The question is often raised, as to why medical schemes do not pay for certain benefits. Members pay their contributions, but where does this go? What is risk pooling or cross subsidisation?
TCD Outcomes Research (OR) realised that indeed there is a gap in understanding this concept and so an idea was born – to identify and link the truths between administrator, funder and the paying member.
Last Thursday (July 13th) saw the hosting of the first of several workshops aimed at creating awareness, identifying challenges and ultimately working together to find solutions that are patient centric.
Gaining insight from the Medical Scheme Perspective is not an easy task. Our speakers, Milton Streak, Johan Van Zyl and Tienie Stander assisted in providing an objective view of the different industry role players.
Johan discussed the role of the administrator. Oftentimes there lacks an understanding as to the role that the administrator plays. Having years of experience in the field of health management, managed healthcare, health analytics as well as clinical and procedural coding, Johan was able to provide information regarding awareness, challenges faced, as well as potential solutions.
Milton spoke of governance of medical schemes, business trends in health care and amongst others enablers for improving health care. Milton has over 20 years experience serving in senior leadership positions at leading South African Medical Scheme Administrators/Managed Care Organisations and Medical Schemes and is currently an independent Healthcare Strategy Adviser.
Linking both Milton and Johan’s discussions, Tienie provided valuable insight as to how to bridge this gap. It starts with a partnership and joint discussions. The solution is the SA Constitution (S27). “Everyone has the right to have access to social security, even if they are unable to support themselves and their dependents, including appropriate social assistance. The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights.”
We at TCD OR hope that by hosting such workshops we open dialogue that is so urgently required. A dialogue that challenges our approach, and perhaps serves as a catalyst to what ultimately requires a partnership of all stakeholders within the industry.
The Funder Mindset: Insight into the Funder’s World was the first of a series of workshops that will be held over the next few months. Follow us on Linkedin or Facebook to stay informed about our future workshops.
Johann Van Zyl
Johann is a medical practitioner and founder and Managing Director of Clinical Governance Services (Pty) Ltd (CGS).
Johann has 12 years’ experience as a general practitioner coupled with some 19 years’ experience in health management, managed healthcare, health analytics and clinical and procedure coding. He specialises in clinical and procedure coding and the clinical analysis of health claims data.
Johann’s current responsibilities include:
Advising medical schemes on benefit design and related clinical matters
Advising medical schemes on clinical risk management strategies
Healthcare account auditing
Measuring financial and clinical healthcare outcomes
Monitoring outcomes and compliance reporting for contracted health care provider networks
Development of provider profiling models across various disciplines
Development, maintenance and costing of procedural coding structures
Development and maintenance of clinical coding grouping methodologies
Development of predictive models that are applied to analyse past claims experience and forecast scenarios
Advising corporate clients on health and wellness strategies
Education and Credentials
Bachelor of Medicine and Bachelor of Surgery (Studies in Medicine – University of Stellenbosch)
Master’s in Business Administration (University of Stellenbosch)
Registered with the Health Professions Council of South Africa
Milton Streak was born on 31 July 1966 in the Northern Cape Province of South Africa. He matriculated from Potchefstroom Gymnasium in 1984 and obtained a B.Pharm Degree from the Northwest University, Potchefstroom in 1989. His post graduate studies included a Master of Management Degree (with distinction) from the University of the Witwatersrand, specialising in Entrepreneurship and New Venture Creation. Following completion of his Master’s studies, he was awarded the Wits Business School’s MANEX Award in 2012. Further post graduate studies included four Executive Management Programs at Harvard Business School from 2008 to 2016, focused on healthcare innovation and delivery as well as competitive dynamics. He also obtained a post graduate Certificate in Corporate Governance (Cum Laude) at the University of Johannesburg in 2011. He is a member of the Institute of Directors Southern Africa and has completed the IOD’s Directors Program.
Milton’s healthcare career includes both international and South African health insurance and healthcare management experience. His career spans over 27 years, with 21 years’ experience in corporate South Africa, serving in senior leadership positions at leading South African Medical Scheme Administrators/Managed Care Organisations and Medical Schemes, including the largest medical Scheme in South Africa, Discovery Health Medical Scheme, as Principal Officer/CEO from 2009 to 31 December 2016.
He is currently an independent Healthcare Strategy Adviser and has spent the last three months in India working with India’s 3rd largest stand-alone private health insurer on strategic projects.
Tienie graduated from the University of Stellenbosch and obtained an M.B., Ch.B. in 1981. He practised as a MD until 1997 after which he managed a hospital. He was appointed as Principal Officer of a medical scheme in 1998. In 2000 he obtained an MBA at the North West University, South Africa.
He is the founder heXor (Pty) Ltd, now rebranded as TCD Outcomes Research where he acts as managing director.
Tienie was an extraordinary professor at North West University, school of pharmacy and is an external moderator of the School of Pharmacy of North West University. He was a founding member and the first President of ISPOR South Africa and is a member of ISPOR International, International Aids Society and Health Financial Management Association.
He collaborates extensively with international academic organisations such as Harvard Medical School and British Columbia University, as well as most South African universities. International experience includes consulting work in the SADC, Mauritius, Ghana, Libya, Egypt, Sudan, India, Thailand, UAE, Oman and China related to policy, health systems and health economics and outcomes research.