Why you should belong to a medical scheme
Monday, 26 May 2014
The Government Employees Medical Scheme (GEMS), the second largest medical scheme in South Africa, recently released a list of what it calls its ‘top 10 chronic medical conditions'. These are the 10 diseases that cost the Scheme the most in terms of medicines expenditure in 2013.
"The GEMS top 10 medical conditions give us an idea of the kinds of diseases and medical conditions that are having the greatest impact on public servants in South Africa," says Dr Guni Goolab, Principal Officer at GEMS. "The research has also allowed us to see where we should be focusing the Scheme's educational and disease management efforts."
The GEMS top 10 medical conditions for 2013 were as follows:
According to Dr Goolab, there are various reasons why the above medical conditions are proving more costly for the Scheme to cover. In some cases, it is simply that large numbers of members are suffering from a particular medical condition that needs to be treated with medicine, while in other instances the treatments themselves are expensive. Sometimes a medical condition is both common and the medicines used to treat it are expensive, which can further add to costs.
"Whatever the case, the medical conditions highlighted above are all important within the South African context as they affect large numbers of people and represent an important drain on healthcare resources," points out Dr Goolab.
"With the exception of HIV/Aids, all of the medical conditions listed are non-communicable diseases or, in other words, they are not passed from person-to-person via an infectious bacterium or virus. A recent Statistics South Africa report found that non-communicable diseases are one of the leading causes of death in this country today and account for as much as 40% of all fatalities."
"Non-communicable diseases are becoming increasingly common and important not only within the country as a whole, but also to medical schemes such as GEMS which must play a role in the funding of treatment costs. This is one of the reasons why the Scheme is paying non-communicable diseases increasing attention through its education and disease management programmes."
Dr Goolab says that a number of the non-communicable diseases listed above can be linked to an unhealthy lifestyle. For example, diabetes type 2 and high cholesterol often develop in individuals who do not take good care of their health and they are often known as ‘diseases of lifestyle'. These individuals may get little exercise, have a poor diet and drink and smoke excessively. These kinds of diseases are affecting increasingly large numbers of South Africans. The International Diabetes Federation, for example, estimates that no fewer than 1.9 million people in this country have diabetes, and millions of others are at risk of developing the disease. Many cases of hypertension and even chronic renal disease also owe their development to unhealthy living choices.
"GEMS follows a multi-pronged approach to healthcare. Through various educational and screening programmes the Scheme does its utmost to keep its members healthy and prevent them from developing chronic medical conditions in the first place. This is known as a ‘preventative approach to healthcare' and GEMS places a heavy emphasis on it. Where a member does develop one of these conditions, however, GEMS closely manages the disease to ensure that he or she is kept as healthy as possible."
"What these top 10 medical conditions have in common is that they are all manageable in the overwhelming majority of cases, particularly when they are identified early on and are prevented from causing further damage to the body," observes Dr Goolab. "This is one of the reasons why GEMS holds regular Wellness Days in the workplace where a variety of medical conditions are professionally screened for, including HIV, high blood pressure, diabetes and a range of others. These screenings help members detect health risks early, so that they can prevent or reduce the impact of a disease."
Healthcare professionals are made available at these Wellness Days to discuss the member's health history, and to perform the tests. The results of the tests are individually discussed with the member and they receive advice on steps they should take to improve their health.
Another thing that the top 10 medical conditions all have in common is that they are chronic conditions and are covered by the GEMS chronic medicine benefit. This means that all aspects of the treatment and diagnosis of the condition are covered by the Scheme. According to Dr Goolab, GEMS also has powerful disease management programmes in place that work to assist each member to remain healthy, happy and productive individuals.
All chronic medicine needs to be pre-authorised by the GEMS Medicine Management department. A chronic medicine authorisation is a pre-approval request for payment of the member's medicines from the chronic medicine benefit. Ask your doctor to assist you to complete a chronic application form. Once completed, the form must be sent to the Medicine Management department for review and pre-authorisation. If the authorisation request is approved, GEMS will send you a Chronic Medicine Access Card as confirmation of your chronic medicine authorisation. You will have the choice of receiving your medicine either through the courier pharmacy or your nearest GEMS network pharmacy.
"Belonging to a medical scheme such as GEMS brings considerable peace of mind because members know that they will be covered for the treatment of a broad range of chronic medical conditions. GEMS's rates are also highly affordable which ensures that the member gets nothing short of excellent value for money."
"Nothing is more important to GEMS than its members and every single one counts. GEMS members can know that the Scheme will be at their side through sickness and health," concludes Dr Goolab.
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