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Benefit design PowerPoint PPT Presentation


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Benefit design. Trustee training. DOH vs CMS strategy. Hospital care. Primary care. BBP. DOH. CMS. Primary care. Hospital care. 1990s vs 2000s. Traditional plans 100% 80% 70% Nu-gen 100% benefit Nu-gen co-payment / risk share plans . Healthcare Product.

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Benefit design

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Benefit design

Trustee training


DOH vs CMS strategy

Hospital care

Primary care

BBP

DOH

CMS

Primary care

Hospital care


1990s vs 2000s

  • Traditional plans

    • 100%

    • 80%

    • 70%

  • Nu-gen 100% benefit

  • Nu-gen co-payment / risk share plans


Healthcare Product

  • Like any other commercial product

    • Identify market

      • Targeting and segmenting

        • Age/sex distribution

        • Salary distribution

        • Geographic distribution

    • Identify needs

      • Age/sex distribution

      • Disease profile

        • Will PMB/CDL be enough?

      • Access: Geographic distibution

    • Meet the needs

      • Satisfied member / Grow the demand

      • Build the brand / loyalty


First step

  • Demographic profile

    • Developed world

    • Developing world

      • One cross subsidised product or….

  • Public health needs

    • Maslow’s theory

  • Consumer demands

  • Marketing/branding benefits


Public health needs

  • Water, sanitation, housing, security

  • Primary care:

    • Immunisation,

    • preventative care,

    • Consults, medicine, diagnostic, dental and optical benefits

  • Consumer demand

    • Comprehensive hospital cover – high ticket item

    • High cost outpatient care cover e.g. MRIs

  • Marketing benefit

    • Lifestyle benefits


Some benefit design scenarios

Non-PMB chronic cover

Savings

Risk transferr

Risk transferr

Savings

Non-PMB chronic cover

Savings

Higher add-on benefits:

Some non-PMBs specified in terms of Rand amount per member per year and / or limits for specific forms of treatment

Savings

Add-on benefit: some non-PMBs specified in terms of Rand or limits

Non-PMB hospital cover

Prescribed minimum benefits

Adapted from Trustee training presentation,E Stipp 2005.


Provider re-imbursement

  • FFS

  • Per diems

  • DRG

  • Capitation

  • Risk adjusted capitation

  • Risk share arrangements


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