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Managed Care is not only about containing costs Geraldine Bartlett

Managed Care is not only about containing costs Geraldine Bartlett. Medical Scheme. FINANCIALS. Medical Scheme. Financials. Health of member. Financials Health. Where does Managed CARE come in?. What is Managed Care?. fee arrangements with providers. hospital utilisation management.

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Managed Care is not only about containing costs Geraldine Bartlett

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  1. Managed Care is not only about containing costs Geraldine Bartlett

  2. Medical Scheme FINANCIALS

  3. Medical Scheme Financials Health of member

  4. FinancialsHealth

  5. Where does Managed CARE come in?

  6. What is Managed Care?

  7. fee arrangements with providers hospital utilisation management pre-authorisations drug utilisation review (DUR) baskets of care risk sharing and risk transfer arrangements disease management programmes co-payments case management preferred providers & DSPs formularies capitation predictive modelling provider profiling gate-keeping second opinions

  8. Managed Care • Broad and varied strategies and tools • Involves interventions by the MCO

  9. Managed care interventions Costs Care

  10. What should be happening in Managed Care?

  11. What is your MCO doing to manage the health of your members? • What is your MCO measuring re the health of your members? • What do you know about the health of your members? • What types of reports should you be asking for?

  12. The Health Continuum Wellness Illness

  13. Do you know ? • How many members have chronic illnesses? • What chronic illnesses? • How many are receiving quality care? • What is being done to improve care? • What are the outcomes?

  14. Chronic condition prevalence

  15. Are these members receiving quality care?

  16. Measuring Care DonabedianModel

  17. Diabetes - measuring care (process) Case study : Diabetes Disease Management Programme

  18. Diabetes - measuring care Case study : Diabetes Disease Management Programme

  19. % of diabetic patients having HbA1c test Case study: Diabetes Disease Management Programme

  20. But ….is their chronic condition well controlled?

  21. Benefits of Good Control Ref: SEMDSA Guidelines on Management of Type 2 Diabetes 2012 South African Dyslipidaemia Guidelines Consensus statement 2012 South African Hypertension Guideline 2011

  22. SEMDSA Guidelines on Management of Type 2 Diabetes 2012

  23. Diabetes - measuring care Case study: Diabetes Disease Management Programme

  24. HbA1c within acceptable levels

  25. Diabetes- Improving Outcomes Hospital admissions * Per annum

  26. Asthma Number of patients using medicines correctly GINA: Update 2014

  27. Asthma – Health status Asthma control Ref: GINA Update 2014

  28. Asthma- Improving Outcomes Hospital admissions Case study: Asthma Disease Management Programme

  29. HIV – Health status WHO Consolidated guidelines on use of antiretroviral drugs for treating and preventing HIV infection. June 2013

  30. ? Are these patients having Viral load tests CD4 counts

  31. HIV – Health status Ref: HIV Disease Management Programme

  32. What do you know about hospital admissions?

  33. How many hospital admissions are preventable?

  34. Prevention and Screening • Flu vaccines • Pneumococcal vaccines • Mammograms • Cervical cytology • HIV screening • Cholesterol screening • Glaucoma screening • Colorectal cancer screening

  35. Managed Care is not only about cost savings • Managed Care is also about CARE - members’ health • MCO’s should be measuring costs and care • MCO’s should be reporting on members’ health/care Every Board of Trustees should have at least one person who has a medical background.

  36. THANK YOU

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