1. Vision CMS ( )
Dr S Kabane
BOT Forum

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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

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

17. Roadshow

18. Roadshow

19. Roadshow

20. 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

21. Thank You!!! The End!!!