Why is it necessary for a member to nominate a single/primary GP to manage all PMB chronic conditions?
Primary care GPs manage the day-to-day healthcare needs of members. A patient’s primary care GP will establish their health history, conduct screening and prevention tests, coordinate specialist referrals where necessary, and make recommendations to improve health and wellness. This continuum and coordination of care is particularly important for the effective management of complex health conditions.
Both internal and international research show clear evidence that an established relationship with a single primary care GP improves the long-term health outcomes of members managing chronic conditions. These efficiencies arise through the provision of an efficient and consistent access point to the healthcare system, with better management and coordination of care. According to a recent World Health Organisation report, patients have a preference to see a single provider for coordinated care and place greater value on seeing a provider they know and trust. Patients who saw the same doctor recorded 13% fewer hospital admissions and 27% fewer visits to the emergency department, substantially improving the quality of care for members with complex healthcare needs.
Based on the significant opportunity to improve health outcomes, from 2024, all members registered for Prescribed Minimum Benefit (PMB) chronic conditions will be required to nominate a primary care network GP for the management of their chronic illnesses.
Do all DHMS members need to nominate a primary care GP?
All members registered for PMB chronic conditions, with the exception of those on the Executive plan, will need to nominate a primary care GP to access full cover for consultations associated with their chronic condition.
What will happen if a member does not nominate a GP or visits any GP other than their nominated GP?
Should a member with a registered chronic condition opt not to nominate a primary care network GP, or should a member voluntarily choose to consult a GP other than their nominated network GP, the Scheme will cover the GP consultation at 80% of the Discovery Health Rate from 1 January 2024. No co-payment will be required in the event of an emergency or involuntary use of a non-designated service provider. Members who have nominated a primary care GP will have access to one GP consultation at a network GP who is not their nominated GP, without any co-payment.
Members receive full cover for GP consultations for their chronic conditions at their nominated primary care network GP.
What benefits will be subject to a 20% co-payment if the nominated primary care GP is not consulted?
The 20% co-payment will only apply to consultations relating to the management of the member’s chronic condition.
Cover for prescribed chronic medicine, chronic illnesses managed by specialists, or consultations relating to acute conditions, will not be impacted by a member visiting a non-nominated primary care GP and will continue to be covered subject to the member’s chosen plan.
Does the nomination of a primary GP need to take place for both Chronic Disease List (CDL) and Additional Disease List (ADL) conditions?
Members are required to nominate a primary GP for the treatment of Chronic Disease List and OH DTP-PMB chronic conditions. While no co-payment will be incurred for consultations and referred services for non-PMB ADL conditions with GPs outside of the Discovery GP network, members are strongly encouraged to use the same GP to treat and manage all their chronic conditions.
Will members be allowed to nominate any primary care GP to manage their PMB chronic conditions?
Affected members will need to nominate a GP participating in the Discovery Health GP Network or nominated Network GP, depending on the member’s chosen health plan, for full cover to treat all PMB chronic conditions. Members will be able to nominate a non-network GP however, a 20% co-payment will be applied to consultations relating to the management of the member’s chronic condition.
KeyCare members must use their nominated KeyCare network GP and members on the Smart plans must make use of a Smart network GP.
How does a member nominate a primary care GP?
Members will be able to nominate a primary care GP on the new Discovery app or on the Discovery website:
• Members that have visited a network GP before will simply be asked to confirm the nomination of their GP.
• Members that have not visited a network GP before will be able to search for a GP in their area and are then able to nominate their primary care GP.
Members are also able to nominate their GP through the Discovery call centre or their chosen network GP.
As part of the Scheme’s year-end communication, impacted members will be receiving additional information regarding the process to nominate and change their nominated primary GP.
Can different beneficiaries on the same health policy nominate a different primary GP to treat their individual chronic conditions?
Yes.
Can a member select a medical practice or group instead of one primary GP for the treatment of their PMB chronic conditions?
Yes, provided the medical practice is part of the network.
Will a member be able to change their nominated doctor?
Yes, a member will have the option to change their nominated GP three times per year.
How will a member’s cover be affected if they are travelling and cannot access their primary GP?
Members who have nominated a GP will be allowed one GP consultation at a GP who is not their nominated GP. For full cover members must ensure this visit is still to a network GP. KeyCare members who have not nominated a KeyCare Primary GP will be part of the KeyCare out-of-area clinic visit.
