However, Moloabi said the scheme was not about costs, but about health.
He said in 2017 the scheme introduced “care co-ordination” for its two low contribution plans, Emerald Value and Tanzanite One.
“When you are on these two (plans), you have to be subject to care co-ordination. It was to solve a problem that leads to high costs in healthcare.”
Members on the two plans were required to nominate a general practitioner (GP) who would see them for day to day ailments that did not need specialised care.
“If (the GP) decides you need a specialist, they will refer you.”
Moloabi said with GP nomination, there was no “doctor hopping, where patients see one doctor today and if they do not feel better two days later they go to another doctor and they do not usually reveal they have been to another doctor.”
He said sometimes patients obtained duplicate medicines, leading to wastage.
“In care co-ordination, you see one doctor with GP nomination, and you go back to that same doctor who reviews why you are not getting better. That is cost saving.
“You do not go straight to a specialist. A GP refers you to a specialist. The specialist within this care co-ordination environment will refer you for admission to a network hospital.
“All of the initiatives have led to cost savings that we think could be a model for policy changes aimed at getting universal health coverage in SA.”
Moloabi said the scheme had also been growing from a revenue point of view and paid out R51bn in claims in 2023.
He said challenges the scheme had identified were fraud, wastage and abuse.
Moloabi said in one case, pharmacists in KwaZulu-Natal, Gauteng and North West all had prescriptions from one doctor.
“The sophistication is that they know how to claim. We will pick them up at some stage. How can a doctor be practising in different provinces? The sophistication is that they establish a syndicate and we catch up with them,” Moloabi said.
He said there were instances where there was collusion between pharmacists and Gems members.
“In Mpumalanga a year ago, pharmacists were arrested with Gems members.”
TimesLIVE
Gems’ path to growth as second biggest scheme in 18 years
The Government Employees Medical Scheme (Gems) has had 18 successive unqualified audits since it started operating in 2006, and this speaks to the scheme’s sustainability and prudent management of the members’ funds.
Dr Stanley Moloabi, principal officer of Gems, made this remark recently as the scheme is set to mark 19 years since it started operating.
Moloabi said the scheme, the second biggest medical scheme and largest closed scheme in the country, had been able to achieve financial stability because of its size.
“We are a big scheme, (and) because of our size the risk profile is diluted.”
The scheme has 860,000 members and covers more than 2.3-million beneficiaries. The pensioner ratio of registered members is at 19.96% as at the end of August.
“Being a big medical scheme, those who are joining are younger. They are expected to claim less than they contribute. It is called cross-subsidisation,” Moloabi said.
He said older members were the ones who got sick more often, had chronic conditions and tended to claim more.
“The expectation is that the young subsidise the old.”
Moloabi said from a single member registered in December 2005, the scheme had grown to become the biggest closed medical scheme.
“The growth is one of our milestones. One of the things that has been important relates to affordability. The cost of healthcare is very high and one of the challenges we are facing is we must maintain affordability.
“What we have achieved as a milestone is we have been on average between 25% to 27% more affordable when we are compared with similar products (from other medical schemes)”
He said Gems is more affordable because of a very generous subsidy from the employer.
Moloabi said the subsidy from government made it possible for employees on income levels 2 to 5, which range from R131,265 to R254,928 per annum, who would otherwise not be able to afford health insurance to be able to have cover.
However, Moloabi said the scheme was not about costs, but about health.
He said in 2017 the scheme introduced “care co-ordination” for its two low contribution plans, Emerald Value and Tanzanite One.
“When you are on these two (plans), you have to be subject to care co-ordination. It was to solve a problem that leads to high costs in healthcare.”
Members on the two plans were required to nominate a general practitioner (GP) who would see them for day to day ailments that did not need specialised care.
“If (the GP) decides you need a specialist, they will refer you.”
Moloabi said with GP nomination, there was no “doctor hopping, where patients see one doctor today and if they do not feel better two days later they go to another doctor and they do not usually reveal they have been to another doctor.”
He said sometimes patients obtained duplicate medicines, leading to wastage.
“In care co-ordination, you see one doctor with GP nomination, and you go back to that same doctor who reviews why you are not getting better. That is cost saving.
“You do not go straight to a specialist. A GP refers you to a specialist. The specialist within this care co-ordination environment will refer you for admission to a network hospital.
“All of the initiatives have led to cost savings that we think could be a model for policy changes aimed at getting universal health coverage in SA.”
Moloabi said the scheme had also been growing from a revenue point of view and paid out R51bn in claims in 2023.
He said challenges the scheme had identified were fraud, wastage and abuse.
Moloabi said in one case, pharmacists in KwaZulu-Natal, Gauteng and North West all had prescriptions from one doctor.
“The sophistication is that they know how to claim. We will pick them up at some stage. How can a doctor be practising in different provinces? The sophistication is that they establish a syndicate and we catch up with them,” Moloabi said.
He said there were instances where there was collusion between pharmacists and Gems members.
“In Mpumalanga a year ago, pharmacists were arrested with Gems members.”
TimesLIVE
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