Dear Specialist,
SAMWUMED has three main goals.
- To ensure that our members have benefits to access private healthcare.
- To ensure that benefits assist our members to maintain or improve their health.
- To ensure that membership of SAMWUMED remains affordable.
SAMWUMED, like most medical aid schemes in South Africa, is facing financial challenges due to increasing healthcare expenditure. This has resulted in contribution increases over 10% across the industry in the last few years.
To ensure that SAMWUMED remains financially stable, and members maximize their available benefits, the Board has decided to implement a coordination of care strategy. Co-ordination of care has been shown to improve clinical “outcomes”, and is essential to improving universal access to care, and is a key component of the planned NHI system.
SAMWUMED’s strategy has the following components:
- All members must nominate a GP to co-ordinate their care.
- Preferably the nominated GP should be contracted to the SAMWUMED GP Network so that members do not experience co-payments.
- SAMWUMED is contracting a Designated Service Provider (DSP) Specialist Network for 2024 that is affiliated with our Hospital Network. We strongly request that you consider joining the SAMWUMED Specialist Network. To encourage participation in the Specialist Network, Specialists who join the network will be reimbursed at 150% of the Scheme Rate.
- Members must be referred by their chosen GP to a Specialist, ideally a SAMWUMED Network Specialist, for their claims to be funded.
SAMWUMED will be refocusing its clinical risk management strategy to work proactively and constructively with the Specialist Network to ensure member access and keep care affordable.
While members may express concern about having to access specialists by GP referral, this enables diagnostic work up to guide Specialist treatment. GP referral to specialists also ensures that members are seen by the most appropriate specialist, preferably one that is on the SAMWUMED Specialist Network.
We look forward to working with you embracing the strategy of coordination of care, to ensure that SAMWUMED becomes a healthier and more financially stable scheme.
In cases where members have a medical emergency, they must always be encouraged to access the closest medical facility, to ensure they immediately get the care they need.
Yours in good health
SAMWUMED
