Medicine Risk Management


The Medicine Risk Management (MRM) Programme aims to optimise medication used by members in managing their conditions. More specifically the programme aims to control medicine expenditure, promote appropriate prescribing habits, identify and control financial risk, analyse data to provide useful outcomes information and to practice evidence-based medicine. Protocols and formularies are applied to ensure that appropriate and cost-effective drugs are prescribed to members.


The MRM Programme is a critical link between the scheme and the Risk Equalisation Fund (REF). REF submissions will be based strongly on the pre-authorisation case (ICD linked to the NAPPI code) information. To ensure that the scheme understands its status of net receiver from REF, Metropolitan Health Risk Management will report as necessary in this regard.


Differentiating features

  • Real-time link between pre-authorisation and medical service provider systems.
  • System-driven quantity and frequency checks for pre-authorised drugs.
  • Pharmacist Online facility for medical practitioners and pharmacists.


The MRM Programme is a holistic programme managed by qualified pharmacists who assist in the identification of disease risks and ensure that appropriate, cost-effective and quality pharmaceutical treatment is provided to all members, especially those that pose a high risk to the medical scheme.


The 2008-2009 Council for Medical Schemes (CMS) annual report indicates that medicine accounts for 17.3% of total benefits paid in 2008. Together with the advent of a set of Prescribed Minimum Benefits (PMB) for a list of 25 chronic conditions known as the Chronic Disease List (CDL), medical schemes are obliged to cover all medication and treatments related to these conditions in full. The management of medication, both chronic and acute, is therefore a vital component of any schemes management armamentarium.


Our approach to managing medicine benefits in a holistic way rests on the following key pillars:

  • Our MRM process places the member at the center of its services and is motivated by the belief that care management and cost containment measures should be introduced with the needs of the end user clearly in focus.
  • Quality care is achieved by practicing sound evidence-based medicine and through access to the most up-to-date clinical knowledge.
  • Cost containment is important as it ensures that unnecessary expenditure and medical inflation does not consume the funds available to manage members' health. Cost containment measures are only considered where they can be introduced without unduly compromising service and quality care.




Total benefit management


Drug Utilisation Review (DUR) pharmacists actively communicate with service providers when members are likely to exceed benefit limits within a benefit year. This is done through an audit of the clinical data and is based on agreed triggers, such as cost of medication and repetition of prescriptions. Should the prescription exceed the monthly or annual limit, the pharmacist will endeavour to reduce the price of the prescription at the point of communicating with the doctor.


Clinical expertise


An important objective of MRM is to practice sound evidence-based medicine. This is done via the Drug and Therapeutics Committee, which consists of Metropolitan Health Risk Management's own clinical staff and independent clinical consultants with expert knowledge of drugs and therapeutics. The panel includes clinical pharmacologists, physicians and professionals with experience in pharmaco-economics. The panel functions to review all new and existing drugs for their clinical efficacy. An information specialist performs independent literature searches and provides the panel with information on reviews and studies of the relevant drugs. Another important focus of the committee is to evaluate clinical trials for design, methods, and integrity of data, statistics and health outcomes. All decisions are evidence-based, and guidelines for pharmaco-economic evaluation have been developed.


Pharmacist Online


Through our Pharmacist Online functionality, the prescribing doctor or pharmacist is able to obtain immediate authorisation for the desired chronic medicine by contacting dedicated call centers manned by pharmacists and supported by a medical advisory panel.


The telephonic authorisation is completed within a few minutes and ensures that the doctor can prescribe without delay in dispensing. This process also gives the pharmacist the opportunity to discuss interventions/alternative or more cost effective therapy with the doctor at the point of prescribing. Any agreement reached is then also communicated to the patient.


Straight Through Process (STP)


To increase efficiency and member satisfaction with the chronic medicines authorisation process, Metropolitan Health Risk Management has an automated authorisation process, referred to as the Straight Through Process (STP). Through the application of disease and product reference codes (ICD-10-nappi crosswalk), and application of clinical rules, the STP allows straight forward applications to be processed more efficiently, with only the more complex applications requiring DUR pharmacists' or medical advisors' attention.


Formularies and protocols


Essential to the management of chronic medication costs and patient health is the development and maintenance of a list of chronic conditions that could be covered by the scheme's chronic medicine benefit. Our MRM specialists apply their expertise and knowledge to create evidence-based formularies and to supply up-to-date protocols for the management of these conditions. The formularies are an essential tool in the automation of the authorisation process and consist of medicines which have been researched and are known to be cost-effective. Our superformulary provides two formularies, a core and comprehensive formulary, which respectively caters for the low and high premium benefit options. The former is typically more restrictive and includes preferred products indicated in the management the PMB CDL conditions, whereas the latter provides a more generous list of products for a more comprehensive list of chronic conditions.


Therapeutic and Generic Reference Pricing


Generic substitution refers to the substitution of a patented or branded product with an equivalent that has the same active ingredient. To manage medicine costs, this practice is encouraged through the use of generic reference pricing known as the Metropolitan Health Reference Price (MetRef). For a given condition, our formularies allow access to a list of appropriate generic equivalent products with the application of the reference price. MetRef is derived through an automated process that calculates the average price across a group of generic equivalent products, and if the member or provider insists on a product that is more expensive than MetRef, the member will be liable for a co-payment.


Therapeutic substitution is the substitution of a costly drug for a more cost-effective one in the same pharmacological class and with the same clinical efficacy. This is done according to a list prepared by specialists and will be done in discussion with and upon the agreement of the prescribing doctor.


MRM believes that promoting the use of cost-effective medication in this consultative way will pay dividends for the medical scheme.


Drug Utilisation Review (DUR)


An effective DUR process evaluates all drugs in a holistic and comprehensive manner. The goal of an effective, concurrent DUR programme is to ensure that drug treatment is rational, appropriate, and cost-effective by taking into account all patient factors such as age, gender, organ function, co-morbid diseases and drug metabolism which might influence drug therapy. MRM will review all drug applications for appropriateness of diagnosis, drug-drug interactions, drug-disease interactions, drug duplications, length of authorisation, frequency and quantities.




Concurrent reviews ensure that the volume and frequency of medicine claims are monitored and measured to determine compliance. Any irregularities are managed immediately.


Reporting to the Scheme


Metropolitan Health Risk Management has a dedicated team of Informatics specialists that produce comprehensive reports for the scheme on a regular basis. These reports include provider profiling, benefit expenditure and trend analyses. Our reporting capability is enhanced through the integration with Metropolitan Health's administration systems.


Quality Assurance (QA)


Metropolitan Health Risk Management has established a dedicated QA and training unit, who monitors compliance to our medicines policy and guidelines, and implements appropriate corrective measures where necessary. This is done through quality assurance of the telephonic and written chronic medicine authorisations. Errors are noted and dealt with appropriately. This ensures that medication are authorised in a consistent and objective manner and in compliance with evidence-based policy.