What medical schemes mean by “risk stratification” – in simple terms
Kevin Aron, Principal Officer at Medshield Medical Scheme
2 December 2025
Johannesburg - Chronic disease is one of the biggest drains on both our health and our wallets. Too often, we treat symptoms instead of causes, thus reacting late, spending more, and achieving poorer outcomes. At Medshield Medical Scheme, we're breaking that cycle by focusing on personalised prevention. Through risk stratification, digital screening, and human coaching, we intervene earlier, support members better, and bend the long-term cost curve in the right direction.
Risk stratification may sound technical, but it simply means placing members on a continuum from "unwell" to "well," allowing support to be tailored to their specific needs. We do this by analysing demographics and behaviours, such as age, gender, and smoking habits; social factors like stress, living conditions, and diet; and clinical indicators, including test results and body markers. These inputs generate a risk score that guides action – whether it's lifestyle advice for low-risk members or proactive outreach for those at higher risk, including nursing coach calls, medication reviews, or referrals. It's not one-size-fits-all; it's care designed for each individual.
One of the costliest challenges in chronic care is hospital readmission soon after discharge. To address this, Medshield developed a machine-learning model that flags members at high risk of readmission within 30 days. Those members receive immediate support from a senior nursing coach to review medications, arrange follow-up appointments, and provide guidance on recovery. Previously, 30-day readmission rates ranged from 10% to 15%. With targeted intervention, we've reduced that figure to around 6%. Beyond the statistics, members consistently share how reassuring it is to know their scheme is checking in during such a vulnerable time. This blend of prioritising data and personalising members turns prevention into a tangible, measurable impact.
Why engagement is hard and how we lower the barriers
Prevention works best when members engage; however, there are usually several barriers to overcome such as the inconvenience of in-person checks, limited awareness about the importance of early screening, and the fear of what a test might reveal. Since untreated risks remain invisible, these barriers must be addressed.
To make participation easier, Medshield is piloting a smartphone-based digital health assessment that can be completed privately at home. It combines a short questionnaire with non-invasive facial scanning to create an initial risk profile, with the option to connect directly to a clinical nurse for guidance. For many, this private first step becomes the bridge to booking blood tests, visiting a GP, or scheduling long-postponed screenings. By reducing friction and anxiety, prevention becomes more straightforward, more accessible, and more likely to happen.
From there, consistent small actions make the most significant difference
- Book regular screenings through a GP, pharmacy clinic, or the digital health assessment pilot to catch issues early.
- Use Medshield’s SmartCare nurse-led and GP consultations for reassurance, to confirm treatment plans, or to flag concerns before they escalate.
- Stay in-network to manage costs and keep claims seamless.
- Schedule regular follow-ups to maintain continuity of care and prevent minor issues from escalating into major crises.
- Ask for help – whether from a broker or directly from Medshield – because contributions are not just payments; they are investments in long-term health, carrying the right to clear information and dependable support.
From early screens to lasting resilience
Prevention does reduce costs, but the impact unfolds gradually. In the short term, driving rigorous primary care and screening such as Pap smears, mammograms, PSA tests, colon screenings and routine blood checks inevitably increases healthcare claims, but they are investments in early detection.
Over the medium term, preventative claims begin to replace the avoidable late-stage disease and emergency admissions costs. In the long run (typically five to ten years), the benefits are most visible. Models such as Kaiser Permanente demonstrate that population health management leads to fewer catastrophic events, fewer undiagnosed conditions, and more sustainable overall costs. It is not an instant solution but a long-term strategy that requires buy-in from providers, policymakers and members. The reward is better health outcomes, less distress, and more value from every rand invested.
For this to work, data is only part of the equation. Risk engines do not change lives; people do. It is why Medshield integrates human coaching with digital tools. Our nursing and wellness coaches support high-risk members, particularly those who have recently been hospitalised. Our Virtual Care GP benefits, makes treatment adherence easy. In-network navigation ensures affordability and convenience, protecting members from unexpected shortfalls and simplifying the claims process. Our app and online tools make it simple to find providers. When members stay in-network and engage digitally, their care becomes more continuous, more affordable, and more effective.
Prevention that protects your health and your wallet
Healthcare inflation in South Africa continues to outpace general consumer inflation, driven by rising costs, advanced technologies, medicines, and the growing burden of chronic disease. For households, this means healthcare consumes an increasing share of income. For schemes, it creates unrelenting pressure to deliver more value with every contribution. In this environment, prevention is not optional – it is essential. Early detection saves money, spares members unnecessary distress, and saves lives.
That is why Medshield has prioritised expanded networks, digital access points, and wellness programmes designed to help members act sooner and manage conditions consistently. The principle is simple: maintain care that is convenient, continuous, and coordinated.
For members, the message is equally clear: early action changes outcomes. A digital assessment at home, a nurse check-in after discharge, or a quick Virtual GP consult before symptoms escalate – these small steps prevent major crises. Prevention is personal, and it is made easier when you have the right partner. When you are seen as a person, not just a condition, resilience becomes possible.
To learn more about Medshield's wellness and virtual GP benefits and in-network providers, visit www.medshield.co.za.
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