The Government Employees Medical Scheme (GEMS) marks nearly 20 years of operation.During a webinar hosted in partnership with The Mail & Guardian, GEMS representatives discussed the scheme’s achievements, challenges and plans for the future.
Nearing two decades of service
The Government Employees Medical Scheme (GEMS) marks nearly 20 years of operation. It was established to address gaps in affordable healthcare access for public service employees. During a webinar hosted in partnership with The Mail & Guardian, GEMS representatives discussed the scheme’s achievements, challenges and plans for the future. The discussion emphasised affordability, member needs as well as the evolving healthcare landscape.
Principal Officer Dr. Stanley Moloabi spoke about GEMS’ inception in 2005 following research on public service employees’ healthcare needs. By January 2006, GEMS began operations to provide comprehensive, equitable and affordable healthcare.
Understanding the structure of medical schemes
Medical schemes operate by pooling contributions from members, which are then used to fund members’ medical treatment and other healthcare expenses. Chief Operations Officer Dr Vuyo Gqola explained that GEMS functions as a restricted scheme exclusively for public servants. With over 2.3 million beneficiaries, GEMS is the largest restricted medical scheme in South Africa.
Dr. Gqola highlighted the critical role of member education in selecting appropriate benefit options to ensure that members receive sufficient healthcare coverage. She stressed that understanding the terms and conditions of medical schemes prevents misconceptions about their limitations and responsibilities.
Cross-subsidisation: A pillar of sustainability
Dr. Moloabi addressed a common misunderstanding among members: the notion that unused contributions are wasted. He clarified that contributions support a cross-subsidisation model to ensure resources are available when needed, even for catastrophic events. Chief Financial Officer Karyna Van Lingen reinforced this, explaining that the financial model relies on contributions from healthy members subsidising care for those who require extensive medical attention.
The panellists also warned against postponing membership, as late joiners may face penalties to protect the reserves built by long-term members.
Fraud and abuse in healthcare systems
Fraud, waste and abuse remain significant challenges for medical schemes. Examples include members visiting multiple doctors for the same issue or submitting false claims. Dr. Moloabi shared that syndicates involving healthcare providers and members exploit the system through fraudulent claims, which result in higher costs.
Dr Gqola highlighted cases where members may unknowingly commit fraud, such as obtaining prescriptions for non-covered items under false pretences. She emphasised the collective impact of such actions, which ultimately raises contributions for all members.
Innovations and achievements
GEMS has been progressively implementing innovative benefit design aimed at improving efficiency and healthcare outcomes. Dr Gqola discussed flagship options like Emerald Value and Tanzanite One, which are underpinned by care coordination. Care coordination has resulted in improved surrogate health outcome measures, improved access to primary healthcare and preventative care, and cost efficiencies. Recognised for its Emerald Value Option, GEMS received the Board of Healthcare Funders Titanium Award for Access to Healthcare in 2020.
GEMS has also implemented value-based care initiatives in collaboration with healthcare providers, where healthcare providers are incentivised for improved patient outcomes.
One of GEMS’ most notable achievements is that it has consistently received clean and unqualified audits for 18 consecutive years (since its inception).
Future prospects amid changing landscapes
The National Health Insurance (NHI) initiative presents both opportunities and uncertainties for medical schemes. Van Lingen warned members against cancelling their medical aid cover prior to the implementation of NHI. She also noted that while the NHI aims to provide a basic benefit package, members may still need supplementary medical cover for comprehensive care.
Dr. Moloabi underscored the importance of innovation, particularly in leveraging digital tools and artificial intelligence, to improve healthcare delivery. He cited telemedicine as an example of how technology is reshaping interactions between patients and providers.
In preparation for the NHI and other developments, GEMS aims to simplify its offerings and expand access to underserved populations. The scheme also plans to consolidate options to reduce complexity while maintaining affordability and quality.
Conclusion
GEMS’ commitment to innovation, affordability and member-centric care positions it as a leader in South Africa’s medical scheme landscape. As it navigates evolving healthcare policies and challenges, GEMS aims to remain responsive to member needs while contributing to broader goals of universal healthcare access.