“Care Plan” Programme

1. The objectives of the Care Plan Programme to be provided to a medical scheme are threefold:
  • To manage and reduce a medical scheme’s expenditure for the PMB Chronic Disease List conditions (“PMB-CDL conditions”) by implementation of a PMB Care Plan Management Programme;
  • To intervene on behalf of the medical scheme to reduce excessive, unnecessary or unjustified utilisation of medical scheme benefits by members by implementation of a High Cost Member Management Programme; and
  • To identify high-cost and/or high-risk medical scheme patients and where possible to intervene in such a manner as to optimise therapy, utilisation and expenditure by implementation of a Red Flag Intervention Programme.
2. For convenience the three programmes referred to above are collectively known as the MHS Care Plan Programmes.

3. MHS strives not to impose burdensome administrative constraints upon the medical schemes’ members other than where this is unavoidable and/or no viable, cost-effective alternative exists. Hence it is intended that the three programmes referred to as the Care Plan Programmes should be provided not through the imposition of coercive restrictions upon members but by counselling, guidance and motivation.

The deliverables of the three programmes that are collectively known as the MHS “Care Plan” programme are provided below:

i. PMB Care Plan Management Programme:
  • The management of PMB-CDL Care Plan enroles to ensure that their medical scheme benefits are utilised correctly and to employ these benefits in a manner to control the members’ CDL condition/s to avoid expensive hospital admissions and treatments, whilst at the same time ensuring the member’s optimum health.
  • Management Reports reporting monthly on agreed parameters and Key Performance Metrics.
  • Where members require additional consultations due to instability or advanced disease stage over and above those available in the primary basket, further authorised allocations may be made from the secondary and tertiary baskets and will be reported on a case by case basis

ii. High Cost Member Management Programme:
  • The counselling of all members who are identified as high cost in order to decrease inappropriate utilisation.
  • Monthly management reports covering the agreed key performance metrics.

iii. Red Flag Intervention Programme:
  • The management of identified Red Flag cases amongst the membership of the scheme.
  • Appropriate utilisation of medical scheme resources in order to attain reasonable health care for all members and to eliminate wastage/ unnecessary costs.
  • Decreased cost for scheme and cost-effective, appropriate care for members.