MANAGEMENT OF MEMBER COSTS

MHS MEMBER COUNSELLING

DEFINITION
High-risk members are identified based on retrospective claims analyses and /or outcomes of the health risk assessment (Health Profiler). Regular, individualised, targeted, one-on-one telephonic interaction then occurs. This is conducted by experienced nurse counsellors, empowering and educating members, resulting in changes to aberrant health care-seeking and lifestyle behaviour.

FEATURES
Member counselling has two foci:

• Retrospective claims analyses are performed and Patient Profiles generated.

• Members showing aberrant health care-seeking behaviour are identified according to various criteria (e.g. doctor-hopping, abuse of acute medication, frequency of consultations, etc.).

• Identified members are contacted telephonically and motivated and empowered to become better consumers of health care services.

• Member health care-seeking behaviour is tracked.

• Based on the outputs of the heath risk assessment (obtained using Health Profiler), clinically high-risk members are identified.

• Identified members are then contacted telephonically.

• Lifestyle modification, health risks, preventive medicine and selfcare issues are addressed.

• Member health risk is tracked to show change.

The counselling process is supplemented by an email-fax facility which enables nurse counsellors to fax or email health care information to members, based on the outcome of the telephonic conversation.

These two approaches may be employed simultaneously or independently to manage risk.

• Empowered, informed, responsible consumers of health care,

• More appropriate utilisation of health care resources by members,

• Increase in member awareness regarding cost-effective health care,

• Effective promotion of healthy lifestyles and enhanced health status of members,

• Shift in the focus of health care from a reactive, curative process, to a proactive, preventative focus.

Service results are reflected in detailed Activity, Exception and Metrics Reports.