Document Sample
oNCoLoGY Powered By Docstoc
					   THe sTePs are as foLLows:
      Patient’s oncology treatment plan is received from
                treating doctor via fax or e-mail

  oncology Case manager assesses treatment plan according                                                                           rIsK maNaGemeNT
 to clinical guidelines to approve in line with available benefits

                                       **If TreaTmeNT PLaN Is

                                        Treating doctor is notified
                                      and may then submit revised
                                       treatment plan for approval
                      *If TreaTmeNT PLaN Is aPProVeD…
                       Qualsa notifies treating doctor who then
                                interacts with patient

                     All oncology-related consultations, treatment,
                     chemotherapy and medication are paid from
                      the oncology benefit according to medical
                                     scheme rules

              If TreaTmeNT PLaN Is PeNDeD…

 Referred to the Qualsa Medical Advisor, who assesses treatment
  plan and approves, refers or declines – these would be cases
        where the standard treatment protocol is not met

 If TreaTmeNT            If TreaTmeNT              If TreaTmeNT
     PLaN Is                 PLaN Is                   PLaN Is
  aPProVeD…             referreD To THe             DeCLINeD…
                          saoC UrC…
 Qualsa notifies                                   Treating doctor
 treating doctor            SAOC URC                is notified and                          CoNTaCT DeTaILs
who then interacts          assesses and           may then submit
   with patient            advises of their       revised treatment             Should you have any further queries regarding the
                               opinion            plan for approval           Oncology Risk Management Programme, please contact
                                                                                your medical scheme’s client services department
                                                                                 and request to be transferred to the Oncology
                aPProVeD*             DeCLINeD**

   All oncology-related consultations, treatment, chemotherapy                             websITe
 and medication are paid from the oncology benefit according to
                      medical scheme rules
                                                                                     a member of meTroPoLITaN HeaLTH GroUP
                                                  The primary function of the Programme is to
                                                  pre-authorise oncology treatment and to interact
                                                                                                                                sTePs To
                                                  with oncologists regarding treatment plans for                               TreaTmeNT
                                                  cancer patients. The ultimate objective is to                              PLaN aPProVaL
                                                  ensure that patients receive the care they require                            oVerLeaf
                                                  and to optimise the oncology expenditure within
                                                  their medical scheme’s benefits. The Programme
                                                  includes member education, the promotion of
                                                  wellness and pre-authorisation which grants
                                                  access to medicine and hospital benefits.                   E	 Basic counselling by case managers for newly-
                                                                                                                 diagnosed members and advice on access to further
                                                                                                                 psychological support, if needed
                                                  How Do we aCHIeVe THIs?                                     E	 Assessment of your medication in accordance
                                                  Qualsa Healthcare (Pty) Ltd (Qualsa) employs a team            with treatment guidelines and protocols that are
                                                  of dedicated oncology case managers and a full-time            maintained and updated
                                                  Medical Advisor who deal with all oncology cases.           E	 Interaction and co-operation with service providers
                                                                                                                 in order to improve care and cost-efficiency without
                                                  In addition to these internal resources, Qualsa interacts      compromising quality
                                                  closely with the following specialists:                     E	 An oncology Medical Advisor who evaluates referred
                                                  E	 oncologists affiliated with Tygerberg Hospital and          problems
                                                     the University of Stellenbosch Faculty of Medical        E	 An oncology specialist group to whom referrals are
                                                     Sciences                                                    made. We interact with our own appointed advisors
                                                  E	 a gynaecological oncologist on the Witwatersrand            and with the South African Oncology Consortium

   INTRODUCTION                                      University Health Consortium panel
                                                  E	 the South African Oncology Consortium (SAOC)
                                                                                                                 Utilisation Review Committee (SAOC URC)
                                                                                                              E	 Relationship development with oncologists
                                                     for the purposes of peer group management and
       The Qualsa Oncology                           protocol evaluation. The SAOC represents more            We also continuously strive to enhance our existing
   Risk Management Programme                         than 90% of South African oncologists and supports       Programme to improve your experience during a
aims to ensure that the treatment of cancer is       Qualsa’s approach to cost-effective management of        difficult time.
 done in an effective and affordable manner in
                                                  E	 for certain benefit options of medical schemes, we
co-operation with your oncologist. With all the      may interact with the Independent Clinical Oncology      THe ProCess
  risks associated with oncology management,         Network (ICON).                                          Once you have been diagnosed with cancer, your doctor
treatment and medication, there is value in the                                                               needs to submit a treatment plan on an official SAOC
                                                                                                              form to Qualsa. (Should your doctor not have this
  effective management of cancer patients. We
                                                  wHaT Does THe ProGramme offer?                              form, he/she may contact your medical scheme’s client
 understand the implications and fears that are   E	 Pre-authorisation of oncology treatment through          services depar tment and ask to be transferred to the
 associated with cancer and we strive to apply       specialised case managers and a strong supporting        Oncology Department to request a copy.) When you
  sound and effective care within your medical       clinical team                                            receive a prescription for your cancer medication, it is
                                                  E	 Clinical advice and guidance regarding your treatment,   important that you immediately contact your medical
                 scheme benefits.
                                                     and referral to appropriate national support groups,     scheme's client services department and request to be
                                                     when appropriate                                         transferred to the Oncology Depar tment.