GEMS and Innovation. 28 August 2009
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- Wendy Nicholson
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1 GEMS and Innvatin 28 August 2009
2 Purpse The purpse f this presentatin is t prvide an verview f the rle innvatin plays in GEMS business envirnment. In s ding, I will discuss: Imprtant backgrund infrmatin; GEMS apprach t innvatin; Examples f innvative initiatives which have been applied; and Sme f the gains that are being realised.
3 Structure Imprtant backgrund infrmatin GEMS apprach t innvatins Examples f innvative initiatives Results
4 GEMS: Funding Plicy The verarching mandate apprved by Cabinet in 2004 The state as an emplyer seeks t ensure that there is adequate prvisining f healthcare cverage t public service emplyees that is efficient, cst-effective and equitable; and t prvide further ptins fr thse wh wish t purchase mre extensive cver The mandate was infrmed by entrenched inequity, high csts, absent emplyer cntrl/influence and limited access t scheme benefits by all emplyees
5 GEMS: Legal Frm Restricted membership medical scheme Subscribes Fully registered under the Medical Schemes Act Reprts t the Registrar f Medical Schemes t Medical Schemes Act 131 f 1998 Eligibility limited t emplyees and pensiners f: Natinal Departments and Prvincial Departments & Administratins listed in Schedule 1 and 2 f the Public Service Act Organisatinal Cmpnents listed in Schedule 3 f the Public Service Act Apprved emplyer grups (r related gvernment structures)
6 GEMS: Crprate Structure Crprate structure cnsists f: Bard f Trustees (50% f Trustees elected by members; 50% appinted by the MPSA) that gverns the affairs f the Scheme; PO implements directives f the Bard and manages the business; and Scheme Executive (5) supprts PO in mnitring and managing the service levels and cntractual bligatins f appinted service prviders Efficient scheme head ffice f 26 team members Strategic and risk management Operatinal activities utsurced Resurces dedicated t ensuring effective member services Perfrmance f the scheme is cnstantly mnitred Lcus f cntrl always rests within the Scheme
7 GEMS: Benefits and Cntributins
8 GEMS: Member Services Call Centre Fax Please call me SMS service Cnfidential HIV & Aids Helpline Emergency Medical Services Walk In Centres 2 in each Prvince Secure Website Pstal Address Private bag X782, Cape Twn, facilities SMS services Enquiries, cmplaints, cmpliments, jin, presentatins, premiums... Prviders, benefits, ICD 10 and infrmatin
9 GEMS: Prgress Made
10 Structure Imprtant backgrund infrmatin GEMS apprach t innvatins Examples f innvative initiatives Results
11 GEMS and Innvatin What is Innvatin? Innvatin is the effrt t create purpseful, fcused change in an enterprise s ecnmic r scial ptential Peter Drucker Innvatin is any gd, service, r idea that is perceived by smene as new Ktler and Keller What is innvatin t GEMS? Identifying new slutins t current prblems which will result in efficiency gains fr members and the Scheme.time, peple, resurces, mney and enhanced satisfactin..
12 GEMS and Innvatin Why des GEMS innvate? T ensure the fulfillment f ur mandate T prmte sustainability, affrdability and accessibility at all times T eliminate wastage T reduce csts which in turn relates t savings fr members and the emplyer T prmte the ptimal use f Scheme services by members GEMS is an innvatin in its wn right, but the innvatins discussed in this presentatin are nt nly new t GEMS, but in mst instances are new t any medical scheme
13 Structure Imprtant backgrund infrmatin GEMS apprach t innvatins Examples f innvative initiatives Results
14 Innvatin at GEMS: FOG Friends f GEMS SMS and nline service where members request and receive the cntact details f cst effective healthcare prviders in their vicinity. Over 10,000 healthcare prviders are registered n the prgramme wh have agreed t care fr GEMS members withut any additinal surcharges Members send an sms and receive an immediate respnse Over 6,000 hits per mnth , GP, Hillcrest Dr A Feinberg 103 Kingsley Centre Church Street
15 Innvatin at GEMS: FOG
16 Innvatin at GEMS: FOG
17 Innvatin at GEMS: FOG Benefits f Friends f GEMS Prmtes members access t care Especially fr member s n netwrk ptins Algrithm t identify clsest alternative area if n prvider fund in requested area Prmtes access t affrdable care Saves members and the Scheme mney, which in turn permits resurces t be allcated t additinal benefits and reduced cntributins in future years Markets affrdable healthcare prviders t a base f 1 millin beneficiaries Serves as a viable mechanism t channel all preferred reimbursement arrangements that GEMS has in place with prviders
18 Innvatin at GEMS: Benefit Check SMS Benefit Check up The service enables members and healthcare prviders t cnveniently access the available medical scheme benefit limits at any time f the day. Over 12,000 hits per mnth Benefit, , Day, M as at 01/02/09 12:30, 00, Day ; R1000 Fam R3300; NB Subject t Schem e rules.
19 Innvatin at GEMS: ICD ICD 10 Lk Up Makes it easier fr healthcare prviders t submit crrect and cmplete claims, which will ensure that they receive quick and efficient payment. Prviders send an sms t and receive an immediate respnse Website service available t ICD, , Angina Dr , 01/01/09: ICD cde: I20.9.
20 Other Innvative Applicatins Call center: IVR Self Help Allws members t btain infrmatin (such as hspital and medicine authrizatins and applicatin frms) via the call centre line withut queuing fr an agent Please call me SMS s Scheme members are able t send a free SMS t request the Scheme t cntact them Business Reply Envelpes (BRE s) Members are mailed prepaid envelpes, where any infrmatin requested by the Scheme is mailed back at n cst t the members
21 Structure Imprtant backgrund infrmatin GEMS apprach t innvatins Examples f innvative initiatives Results
22 Results t Date
23 Results t Date Beryl: GP Cnsultatins Mnths DSP_Flag Visits Ttal_Visits Percentage Jun 2009 CONTRACTED 9,473 9, Jun 2009 NON-CONTRACTED 104 9, Jul 2009 CONTRACTED 8,162 8, Jul 2009 NON-CONTRACTED 87 8, Sapphire: GP Cnsultatins Mnths DSP_Flag Visits Ttal_Visits Percentage Jun 09 CONTRACTED 14,669 14, Jun 09 NON-CONTRACTED 87 14, Jul 09 CONTRACTED 12,549 12, Jul 09 NON-CONTRACTED 54 12,
24 Cnclusin Imprtant lessns have been learnt ver the last three years New members jining GEMS have diverse expectatins and knwledge f hw the Scheme, and a Scheme, wrks It is imprtant that technlgy is aligned t member needs and capabilities Innvatin shuld be applied in instances where there is a clear business and member satisfactin imperative There are instances where innvatin may nt be the best ptin The jurney has just begun and mre is yet t cme.
25 THANK YOU!
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