BPSA Medical Aid Society

1
BPSA Medical Aid Society

• 2004 Benefit Structure
• December 2003
• Andrew Mestern Chairman
• Cheryl Robertson Principal Officer
• Lorraine Davies Scheme Manager

2
Agenda

• How the Medical Aid Works
• Why the BPSA Medical Aid?
• Ways of Saving Costs
• Member Demands
• Factors driving costs upward in 2004
• Meeting demands
• Other Benefit Changes
• Costs for 2004 vs 2003

3
How the Society Works
Investment Returns/Interest
Member Contributes
BP Contributes
 
BPSA Medical Aid Society
Benefits Expenses
4
How the Society Works
If benefit payments go up
Contributions must also go up
. to keep the scale in balance
5
Why the BPSA Medical Aid

• Condition of Service
• Good risk pool
• Reduced administration fees
• Non-profit
• Control over benefit structure and contribution
  increases
• Control over reserves
• BPSA sponsors the Society
• BPSA Management Expertise
• BPSA Governance Assurance

6
Cost Saving Initiatives
7
Factors driving costs upward in 2004

• Medical Inflation
• Medical costs to increase by more than consumer
  inflation (CPI).
• Without benefit improvements
• - in-hospital expenses to go
  up by 10 next year,
• - out-of-hospital costs to
  increase by 8, and
• - chronic medication to go up
  by 12.

8
Factors driving costs upward in 2004

• Increase in average age
• Average age of our members increases each year
• Medical expenses increase with age
• This adds 3 to the cost of providing benefits

9
Factors driving costs upward in 2004

• Prescribed Minimum Benefits PMB CDL Conditions
• From 1 January 2004
• Pay for treatment of 25 chronic medical
  conditions
• Addisons Disease Asthma Bronchiectasis
• Cardiac Failure Cardiomyopathy Chronic Renal
  Disease
• Chronic Obstructive Pulmonary Disease Coronary
  Artery Disease Crohns Disease
• Diabetes Insipidus Diabetes Mellitus Types 1
  2 Dysrhythmias
• Epilepsy Glaucoma Haemophilia
• Hyperlipidaemia Hypertension Hypothyroidism
• Multiple Sclerosis Parkinsons
  Disease Rheumatoid Arthritis
• Schizophrenia Systemic Lupus Erthematosus Ulcera
  tive Colotis

10
Factors driving costs upward in 2004

• Prescribed Minimum Benefits
• Pay for
• Consultations
• Medication
• Medical Management (Pathology Radiology)
• Cost-saving measures
• Care Plan (list of approved consultations
  tests)
• Formulary (list of approved drugs)
• MMAP (Generics)
• Estimate additional cost of 3 (but full impact
  unknown)

11
Member Demands for more Affordable Medical Aid

• Driven by lower income earners
• Assessed Discovery Health, Ingwe, ThebeMed Open
  Plan.
• Benefits lower than BPSA
• Contributions higher, increased co-payments.
• Feedback from members
• Savings Accounts not Feasible
• No co-payments
• Higher day-to-day benefits
• Higher optical benefits

12
Meeting Demands

• Spectacle Benefits
• R1000 per beneficiary
• 2 year cycle 2003/2004
• Includes hard-coating
• Limit excludes consultation
• 80 of Optical Association Tariffs

13
Meeting Demands

• Consultations
• PMB Conditions
• 100 of medical aid rates
• Care Plan will confirm
• Number of approved consultations, and
• Type of consultation (e.g. GP or Specialist)

14
Meeting Demands

• Consultations
• Non-PMB Conditions
• 4 consultation _at_ 100 of medical aid rates, per
  beneficiary
• Thereafter _at_ 80
• Limits M R 3 000
• M1 R 4 000
• M2 R 5 000
• M3 R 6 000
• Once limit is reached, only consultations for PMB
  conditions will be paid

15
Meeting Demands

• Chronic Medication
• PMB Conditions
• 100 of cost from Direct Medicines
• Subject to
• Care Plan
• Formulary (list of approved drugs)
• MMAP (generics)
• If Direct medicines is not used, co-payment
  equals difference between
• Direct Medicines price and
• Actual cost

16
Meeting Demands

• Chronic Medication
• Non-PMB Conditions
• 80 of cost (after discount) from Direct
  Medicines co-payment is 20 of cost
• Subject to
• Pre-authorisation
• MMAP (generics)
• If Direct Medicines is not used, co-payments
  equals
• 20 of cost (after discount)
• plus difference between Direct Medicines price
  and actual cost

17
Meeting Demands

• Chronic Medication
• Limit R 16 500 per beneficiary
• Limit applies to PMB non-PMB conditions
• When limit is reached, only PMB medication will
  be paid

18
Meeting Demands

• Direct Medicines
• Mail-order pharmacy in Johannesburg
• Complete application form
• Fax to Direct Medicines with script
• Direct Medicines will deliver your chronic
  medication to
• Home address
• Office
• Closest Post Office

19
Meeting Demands

• Acute Medication
• 100 of cost up to R500 per beneficiary
• Thereafter 80 of cost
• Subject to MMAP (generics)
• Limits M R2118
• M1 R3328
• M2 R3751
• M3 R4145
• Over the counter medication R65 per ailment,
  included in above limits

20
Other Benefit Changes

• Prosthesis External Internal
• 100 of cost from designated service provider
• Limit of R 8 000 per beneficiary per prosthesis
  except
• Knee Replacement R 16 500
• Total Hip Replacement R 16 500
• Pacemaker R 16 500
• Cardiac Valves R 16 500
• Cardiac Stents R 16 500
• Partial Hip Replacement R 13 000
• Spinal Fusion R 13 000
• Overall limit of R 16 500 per beneficiary per
  annum

21
Other Benefit Changes

• Private Hospital Accommodation
• 100 of cost at MediClinic Hospitals
• 10 co-payment at other Hospitals
• Co-payment will not apply if
• If you live outside 25km radius of MediClinic
  Hospital, or
• if the service is not available at MediClinic
  Hospital, or
• emergency admissions
• List of MediClinic Hospitals in Communication
  Pack
• Choose specialists who practice in MediClinic
  facilities
• Subject to pre-authorisation

22
Other Benefit Changes

• Emergency Ambulance
• ER24
• From 1 January 2004
• 084 124
• Loyalty Programme
• The Good Life Programme
• From 1 January 2004

23
Other Benefit Changes

• HIV/AIDS (Part I)
• HIV ELISA test
• 5 GP consultations
• Anti Retroviral medication
• Anti Retroviral prophylaxis
• Pathology tests
• Flu vaccine
• Dedicated information line

24
Other Benefit Changes

• HIV/AIDS (Part II)
• 100 of Agreed Tariff
• Limits
• R 30 000 per beneficiary per annum for pathology,
  medication consultations
• R 30 000 per beneficiary per annum for
  hospitalisation related services
• Subject to registration on compliance with
  programme
• Strictly Confidential!

25
Other Benefit Changes

• Ex-Gratia Awards
• Budget R 200 000 for financial hardship
• R 200 000 for consultations
• Ex-Gratia Committee meets at month end
• Completed applications by mid month

26
Costs for 2004 vs 2003

•   2003 Benefits 2004 Benefits Increase
• In-Hospital Costs 715 792 11
• GPs Specialists 103 158 54
• Radiology Pathology 58 65 11
• Day-to-day Medicines 171 203 19
• Chronic Medicines 178 215 21
• Dentistry 69 77 11
• Optical 38 44 17
• Other 47 52 11
• PMB 0 35 N/A
• Emergency Ambulance 3 3 5
• Administration fees 65 68 5
• Managed Care fees 16 17 5
• Other 26 27 5
• Total required R 1 487 R 1 755 18

27
Cost for 2004 vs 2003

• Benefits increased from 1 January 2004
• Contributions increase from 1 April 2004
• Actual increase will be 10
• Save costs through
• Responsible behaviour of members
• Introduction of measures to contain costs
• Discounts offered by MediClinic and Direct
  Medicines