Medical schemes a valuable resource
Continuously striving to improve quality of care and offering benefits that cater for the needs of members at each life stage, as well as working closely with doctors and hospitals to achieve the best possible results, South Africa’s medical schemes remain a valuable resource, says Andrew Edwards, Executive Principal Officer of Liberty Medical Scheme (LMS).
Medical schemes offer members a number of benefits that considerably enhance their lives. Via medical cover, members have access to some of the best doctors, hospitals and life-saving procedures in the world. In addition, medical schemes pay for many other healthcare needs such as nursing, surgery, dental work, medicine, physiotherapy and eye-care.
“But perhaps most importantly, medical schemes protect their members financially if they suddenly have to pay large, unexpected medical costs. Generally, medical scheme members can also rest assured that there will be little, if any, delay in medical treatment,” says Edwards. “Without medical scheme cover, people will have no choice but to rely on the overburdened state healthcare facilities – or fund the cost of treatment out of their own pocket.”
“Younger, healthier individuals could pay for the occasional doctor’s visit and medicine out of their own pockets, but what if they need specialist or long-term medical attention because of an unexpected illness or a tragic accident?”
Although LMS fully supports the objectives of the National Health Insurance (NHI) system, the reality is that the roll-out of NHI may take as long as 15 years. As State hospitals are already struggling and under huge pressure to provide care to the majority of the South African population, the public healthcare system simply won’t be able to accommodate millions more patients.
While it is expected that NHI will offer a better service than that which is currently available in the public healthcare sector, providing access, benefits and affordability – the three pillars of quality healthcare – in equal measure is likely to prove challenging. As NHI will be more focused on primary care, it is expected that the provision of benefits and services will be quite different from those of medical schemes.
With both private and public hospitals already stretched to the limit in terms of capacity and resources, existing private hospitals as well as new entrepreneurs may seize the opportunity to develop a new, more affordable hospital model that will fill the gap between over-burdened State facilities and expensive private hospitals says Edwards.
On the issue of affordability, he says private healthcare costs are largely being driven by hospitalisation and the fact that medical scheme membership is not compulsory. Fraud also comes into play and drives up costs, but, on average, schemes have forensic units and measures that keep a watchful eye and expose culprits. Tried and tested managed care systems and formularies also ensure that hospitalisation and medicine costs are kept in check.
“Although medical scheme contributions are seen to be high, it is important to note that members are paying for quality. As medical schemes’ risk profiles age year after year, younger and healthier members are needed to balance the books,” he adds.
Well aware that affordability is increasingly becoming a major problem for many South Africans, LMS has focused its efforts on carefully shaping options for members that give them access to quality healthcare relevant to their particular life stage. This means there is a greater focus on what members need, offering them both value for money and affordability. In addition, LMS has a healthy solvency ratio of 27% and AA- credit rating by Global Credit Ratings, which confirm the scheme’s financial health.
“Good medical schemes will revise and review their options every year to ensure that the benefits are appealing to members, are appropriately priced and affordable. As a result, medical schemes will continue to play a crucial role in helping a significant number of South Africans meet their healthcare needs,” says Edwards.
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