Category Archives: Medical Aid

Information on Medical Aid schemes in South Africa

5 tips on choosing a medical aid

You Need Posted on by

Medical aid is one of the biggest cost centres on many family budgets, then there is the tricky business of understanding what is covered and what is not. It’s therefore important to choose one that is right for you and your health needs and will potentially not leave you financially ruined?

Tip 1: Find a medical aid you can trust

All official medical schemes should be registered with the Council for Medical Schemes (CMS). If you are worried that a certain provider is not legitimate, you can go to the CMS website to verify their validity.

No one knows your needs better than you. It’s up to you to do your own research. Luckily, schemes provide smart internet capabilities which can compare a wealth of information of their products in the market. Easy to access member feedback portals also provide first-hand accounts on how schemes treat their members.

You can also speak to a broker. With so many schemes out there, it can feel impossible to properly weigh up the pros and cons of them all. A reputable broker has knowledge of the different schemes and can provide a personalised answer based on your needs.

Tip 2: Know the difference between a medical scheme and health insurance

Confusion tends to set in when deliberating the difference between medical schemes and health insurance. In the end it comes down to cost versus benefits and remember cheap usually means fewer benefits.

If you need peace of mind or more generous care, then you definitely need a medical scheme. If you are looking for affordable basic cover under R500 a month, then you can look at health insurance. However health insurance products typically pay a larger proportion of your premium to marketing, distribution and administration costs.

When belonging to a scheme, remember you effectively are a shareholder of the business and with any remaining profit or “surplus” at the end of the year is then saved for future years claims. Medical schemes even the lowest cover sometimes refer to as “hospital plans” must offer what is known as Prescribed Minimum Benefits. According to CMS, these are benefits that ensure that all medical scheme members – regardless of the provider and the benefit option – must have access to certain minimum health services.

Prescribed Minimum Benefits are defined in the Medical Schemes Act, and all medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  • Any emergency medical condition
  • A limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
  • 25 chronic conditions (defined in the Chronic Disease List)

Medical insurance sits on the other end of the value scale, paying a set amount for your stay in hospital. This cost is often not nearly enough considering the high costs of medical care in a general, high care or intensive care unit.

Tip 3: Understand the limits of a hospital plan

To cut costs, many people choose to downgrade their medical aid cover to a hospital plan. If you’re with a CMS accredited medical scheme, then you can rest assured that even the lowest level hospital plan should comply with the above mentioned Prescribed Minimum Benefits. You also need to be aware that every visit to the hospital emergency rooms does not count as hospitalisation. Even if you think it was a medical emergency, there is a difference between getting treated as an out-patient and being admitted and so some visits to emergency rooms may in fact come from your day-to-day or savings benefits unless you are admitted.

It is critical to understand that that many schemes have a limit on their hospital cover. They will require you to attend only certain hospitals and may have a hospital limit on what is covered depending on your scheme and plan.

Tip 4: When first becoming a member of a scheme, prepare to wait

If you are looking to sign up for medical aid, you can almost certainly expect a waiting period. There are two types of waiting periods or underwriting conditions.

The first is the general waiting period. If you are healthy, under 35 and haven’t been on a medical scheme before, you will generally only have to wait three months before full cover takes effect.

The second is called condition specific waiting period. This applies if you have a pre-existing condition or injury prior to joining the scheme. In these cases, the standard practice is that schemes apply a 12-month condition-specific waiting period before you can access benefits relating to these pre-existing conditions, which is standard practice.

It is best to disclose your pre-existing conditions as three or 12 months is not a long time to wait. This is a contractual relationship at the end of the day and by not disclosing your condition after signing the contract, the scheme has full rights to terminate you from the scheme and refuse cover.

An additional matter to be aware of is if you are delaying becoming a member of a medical scheme, you may be required to pay late joiner penalties for the rest of your life. This is applied by all schemes to encourage younger members to join early rather when its too late. These penalties will follow you regardless if you move medical schemes at a later stage and can cost you up to 50% more than the scheme premium. This is depending on your age.

Tip 5: Be careful of loyalty frills

It’s easy to get caught up in the excitement of loyalty benefits. The reality is that promoting healthy behaviour improves your lifestyle but things such as discounted flights or free movie tickets won’t help you when you have a car accident and are taken to the ICU. Too many people mistake frills and loyalty-based products as core healthcare benefits they are buying only to discover that they don’t have the proper cover they need when the time comes.

Don’t be fooled by big brands that market frills because you will literally pay the price when it is too late. Ultimately, it’s important to understand the pros and cons of choosing a medical aid especially based on your needs and affordability.

Heading towards value-based care

You Need Posted on by

Accessible and quality healthcare is a pillar of sustainable development and global security. The principle behind this is that no one should fall into poverty because they get sick and need healthcare. South Africa’s response to the global call for universal healthcare is the National Health Insurance (NHI) bill, which aims to provide everyone with access to appropriate, efficient and quality health services.

“The Health Market Inquiry has spelt out the failure of the private sector to make affordable quality healthcare available to more people. To move towards universal health coverage, holistic care delivered by a multidisciplinary team is required,” says Dr Brian Ruff, co-founder of PPO Serve.

Access to quality healthcare forms the basis for the realisation of a wide variety of socioeconomic rights. The purchaser role put forward by the NHI will ensure the efficient use of resources to benefit the country’s entire health system. “The model introduces a single fund that will also support the purchasing of medical services for the country,” he says.

In contrast to the current model, in which schemes attempt to manage care and spend through restricted benefits and pre-authorisation, the NHI fund will be responsible for the lives of 57-million South Africans. “Under it, providers – whether public, private, or not for profit – will compete for local contracts based on how well they deliver value. This includes primary healthcare and hospital services,” says Ruff.

Value-based care

The goal of universal health coverage is to provide full comprehensive care to all citizens and legal residents of a country. “By pooling funds, the NHI has the ability to provide access to quality and affordable health services for all South Africans based on their healthcare needs and irrespective of their socioeconomic status. There are many countries, with less resources who provide quality healthcare care for everybody,” he says.

To work effectively, the NHI needs to appoint a competent team to design template strategic contracts that are robust and fair. “These value-based care contracts must use payment models that support the use of all available resources, that reflect population needs and that reward good outcomes. This means the model needs case mix tools – data which shows that patients are treated at the right level of care relative to their illness – to be available at every level of the system.”

Population medicine models demonstrate their value by improved measures of both the quality of healthcare delivered, as well as a reduction in spend. “The strength of this team-based and community level model is in managing complex medical conditions as well as the direct impact of social, psychological and financial circumstances on patients’ illnesses and treatment,” says Ruff.

Sama makes NHI submission to Parliament

You Need Posted on by

While the South African Medical Association (Sama) is in support of the principles of universal health coverage and quality care for all, it has not been able to support the 2019 National Health Insurance (NHI) Bill in its current format, the organisation said in its submission to Parliament.

Sama raised many concerns and queries about unclear aspects in the 2018 draft Bill, and objected to many aspects proposed to be written into law. Examples include contracting and payment mechanisms which have never been implemented in the country before, as well as missing detail on quality of care expectations. There are also concerns about the amount of power which the Bill hands to the minister of health.

Sama ran a membership survey in November 2019 to gauge the feelings of its membership in relation to the Bill and the NHI proposals. It received 1,000 responses in the short two-week period in which the survey was open. Members do not think that a single fund is the only answer to securing universal health coverage for the population, and the membership is generally concerned about the lack of detail in contracting mechanisms, accreditation procedures and quality of care in general. The written responses indicate a deep mistrust of the government structures in general and the ability of the Department of Health to implement their plans in realising coverage for all.

Members agreed that the proposals for payment arrangements in the Bill are premature, and untested in the South African environment. Overall the Department of Health should pursue quality and finance improvement initiatives already proposed for the public and private sector before fundamentally changing the healthcare delivery system in the country.

Join the modern workplace with Microsoft Office 365 and Tarsus on Demand

You Need Posted on by

Struggling with admin, patient bookings, and general time management? You don’t need to, when one software suite can solve it all. Join the modern workplace with Microsoft Office 365 and Tarsus on Demand! We’d love to introduce you to an incredible business solution that will not only save you time but allow you to focus your attention on the things that matter – like your patients.



Focus on your patients, don’t lose your patience. Have more time for your patients while Microsoft Office 365 helps you manage patient bookings and keep your patient records secure.

Get one software suite to reduce admin and save you time.

That’s where Office 365 comes in, designed for busy medical professionals to ease their admin and improve their time management. We call it the modern workplace. But the Office 365 suite isn’t just a word processor – it’s a sophisticated platform that can help you:

  • Securely and efficiently store patient information
  • Schedule and manage appointments in a customized booking system
  • Access your files anywhere, anytime
  • And so much more!

If you’d like to hear more about how you can use digital tools like this to manage your time, patient information, and grow your business, we are here for you. Discover Office 365 and join the Modern Workplace now.

For more information, visit:
https://connect.tarsus.today/modern-workplace-healthcare

When you have a pain in the neck or back

You Need Posted on by

Back pain is a common problem – 80% of us will experience an episode at some point in our lives. It is associated with many factors that vary from person to person but can be caused by an injury, a disc or joint problem, an irritated nerve root or poor posture. The pain might be acute or chronic but living with either can be debilitating.

Pain is considered chronic if it lasts more than three months and exceeds the body’s natural healing process. Either way, failing to get pain relief after different treatments is very frustrating. It can lead to depression, loss of working hours, extensive treatments and often sufferers lose hope and resort to popping painkillers or going for surgery. Both of which can be counterproductive.

Surgery not the only option

Many people assume that surgery is their only option to treat severe back pain. However, according to Dr Jacques Gilau, clinical head for Dr JJ Gilau and Partners utilising Documentation Based Care (DBC) technology in South Africa, ‘only a small percentage of people with back pain require surgery.’ DBC uses effective methods of musculoskeletal rehabilitation and physiotherapy for back and neck pain. Usually a 6-week interdisciplinary programme that includes treatment by doctors, physiotherapists and biokineticists. 

Bonitas Medical Fund has partnered with DBC so that its members have access to a back and neck programme of up to six weeks, to either prevent surgery or, when it is unavoidable, prepare and strengthen ahead of surgery and rehabilitate afterwards. 

Lee Callakoppen, Principal Officer of Bonitas says, ‘We believe in the preventative management of chronic back and neck pain and since partnering with DBC have received excellent feedback. Members are staying active, developing a better understanding about their pain, identifying the factors involved in their pain and living regular lives. For this reason we cover the full DBC treatment programme.’

According to the DBC statistics, the success rate for treating chronic back and neck pain to avoid surgery is 91% at two years follow-up. DBC has 18 equipped centres in South Africa and the treatment programme is for up to 6 weeks, after which time there are check-ups to ensure that the home programme is effective. 

Back, neck and shoulder problems affect many people and are often the result of stress and lifestyle specific issues. Those receiving treatment at the DBC centres range from between the ages of 11 and 93.

Bonitas does not wait for members to contact the scheme when they need help, as part of the Managed Care programme, they use predictive modelling capabilities to support members who may benefit from this service by proactively contacting them and encouraging them to join the DBC programme. 

One patient who was contacted by Bonitas when she was suffering from chronic back pain tells her story. 

Bonitas back and neck programme give woman her life back

Thandiwe* has Lupus, a systemic autoimmune disease that occurs when your body’s immune system attacks your own tissues and organs. Inflammation caused by Lupus can affect many different body systems — including your joints. She has already been through two hip replacements, surgery to both shoulders, her right knee and her ankle. In 2018 when she started developing lower back pain that went down into her thighs and knees, she knew the disease had started to affect her back. She had to use either a walker or a wheelchair. 

She says, ‘I couldn’t walk because of the sharp burning pain. I went to see an orthopaedic surgeon and a neurologist and they confirmed that Lupus was affecting my spine.’ Thandiwe was not a candidate for surgery and was at her wits’ end. Besides not being able to walk she couldn’t do house chores, go the mall or visit family or friends. ‘The worst was when the pain sort of locked my knees, even making standing painful.’ 

Bonitas, with whom she has been a member for 28 years, phoned her during this time and told her about the DBC back and neck programme. 

The doctor at DBC said that her lower lumber vertebra, L4 and L5 are degenerating and that the multi-disciplinary programme of healthcare practitioners would help her. 

The six week programme started immediately and she said that apart from consulting with the doctor she saw various therapists and had a range of treatments, including, deep tissue massage, dry needling and thermal therapy. DBC creates a customised set of therapies according to the patient’s particular needs. ‘Initially using the exercise equipment was very difficult but I felt more comfortable once the doctor checked my progress and gave advice.’ 

She says after a month, she started to walk slowly without a walker and didn’t need her wheelchair. ‘I felt much better and the doctor was pleased with my progress but recommended that I continue with the programme. 

‘The best part of the programme is the fact that the pain is reduced, at last I can sleep on both sides and turn in my bed and I can also use the exercise equipment without feeling so much pain. I just feel so much better. I can walk around the house without any assistance. I still keep up the exercises I was given.” 

Thandiwe is on the Standard option with Bonitas and the entire cost of the DBC programme was covered. 

‘Continuous pain makes you feel depressed and you feel as if you have no life. I am feeling so confident and my self-esteem has started to return. I have my life back! 

‘I still have a long way to go but it is the best thing I have ever done. I am continuing with my exercises and looking forward to even more improvement.’

*The name has been changed for privacy purposes

How a lack of competition in South Africa’s private health sector hurts consumers

You Need Posted on by

The investigation ran over five years and included over 43 million individual patient records, 11 million admissions, specifically commissioned studies, written submissions, public hearings and seminars. The investigation focused on hospitals, doctors, and funders. Funders include the medical schemes who purchase healthcare on behalf of members, and the administrators and managed care organisations that medical schemes contract with.

South Africa’s Competition Commission set up the inquiry in response to prices in the private healthcare sector which, it said, only a minority of South Africans could afford. The country has a two-tiered health system. About 71% of the population uses public sector, while the private sector serves around 27%.

Ideally competition should translate into lower costs and prices, better quality, and generally more value for money for consumers. In its final report, which was released recently, the inquiry found that competition wasn’t working as it should in private healthcare. The sector was characterised by high and rising costs, significant overuse, and no discernible improvements in health outcome.

Lack of competition

There were a number of factors that – alone or in combination – led to a lack of competition in the sector.

One factor is that three hospital groups dominated the facilities market: Netcare, Mediclinic and Life. They accounted for more than 80% of the hospital beds and 90% of all the admissions. These three hospital groups, both individually and collectively, were able to secure steady and significant profits year-on-year. A few firms owning the majority of the market is an indication that competition may not be working effectively.

Hospitals don’t attract patients, they compete for doctors who admit patients. Most doctors had contracts with the big three. Successful entry by new hospital owners is very difficult as they cannot attract doctors as easily.

Hospital groups are also able to build additional hospitals where they aren’t needed, resulting in an oversupply of beds and ultimately overuse of services.

In South Africa more people are admitted to ICU compared to eight other countries with comparable published data. The inquiry panel estimated that the country could save more than R2.7 billion – or 2% of its current private health care spend – if it halved the number of people admitted to ICUs and improved the care for patients in wards. Only the critically ill should be admitted to ICU. But the inquiry found that some of the patients who were in ICU could have been treated in wards.

There are no measures of quality of care in the public domain. This means that members of medical schemes and funders (who purchase healthcare on behalf of medical scheme members) weren’t able to judge if the care provided by doctors and specialists was effective.

The entire premise of effective competition is that purchasing healthcare services should be based on value – a combination of price and quality. This isn’t possible in South Africa.

There’s no way to assess if the care provided was improving health outcome. This is particularly problematic as the inquiry found significant over-servicing by doctors which cannot be explained by their patients’ level of illness. Doctors use a fee-for-service billing model. This means they bill patients for each service they perform during a consultation. In this system, the more you do the more you earn. This is called a perverse incentive and without knowing the impact of health outcomes neither doctors nor patients know if the extra tests or interventions are worth the cost. They also don’t know if it is improving health outcomes.

The inquiry also found doctors and specialists worked as individuals -– not as a team. There is growing evidence and acceptance internationally that team-based care is better and more cost effective.

Medical schemes compete for younger and healthier individuals. To do this, schemes have created numerous benefit packages. But these packages aren’t comparable. Medical schemes have done this in response to the absence of a mechanism for equalising risk between medical schemes. Medical scheme members do not know what they are paying for. Neither are they able to judge the quality of care.

Recommendations

The recommendations are aimed at creating greater competition, transparency, and accountability on how medical scheme member’s money is spent. They also aim to increase competition on the supply side (hospitals, doctors, and specialists) and on the demand side where funders represent the consumer.

Recommendations include a supply side regulator, whose job will be to:

  • assist provinces in issuing licenses for hospitals;
  • assist with a process and a platform for price setting for doctors;
  • conduct or contract out research looking at cost-effective healthcare interventions, including technology; and
  • facilitate access to reliable information on quality of health and health outcomes measurement.

To increase competition on the funder’s side, and to improve transparency for the consumer, the recommendations include that all medical schemes offer one comparable insurance package. In addition, government should introduce a mechanism to equalise risk between medical schemes so that they compete on the merits – not on risk or age selection.

What next

The recommendations have implications for the South African governments plan to introduce a National Health Insurance in a bid to level out the playing field between the public and private health care sectors. The plan is that the National Health Insurance will operate as a funding mechanism to move South Africa closer to universal health coverage.

Implementing the recommendations set out in the inquiry report is an essential step towards creating an environment where the purchaser – the National Health Insurance fund – will purchase from a private healthcare market that is competitive with lower costs and prices, and more value for money for consumers.

The National Health Insurance bill talks about strategic purchasing or value based purchasing which refers to using the capacity in the private sector to relieve the public sector. This aligns with the health market inquiry recommendations.

But it needs an independent supply side regulator to enable competitive price setting and coding mechanisms. Codes form the basis on which prices are determined – which is necessary for the National Health Insurance fund to reimburse providers. Value based purchasing also requires implementation of performance and outcomes reporting and monitoring.

This article is republished from The Conversation under a Creative Commons license. Read the original article.The Conversation

Medical Aid – Making the right choice

You Need Posted on by

Private and public healthcare has been in the news lately and will continue to be a topic of discussion due to the Department of Health’s proposed National Health Insurance (NHI) Bill, the Health Market Inquiry (HMI) report as well as the current socio-economic landscape.

Traditionally, this is the time of year when private medical aids present their products, plans and pricing for 2020 to existing members or potential members, so that they can make informed choices. “It is imperative that the decision you make regarding your and your family’s health and wellness is balanced against affordability,” explains Lee Callakoppen, Principal Officer of Bonitas Medical Fund.

“For existing medical aid members, it’s the time to analyse the plan you are on, whether it meets your health needs and compare it to the various options available.”

Medical aid plans can be confusing which is why it’s important to compare the various options and benefits to ensure you find a medical aid that works for you and your family’s health and that is within your budget. For people who have a broker, that should be the first point of call to help you can make an informed decision.

Here are some steps to help simplify the decision.

Analyse your healthcare needs

Completing a quick personal healthcare needs’ analysis will help you determine what level of cover you need. If you have dependants, factor in their healthcare needs too. Consider how much you and your family spent on medical expenses over the past year as a guide and then ask the following:

  • How often did your family visit a doctor?
  • Do you require medicine often?
  • Did you or the family need to visit a specialist?
  • Are any of you in need extra cover for cancer, HIV, renal failure or any other specific conditions?
  • How much did you spend on dentistry, optometry and over-the-counter medicine?

Then consider which expenses were once-off and won’t come up again soon (like childbirth) and which are likely to come up again and again (such as flu) as well as chronic conditions like high blood pressure and diabetes.

Check how much cover you require

If you find you hardly claimed (if you are on a medical aid) or have very few medical expenses, then you will need a lower level of cover. However, if you have a large number of medical expenses, you will require one of the more comprehensive plans. Once you’ve established this, you can decide whether you require a full medical aid or a hospital plan.

Are you happy to use a network

Some plans require you to use a specific GP, hospital network and have a list of Designated Service Providers (DSPs). This helps to keep costs down because the Scheme will have negotiated special rates with these services providers. Check whether there is a wide enough network in your area to cover your specific needs.

Check your budget

Once you have an idea of what you might need for the year ahead in terms of healthcare, then it’s time to look at your budget. Decide what you can afford and remember that the rule of thumb is that contributions should not exceed 10% of your monthly income.

Read the small print

Make sure you read all the details, including the benefits. These vary from plan to plan so establish what is covered and look at whether it offers additional risk benefits which can potentially save on day-to-date expenses. These could include anything from free wellness screenings (blood pressure, cholesterol, blood sugar and BMI measurements) through to maternity benefits, flu vaccinations, mammograms, pap smears and HIV tests. All of these are costly if you have to pay for them yourself.

What about savings?

Medical savings are a fixed amount a medical scheme gives you at the beginning of the year. You can use your savings for daily out-of-hospital medical expenses, such as GP and specialist consultations and over the counter medicine. There are ways to maximise your savings but first you need to know what you annual allocation is.

Age can influence the decision

If you have young children, ensure that the medical aid option you select provides sufficient child illness benefits. For young couples looking to start a family, ensure the option provides sufficient cover for maternity benefits. However, if you aging then you need an option that covers chronic conditions and provides sufficient in-hospital cover in the event of hospitalisation.

Some additional advice

  • Remember to be honest on your application form, disclose all information about you and your dependents’ health. Membership can be suspended or cancelled if you fail to do so.
  • Any waiting period or exclusions? Schemes may impose certain waiting periods for new members joining or for a pre-existing medical condition. This is based on the guidelines of the Medical Schemes Act and the specific scheme’s rules.

Finally, get expert advice

“Your health and that of your family is important so it is vital that you are comfortable with the choice you make and are confident your healthcare needs will be taken care of,” says Callakoppen. “My advice is to make sure you are informed. Read the information and fine print and compare what the different plans are offering before you commit. If you are still unsure, phone the scheme and ask questions or check with your broker or financial advisor.”

Medical schemes performance underwhelming

You Need Posted on by

As the economy bites and more consumers are downgrading their medical scheme cover to lower benefit options to cut costs, they are not realigning their ‘consumption-based’ expectations and are struggling to decipher the complexity of benefit options and scheme rules.

The South African Customer Satisfaction Index (SA-csi) for Medical Schemes (2019) provides insights into the overall level of satisfaction of customers of medical scheme providers – Bonitas, Discovery, Gems, Medihelp and Momentum. Gems is the only closed medical scheme included in the survey. Consulta, which conducted the survey, polled 1,707 medical scheme members across five of the leading schemes by membership numbers.

Overall, customers indicated that they do not believe that the premiums paid match the quality of cover and experience on offer. Across the board, the industry is struggling to meet the needs of customers in terms of benefit design that meets the needs of customers in a simple and transparent manner. No outright leader was identified in this year’s index, with Bonitas and Discovery obtaining a joint leadership position, Medihelp coming in on par with the industry average (72.9) while Momentum is just below par and Gems lagging in last place.

Customer satisfaction – overall index

Bonitas (75.1) and Discovery (74.8) lead the industry, Medihelp (73.5) come in on par with the industry average score of (72.9), while Momentum scores just below and Gems with the lowest score at 68.3. Overall customer satisfaction for the industry has increased to 72.9 compared with 71.6 in 2018.

Bonitas and Discovery were the only two schemes to show an improvement on 2018 scores, with Bonitas showing a big improvement of 4.9 index points in 2019, followed by Discovery with 1.7 index points.

Gems (-0.5), Medihelp (-1.6) and Momentum (-1.3) showed a decline on overall customer satisfaction compared with 2018 scores.

While Discovery, Gmes, Medihelp and Momentum have stayed relatively stagnant on overall customer satisfaction scores for the last two years, Bonitas has made a significant improvement in 2019, suggesting that recent strategic reviews of its benefit options and member focus are starting to pay dividends.

Customer expectations and perceived quality

Across all brands, customer expectations are not being met consistently. South African customers have very high expectations of their medical scheme providers (industry average of 80.6) given the fact that it’s an expensive buy and communication around benefits is often not done clearly.

Bonitas and Medihelp are the only two brands that showed a positive gap – albeit marginal – where perceived quality meets customer expectations.

Perceived value

Perceived value is a measure of the quality, relative to the price paid. The perception of value for money is a very strong predictor of future usage and company growth.

In terms of the value index, Medihelp (71.6) takes the lead, Bonitas (70.9), Discovery (70.6) and Momentum (71.4) are all on par with the industry (69.6). Gems is below par at 66.1. Bonitas and Discovery are the only two schemes that saw a marginal increase in perceived value score compared with 2018.

However, when perceived value is overlaid with the price-quality alignment, customers of all brands feel that the premiums charged do not match the quality of the cover and experience on offer. In this regard, Discovery has the biggest gap (-6.2) in perceived value and price-quality alignment, followed by Bonitas (-5.8), Medihelp (-4.9), Momentum (-3.9) and Gems (-2.3).

Complaints incidence and resolution

Of the complaint incidence across the industry, customers complained most about fees and charges (22%), claims issues (19%), terms of cover or scheme rules (13%), feedback (9%) and waiting time (7%).

Discovery and Medihelp have the most complaints about fees and charges, both at 28% and above industry average (22%).

Medihelp has the highest incidence of claims-related complaints at 26% and well above industry par of 19%.

In terms of complaints incidence and handling the industry average of complaints incidence is 15.9/100 and complaint handling is 48.6/100.

Discovery has the lowest complaint incidence at 13.2/100 and complaint handling of 51/100. Bonitas’ complaint incidence is at 14.3/100 and complaint handling of 51.5/100. While Medihelp has a complaint incidence slightly higher than industry par at 15.8/100, its complaint handling score is well above industry par at 55.7.

Momentum and GEMS perform below average in this category.

Customer loyalty

Bonitas has the most loyal customers at 69.4%, above industry par of 64.0%, and has also seen a big improvement of 7.5% in loyalty score compared with 2018 (61.9%).

Discovery, Medihelp and Momentum all saw a decline in customer loyalty scores.

Net promoter score

This measures the likelihood of a person recommending a brand.

Bonitas has the highest net promoter score (NPS) at 21.6%, which is well above the industry average (9.5%). Customers are active promoters of the brand to others, with 45% of customers recommending the brand. It also has the lowest number of detractors at 24%.

Compared with 2018, Bonitas has seen a radical increase in NPS score when it came in at a low of 2.6%, suggesting that its focus on benefit simplification and customer satisfaction and complaints handling have had a marked impact on how customers perceive the brand, and their willingness to endorse it to others.

Discovery follows with an NPS of 14.5% which is on industry par and marginally up on its 2018 score of 12.2%. 41% of Discovery customers actively promote the brand, and 27% are detractors.

The balance of scores see a big drop-off on NPS performance well below industry par – Medihelp (10.9%), Momentum (8.4%) and Gems (-6.7%).
Gems has a high percentage of detractors at 43%, well above its promoters at 36%.

Treating Customers Fairly (TCF)

The degree to which customers feel they are being treated fairly by their medical scheme is highest with Medihelp (78.2) and Bonitas (78.9) – both above the industry score of 76.2.

Discovery follows with a score of 77.1 which is in line with the industry.

Gems (73.6) and Momentum (72.9) are lower than the rest of the industry.

Overall score

The make-up of the overall TCF score looks at seven key aspects including:

  • Fair treatment of customers
  • products and services that address customer needs
  • Transparent and easy to understand information
  • Advice that is suitable for the customer’s circumstances
  • Products and services deliver as expected
  • It is easy for customers to claim, change provides, complain or consider other providers
  • Customers are treated with respect and there is an open relationship

Annual private healthcare increases have been well above, if not double inflation, for more than two decades now which has steadily eroded the benefits that consumers can afford, with many forking out as much as 20% of their monthly income for medical aid. In response, consumers have opted to downgrade to more affordable benefit options.

HMI recommendations will contribute to universal coverage

You Need Posted on by

Once implemented, the majority of recommendations in the Competition Commission’s Health Market Inquiry (HMI) will provide a conducive environment for attaining universal health coverage.

“These recommendations introduce mechanisms for progressive and positive changes to occur in the private healthcare market, such as moving towards alternative reimbursement systems and away from the traditional fee for service system, which has led to perverse incentives,” Lerato Mosiah, CEO of Health Funders Association (HFA), says.

The recommendation for maximum tariffs for Prescribed Minimum Benefits (PMBs) is positive. However, Mosiah believes that in order to achieve this, funders and providers should come together to work on an industry wide single set of billing codes before the Supply Side Regulator for Healthcare is established, as suggested by the HMI. Clarifying the definitions of PMBs will also assist with this.

The HFA agrees with the recommendation for an industry-level role for health technology assessment and believes that this will assist the entire industry to make funding decisions based on the quality and efficacy of new technology entering the market, such as biological medicines and new equipment. This competency will also improve the health system’s capacity to assist patients with rare diseases.

“Most other health systems in the world rely on a central entity for health technology assessment in order to provide guidance in benefit design and funding decisions. In South Africa, each medical scheme has been left to do this work on their own for their own members. This is not only a duplication of work but also a waste of funds”, she said.

The association welcomes the proposed mechanisms to introduce greater transparency for members of medical schemes, such as a standardised benefit option and comparable top-up cover, as these will empower members to make more informed decisions about their healthcare.

The HMI also emphasises the importance of a well-functioning medical schemes market in healthcare provision. The recommendation for the creation of a risk adjustment mechanism may contribute in this regard and would close some of the gaps in the incomplete private healthcare sector regulatory regime.

“The recommendations will bring about more cohesive and efficient private and public healthcare sectors that will improve the quality of care experienced by patients,” concludes Mosiah.