How health insurance supports patient access to quality primary health care

By Paul Cox, Managing Director at the Essential Group of Companies including health insurance provider, EssentialMED

Paul Cox

Access to quality primary health care will address around 90% of our population’s health needs throughout their lives, largely through early detection and prevention of disease, preventative care and health screenings including vaccinations, cancer screenings, prenatal and antenatal care, as well as ongoing management of chronic conditions, building a more resilient, healthier, productive population. However, disparities in access to quality primary health care create barriers for many people.

Around 80% of the population relies on the availability of public primary care services. However, aspects such as poor resourcing, quality of care, inability to access clinic services after normal work hours, a lack of equipment and even medicines at state facilities will often see people forgo their primary health care needs.

It is certainly not unheard of to have patients relying on the public health services waiting all day for something as seemingly simple as a GP visit or having a repeat chronic prescription filled, only to be turned away due to a lack of human resources or medicines, or clinic operating times that simply do not cater for the working class.

Another significant challenge is the loss of income that a patient could face if they are taking an entire day’s leave to attend to a simple health check-up. Faced with such challenges, statistics show that a lack of private health insurance clearly correlates with a decline in the use of preventive and primary health care services and a commensurate increase in poor health outcomes.

In a report published by HealthyPeople, the authors state that individuals without health insurance will typically delay seeking primary care when they are ill and are thus more likely to be hospitalised later, especially for chronic conditions such as diabetes and hypertension and often at less treatable stages for serious illnesses, such as cancer – conditions that are all-pervasive in South Africa. Overall, having health insurance increases the use of primary health services and improves health outcomes.

When you consider the cost of an out-of-network GP visit in private practice – anywhere between R400-R600 for a consultation only, as well as other aspects such as travel costs, costs of medication, and even a shortage of healthcare providers in certain areas, it’s easy to see why so many South Africans without any health insurance put their primary health care on the backburner – affordability, accessibility and quality play a massive role.

The downside is that the neglect of primary and preventative care ultimately leads to more serious and costlier health conditions to treat and often a poorer prognosis for the patient. This is where having health insurance plays a fundamental role in facilitating access to quality primary health care for people who would otherwise have to rely on an overburdened and inefficient public health service.

There is an opportunity for private health insurance to support patient access to quality primary health care and certainly to play a much bigger role in the employee benefits space where the cost of medical scheme benefits is simply unaffordable for employers and lower-income workers.

Health insurance, for a start, is significantly more affordable than a medical scheme benefit, which at an average cost of around R1200 per month for the most basic core benefit per member, is largely out of reach to 80% of the population. A further challenge is that a significant part of the cost of a medical scheme benefit relates to funding prescribed minimum benefits (PMBs), a set of regulated benefits that schemes must offer and which many members will never need or use in their lifetimes, despite paying for it.

On the flip side, a health insurance plan like EssentialMED’s Day-to-Day cover costs around R400 per person or R600 for a family per month, providing unlimited managed visits to a network doctor with no upfront cash payments, unlimited acute and chronic formulary medication for 25 chronic conditions when prescribed by a network doctor, monthly ARV medication up to R500 per month and R6000 pa, unlimited dentistry cover for pain control, fillings and extractions as well as radiology and pathology benefits with unlimited blood tests and x-rays when referred from a network doctor, and basic optometry – fundamentally 100% of the benefits are focused on primary health needs, so there is no wastage when it comes to paying for benefits you’re unlikely to use.

In terms of access, a national network of healthcare providers is contracted, and rates are pre-negotiated by the health insurer, so there are no surprises for patients and out of pocket expenses unless they choose to go to an out-of-network provider. The size and scope of the provider network also mean that primary care is available to treat patients in close proximity to where they live, without having to spend a day away from work with hefty transport costs, in a crowded public facility, and often with no guarantee of receiving the care needed.

We are seeing the demand grow for health insurance benefits that focus on day-to-day, primary health care needs, not only from individuals but increasingly from employer groups who recognise the impact that strained quality and access to public health services has on worker productivity and morale. Given the massive fiscal challenges the country faces, cuts in healthcare provision are already playing out and will only serve to exacerbate the challenges faced by people who rely on public health services.

It’s not good for people not to have access to quality primary care, and it’s certainly not good for business. Larger employer groups are increasingly investing in health insurance benefits for their employees, and many have permanent onsite primary care clinics and full-time nurses available to employees. Strong primary health care – the frontline of all health systems – plays an essential role in reducing the pressure on health systems as a whole, protecting people against the threats of a health crisis, and building healthy, resilient and productive communities by meeting people’s needs for healthcare throughout their lifetimes.

Having health insurance plays a fundamental role in ensuring that people are able to access quality primary health care when and where they need it, shifting our current curative-oriented health service to a more pre-emptive, preventative one based on empowering people to take better control of their health outcomes.

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