BHF is the representative organisation for 95% of medical schemes throughout South Africa, Namibia, Zimbabwe, Botswana as well as Lesotho. As the industry representative body, the organisation relies on the membership of all medical schemes to ensure that it is able to lobby government and other organisations effectively and to influence policy where necessary on behalf of the entire industry.
BHF has recently expanded its internal research capacity to ensure that it is favourably positioned to analyse regulatory interventions and propose position papers, for which there is a significant need. Through the recruitment of an experienced economist whose expertise lies in policy development, BHF is increasingly able to analyse proposed regulations timeously and ensure that it develops a focused response which represents the best interests of medical schemes. This, together with the recruitment of a clinician in the benefit and risk department has allowed the organisation to service its membership on an operational level as well as to influence policy through effective lobbying on health policy issues.
The overall focus of the Benefit and Risk department is on minimising risks to which schemes are exposed in providing benefits for their members. It ensures that benefits are designed, worded and coded in such a way that there is little or no opportunity for misuse or abuse.
Three panels support the work of the Benefit & Risk Department: the Clinical Advisory Panel (CAP), the Coding and Hospital Panel (CHEP) and the Criteria Committee.
The CAP researches and compiles funding recommendations relating to:
Recommendations emanating from this committee would be regularly reviewed and updated and provided as guidelines to schemes to assist them in offering greater consistency in benefit design and claims adjudication, as well as to assist members to understand the limitations of less expensive options.
The CHEP focuses on specific problems with hospital codes and descriptors, the consumable (non-chargeable) list and new equipment billing practices. It also examines hospital "baskets" for theatre time, ward days, maternity and the like and the development of a zero-based costing document for these fees. While the focus of this panel is on hospitals, they also attend to the schedules of other disciplines.
The Criteria Committee examines requirements for facilities to qualify for PCNS allocation. In consultation with various professional associations, it also gives guidance to schemes about applicable tariff codes chargeable by different categories of facility.
Strategically the department is moving towards initiatives to create more value for medical schemes. The implementation of managed care will become a focus, particularly in assisting medical schemes to determine issues such as surgeons' qualifications, the relative benefits of one surgical method as opposed to another, guidelines for the use of therapies relative to side effects, cost, age of patient and the like. Recommendations and guidelines which reflect industry standards need to be established to enable medical schemes to make informed decisions for each individual case.
The strategic focus for this department for 2006 is as follows:
As a knowledge based organisation, the effective dissemination of information to industry stakeholders is critical. This is done through the media, seminars and workshops, newsletters and other communication modalities to four key industry stakeholder groupings, namely; medical schemes and administrators; medical scheme members and consumers; regulatory authorities and relevant government departments; business and labour organisations.
The annual conference showcases the sector, drawing people not only from the medical scheme sector, but many other related organisations including government departments, actuaries, switching houses, insurance brokers and various provider associations. The conference is seen as a unique opportunity to network and hear of latest trends and developments both locally and internationally. The focus is generally on issues of a more strategic nature.
Forensic Management Unit
A recent initiative of the BHF, the Forensic Management Unit (FMU) has already achieved significant success, saving the medical healthcare industry several hundred million Rands. Established in August 2003, the FMU enjoys the support of over 90% of the industry, including professional associations, regulatory bodies and funders. Its overall objectives are to contain the costs of private healthcare through the prevention of fraud and abuse which costs the industry some R8 billion annually. Representatives of the industry who form the FMU have compiled collective protocols for investigating, assessing and punishing fraud, while safeguarding the rights of those under investigation. They have established a common language which allows duly constituted and consistent decision-making. As both funders and providers participate in the FMU, a united front is presented when engaging with government on both public and private initiatives. A main strategic focus is to lobby for specific healthcare fraud legislation permitting prosecutors and courts specialised in fraud in the healthcare industry. A long-term objective would be to expand this initiative to the public sector. This centralised repository of information avoids duplication by roleplayers and draws together an industry-wide network of investigators to share information. Investigators operate within a strict legal framework following agreed and clearly outlined procedures.
Trustee Development Programme
More than ever before, Trustees of medical schemes are entrusted with the Governance of their scheme and have the responsibility of ensuring that any decisions made regarding the operational aspects of the scheme are made prudently and within a strict legal framework. In order to equip Trustees with the requisite knowledge, BHF have developed a Trustee Development Programme which covers aspects such as:
The role of the department is to provide technical input on systemic and strategic health industry issues from a medical schemes perspective to:
in such a manner as to protect the interests of medical schemes and their members and fulfil the vision and mission of the BHF
In practical terms this includes:
The Health Systems and Policy Unit was established in August 2006. The Unit aims to contribute meaningfully to current and future healthcare financing debates in Southern Africa and beyond. The unit seeks to achieve this through high quality research, the creation and management of a data warehouse and constructive engagement with policymakers and industry stakeholders alike. Areas of focus include:
Haroon Wadee - the Head of the Unit has post-graduate training and experience in health economics, healthcare financing and health policy. Mmabatho Rapotu is a data-miner with post-graduate training in statistics. Sharon Swanepoel is a research assistant with a key interest in project management.
Haroon Wadee
Head: Health Systems and Policy
+27 11 537 0259
+ 27 086 607 3659 (fax)
Mmabatho Rapotu
Data Miner
+27 11 537 0228
+ 27 11 880 6437 (fax)
Sharon Swanepoel
Research Assistant
+27 11 537 0253
+27 086 607 3659 (fax)