Networks help manage costs
Rising healthcare costs, the ongoing credit crunch and the increasing emphasis within the South African healthcare industry on curative health interventions which far outweigh the focus on prevention, are creating a serious challenge for many medical sche
Rising healthcare costs, the ongoing credit crunch and the increasing emphasis within the South African healthcare industry on curative health interventions which far outweigh the focus on prevention, are creating a serious challenge for many medical schemes.
Peter Jordan, Principal Officer of Fedhealth, says one of the biggest challenges facing medical schemes is that of affordability - keeping the monthly contribution members pay within acceptable limits. Jordan says rising hospital costs are a particular concern for schemes, as is the high level of claims from members who consult specialists. A number of larger schemes started introducing network models to try and keep a lid on spiralling costs.
"Fedhealth now has 3 157 specialists contracted on its network, 4 333 doctors on its GP network and 1 679 pharmacies. This is significant when you consider that hospital costs account for 45,3% of the claims submitted by its members, with another 19% going to specialists and 12% to general practitioners. Medicines account for 9.5% of claims," says Jordan.
He believes it is all about achieving the best health outcome and consumers need to be more circumspect in what they are paying for and who they see.
"The reality is we do not have unlimited resources and many of the problems arise from over-servicing in the private sector and under-servicing in the public sector. There needs to be a drive towards encouraging members to utilize the networks which have been put in place more effectively," he says.
"The introduction of accessible networks has certainly helped this move. In 2012, 82% of Fedhealth claiming beneficiaries accessed the Fedhealth GP network and 89% of our claiming beneficiaries accessed our pharmacy network."
"We believe it is the scheme's responsibility to try and provide meaningful benefits to members which is why Fedhealth, on most options, provides unlimited access to GPs in the GP network. GPs are skilled at assessing the body as a whole and often pick up health issues that patients may not be aware of. This can lead to early prognosis and treatment without the need for a visit to a specialist. But in the event they do need a specialist, we have a growing specialist network base for them to access as well. "
Jordan says that Fedhealth sees the merit in working more closely with providers in order to get the balance right and bring down costs, and believes the networks are helping in this regard. "They are without a doubt helping schemes to keep monthly contributions within acceptable limits for members," he concludes.
