- Managed Care Programme offers access to quality healthcare through interventions that ensure good clinical outcomes for BPOMAS members and their dependants.
- Central to MCP is ensuring that quality healthcare is delivered to clients at appropriate cost without adversely affecting clinical outcomes.
- MCP also endeavours to ensure that evidenced based care is delivered by all service providers registered with the scheme.
The programme is administered by a team of healthcare professionals at the Managed Care Department (MCD) who have specialized skills and knowledge of evidence based medicine. These professionals on a continuous basis engage with service providers to ensure that BPOMAS patients get standard of healthcare matching with international best clinical practices. The MCD team applies the well known concept of “Managed Care”, which is used internationally in healthcare insurance industry.
Managed Care as concept looks at issues around;
- The cost and utilization of a wide spectrum of services that members of medical aid schemes access on a regular basis.
- It seeks to establish balance between quality of healthcare and associated cost of interventions.
Managed Care Department has over the years introduced a number interventions or disease management programmes ranging from;
- HIV/AIDS Disease Management
- Chronic illnesses and
- Pharmaceutical Benefit Management.
Plans are at advanced stage to introduce other services such as Wellness Programmes and Case Management for certain specified disease conditions.
HIV/AIDS Disease Management Programme
The HIV/AIDS Disease Management Program was the first intervention to be introduced at Managed Care Department. This involves ensuring that members and their dependants access comprehensive HIV Care in line with the latest national and/or international treatment guidelines.
The spectrum of care includes:
- medical consultationslaboratory or pathology tests for monitoring disease progression.
- and access to antiretroviral medicines.
- adherence counselling and support.
- Enrolment for not on treatment HIV positive beneficiaries
- Enrolment for HIV Post Exposure Prophylaxis (PEP)
- Enrolment for the Prevention of mother to child Transmission (PMTCT)
- Preventive safe male circumcision (SMC)
Only clinicians who have knowledge of HIV/AIDS are allowed to look after patients who are enrolled on the programme. MCD conducts regular Continued Professional Education to ensure that clinicians offer the latest and up to date HIV treatment to BPOMAS members and their dependants.
The program has been very successful since its inception and as at 31st March 2010 a total of 7546 patients were on antiretroviral therapy. The programme continues to grow annually as more patients who are eligible as per the set criteria enrol.
MCD is also involved in the management of chronic disease including hypertension, diabetes, asthma and hyperlipidaemia. These diseases constitute the majority of chronic illnesses prevalent in the general population in Botswana.
Through this program patients register for chronic medication benefit and are given a guarantee letter indicating the medications they are taking. Chronic medication benefit allows members to access bigger amounts of money compared with acute medication benefit.
This has had the effect of ensuring that fewer patients run out funds before the end of the financial year, which was the case before the introduction of this benefit. Only members on BPOMAS High Option can use the chronic medication benefit.
A total of 4351 BPOMAS beneficiaries had registered with the programme as at 31st March 2010.
Pharmaceutical Benefit Management (PBM)
BPOMAS introduced Pharmaceutical Benefit Management system in January 2009. PBM is managed by MCD and partly outsourced. The system was introduced in order to reduce the cost of medicines and to ensure long term sustainability of BPOMAS.
There are two components to PBM namely Generic Reference Pricing and Differential Mark Up. Through Generic Reference Pricing, all branded products that have generic equivalents registered and available in Botswana are reimbursed at the average price of the generic equivalents. The idea is to encourage clinicians to use generic medicine which are generally as effective as their branded counterparts.
Registration in Botswana means that the products have been rigorously tested and assessed for quality, efficacy and safety by the Drugs Regulatory Unit (Ministry of Health) and consequently there should be no doubt as to whether these generic products work.
Differential Price Mark Up involves reimbursing at a higher mark up for the generic referenced medications and a lower mark for the branded products that do no have generic equivalents in the Botswana market. Currently generic products are reimbursed at up to 57% mark up on the basic acquisition price whereas branded products are reimbursed at 35%.
In the short to medium term MCD will introduce the following interventions namely, Case Management and Wellness Programmes. It is hoped that these interventions will enhance the services provided by MCD for BPOMAS members.