1. Proposal to Medical Scheme/Administrator Index of the presentation  Brief resume of SP Net  Service offering by SP Net to Medical Scheme/Administrator  Format of proposed contract with Medical Scheme/Administrator  Proposed risk sharing model  Risk sharing arrangement for downstream costs  Benefits of the MFFS over Capitation for low cost options  IPA Foundation structure  IPA Foundation offering to Schemes/Administrators

2. SAMDP Provider Network (SP Net)  Is a national network of General Practitioners (GP) affiliated to 21 Independent Providers Associations (IPAs)  Represents 1 100 (GPs) spread all over the country  We have a strong presence in Gauteng; Limpopo; Mpumalanga; Free State ; North West and KZN  SP Net is an association of IPAs  SP Net has a company called SP NX Management Services that contracts on behalf of SP Net affiliated doctors  SP NX is a legal persona and is registered as a (Pty) Limited, has contracts with the medical industry players, government and other service providers  SP Net is part of a national GP network called the IPA Foundation that comprises of the SAMCC; ASAIPA and DFPA

3. Service offering by SP Net  Negotiate and sign contracts on behalf of all its affiliated IPAs and doctors  Contract doctors on behalf of the scheme/administrator  Do Quality Assurance on contracts: Peer Mentoring and Peer Review Process;  Devise quality measures that need monitoring with schemes  Negotiate alternate reimbursement models for providers  Communicates regularly with its members via monthly newsletters, website, e mails, SMS, fax and telephone  Organize CPD meetings and other activities for the IPAs and their doctors  Do regular road-shows (visits) to the various IPAs affiliated to SP Net

4. Service offering by SP Net to Medical Scheme/Administrator  Sign a master contract with Medical Scheme/Administrator on behalf of the IPAs and the doctors where Medical Scheme/Administrator requires providers  Contracted doctors will be expected to sign a provider undertaking contract  Monitor the utilisation and performance of the doctors on this contract  Do peer mentoring and peer management  Set up, together with Medical Scheme/Administrator, quality assurance criteria and monitor these  Set up a management committee with Medical Scheme/Administrator where we will have monthly management meeting where data and information is shared

5. Format of proposed contract with Medical Scheme/Administrator  Preferred Provider Network (PPN) that will have doctors charging a Managed Fee for Service (MFFS)  Designated Service Provider (DSP) contract whereby the contracted doctors will manage the CDLs and the primary care of the other PMBs (DTPs)  Medical Scheme/Administrator will not transfer the risk to SP Net; therefore there is no need presently for SP Net to register as an MCO  SP Net provides outsourced function to Medical Scheme/Administrator and will share risk with Medical Scheme/Administrator by managing downstream costs  SP Net has similar low cost option contract (Frontier Plan) with Thebemed  We have contracts with other administrators that operate along the same lines of sharing risk rather than risk transfer  If need be, SP Net can take a capitation contract and outsource the management of a cap to the administrator or any other company

6. Proposed Managed Fee For Service model for consults and medicines  SP Net will assume 100% cover for the consults and acute medicines  Managed Fee For Service (MFFS: consult plus medicines) of R240; limited to 10 visits per member per annum  Professional fees (consult): R190 plus R50 for medicines  Chronics (PMB) Consult plus SEP for medicines plus 16%  Chronic visits limited to a maximum of six visits per annum  Non dispensing doctor to script based on formulary

7. Risk sharing arrangement for downstream costs (future arrangement)  This will be a retrospective payment based on meeting the target budget for these costs. Sharing of savings can be done at the end of a benefit year once all the costs have been finalized.  Savings will be shared based on the percentage reflected in the following manner; SP Net: Medical Scheme/Administrator  Optometry: 20:80, through subcontracting or 100% to Medical Scheme/Administrator  Pathology: 20:80  Radiology: 20:80  Hospitalisation: 10:90  HIV cover 0:100  Auxiliary Services 0:100  Out of network 0:100

8. Benefits of the MFFS over the Capitation contract Managed fee for serviceCapitation Administration of the product done by Medical Scheme/Administrator and has full access to utilisation data No access to utilisation data Members are part of the overall system of managing scheme’s clients Outsourced function where it is like a situation where members are ‘dumped’ Do administration on behalf of its membersCap company may not have good systems Direct payment by scheme to participating doctors Medical Scheme/Administrator is able to give full report to CMS regarding management of its members; has ability to communicate directly with its members with confidence There may be non payment of doctor by cap company Company providing capitation may not have this ability; possibility of removing accreditation of this company because of non- compliance

9. Benefits of MFFS contract  SP Net will be part of the outsourced service providers to administrator  SP Net will be paid a monthly fee for services rendered  Medical Scheme/Administrator is part of growing the network and devising quality assurance criteria  Administrator and the scheme do not lose control regarding what is happening to the members  Administrators/schemes can outsource function similar to a cap; but cannot outsource responsibility

10. Proposed fee for the low cost option to be paid to SP Net  SP Net takes 100% cover for consults and medicines; therefore this fee should be drawn from fees that are to be paid to the doctors for these services  We propose a fee that is based on the number of visits -1 to 1 000 lives : X Rands per visit -1001 to 4 999 lives : X – R2 per visit -5 000 to 9999 lives : X – R5 per visit -10 000 lives a flat fee of per visit X – R7  Alternatively; a flat fee of Y Rands per principal member per month  This fee will cover peer mentoring and other management functions; but exclude peer review  The Peer Review fee will be negotiated and paid for separately

11. The Independent Practitioner Association Foundation (IPA Foundation) structure  Is a collective of 4 IPA network in SA, viz -SP Net -Alliance of South African Independent Practitioners Associations (ASAIPA), -South African Managed Care Cooperative (SAMCC) and -Dispensing Family Practitioners Association (DFPA)  The Foundation has a combined membership in excess of 5 000 GPs. This makes it the largest GP network in the country  It is fully committed to access to affordable quality healthcare, transparency, and aims to enhance the coordinator role of the GP.  It is an “Open Network” member can attend any doctor affiliated  It also contracts with non IPA affiliated GPs

12. IPA Foundation offering to schemes  National footprint across any demographic line  PPN; Primary care for PMBs (DSP); PBR model; Quality Measurements  Has contracted with an MCO that will provide full back office support, including a call centre  Has contracted with an independent profiling company that will do analysis of contact data and present it for peer review  Has signed with one client and is in a process of signing with others  Have an existing contract (Forum) which may be reversed to the Foundation once it is fully registered  Will be registered as a Section 21 company and has made a presentation of its contract and structure to the CC; awaiting this approval  Has an intention of registering as an MCO later  Can take full risk once registered as an MCO  Presently provides risk sharing models only

13. Thank you