RESUMEN
The cost of healthcare is an issue of concern for both consumers and funders of healthcare in South Africa. The country spends approximately 8% of GDP on health care. Health care is financed through the public sector which covers 86% of the population and the private sector which covers 14% of the population. Medical schemes are the main source of healthcare financing in the private sector. Services covered by medical schemes include chronic diseases, emergencies, diagnosis, and treatment of a selected number of diseases. Primary health care services such as screening are limited. The aim of this study was to assess factors associated with members of medical schemes' willingness to pay for a primary health care package in the private sector. A cross-sectional survey was conducted amongst principal members of medical schemes between July and September 2020. All principal members with access to an online questionnaire were eligible to participate in this study. Logistic regression was used to identify factors associated with willingness to pay for primary health care services. A total of 6512 members of medical schemes participated in the study. Thirty-five percent of the participants were willing to pay for the primary health care package. Factors influencing willingness to pay included marital status, employment status, income and household size. The study highlights the need for policymakers to consider socioeconomic factors when designing health care policies.
RESUMEN
BACKGROUND: The Government Employees Medical Scheme (GEMS) introduced an EDO named the Emerald Value Option (EVO) in January 2017. The option was introduced to contain the cost of care whilst simultaneously improving the quality of care by championing care coordination. AIM: This study aimed to assess the impact of introducing an EDO such as EVO as a cost-containment strategy using contracted provider networks and coordinated care. SETTING: The study was conducted using aggregated data from GEMS. Government Employees Medical Scheme is a restricted medical scheme available to government employees in South Africa. METHODS: This is a descriptive pairwise comparison study between the Emerald benefit option (the parent option), which does not have embedded care coordination, and its derivative, EVO. RESULTS: Membership and claims data for 2018 were analysed. Expenditure per life per month in 2018 on the EVO amounts to R1357.01. After adjusting for the risk profile of beneficiaries on the EVO, expenditure per life per month would be expected to be R1621.73 (based on the conventional Emerald option). This translates to a savings of 16.3%. Similarly, health outcomes for EVO were more favourable than expected, actual admission rates were lower at 23.2% versus 26.2% expected. CONCLUSIONS: The EVO benefit design has succeeded in lowering the cost of care through network provider contracting and care coordination. The EVO has saved approximately R490 million in healthcare costs in 2018. If applied across the medical schemes industry, it is estimated that EVO contracting, and care coordination principles could save R20 billion per annum.