Rewriting the rules

As the Government Employees Medical Scheme (GEMS) moves into position as South Africa's largest closed Medical Scheme and the third largest overall, there is no denying the fact that it has re-written the rules of Medical Scheme management in the country.

Dr Eugene Watson, Principal Officer of GEMS, attributes the success of the scheme to three primary focus areas namely:

operational and contractual efficiencies;
good corporate governance; and
exemplary stakeholder relations.
"The advantages of our competitive GEMS specific tariffs secured directly with healthcare providers and our low non-healthcare expenditure, have kept our costs well below the industry range. Savings and cost containment benefits are always passed back directly to members and evidence is seen in the pricing structure of the Scheme. The benefit of our efficient contracting and the rigorous preferred provider arrangements, are both of considerable importance in ensuring added value for our members and the long term sustainability of the Scheme."

According to Watson medical schemes that are still underestimating the value of rigorous, yet fair, tariff negotiations do so at their peril. Members are averse to co-payments and do tend to look to their Scheme for guidance. This sentiment was endorsed by the 2005/2006 T.W.I.G. SA survey which highlighted that 26% of medical scheme members are expecting schemes to negotiate tariffs on their behalf. Customised reimbursement models are well used by GEMS with benefits being applied across the board to members and their families. These business strategies complement the now firmly established operational infrastructure and culture of excellence that is fast positioning GEMS in a league of its own.

Another point of emphasis within the GEMS environment is the active guidance that members are given when it comes to optimal benefit usage. "While it might seem like a small detail to many," says Watson "we see it as imperative to engage with members on the various tools and mechanisms to maximise their benefit.

An example of this is how the Scheme advises members who inadvertently claim for chronic medication from the acute benefits, culminating in the rapid depletion of their benefits. "Intervention and guidance in this area does not only serve to assist members in managing their medical costs better but shapes future contribution determinations.

Corporate Governance has been a hot button at GEMS since inception, but with an objective board effectiveness assessment being performed by an independent facilitator in 2006, the scheme took its corporate governance to new heights. "Our assessment measured the effectiveness of the Board in discharging its duties and exercising its powers under the provisions of the Medical Schemes Act, the Rules of the Scheme and the corporate governance imperatives contained in the King ll Report," explains Prof Levin, Chairperson of the Board of Trustees. "We have modified the performance appraisal system and future assessments, as with the 2006 assessment, will not be limited merely to a ‘tick box' approach" he continues.

GEMS' inaugural trustee election process was recently concluded with a total of 55 eligible candidates nominated to stand in the trustee elections. The elections, managed by Electoral Institute of South Africa (EISA), were certified free and fair and six trustees have been elected to the full Board which is now officially constituted.

Key to membership growth and satisfaction is the final focus area that pertains to exemplary stakeholder relationships. With a stakeholder base of in excess of 110 government departments and a total staff complement of over 1 million employees, transparency, active engagement and regular interaction cannot be over emphasised by an organisation such as GEMS.

Prof Levin goes on to say that the Scheme's standard used when engaging with all its stakeholders, be they employing departments or individual employees, is to treat each stakeholder respectfully, receptively and with a view to surpass all expectations.