complementary health insurance to cover costs not reimbursed by the social health insurance system, with 30 percent of insurers costs going towards the cost of medicines; private insurers provide comprehensive health cover to 10.5 percent of Germans and almost all the population of the Netherlands and Switzerland. Voluntary insurance also plays a significant role in these markets to complement and supplement the statutory benefit package; and, France has the highest density of private health insurers at 893, whereas the industry is concentrated among relatively few players in most other markets - there are 46 insurers in Germany, 30 in the Netherlands and 27 in the UK.

News-Medical.Net, 27 May 2010