Care co-ordination is key to future success
For SA to achieve universal health coverage — one of the UN’s sustainable development goals — greater efficiency from healthcare resources is required.
“As we work towards the implementation of NHI [National Health Insurance] in South Africa, it is vital that all of the country’s health resources are fully utilised to ultimately help secure equitable and adequate access to quality healthcare for all,” says Dr Gunvant Goolab, principal officer of the Government Employees Medical Scheme (Gems).
As the largest restricted medical scheme in SA, Gems has unique insights into the country’s healthcare environment and the opportunity to develop approaches that make the most of the limited resources to fund quality care.
“In order to secure the best possible value for our members, the scheme has drawn from its experience in healthcare funding and its extensive healthcare practitioner and provider networks to develop affordable models that deliver meaningful benefits,” says Goolab.
“Gems’s expertise in healthcare funding and coordination of relevant resources means that we are well placed to contribute to the goal of universal health cover,” he says.
“A recent innovation from Gems contributes to this principle — primarily that of care coordination. The introduction of the Emerald Value Option (EVO), an efficiency discounted version of the scheme’s Emerald Option, in 2017 has seen over 113,000 members and beneficiaries opting to save on healthcare by joining the new benefit option.
“Members on EVO enjoy the same level of benefits as members on the traditional option but pay 10% lower contributions. This is a significant development, particularly if one considers how much could be saved annually in a country where billions of rand is spent on healthcare each year,” adds Goolab.
The use of primary healthcare services is recognised as key to making healthcare more affordable and accessible by directing patients to the appropriate level of care.
“The scheme identified that the majority of our members routinely visit the same general practitioner when they have need for medical care. Gems has long recognised that primary healthcare is central to achieving better health outcomes for patients, and that members who return to the same doctor each time they require healthcare frequently enjoy better health.
“When designing the EVO, we therefore introduced a condition that members on this option nominate a general practitioner as their ‘family practitioner’ and return to the same practice each time they require healthcare, although provision is made for medical emergencies.
“Where specialists’ services are required, these are accessed through referral from the family practitioner to healthcare professionals registered on the Gems Specialist Network.
“This approach has contributed to improved health outcomes, and therefore a reduced need for hospital admissions.
“In the first six months, we have seen members on EVO experiencing a 16% reduction in hospital admissions and a 22% decrease in the need for specialist consultations,” says Goolab.
He says there are a number of choices South African healthcare consumers can make to contribute to maximising the resources we have in preparation for NHI.
Establishing a good, trusting relationship with one general practitioner who can direct you to the most appropriate treatment path, making use of generic medicines where possible and taking care of your health are excellent starting points.