Mon, 01/04/2019 - 10:51
Current Issue 70
We look into the Government Employees Medical Scheme and the work it is doing to improve access to healthcare for South Africa’s government-employed citizens
Writer: Tom Wadlow
Project Manager: Josh Mann
The South African government is on a mission to open up access to healthcare across the country.
Much has been made of the disparity between public and private provision of medical services, a trend which authorities are looking to address through the implementation of National Health Insurance (NHI), a financing system designed to ensure all citizens are provided with essential healthcare, regardless of their employment status and ability to contribute to the NHI Fund.
An eager supporter of this scheme is GEMS, short for the Government Employees Medical Scheme. Set up just after the turn of the millennium, its mandate is to improve healthcare provision to public sector workers.
A key stakeholder in the wider public health scene in South Africa, who better to ask than Stan Moloabi, Chief Operations Officer of GEMS, about the current state of play and the work being conducted by his organisation.
Stan Moloabi (SM): The beginning of the Government Employees Medical Scheme (GEMS) was a historic moment when in 2002 the cabinet approved a framework policy on a restricted (closed) medical scheme for further development by an interdepartmental working group. The approved framework policy centred on the principles of equity, efficiency and differentiation. The GEMS mandate is to ensure that there is adequate provisioning of healthcare coverage to public service employees that is efficient, cost effective and equitable; and to provide further options for those who wish to purchase more extensive cover.
GEMS was registered on January 1, 2005 specifically to meet the healthcare needs of government employees in line with the mandate. GEMS became operational on January 1, 2006 and we are required to help public service employees and their families to get the best possible healthcare at the most affordable cost.
SM: The South African healthcare system remains characterised by inequality, where access depends on the ability of an individual to pay. The ideal of affordable quality healthcare for all can only be achieved through cooperation and buy-in from different stakeholders, including private healthcare funders, and GEMS is committed to putting its experience and expertise behind efforts to make the South African healthcare system more equitable and unified.
GEMS has already made great strides towards broadening access to healthcare, particularly among government employees and their families who previously could not afford healthcare cover. Through implementing models that make more efficient use of healthcare resources, encouraging medical scheme members to make use of primary healthcare facilities and placing a greater emphasis on promoting wellness and preventative care, the limited resources available can go further for all South Africans.
SM: GEMS has grown to become South Africa’s second-largest medical scheme, covering over 700,000 public service employees and approximately 1.8 million beneficiaries, and the biggest restricted membership medical scheme.
GEMS offers six benefit options that were each designed using a rigorous analytical approach, taking into account the requirements of the Council for Medical Schemes, member affordability and benefit design assessment.
SM: The Scheme launched the Emerald Value option (EVO) with an expectation that a significant portion of members will elect to move to this option.
This option has the same benefits and limits as the Emerald option, however members have to access healthcare through their nominated general practitioner, including being formally referred for specialist services when required. EVO members are also required to make use of a network of hospitals. In just 24 months, the Emerald Value option has grown to cover 176,262 beneficiaries.
SM: We consider research and development vital to remaining relevant to the needs of our members. We continually analyse information about how beneficiaries make use of their benefits and take this into consideration when developing benefit packages each year. In addition, the Scheme hosts stakeholder engagements and regularly reaches out to members through Lekgotla Roadshows to ensure dialogue and identify how we can better serve our members.
We have just concluded a research study on level 1-5 members – the objective of the study was to understand barriers to entry and member needs of level 1-5 employees and how the Sapphire benefit option is perceived by both GEMS members and non-members. Our research study showed that Sapphire members wanted increased access to private hospitals. As a result in 2019, beneficiaries on Sapphire will have access to a selected number of additional procedures at GEMS network private hospitals. The Scheme is also reinvesting around R830 million towards the enhancement of member benefits in 2019 across all options.
R&D is key in driving health policy and strategies that are evidence based which, when employed appropriately, can have a significant impact in the health system and health outcomes. The key pillars of the R&D unit are analytics, research and product development. We are creating a culture of decision making that is data driven and research based.
The Scheme has established research and development processes and capabilities which help to inform benefit design changes. This includes enhancements to existing options and the launch of new options. GEMS has established product development and benefit design forums.
Participants in these forums are mandated to propose benefit design changes aimed at improving healthcare outcomes. More specifically, benefit design changes are intended to increase access to clinically appropriate care whilst simultaneously containing unnecessary and wasteful expenditure. Proposed benefit design changes are informed by a combination of clinical and actuarial analytics. These analytics focus on understanding the needs of members.
An illustration of how research and development has contributed towards the development of new options is the establishment of the Emerald Value Option. Our analysis indicated that members who embrace care coordination have improved healthcare outcomes and incur lower healthcare costs. Consequently, the Scheme established the Emerald Value Option whereby members received a 15 percent contribution discount in return for nominating a general practitioner, accessing care via a general practitioner before consulting with a specialist and using a network of efficient hospitals.
Since its establishment in 2017, the Emerald Value Option has grown to around 176,262 beneficiaries. These beneficiaries have experienced a 16 percent reduction in their hospital admission rate as a result of coordination of care.
The Scheme also receives benefit design inputs from a variety of external stakeholders. These include but are not limited to members, unions and doctors and their representative bodies. These suggestions are thoroughly reviewed and assessed by the Scheme and its service providers. This also entails a combination of clinical actuarial analytical processes.
Research and development is critical to ensuring that the GEMS benefit design structure continues to satisfy the needs of members. Research and development plays a similarly important role with regards to claims management, service management and disease management.
SM: GEMS’s Sapphire and Beryl options provide cover to build on the public healthcare offering, with complimentary cover for out-of-hospital services such GP consultations, basic dentistry and optometry, as well as maternity care and selected additional procedures at private facilities. More extensive access to private healthcare services is available on the Ruby, Emerald, Emerald Value and Onyx options.
The public health system has a very important place in South Africa, and through providing healthcare cover for members of the public service and their families, GEMS is helping to alleviate pressure on the public health system.
SM: In order to secure the best possible value for our members, the Scheme has drawn from its experience in healthcare funding and its breadth of healthcare provider networks to develop affordable models that deliver significant benefits.
A few years ago, the Scheme identified that the majority of our members routinely visit the same general practitioner when they have need for healthcare. 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 often enjoy better health.
The use of primary healthcare services is recognised as key to making healthcare more affordable and accessible through directing patients to the appropriate level of care, and this model of care coordination helped to inform the Emerald Value Option benefit design.
The launch of the GEMS Member App is another key development that marks a new era in our interactions with members. Harnessing the power of digital technology not only empowers members to understand the Scheme better, it also allows GEMS and our service providers to work smarter and more efficiently to enhance our service and, ultimately, the member experience.
This new service solution has been specially designed for members and dependants of GEMS, and is available for free download for both iPhone and Android smartphones at Google Play and the App Store.
The App means that members are able to submit a claim, update their personal information and request hospital authorisations for themselves. This is just one of the ways that we are building service innovations around the needs of our members, while enhancing the efficiency of the Scheme’s operations.
Many of the services that members previously had to fill out paperwork or phone the GEMS contact centre for can now be accessed via the app. With the GEMS Member App, members can change their benefit option, and access information including their claims and benefits from their cellphones. This new development brings a highly personalised and interactive tool to our members.
SM: Maturing our five-year strategy, which is already in its third year. Our current thrust is to redesign for growth and efficiency and this will be achieved by product simplification. The main objective is to simplify our products and ensure that they meet the needs of our members. For the next few years our focus will be on product simplification and aligning our products to NHI; this will also entail comprehensive research on option consolidation.
Benefit enhancements are intended to provide members with increased access to clinically appropriate care. Similarly, benefit enhancements are intended to reduce out of pocket payments for members in the context of clinically appropriate care.
We will also continue to promote care coordination to make it easier for members to navigate the evolving healthcare system. The Emerald Value Option which champions care coordination through general practitioner nomination, general practitioner to specialist referrals and an efficient hospital network is an example of such an initiative.
Another priority is to improve affordability. This extends to the application of affordable contribution increases and the development of new and innovative options which help to reduce contributions. For 2019, the GEMS contribution increase is amongst the lowest in the industry at 7.1 percent.
Most importantly, GEMS is committed to ensuring that its benefits are easily understood by both members and healthcare providers. For this reason, simplification and standardisation will increasingly be prioritised when enhancing benefits.
The move towards Universal Healthcare Coverage has presented GEMS with an opportunity to use the experience it has gained over the past decade to put itself forward as a trusted partner that can be engaged as part of the process to implement the remaining phases of the NHI. We are working hard at being the blueprint of NHI in South Africa.