2016 - GEMS Ruby, Emerald and Onyx (REO) Family Practitioner Network
The following fees will be applicable to REO network doctors:
GEMS REO FP network consultation fee (Scheme rate) / R326.70Enhanced consultation fee for REPI2 category 1 FP Network practices / R46.60
Enhanced consultation fee for REPI2 category 2 FP Network practices* / R21.10
*Category 2 practices will be required to achieve the benchmarks indicated in the GEMS quality measures listed above in order to qualify for the enhanced fee.
Please do not add the enhanced consultation fee to your GEMS REO FP network consultation fee, as we will automatically assign it to qualifying practices upon
payment of claims.
The GEMS Care Coordination Strategy
To align with the concept of coordination of care, our members and beneficiaries are encouraged to:
1. Nominate a Network FP for consultations. Nomination or changing a nominated FP can be done by contacting the GEMS call centre on 0860 004 367.
2. Consult their nominated Network FP BEFORE making an appointment to consult a Specialist. This will ensure that the patient is referred to the appropriate
Specialist.
Network Agreement
The GEMS Standard REO Network agreement has not changed for 2016.
2.1. Family Practitioners participating in the Network will be classified according to his or her practice profile on the Scheme's FP profiling tool. Family Practitioners
classified as a category 1 or 2 practice will qualify for an enhanced consultation fee equal to the Scheme rate plus a fee that will be determined annually. The
enhanced fee for category 2 practices is subject to the practitioner meeting the Scheme's specific quality criteria as indicated in below.
2.2. Participating Family Practitioners that are not category 1 or 2 will be paid a consultation fee equal to the Network rate for out hospital consultations.
2.3. Our focus areas for 2016 are diabetic care, hypertension and cardiac care. In order to assist family practitioners with the appropriate management of these
conditions, we support seven quality measures. These were developed in collaboration with the IPA Leadership. Participating network family practitioners will
be profiled against benchmarks for each of the quality measures shown below:
HbA1c coverage - Percentage of registered diabetics who have an annual HbA1C test. / Stable diabetics should have at least 2 HbA1C tests annually.
LDL coverage in diabetics - Percentage of registered diabetics who have an annual LDL test. / Stable diabetics should have at least one LDL test annually.
Monitoring diabetic nephropathy - patients registered with diabetes who have an annual random urine albumin : creatinine ratio test / One urine albumin: creatinine ratio test in registered diabetics per annum.
Statin coverage in type 2 diabetics - Percentage of registered diabetics who are on a statin. / All registered type 2 diabetics should be on a statin.
Diabetes related hospital admission rate - admission rate of registered diabetics with diabetes related complications. / Ideally well controlled diabetics should not require hospitalisation for diabetes related complications.
LDL coverage - Percentage of patients registered with ischaemic heart disease (IHD) and hyperlipidaemia who have had an annual LDL test. / At least one LDL test in stable beneficiaries with hyperlipidaemia or IHD per annum.
Monitoring hypertensive nephropathy - patients registered with hypertension who have an annual random urine albumin: creatinine ratio test. / One urine albumin: creatinine ratio test in registered hypertensive patients per annum.
Thank you for your continued support and cooperation. If you have any further queries, kindly call the GEMS Call Centre on 0860 436 777 or email
Kind Regards,
GEMS Network Management
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