How to save on unnecessary emergency healthcare costs

Hospital admissions and associated treatment consumes roughly 40% of the funds spent by medical schemes, making it one of the healthcare system’s largest cost drivers.

It’s also one of the contributors to medical inflation, which typically runs anywhere between 2%-3% (and sometimes more) above the consumer inflation rate.

Preventative care is therefore critical to managing emergency and specialised healthcare costs, and this has become a key focus for Medshield Medical Scheme.

“The challenge is not simply to reduce healthcare costs, but to reduce unnecessary costs,” says Dr Wayne Riback, chief medical officer at Medshield Medical Scheme.

“A genuine emergency must be treated. The opportunity lies in preventing conditions from developing into emergencies and hospital admissions, whilst managing care more effectively before, during and after a hospital admission.”

Preventing avoidable illness and disease progression is one part of the solution, but it’s just as important to eliminate duplicated care – for example, getting repeat blood and other tests each time you transfer to another doctor – and ensure patients receive treatment in the most appropriate setting.

Medshield has paid in 2026, for the Jan-May period, approximately R2.0 billion in hospital claims, with 38.8% of these cost coming from hospital admissions related costs.

These figures cover total hospital claims costs, rather than emergency admissions alone, but they illustrate the considerable cost of acute and hospital-based care. The causes of medical inflation have been examined in multiple studies, and they all point to the usual culprits – rising costs of treatment, new technology, the need for highly skilled personnel, resource shortages and escalating hospital overheads.

Dr Riback believes a more fundamental problem is that South Africa’s healthcare system is too focused on reactive management of disease, lacking a proactive and preventative approach. Patients frequently enter the system only after an illness has progressed, increasing the likelihood that they will require specialised treatment, hospitalisation or emergency intervention.

Specialists play an essential role, but account for roughly 16 cents of every rand spent on healthcare. Earlier intervention through GPs, nurses, clinics, screening programmes and virtual consultations could identify risks before they become established disease and a risk for acute health interventions.

Dr Riback identifies five main levers for improving efficiency in the healthcare system: prevention, screening, better access to and utilisation of primary care, reduced fragmentation and improved care coordination between healthcare providers.

Tackling fragmented care

Fragmentation occurs when doctors, hospitals and other providers do not have access to the same clinical information or lack of integration of care.

A patient may consult a GP, undergo blood tests and X-rays, and then visit a specialist or an emergency room, who does not receive those results. The tests may be repeated, adding costs without necessarily improving the patient’s care.

Digital health records and case-management tools can improve information sharing and help providers track patients and enable co-ordinated clinical care provision.

However, responsibility for improvement is shared between schemes, healthcare professionals and members. Schemes must design benefits that encourage prevention/screening and make primary care benefits available and accessible. Doctors must educate patients and coordinate treatment, while members should make use of screening and preventative benefits.

This is especially important in managing chronic conditions such as diabetes and hypertension. Regular monitoring allows treatment to be adjusted before a patient’s condition deteriorates into an emergency.

HbA1c, for example, measures average blood glucose levels over roughly three months. Dr Riback says a one-percentage-point improvement in this measure can produce significant health and longevity benefits for people with diabetes, while reducing the risk of complications. Some studies have shown that an absolute 1% reduction in HbA1c (e.g. dropping from 8.5% to 7.5%) can lead to 18% lower risk of cardiovascular disease (heart and blood vessels, 21% reduction in deaths due to diabetes, 37% decrease in eye, kidney and nerve damage, and 14% reduction in heart attacks (myocardial infarctions).

The use of preventative medicine is not the only factor that impacts on lower scheme contributions since numerous factors determine contribution increases. However, preventative medicine, and the delay in progression (or onset) of chronic disease will definitely improve outcomes and moderate the growth of avoidable claims over time, which will have a positive impact on keeping scheme contribution increase down.

Genuine emergencies remain covered

Medical schemes are legally required to fund qualifying emergency medical conditions, irrespective of whether the hospital belongs to the scheme’s network.

Once a patient has been stabilised and is no longer in immediate danger, the scheme may arrange a transfer to an appropriate network facility. Contracted ambulance services, designated hospitals and managed-care protocols can help ensure timely treatment while managing unnecessary expenditure and protecting members from avoidable co-payments.

Members should therefore understand their scheme’s network and when co-payments may apply, says Dr Riback.

“Some patients use emergency rooms for conditions that could safely be treated by a GP, clinic or virtual consultation, particularly after hours. There are some very practical ways to reduce the likelihood of this happening. The main thing is to seek out preventative care as a way to make sure you don’t develop a more serious condition later.”

Safe, clinically appropriate generic medicines provide another opportunity to contain costs. Members can ask their doctors or pharmacists whether a less expensive generic alternative is available.

Medshield also supports value-based care arrangements and the transition over to outcomes based healthcare, in which healthcare providers are assessed and rewarded according to measurable patient outcomes, rather than only the volume of services provided.

Measuring what matters

Success should not be measured purely by money saved. Dr Riback identifies three critical outcome areas relating to the use of emergency care: survival following timely emergency intervention; unplanned returns to emergency facilities; and the patient’s reported experience and recovery.

An unplanned return may point to an incomplete diagnosis, inadequate treatment or complications. Patient-reported measures assess matters such as pain relief, dignity, communication, waiting times and physical or mental recovery after discharge.

Collaboration is vital. Doctors are particularly influential because patients often place greater trust in their healthcare professional than in their medical scheme. Hospitals must also triage patients accurately and use diagnostics, radiology and admissions prudently.

South Africa faces serious obstacles, including shortages of doctors and nurses, staff burnout, poor communication between providers and a growing burden of chronic disease. Limited primary-care access and sub-optimal utilisation also causes some patients to postpone treatment until their condition becomes an emergency.

More efficient emergency healthcare does not mean denying or rationing necessary treatment. It means preventing avoidable illness, recognising risks earlier and directing patients to the right level of care.

The objective is not simply lower expenditure. It is better health outcomes, a healthier population, fewer avoidable hospital visits and the preservation of emergency resources for patients who genuinely need them.

Brought to you by Medshield.

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