MANAGEMENT OF MEMBER COSTS

MHS PATIENT PROFILES

DEFINITION
MHS Patient Profiles are quarterly retrospective analyses that evaluate how individual members of medical schemes have been utilising health care resources. These Profiles identify high-cost, high-risk members as well as those who claim inappropriately. Ideally, the system should be used in conjunction with the Clinical Audit, thus enabling users to 'drill-down' to various levels of the report, according to the level of information needs. "Exception" reports that are generated by the system to alert medical schemes to potential problems include:

• GP and Pharmacy expenses in excess of R2000,

• GP-Hoppers and Pharmacy-Hoppers report. These members utilise multiple GPs and/or Pharmacies resulting in unnecessary duplication of treatment and therefore increased costs.

• A data base with detailed information on every member’s health care consumption,

• Claim patterns, trends and events,

• The design, implementation, and management of member/ patient intervention programmes.

SERVICE RESULTS
Patient Profiles enable the medical scheme to focus its membership intervention strategy where it is really needed, thus reducing costs.

These point the scheme to:

• Potential fraud,

• Members who need to be educated as to appropriate use of health care services,

• Members who may be dissatisfied with the level of health care they are receiving,

• Members who require chronic disease management.