Access To Affordable Quality Healthcare in SA
THE Government Employees Medical Scheme (GEMS) has, according to its Principal Officer, successfully explored avenues for managing expenditure without compromising on the benefits its members are accustomed to.
Dr Gunvant Goolab says, “For every R100 GEMS receives in contributions, R94.90 is spent on members’ healthcare needs.
“The scheme runs extremely efficiently and the Council for Medical Schemes’ latest annual report reflects our non-healthcare expenditure at only 5.1 percent.”
Last year the healthcare funding industry and consumers faced significant financial pressures, with many medical schemes having to post double-digit contribution increases for 2017.
He elaborates on the GEMS solution, “We knew that for our members, and indeed most South Africans, every rand counts and therefore any contribution increase would be cause for concern.
“To help alleviate such financial pressures we had to provide viable alternatives to ensure GEMS adhered to its commitment to provide members with choice and value.
“However, the financial climate meant that the fees on our standard benefit options would need to increase to keep pace with healthcare costs.
“This was for the protection of members and to avoid eroding their benefits. In fact, GEMS’s 2017 benefit options bouquet extended several key benefit areas to assist members.”
Approximately 50 000 members moved from one benefit option to another, with the majority migrating to the new Emerald Value Option which is less expensive than the options they were initially on.
As of the end of December, GEMS had 694 262 members, compared to 674 273 members the previous year.
Dr Goolab notes, “We identified that more than two-thirds of members visit the same general practitioner when they need medical care.
The use of primary healthcare services is globally recognised as key to making healthcare more accessible through directing patients to the appropriate level of care, thereby making the most efficient use of scarce resources for the greatest benefit to patients.
“GEMS identified an opportunity for responding to members who follow this path when accessing healthcare.
“This led to the introduction of our new Emerald Value Option (EVO).
“In terms of this benefit option, members can access the same benefits as on our very popular Emerald Option but at a reduced rate if they agree to use the nominated network of healthcare providers and access healthcare services through their general practitioner.”
Members on this option first visit their nominated GP on the GEMS network for healthcare. If required, the GP then co-ordinates their care through referrals to network healthcare specialists.
Where hospitalisation is required, members and their dependants on the EVO must make use of network hospitals.
“They therefore have access to quality healthcare at a more affordable rate, while practising responsible principles that will ultimately preserve resources, prevent unnecessary waste and thereby minimise contribution increases in future,” he concludes.