Medical & Clinical Reviews

Commentary

General Practitioners (GPs) serve as gatekeepers in many healthcare systems; furthermore, cost containment strategies usually focus on the role of GPs as the point of entry [1]. According to Geva, Kimberly and Azeem, gatekeeping has crucial influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction [2]. Health care expenditure on GPs as a proportion of health care spent by medical schemes in South Africa has been declining over the past ten (10) years [3]. This could be attributed to a shift in benefit design and product development. The aim of the study was to investigate GP health spent in medical schemes, and the level of co-payment that members are subjected to.

A cross-sectional analysis was performed by linking the annual statutory returns data, the claims data and the provider distribution data, collected on an annual basis [3]. The data was further mirrored to the Practice Code Numbering System (PCNS) data received from the Board of Healthcare Funders (BHF). The data is mainly considered a primary doctor. As a result, the referral patterns between respective providers was not assessed. In this study there were 7 849 GPs claiming from medical schemes in 2018. This was up from 7 785 in 2017, showing an increase of a total of 64 more GPs. The study also revealed that the median cost of a GP visit in 2018 was four hundred and forty-five-rand (R445.00) IQR (R391-R475). The level of co-payment for a GP visit ranged between four to forty percent (4%-40%) of the claimed amount. Lastly, GPs continue to account for fewer benefits paid over the period, whereas in 2010, they accounted for just under eight percent (8%) of health expenditure experienced by medical schemes. This reduced significantly to less than six percent (6%) in 2018.

The study revealed a shift in benefit design and that medical scheme members possibly bypass GPs, thus undermining the role of gatekeeping by GPs. The decrease in the healthcare spending of GPs, as a proportion of overall healthcare spending may be attributed to various reasons. Studies have shown that there is an inverse relationship between health spending and co-payments, Hansen and Andrioti argued that Introducing out-of-pocket payments may lead to decreased health expenditure [4]. It is still concerning that a GPs consultation is attracting a co-payment of as high as forty percent (40%). Reprioritisation and an emphasis on the role of GPs as gatekeepers; as a function of the benefit design process is key to improving the quality of care.

References

1. Garrido MV, Zentner A, Busse R (2011) The effects of gatekeeping: A systematic review of the literature. Scand J Prim Health Care 29: 28-38.
2. Geva G, Kimberley F, Azeem M (2016) Rethinking primary care’s gatekeeper role. BMJ 354: i4803.
3. www.medicalschemes.com/Publications.aspx
4. Hansen C, Andrioti D (2017) Co-payments for general practitioners in Denmark: an analysis using two policy models. BMC Health Serv Res 17: 9.