Almost five months ago elective surgeries came to a standstill. This was reflected in claiming patterns in the private healthcare sector during lockdown – a disruption of the norm globally. In South Africa, elective surgery in both the private and public healthcare space and specialists’ visits are just two of the areas which have been affected by Covid-19. The link between the two is clear: Fewer specialists’ visits mean fewer referrals for surgery.

So what exactly is elective surgery?
The term can be ambiguous. It does not mean, as the name implies, that the surgery is optional but rather that it doesn’t need to be performed immediately. It can be scheduled at the patient’s and surgeon’s convenience. Some of these surgeries are necessary to prolong life, for example an angioplasty or, as in most cases, improve the quality of life. In brief, elective surgery is ‘A planned, non-emergency surgical procedure’.

Elective surgeries dropped by over half
According to Lee Callakoppen, principal officer of Bonitas Medical Fund, “there has been a 60% reduction in hospital authorisation requests compared to 2019. A study release in March predicted that an estimated 28.4 million elective surgeries worldwide, would be cancelled during the 12 weeks of peak disruption due to the global pandemic. This has been a similar experience to other industry role players and is predominantly due to a combination of member fears related to Covid-19, lockdown and provider caution.”

Surgeries delayed not cancelled
The postponement of surgeries was done to prevent patients taking up hospital beds and to avoid unnecessarily exposure to the virus – a strategy that worked well to flatten the curve. Surgeries were delayed based on provider discretion and subsequent patient engagement. Callakoppen says: “Providers are best placed to make these clinical decisions in the interests of their patients. If the procedures were emergencies or urgently required to enable member quality of life, those would have proceeded.”

The public sector too experienced backlogs in terms of elective surgeries. Examples are procedures including but not limited to, cataracts, orthopaedic surgeries, scopes, caesarean sections, tonsillectomies and adenoidectomies.

BHF cautioned funders
In July, The Board of Healthcare Funders (BHF) and its members in the healthcare funding space requested members of medical schemes to proceed with caution in scheduling elective surgical procedures. Dr Rajesh Patel, head of benefit and risk at the BHF, said: “While the relaxation of the lockdown restrictions is good news for people, the country and the economy at large, we are still in the eye of the storm.”

The way forward?
“As we move toward Level one, elective surgeries are almost back to normal,” says Callakoppen. “It’s time to address the backlog of surgeries not considered emergencies during lockdown. These include slow-growing cancers, orthopaedic and spine surgeries, airway surgeries, surgeries for non-cancerous tumours as well heart surgeries. We caution against a rush of elective surgeries though. Any surgery has an impact on the immune system, which means the patient has a greater risk of contracting Covid-19 and developing complications from it.

“It must further be noted that in some instances surgery is often recommended by specialists as one of the key courses of action. But we have noted that managed care protocols, in many instances, improve clinical outcomes with lower risk to the patient. One such example of this is spinal surgery, which is often unsuccessful. From a Bonitas perspective, we have noted that in the back and neck programme, which enforces functional rehabilitation has been far more effective for our members. In addition, the risk to the member is significantly lower.”

Bonitas recommends the following is taken into account:

• That elective surgeries should only be resumed in instances where not having the procedure will severely impact the members’ health and quality of life
• That the current state of a patient’s healthcare is assessed – individuals with chronic conditions such as diabetes, asthma HIV/Aids and hypertension, are at high-risk of developing Covid-19 complications
• The patient’s age is taken into consideration (older individuals are identified as one of the most vulnerable groups)
• The impact of waiting on the patient’s healthcare outcomes (for example, is it essential that the surgery takes place now or can it safely be deferred for a few months)
• Alternative care protocols – in some cases surgery, which should be a last resort, is prescribed without considering other treatment protocols such as rehabilitation. The most common examples of this include back and spine procedures, elective c-sections as well hip and knee replacements
• The use of day hospitals and clinics, where possible, to limit the possible chance of infection

We may have flattened the curve but we are by no means out of the woods. Current Covid-19 cases in South Africa prove that.

What is happening in hospitals?
“Surgeries are being resumed responsibly with due collaboration and consideration exercised between the surgeon, the patient and hospital staff,” says Callakoppen. Where there are capacity constraints, surgeries will be classified in terms of priority at the various hospitals. Pre-operative screening will continue. Facilities will continue to utilise separate zones for Covid-19 positive patients, Persons Under Investigation (PUI) and those for whom the status is unknown at the point of admission. Surgeries will be carefully planned and scheduled.

Specialist visits on the up
“Consultations are starting to increase once again but providers in general are likely to remain prudent. However, we urge people who have not had their necessary annual check-ups, particularly our high risk members, to consult with their doctors. There may be members who have put these consultations on hold and are now more comfortable to visit a specialist. But care coordination is essential. Your GP should be your first point of contact – particularly in cases where you are not already under specialist care.”

Callakoppen says that members may also need to be physically examined if they are no longer as responsive to their medication, are concerned about general matters relating to their health or have received a specialist referral from their GP.

“The healthcare of our members is critical, particularly as we want to prevent them from developing unnecessary and preventable complications further down the line. It is important that we don’t have tunnel vision and only focus on Covid-19. We need to consider the overall healthcare needs of our members. Healthcare professionals are best positioned to decide if surgery should go ahead or not but it is ultimately the patient’s decision on how to proceed.

“We strongly urge patients to make informed decisions and weigh up the pros and cons. During the pandemic we all need to act responsibly and make informed decisions that won’t place patients, healthcare providers and the healthcare system under more pressure than necessary.”

Callakoppen highlights some of the key challenges facing consumers and the way forward.

Covid-19 testing
Challenge: Costs and availability of Coronavirus tests

Solution: Negotiation and co-ordination to manage tests and a payment plan put in place

Our administrator and business partners are collaborating with the National Institute for Communicable Diseases (NICD), the Department of Health (DoH), pathology laboratories and the Radiology Society of South Africa to try to monitor and manage the availability and cost of tests. In addition, we are collaborating on the provision and delivery of medicines and co-ordination of treatment available in order to ensure sustained, quality healthcare is available to all members. Bonitas covers Covid-19 as a Prescribed Minimum Benefit (PMB), paying for up to three PCR tests from risk – regardless of the result.

“One of the problems has been a shortage of tests in South Africa and we have urged our members to follow the guidelines from the Government and the World Health Organization, only testing when absolutely necessary, such as when they have come into contact with a known Covid-19 positive case, are showing symptoms and have received a referral from a healthcare practitioner for a test,” Callakoppen says. This step aims to ensure that tests are reserved for those who really need them. These measures also go a long way in helping to curb misuse of tests and mistaking the symptoms of other respiratory illnesses for Covid-19.

“We note that as the number of Covid-19 positive cases increase, there is a significant increase in the number of tests conducted. However, again we strongly urge the public to only test when absolutely necessary or when advised by their Healthcare practitioner to do so, as a shortage of tests could have a much more far-reaching impact on the spread of the disease.”

Addressing affordability

Challenge: Helping cash-strapped members continue paying their medical aid premiums

Solution: Proactive application to CMS for concessions and looking for ways to add value to our members and South Africans

“The economy and livelihoods of many South Africans have been adversely impacted by the pandemic. We definitely sympathise with this and, as the cost of living continues to increase it was very clear to us that affordability of medical aid, as well as daily living expenses, would become a concern. We began engaging with the CMS prior to the issuing of the CMS Circular 28 of 2020 containing Covid-19 Medical Schemes Industry Guidelines to try and offer our members some respite from the harsh economic impact. However, as medical schemes we are highly regulated in terms of our operations. As such there is a lack of parity between the level of relief we would have liked to offer our members to the level of relief that was approved.”

CMS issued an additional industry circular in April 2020, outlining how medical schemes can apply for exemptions to the Medical Schemes Act to launch lifelines to members, such as contribution holidays or accessing their medical savings accounts to cover premiums. The R160bn medical scheme market covers about 8.9 million members, most of whom are subsidised by their employers.

Callakoppen says, “The CMS regulates the industry and has been very specific in terms of what medical aids may and may not do. Schemes are required to request exemptions from the Medical Schemes Act to relax certain credit management policies through the CMS.

“We approached the CMS in April with requests for concessions and have implemented those they approved. At present, our concessions include allowing contributions to be funded from savings. In addition, we have special concessions in place for members who belong to employer groups.”

Despite the regulatory environment, Bonitas has been agile in its approach. “We used the challenges of the current landscape to become more innovative in terms of what we can do, within our environment, to assist our members and South Africans at large with some relief. We therefore introduced free virtual GP consultations to all South Africans through the Bonitas Member App so that they would continue to have access to healthcare during this time.

We continue to keep the issue, of how members are impacted due to the economic challenges, top of mind and this informs your strategies to respond and address the challenges consumers are experiencing.”

Hospital beds

Challenge: Shortage of high care and ICU beds

Solution: Negotiations to have access to facilities outside of network hospitals and standardised tariffs

Together with Medscheme, our administrator, we have implemented tariff enhancements to ensure that sub-acute and day hospitals can accommodate admissions where provincial licence exemptions have been granted, when the time comes.

There are about 25,800 adult acute beds in the private sector and about 3,700 day hospital and sub-acute hospital beds that stable patients could be sent to. In addition, there are 3,600 dedicated paediatric beds nationally.

“As a Fund we have negotiated with hospital groups to ensure that members do not have to go to a network hospital during this time when private hospitals may experience capacity constraints. Our key mandate is to act in the best interests of our members at all times and as such we strive to ensure that they have access.”

Virtual Care 24/7 for everyone

Challenge: How to maintain your health during the Government’s call to stay at home and social distancing

Solution: Virtual Care

Early in April, Bonitas launched its Virtual Care, offering it to all South Africans, at no cost, during the Covid-19 crisis. These virtual medical consultations, with GPs and other physicians, were extended to have a ‘Dr on call’ 24/7.

“We know that illness doesn’t keep office hours,” says Callakoppen, “so we approached ER24 to join forces with us to extend the availability of free consultations to round the clock. This offers peace of mind to anyone who is feeling ill, needs some reassurance about symptoms they are experiencing or requires a prescription. It can all be done virtually, by appointment.

“And, because we understand how severely depressed the economy is, we took a decision to offer this virtual care service, free of charge, to all South Africans, not just our members. All you need to do is download the Bonitas App.”

General Practitioners (GPs)

Challenge: Limited face-to-face consultations

Solution: Opening virtual care up to all healthcare practitioners

The Virtual Care App not only enables all South Africans to get quality healthcare without leaving their homes, but is also an opportunity for healthcare practitioners to sign up to ensure that they see patients during this time. Healthcare practitioners have seen a substantial decrease in patient numbers in their rooms and many are struggling to keep their practices afloat.

By registering on the Virtual App and informing their patients that they are consulting virtually, we hope that this will assist them in increasing patient consultations and enable South Africans to get sound medical advice. We have been in consultation with GPs in terms of finding the best treatment protocols and communicating with our members so that they follow these pathways.

Medicine deliveries

Challenge: Maintaining your chronic medication regime during lockdown

Solution: Home delivery of chronic medication and extended scripts

Two years ago the Human Sciences Research Council (HSRC) and the Medical Research Council cautioned that chronic diseases such as diabetes and heart disease are becoming the biggest threat to South Africans’ health. The three most commonly associated Covid-19 comorbidities are hypertension (or high blood pressure), diabetes and obesity. “In our country we have a very significant burden of these three diseases. These risk factors are important to take into account because they are also serious factors when it comes to the severity of, and complications related to the Coronavirus infection,” says Callakoppen.

“We are pleased that Pharmacy Direct has continued to deliver chronic medication to members during the lockdown. This has helped to ensure that they are following their treatment regimens, especially in light of the pandemic. In addition, the changes to laws around prescriptions means that these are now valid for 12 months which helps to alleviate some of the burden on the healthcare system.

“It is important to ensure that there is no disruption for members or to their chronic medicine management – which includes coaching and compliance – during the lockdown period.”

“We believe implicitly that tackling this unprecedented pandemic requires us to work together to find the best practice to deal with Covid-19,” says Callakoppen.

Couple this with many people experiencing financial hardships during this time and one must also try and stretch the benefits that their medical scheme has to offer. So, what should people be looking out for?

Covid-19 testing is a prescribed minimum benefit (PMB)

The Council for Medical Schemes has mandated medical aids to consider Covid-19 testing a PMB. All registered medical schemes in South Africa need to provide PMBs on all plans offered to members, regardless of plan type. In terms of the Medical Schemes Act, these PMBs are a set of defined benefits that relate to 270 categorised conditions that all medical scheme members can utilise.

How is Covid-19 defined and what is covered by PMB?

It is defined as “an acute respiratory illness caused by a novel coronavirus”; and annexure A of the Medical Schemes Act (which lists PMBs) has been amended by the minister of health to include this new illness.

Along with these 270 conditions that the medical schemes are obliged to fund from the risk benefit, they are able to curb their risk by requiring members to utilise designated service providers (DSPs) only. By using providers in the medical scheme’s network, members can rest assured that their scheme will cover that in full. Should a patient choose not to use a DSP, then the medical scheme is only required to pay in line with medical aid rates.

There are certain instances in which patients can make use of a non-DSP, but these extend to life-threatening emergencies.

What is and is not covered?

According to Covid19 PMB guidelines, the recommended test at PMB level of care is the reverse transcription polymerase chain reaction (RT-PCR) test. In a situation where a person is to be treated out of hospital and they present with symptoms, they must be screened by a healthcare provider who deems the test necessary due to the suspicion that the patient may have Covid-19. Regardless of test results, as long as the member was screened by a healthcare professional and was deemed necessary by a medical professional (who is a DSP) and the RT-PCR test is used, it must be funded from the medical aid’s risk benefit as a PMB. Where the person tests negative, any follow up care is not covered. In the case of a positive test, hospitalisation (including ventilation) and medical management of the patient’s condition thereafter would be funded from the risk benefit as a PMB and not from the members day-to-day benefits.

Where patients are to be admitted to hospital for other reasons (such as elective surgical procedures) they may be requested to undergo a Covid-19. test beforehand. In these situations, it is not PMB level of care therefore medical aids do not have to fund the test from the risk benefit. Here, the cost of testing would most likely come from the members day-to-day benefit or be self-funded. Should a person voluntarily choose to make use of a non-DSP then, that member is likely to be exposed to a medical expense shortfall for the in-hospital treatment.

It is also important to note that while the focus of many is on Covid-19 it is not the only reason why people are being admitted to hospital during this time period. People are still admitted to hospital for essential treatment such as heart attacks, fractures, cancer treatment, organ transplants.

Is gap cover going to help with Covid-19 medical scheme shortfalls?

Many families are facing financial hardship and gap cover is the smart way of minimising the risk of costly in-hospital medical expense shortfalls. This is the difference between what private healthcare providers charge and the rate the medical aid pays for in-hospital treatment. Moreover, hospital admission may not always be as a result of Covid-19, however, in the current circumstances people need to be prepared for out of pocket medical expense shortfalls – regardless. It is also important for consumers to understand their medical scheme coverage and even more importantly the PMB benefits for Covid-19.

Lee Callakoppen, Principal Officer of Bonitas Medical Fund, says, ‘We are following the data closely as the fund represents over 700,000 lives which is roughly 8% of South Africa’s total medical aid membership and 1.2% of the national population.’

Bonitas has monitored international, local and scheme-specific data to assess the incident proportion and to inform its decisions in support of its members and South Africans at large. The fund continues to evaluate this on an ongoing basis as more data becomes available. However, this remains a challenge in light of the limited data available at the time, which impacts modelling.

‘What we do know is that if the pandemic is not managed responsibility and with rigour, it will have a severe impact on the healthcare resources of the country both public and private. The ongoing analysis from a Bonitas perspective, is to ensure that the fund adequately manage its reserves, to ensure that the claims of members are paid when they access benefits.’

Callakoppen offers a round-up of the situation at Bonitas as of 21 May 2020

‘Bonitas has seen approximately 10,000 members being tested with 282 confirmed positive. In relation to the hospitalisation rate, the fund has seen a total of 120 admissions, with a positive recovery totalling 32. Unfortunately, we have sadly lost 16 of our members to the virus.’

The expected number of total infections and level of care assumptions are drawn from international experience to-date and expectations on ultimate detected infection levels, while keeping a view of the local trajectory.

Callakoppen says, ‘Projections are highly uncertain at this time but our actuarial team has estimated around 30% or 215 851 members of the Bonitas population are at risk of contracting Covid-19, based on co-morbidities. Of these 30% are based in Gauteng, 19% in KZN and 15% in the Western Cape. The conservative financial impact to the Scheme could potentially exceed R450m, in addition to annual claims cost which amounts to R15bn annually.

Counting the costs

The key cost-drivers are hospital admissions, additional cost for Personal Protection Equipment (PPE) to ensure healthcare workers and patients are protected, pathology test costs as well as home care and healthcare support to members in the workplace as the economy re-opens.

Callakoppen says the Covid-19 pandemic is having a major impact on the costs of providing healthcare benefits to members. In certain benefit categories such as in-hospital admissions there has been a decline in claims due to the prudent action taken by healthcare groups to defer elective surgeries and only attend to emergency matters. While, in other categories like medication, there has been a marked increase in claims and costs. This trend is set to continue until at least the end of September 2020, as the Covid-19 infections are expected to peak in early August 2020.

Projected levels of care

There is a high level of uncertainty around the level of care that would be required for the Bonitas population over the course of the pandemic, but Bonitas projects that Covid-19 cases will be managed as follows:

• 20% requiring hospitalisation
  
• 5% requiring treatment in ICU
  
• 60% requiring treatment at home
  
• 20% are asymptomatic or do not require treatment

Hospitalisation can be as high as 6 days in a general ward, 8 days in high care and up to 15 days in ICU.