Vision CMS (2019-2023) Dr S Kabane BOT Forum

Current Focus Regulation of: Medical Schemes Administrators Managed Care Organisation Brokers Limited resources More of the same Inward Looking Varied success

New Vision More focus on the following policy areas: Policy, Research and Monitoring Technical support for National Health Insurance related projects Implementation and support of HMI Recommendations Fraud, Waste and Abuse Managed Care Cost interventions (Alternative Remuneration Mechanisms; Care co-ordination, Discounted Options) Establishment of a coding authority (PCNS, ICD 11 etc) Health Technology Assessment and Benefit Services Regulation Become a key co-ordinator of regulators within SADC

Policy, Research and Monitoring Establishment of a policy, research and monitoring unit Increase research capacity Partnering with Academic institutions and key industry players Create a knowledge generation platform for researchers and students

Technical support for National Health Insurance related projects Standardisation of Options Consolidation of Schemes <6000 members Consolidation of Government Funded Schemes Consolidation Transition arrangements PMB Review and consolidation of Financial Arrangements Price Regulation Beneficiary Registry

Implementation and support of HMI Recommendations: Cost Reduction Managed Care Governance Price regulation Quality and Costs

Managed Care Cost interventions (Alternative Remuneration Mechanisms; Care co-ordination, Discounted Options) Reduce the costs of health service delivery Networks and Discounted Options Care co-ordination Alternative Remuneration Models/Mechanisms Atypical Managed Care entities

Fraud, Waste and Abuse Extend this beyond advocacy Support development and implementation of fraud detection and management across the industry Partner with key industry players to develop standardised SOP’s Develop industry Code of conduct or Charter

Establishment of a coding authority Various codes located with different stakeholders Coding disputes have no final arbiter Need for a central coding authority Coding a key feature appropriate billing processes, fraud prevention and member protection

Health Technology Assessment and Service Benefit Regulatory Capacity Key part of the regulation of entitlements Pharmaceuticals Service providers Equipment Investigations, Diagnosis, Treatment and Rehabilitation Clinical protocols and Guidelines Size and Cost of Service Benefit

Become a key co-ordinator of regulators within SADC Establish ties with all SADC regulators Key supporter of other regulators in SADC Harmonise the scheme regulatory framework in SADC Provide sound policy advice to the SADC secretariat on scheme regulation

Partnerships National Department of Health National Treasury World Health Organisation World Bank Development Bank of Southern Africa Health Systems Trust Institutions of Higher Learning Medical Schemes, Administrators and Managed Care Organisations

Areas of Collaboration Policy, Research and Monitoring Academic Institutions WHO Schemes and Administrators Quality Standards NDOH OHSC

Areas of Collaboration National Coding Authority NDOH WHO Academic Institutions HPCSA Service Provider Associations BHF Pharmaceutical Industry Associations

Areas of Collaboration Price Regulation and Cost Reduction Schemes and Administrators Managed Care Organisations Competition Commission Service Provider Associations Service Benefit Design and HTA South African Health Products Regulatory Authority, NDOH, WHO, Academic Institutions Schemes and Administrators, Professional Associations

Areas of Collaboration Fraud Waste and Abuse HPCSA Schemes and Administrators SIU SAPS Professional Associations

Roadshow

Roadshow

Roadshow

Roadshow 19 Mediscor PBM Grant Holworthy Meeting confirmed for 10:00   Mediscor PBM River Falls Office Park, Baobab Building, 262 Rose Ave, Centurion Grant Holworthy Meeting confirmed for 10:00

Thank You!!! The End!!!