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.

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Benefit design l.jpg

Benefit design

Trustee training


Doh vs cms strategy l.jpg
DOH vs CMS strategy

Hospital care

Primary care

BBP

DOH

CMS

Primary care

Hospital care


1990s vs 2000s l.jpg
1990s vs 2000s

  • Traditional plans

    • 100%

    • 80%

    • 70%

  • Nu-gen 100% benefit

  • Nu-gen co-payment / risk share plans


Healthcare product l.jpg
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 l.jpg
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 l.jpg
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


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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.


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Provider re-imbursement

  • FFS

  • Per diems

  • DRG

  • Capitation

  • Risk adjusted capitation

  • Risk share arrangements


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