Open communication is key to medical schemes' affordability

Dr Tumi Seane, Acting CEO of Sechaba Medical Solutions

The affordability of medical schemes and medical insurance cover is a hot topic at the moment especially with the likes of NHI under discussion. Dr Tumi Seane, Acting CEO of Sechaba Medical Solutions, says uptake at medical schemes is currently slow w

Another aspect that needs to be understood is that service providers, including hospitals, pharmacies, specialists and GPs, want to make a profit and while these service providers don't intentionally put financial pressure on schemes, their rates aimed at making a profit can jeopardise the financial viability of schemes. "Service providers may also be partially to blame for members' unrealistic expectations that schemes will be able to cover all medical expenses and services. The reality is that higher claiming patterns can result in schemes needing to up their premiums and in essence start to out-price themselves in the market," adds Seane.

"Another aspect that needs to be understood is that medical costs cannot fully cover private fees of healthcare professionals. Understandably they are private enterprises that are entitled to make a profit but this places undue pressure on schemes and often creates unrealistic expectations from members. It is a vicious circle with claim increases resulting in increased premiums which members can often no longer afford," adds Seane.

"The solutions," he says, "lie in schemes and administrators finding a way to empower the board of trustees to make decisions that will keep schemes financially sustainable." Seane recommends calling in advisors and experts who can offer insights into the industry, track public and economic trends and then suggest options that make sense for the scheme and its members.

Schemes also need to find creative ways in which to incentivise service providers so channels can be opened for negotiations resulting in win-win solutions. "Once incentivised appropriately, service providers will feel it is worthwhile to consider what is economically right for the scheme and the members and will act accordingly. This has resulted in the emergence of a number of network options which have proved highly successful. Only through partnerships and engaging with service providers can this be achieved," he says.

Seane says both schemes and service providers should be encouraged to assist in educating their patients and members on the importance of preventative measures. "Wellness of members is a vital key to assisting in the sustainability of schemes. It is encouraging to see an increase in corporates looking for wellness managers and wellness programmes and members becoming more empowered about their own well being." Employers understand the benefits to their organisations when employees are treated during the early stages for chronic diseases and preventative measures put in place.

"Before absenteeism becomes a major problem, it makes sense for employees to be screened by a health professional, advised on the necessary preventative treatment and empowered with knowledge on what is going on in their bodies.

Most chronic conditions, such as obesity, diabetes, HIV and so on, can be managed effectively if they are picked up during the early stages. Ensuring they are picked up early, means that employees need access to screening days and health professionals which is where employers can step in. Having members on prescribed medications for the long term also makes more financial sense for schemes as absent employees or very sick employees no longer contribute to the schemes' financial reserves," he says.

While there are organisations that have invested in full-time, in-house health personnel, most organisations still opt for wellness days managed by external health professionals, provided by medical schemes and administrators. "We have seen that generally employees are more willing to interact with an external professional as they feel there is a greater level of confidentiality. Someone not associated with management seems like a better option for employees. However, management can assist by encouraging employees to use the resources at their disposal, whether it be through free screenings or the knowledge made available," says Seane.

"Communication is key with all stakeholders to ensure positive health outcomes and a more sustainable model," he concludes.