Public Hearing Presentation Retaining Value and Quality in a changing healthcare landscape

Transcription

1 Public Hearing Presentation Retaining Value and Quality in a changing healthcare landscape Teddy Mosomothane 17 May 2016

2 Embracing the opportunity to contribute We appreciate the inquiry process as partly leading towards recommendations on: Appropriate policy and regulatory mechanism that would support the goal 34% of achieving accessible, affordable, of contributions innovative and quality private health care; Role of competition open medical policyscheme* and competition law in achieving pro-competitive outcomes in health care. Bankmed intends to share some insights primarily from a closed medical scheme perspective in the banking industry. 2

3 Agenda 1. About Bankmed 2. Insights on risk pooling successes resulting in better The average value Bankmed member is currently 3. Investment by employer groups in health and 34% wellness of contributions 4. Targeted focus on quality of healthcare 5. The challenge of behaviour change 6. An opportunity for collaboration and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 3

4 About Bankmed Collaboration among bankers, going back to 1914 Not-for-profit restricted medical scheme in the banking industry Healthcare better funding off to financially more than by 50 an financial amount institutions of principal 34% members, beneficiaries (31/12/2015) of contributions Market share: 2.55% of the open total industry s medical scheme* principal members (and 2.31% of beneficiaries) 6.16% of the restricted medical schemes principal members (5.20% of beneficiaries) 4

5 Bankmed Vision & Mission Vision To be better the Medical off financially Scheme by of Choice an amount for the of Banking Industry Mission To be an affordable Medical Scheme that guarantees best-of-class member experience, value and quality 5

6 Strategic Overview Competitive Benefit Offering Health & Wellness Service Excellence Relevance in a changing environment Integrated digital strategy Innovation / Research & Development Value to members 6

7 Value Network Analysis (limited to core deliverables) 7

8 Partnership Philosophy Collaborate optimally, extract as much value as possible from the partnership, while maintaining the Scheme s brand identity, and an appropriate level of autonomy 8

9 Bankmed Value Attributes What sets Bankmed apart 33% Better value AA + Compared to an average Open scheme 9% vs industry average of 11% 42,5% 34% Global of Credit contributions Rating 2015 versus if (Highest the member in the Industry) joined the average Non-healthcare Expense Ratio (Administration, Managed Healthcare & General Administration expenses) 6 Benefit Options vs 33,3% Solvency Ratio (2015) vs Industry Average (2014) A fair spread of benefits providing for low to high Healthcare needs and affordability 9

10 Bankmed AA+ Credit Rating Bankmed retained an AA+ credit rating in 2015, the highest rating a medical scheme can attain. Rating The assigned average by Bankmed Global Credit member Ratings is currently (GCR). Bankmed is one of only two South African medical schemes with an AA+ credit 34% rating. of contributions Attributes versus contributing if the member to the AA+ joined rating the according average to GCR: Strong earnings capacity which is well managed Large and stable membership base with a favourable age profile High level of solvency and strong historical track record Large and diverse investment portfolio generating significant investment returns at reasonable risk levels 10

11 Agenda 1. Background about Bankmed 2. Insights The average on risk Bankmed pooling member successes is currently resulting in better value 3. Investment by34% employer of contributions groups in health and wellness 4. Targeted versus focus if the on quality member ofjoined healthcare the average 5. The challengeopen of behaviour medical change scheme* 6. An opportunity for collaboration and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 11

12 Bankmed benchmarking Benchmark against 128 options offered by 12 leading open membership medical schemes 12

13 Bankmed benchmarking Benchmark against 128 options offered by 12 leading open membership medical schemes 13

14 Bankmed benchmarking Benchmark Bankmed against 12 leading open membership medical schemes Results as a percentage of Bankmed contributions: Cost Benefit Value PMB Plan -66% -44% 22% Basic Plan -13% 15% 28% Core Saver Plan -24% 1% 25% Traditional Plan -34% 3% 36% Comprehensive Plan -19% 19% 38% Plus Plan -26% 6% 32% -22% 11% 33% 14

15 Bankmed benchmarking Benchmarking exercise: Bankmed members would (on average) be 33% worse off on an equivalent open membership medical scheme option The calculations of relative value have been prepared by Willis Towers Watson using the Bankmed 2015 membership and claims profile The value differential has increased each year from 2013 to 2016 Reasons for the value differential: The value differential of 33% can be only partly explained by the younger age profile of the Bankmed membership (12%) and the lower non healthcare costs (3%) The unexplained value differential (18%) is due to the compulsory nature of the Bankmed membership 15

16 Protecting Our Future - and the Future of Our Members The average Employers Bankmed Groups member can is currently better protect off financially the Bankmed by an risk amount pool of 34% from the loss of younger of contributions / healthier members to a large degree by retaining the condition of employment that requires membership of Bankmed This will enable the Employer Groups to offer their employees access to affordable private healthcare on a sustainable basis in the future. 16

17 Agenda 1. Background about Bankmed 2. Insights The on average risk pooling Bankmed successes member resulting is currently in better value 3. Investment better by off employer financially groups by an in amount healthof and wellness 4. Targeted focus 34% on quality of contributions of healthcare 5. The challenge versus if of the behaviour member joined changethe average 6. An opportunityopen for collaboration medical scheme* and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 17

18 Partnerships in Health Aligned The health average and wellness Bankmed strategies member is currently 34% Sharing of information on of the contributions health of the organization Monitor performance of the health and wellness initiatives 18

19 Employer Group Client Reporting Demographic overview Claims & Utilization Clinical Review HIV/AIDS Personal Health Assessment (PHA) and Individual Stress Assessment (ISA) 19

20 Membership by Gender (Jan Dec 2014) 60,00% 57,04% 55,46% 50,00% 40,00% 30,00% 20,00% better off 42,96% financially by an amount of 44,54% Female Male 10,00% 0,00% Employer Client: X Bankmed 20

21 Membership by Age (Jan Dec 2014) 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 5,00% 0,00% 22,89% 23,34% 33,10% 32,06% 34% 17,56% 17,34% of contributions versus if the member joined 11,48% the 11,32% average 4,81% 4,57% 10,68% 10,74% 0,06% 0,04% Bankmed Employer Client: X 21

22 Membership by Dependant (Jan Dec 2014) 50,00% 45,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 43,41% 44,77% 28,30% 29,15% versus 14,37% if the member joined the average 14,08% 10,41% 9,25% 5,00% 0,00% 2,87% 2,29% 0,53% 0,40% 0,11% 0,06% M+0 M+1 M+2 M+3 M+4 M+5 M+6+ Bankmed Employer Client: X 22

23 Membership by Income Band (Jan Dec 2014) 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 34% of 37,77% contributions 26,47% 55,91% 67,84% 10,00% 6,32% 5,70% 0,00% R0 - R5 000 R R R Bankmed Employer Client: X 23

24 Membership Duration (Jan - Dec 2014) 45,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 7,75% 8,97% versus 18,00% if the member joined the average 15,55% 10,90% 10,51% 25,87% 25,22% 39,75% 37,49% 5,00% 0,00% >1 yr 1-3 yrs 3-5 yrs 5-10 yrs > 10 yrs Bankmed Employer Client: X 24

25 Employer Client: X Wellness & Preventative Care Percentage Utilisation X 2014 Bankmed 2014 Mammogram coverage 24.29% 29.92% Cervical Cytology coverage 38.31% 42.71% Bone Densitometry coverage 4.84% 8.81% PSA Screening 29.84% 45.61% Colorectal Cancer Screening 1.67% 3.11% Glaucoma Screening 9.39% 15.53% HCT Coverage 3.71% 6.27% Beneficiaries Visiting Dentists ( >2yrs) 22.20% 36.15% PHA Coverage 7.57% 19.94% 25

26 Employer Client: X High Risks ,00% 12,00% 10,00% 11,32% 11,70% 10,94% 9,53% 8,00% 6,00% 4,00% 2,00% 1,95% versus if the member 5,36% joined the average 4,65% 3,71% 3,73% 2,79% 2,10% 4,57% Diabetes Hyperlipidaemia Hypertension 0,00% Employer Client: X Female Employer Client: X Male Bankmed Female Bankmed Male 26

27 Employer Client: X - Abnormal Waist Circumference 2013 and ,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 36,10% 41,01% 26,63% 28,66% 37,42% 25,20% Female >90 Male >100 10,00% 5,00% 0,00% Employer Client: X 2013 Employer Client: X 2014 Bankmed

28 Employer Client: X HIV Provincial Distribution by Gender 28

29 Employer Client: X - HIV Provincial Distribution by Gender and Age 29

30 Employer Client: X - HIV Disease Management Enrolees Employer Client: X 2013 Employer Client: X 2014 Bankmed 2014 Females 789 (78.27%) 807 (77.29%) (70.06%) Males 219 (21.72%) 237 (22.70%) 944 (29.93%) Total Post Exposure Prophylaxis (monthly average) Deceased

31 Number of HCTs completed per Annum Employer Client: X 2013 Employer Client: X 2014 Bankmed

32 Employer Client: X - Number of Tested Positive 2,50% 2,00% 2,08% 2,09% The average Bankmed 1,89% member is currently 1,67% 1,50% 1,00% 0,50% 1,32% 1,11% Female Male 0,00% Employer Client: X 2013 Employer Client: X 2014 Bankmed

33 Employer Client: X HCTs % Enrolled 90,00% 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 78,79% 68,52% 60,00% 34% 50,00% of contributions 34,78% 71,74% Female Male 20,00% 10,00% 0,00% Employer Client: X 2013 Employer Client: X 2014 Bankmed

34 Employer Client: X ISAs per Annum

35 Employer Client: X Most significant Stressors reported Most significant stressors reported Work-related stressors and job stress Personal financial stressors 59% 64% Personal relationship difficulties Environmental stressors e.g. crime, pollution, living Children or family stressors 47% 50% 50% Health-related stressors e.g. chronic illness Social stressors e.g. friends, social isolation, religious 38% 41% 0% 10% 20% 30% 40% 50% 60% 70% 35

36 Employer Client: X Top 5 Surgical Admissions Procedure Type Admissions 2013 Admissions 2014 Caesarean Delivery R Dental Procedures R8 692 Ophthalmic Biopsies and Excisions R Stomach and Duodenal Procedures R Urinary Functional Procedures R Cost / Admission (2014) 36

37 Procedure Type Admissions 2013 Employer Client: X Top 5 Medical Admissions Admissions 2014 Pneumonia R Maternity R Major Depression R Paediatric/Neonates R Cardiac Failure N/A 60 R Cost / Admission (2014) 37

38 Top 5 Chronic Medication spend 2013 vs Rank Condition No. of better off Claimants financially by an amount of Rank Condition No. of Claimants 1 Hypertension Hypertension Hyperlipidaemia Hyperlipidaemia Coronary Artery Disease Coronary Artery Disease Hypothyroidism Depression Depression Hypothyroidism

39 Employer Client: X Chronic Medication Compliance 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 37,06% 53,50% 63,81% 10,00% 0,00%

40 Employer Client: X Care Plan Services Compliance 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 32,02% The average Bankmed 42,98% member is currently 47,71% 0,00%

41 Employer Client: X Cancer type by number of Enrolees better 204 off financially by an amount of Breast Cancer Prostate Cancer GIT Dermatological Cancer Lymph Nodes & Lymphoma 41

42 Employer Client: X Summary of Risks 45,00% 40,00% 35,00% 30,00% 41,01% 28,66% 25,00% 20,00% 15,00% 10,00% 5,00% 11,70% 11,32% 9,89% 4,65% 5,36% 3,71% 1,95% 5,36% Female Male 0,00% Hyperlipidaemia Hypertension Diabetes Smoking Obesity 42

43 Recommendations and the Way Forward Focussed approach at Wellness Experiences Days (Dietician) Online Stress Assessment (early ID of at risk for depression) Quarterly Wellness Forums (align Bankmed Wellness Strategy with Employer Group Strategy) On-going screening (not limited to Wellness Experience Days): employer driven competition amongst BUs. CEO to lead by example Regional Strategy for increasing screening Call centre strategy Move from fragmented to integrated wellness offering 43

44 Agenda 1. Background about Bankmed 2. Insights on risk pooling successes resulting in better value 3. Investment better byoff employer financially groups by an in health amount andof wellness 4. Targeted focus 34% on quality of healthcare of contributions 5. The challenge versus if of the behaviour member change joined the average 6. An opportunityopen for collaboration medical scheme* and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 44

45 Health Quality Assessment Benchmarking exercise in the funding industry Highlights key quality issues in the SA medical scheme industry Drives improvement in the delivery of evidence-based medicine 18 participating Schemes 34% in the 2014 HQA of contributions Comprised of 88 benefit options Represented 6,78 open million medical beneficiaries scheme* (77,21% medical scheme population) Four categories are evaluated, namely: Prevention and Screening Hospitalization Maternity and New-born Chronic Disease Management 45

46 Agenda 1. Background about Bankmed 2. Insights on risk pooling successes resulting in better value 3. Investment by employer groups in health and wellness 4. Targeted focus 34% on quality of healthcare of contributions 5. The challenge of behaviour change 6. An opportunity for open collaboration medical scheme* and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 46

47 The challenge of behaviour change Individual member s responsibility Opportunity better to embrace off financially innovative by an interventions amount of 34% Regulatory obstacles of contributions Prevention better open than cure medical scheme* Shift away from hospicentricity Flexibility in response to unintended consequences 47

48 Agenda 1. Background about Bankmed 2. Insights The on average risk pooling Bankmed successes member resulting is currently in better value 3. Investment by employer groups in health and wellness 34% 4. Targeted focus on quality of contributions of healthcare 5. The challenge of behaviour change 6. An opportunity for collaboration and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 48

49 Phased approach to change Lessons on collaboration Acknowledging current reality Carrying versus forward if successful the member practices joined the average Interim dispensations in a changing landscape 49

50 Agenda 1. Background about Bankmed 2. Insights on risk pooling successes resulting in better value 3. Investment by employer groups in health and wellness 4. Targeted focus 34% on quality of healthcare of contributions 5. The challenge of behaviour change 6. An opportunityopen for collaboration medical scheme* and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 50

51 Outcome of Tender Process Strong business The average case, Bankmed based member on a is combination currently of the evaluation better off financially criteria, by to an appoint amount of the successful 34% bidder of contributions which was a new administrator. 51

52 Triggers of the Tender Process The tender process itself was triggered by the following factors and considerations: Good Governance: considered good governance practice to occasionally test the market with a view to evaluating whether or not the Scheme (and ultimately the members) is / are getting the best value via key outsourced service providers. The Scheme also identified a need for a more Integrated service offering An opportunity for the Scheme to refresh its Service delivery requirements, and evaluate proposals from competing bidders An opportunity to secure a Competitive price for the refreshed service delivery offering, in the best interest of the Scheme and its members 52

53 Tender Process Outline Used independent Tender Administrator Robust process Compliance The average with Bankmed procurement member policy is currently Expert independent input when required Clear rationale for selection of invited bidders Closed tender open (3 major medical players) scheme* invited based on the rationale referred to above A cross-functional Tender Sub-committee Compliance with relevant regulatory notices 53

54 Agenda 1. Background about Bankmed 2. Insights The on average risk pooling Bankmed successes member resulting is currently in better value 3. Investment better byoff employer financially groups by an in health amount and of wellness 4. Targeted focus 34% on quality of contributions of healthcare 5. The challenge versus if the of behaviour member joined change the average 6. An opportunityopen for collaboration medical scheme* and a phased response to necessary change 7. Bankmed s recent change of administrator 8. Conclusion 54

55 Conclusion Acknowledgement of an unsustainable system Some issues not unique to South Africa Acknowledgement The average Bankmed of other member socio-economic is currently factors Acknowledgement of positives Medical schemes price takers A call for stakeholders open medical to rise scheme* above the inherent tension and work together The tone about medical schemes must change Solutions located in common interests and diverse insights Interim dispensations should be part of the solution 55

56 Thank You