PUBLIC SERVICE MEDICAL AID SCHEME (PSEMAS)

The Public Service Medical Aid Scheme ( PSEMAS) is a benefit available to staff members and aims to:

(a) Assist its members with the cost of Medical Care in particular; and

(b) Promote the health of members in general through its wellness and chronic disease management programmes

Managed Care

What is the aim of Managed Care on PSEMAS?

• Managed Health Care is a programme to organise and deliver cost effective and appropriate treatment from the best source. Managed health care is the system/structure established for the funding and provision of health care with the aim of managing the costs, utilisation and quality and/or outcome of the service rendered in a way that ensures cost-effectiveness and high quality. The main objective of Managed Health Care is the successful long-term provision of quality care at an affordable price.
• The Managed Health Care system makes provision for contractual agreements between the Ministry of Finance and Public Enterprises, as custodian of PSEMAS, and the providers of Health Care. The quality of service is continually monitored and methods have been introduced to influence the behaviour of consumers of services and service providers.

NamHealth Administrators in association with Methealth Namibia administrators follow 3 basic strategies in containing the cost of health care on PSEMAS.

• Health Promotion Strategies to promote health in general. Examples are programs to promote basic health and fitness. The purpose is to curb costs over a long term.
• Health Care benefit design strategies are measures taken to discourage members from claiming unnecessarily. The purpose of these efforts is to curb over-utilisation. The claiming patterns of each PSEMAS member are available on the data base.
• Health care supply/delivery system strategies to effect savings. For example, pre-authorisation is required for PSEMAS members who require hospitalisation at a private hospital. This is done to curb unnecessary expenditure, by not allowing a patient to be hospitalised unnecessarily and preventing hospitalisation for longer than is medically necessary. Such strategies also ensure that the patient receives the correct treatment the first time, thus improving quality of care and generating further savings.

All accounts submitted to NamHealth are audited in the context of appropriateness. Quality claims management not only controls cost but also delivers the best clinical outcomes for the PSEMAS members. Claims are further audited in terms of the applicable benefits and conditions under PSEMAS. For costly procedures it is always important to first find out what benefit conditions are applicable.

Stricter control measures are being introduced to control the manner in which membership cards are used. In practice certain PSEMAS members have been found guilty of providing their membership cards to family or friends who are not registered members resulting in unnecessary financial strain to the government of Namibia. This will no longer be permitted as service providers are now required to obtain proof of identity prior to providing the service to any PSEMAS members.

Managed Health Care is a necessity to control and manage costs, to ensure efficiency and to promote general health within an environment of accessibility and affordability.