General practitioner as a gatekeeper and medical scheme benefit design in South Africa.

Abstract

General Practitioners (GPs) serve as a gatekeeper function in many healthcare systems. Cost containment strategies in the health care ecosystem usually focus on the role of GPs as the point of entry. The healthcare expenditure as the proportion of total healthcare spent on medical schemes in South Africa has been declining over time. This could be attributed to a shift in benefit design and product development employed by schemes. The aim of this study was to investigate GP health spending by medical schemes, the average spent per GP visit, the level of co-payment that members are subjected to and the GP to member ratio in South Africa. The study design was a cross-sectional study which was performed by linking annual statutory returns data, claims data and provider distribution data collected on an annual basis by the Council for Medical Schemes. The data was further mirrored to the Practice code numbering data received from the Board of Healthcare Funders (BHF). A total of 79 medical schemes claims data was included in the analysis, this accounted for nearly 82% of beneficiaries (81.6%). The average number of visits per beneficiaries was 3. The distribution of GPs claiming from medical schemes follow the distribution of beneficiary by province. The ratio of claim GPs per 1000 beneficiaries is 2. These results further revealed a shift in benefit design and that medical scheme members bypass GPs directly to specialist services which is a secondary level of care, thus undermining the role of GPs as gatekeepers. It is concerning that GPs consultation is attracting a co-payment of as high 39%. Reprioritisation and emphasis on the role of a GP as gatekeepers as a function of the benefit design process is key to improving quality of care.