Simpler healthcare is more affordable healthcare - TimesLIVE

Healthcare systems only function optimally when every participant understands their role.

Medical schemes must enable access to care and build efficient and cost-effective networks. Providers must coordinate care. Members must actively engage with the tools and resources available to them. Sustainable healthcare is ultimately a shared responsibility.

About the author: Dr Wayne Riback is chief medical officer at Medshield Medical Scheme. (Medshield) Patients should be able to focus on getting better, not on navigating a complicated system of referrals, providers, tariffs and benefit rules. Yet for many South Africans, accessing private healthcare too often feels as challenging as the illness itself.

This complexity is not simply an inconvenience; it carries a real cost. When healthcare providers operate independently rather than as part of a coordinated system, the result is unnecessary expenditure, fragmented care, poorer health outcomes and a frustrating experience for patients.

Every rand lost to duplication and inefficiency is a rand that could have funded care.

South Africa’s private healthcare system offers excellent clinical expertise, but it remains highly fragmented.

GPs, specialists, hospitals and pharmacies often operate independently, leaving members to coordinate their own care. The result can be duplicated tests, unnecessary referrals, inconsistent treatment and higher healthcare costs.

Fragmented care also creates opportunities for fraud, waste and abuse, placing additional pressure on the sustainability of private healthcare.

One of the most effective ways to address this challenge is through well-designed healthcare networks.

Unfortunately, healthcare networks are often misunderstood, with many people viewing them as a way of limiting choice.

In reality, they are designed to improve access to quality care, strengthen coordination between healthcare providers and make healthcare more affordable for members, so that healthcare functions as one connected journey rather than a series of disconnected appointments.

A healthcare network brings together general practitioners, specialists, hospitals and pharmacies that meet agreed quality standards and contracted tariffs.

For members, this means better access to healthcare providers close to home, greater certainty about what their medical scheme covers and fewer unexpected copayments, and ideally improvement in coordination of care, which results in better health outcomes rather than simply more consultations or procedures.

A key part of making this work is strengthening primary healthcare.

Over time, private healthcare has become increasingly specialist- and hospital-centred, yet many conditions can be diagnosed, treated and managed effectively through a trusted GP.

The challenge is that South Africa faces a shortage of doctors, with an estimated 15,000 to 18,000 private GPs serving approximately 9-million medical scheme beneficiaries.

Medical schemes therefore use geographic mapping to identify where members have limited access to GPs and expand provider networks accordingly. At Medshield Medical Scheme, in excess of 95% of members have access to a network GP within a 10km radius of where they live.

Members also have an important role to play. Most medical schemes provide provider locators through websites, member portals, mobile apps and dedicated call centres, making it easier to identify network providers before healthcare is needed.

Understanding these resources before illness strikes makes the healthcare journey significantly easier.

Ideally, members should be able to consult a network GP who refers them to a network specialist practising at a network hospital, with prescriptions dispensed through a network pharmacy. This creates a more seamless healthcare journey while helping members avoid unnecessary out-of-pocket expenses.

Healthcare providers are equally central to making this work. Medical schemes increasingly encourage GPs and specialists to refer patients within established networks wherever appropriate.

Provider directories and digital tools make it easier for healthcare professionals to identify network specialists, hospitals and pharmacies, supporting continuity of care.

Achieving this level of coordination is not always straightforward. While South Africa has a shortage of GPs, the shortage of specialists is even more pronounced. This becomes even more dire in certain specialised disciplines, with relatively few practitioners nationally, and many concentrated in major metropolitan areas.

Expanding comprehensive provider networks therefore requires ongoing collaboration, sustainable reimbursement models and long-term partnerships with healthcare professionals.

This is also where managed care plays a critical role. It is often viewed simply as a system of authorisations and clinical approvals, but its purpose is much broader.

When integrated with healthcare networks, managed care helps coordinate treatment, supports evidence-based medicine and encourages the appropriate, clinically justified and cost-effective use of healthcare resources.

Successful managed care therefore delivers benefits beyond cost containment. Members stay healthier for longer, benefits remain available when they are needed most, and fewer unnecessary interventions and avoidable hospital admissions support both better patient outcomes and the long-term sustainability of private healthcare.

There is still work to do. Provider networks must continue expanding, more healthcare professionals need to participate, and members need greater awareness of the tools available to them.

Ultimately, every member wants the same thing: access to quality healthcare close to home, confidence that they will receive the right care when they need it, and protection from unnecessary financial surprises.

That is what an optimised healthcare network is designed to achieve. It is not about restricting choice, but about creating a healthcare system that is more connected, more sustainable and better equipped to deliver improved health outcomes.

When healthcare providers, clinicians and medical schemes work as one coordinated ecosystem, people experience what healthcare was always meant to provide: confidence, certainty and care delivered at exactly the moment it matters most.

Simplicity in healthcare is not a luxury. It is the mark of a system designed around the patient. That is the standard to which South African private healthcare should hold itself.

With eight plans tailored to different needs and life stages, Medshield Medical Scheme members have access to established networks of GPs, specialists, pharmacies and hospitals. Visit the Medshield website for more information.

This article was sponsored by Medshield Medical Scheme.