Medical Aids

Council pursues bogus health practitioners

A rise in bogus health practitioners has forced the Health Professions Council of SA (HPCSA) and medical schemes to strengthen their forensics units to curb fraud.

A team at the HPCSA is conducting about 400 investigations into bogus practitioners. To date, just more than 40 arrests have been made, but prosecutions are slow.

Data from this special investigation unit suggests that about 7% of all medical aid claims in SA are fraudulent and stem from both bogus practitioners and unscrupulous ones.

Estimates are that this type of fraud costs the private sector R22bn a year.

Bogus practitioners include those who had previously been registered with the HPCSA, but were struck off for various infractions, while others had no medical qualifications or experience and used practice numbers belonging to registered healthcare practitioners.

Eric Mphaphuli, a senior inspector at the council, said on Monday that, initially, his team had issues getting the police on board and had to convince the authorities that the problem was serious and on the rise.

Since that conversation took place, arrests were being made every other week. “Recently a practitioner was arrested and sentenced to 20 years for practising illegally,” Mphaphuli said.

Bonitas Medical Fund, the second-largest open scheme in SA, had identified more than R79m in irregular claims involving medical practitioners in 2016 and recovered about R20m.

Gerhard van Emmenis, Bonitas’s principal officer, said the biggest single deterrent to fraud, waste and abuse was making it known that schemes were actively investigating every suspicious or unusual claim or activity.

In 2016, Bonitas introduced advanced analytical software into the live claims environment, using a mix of technology, analytics and expert skills to identify fraud, waste and abuse.

During this process, Bonitas red-flagged 574 healthcare professionals, 34 of whom were charged, while another four were arrested.

“We believe the HPCSA are too lenient on offenders. According to section 66 of the Medical Schemes Act, medical aid fraud, committed either by a member or a healthcare practitioner, is a criminal offence which carries a fine or imprisonment or both,” he said.

The National Education, Health and Allied Workers Union said it was concerned about rising corruption in the healthcare system.

Union spokesman Khaya Xaba said bogus practitioners compromised the healthcare system and the union was concerned about this.

United Democratic Movement general secretary Bongani Msomi said the Department of Health needed to “blacklist” bogus practitioners.

#InnovationMonth: How tech is transforming healthcare

We’re human. We’re programmed for instant gratification. Using this principle, Discovery Health has built its very successful Vitality programme, which is a blueprint for other rewards schemes, not only in healthcare, but other sectors too.

Free smoothies or wearable tech for doing a daily dose of exercise or changing your eating habits is not just Discovery Health being Mr Nice Guy. There is an ulterior motive, albeit a well-intentioned, strategic one. The company is using behaviour modification to build a shared value business model, which is sustainable.

Short-term rewards for long-term gains

It boils down to managing the growing epidemic of lifestyle diseases such as diabetes, heart disease and certain cancers, the estimated cost of this to the global economy is over $30trn over the next 20 years. Dr Ryan Noach, deputy chief executive officer, Discovery Health, says most non-communicable diseases (NCDs) are modifiable through changing habits such as eating and exercise. “Individual behaviour tends to be irrational. For example, when questioned, 52% of people with up to five NCDs, were inherently optimistic about their health, and had deferred action.”

So, in a nutshell, Vitality rewards members today to bend the mortality curve for longer-term risk mitigation, he says.

There’s been a massive and rising investment in digital healthcare, particularly along three themes, namely telemedicine, enterprise software and business-to-consumer interface, he says.

He touches on telemedicine, but speaks very enthusiastically about the other two themes, probably because of the amount of capital Discovery Health has ploughed into them.

Enterprise software

Fragmentation and a lack of care coordination are costing medical aids. For instance, diagnostic tests are often repeated in the chain of care. A GP may order a blood test to confirm a diagnosis before referring a patient to a specialist, who will repeat the same test because he or she does not have access to the results of the prior test.

The same goes for providing a medical history. A patient generally has to complete the same paperwork at each practitioner he or she visits, which creates unnecessary admin work. There have also been situations where patients have forgotten to mention information that could have implications on treatment protocols.

So, Discovery Health is developing a centralised electronic medical records platform where practitioners can access patient information (with the patient’s permission, of course) and get a full medical history at a touch of a button, he explains.

Business-to-consumer interface

Noach is excited about Discovery Health’s new digital healthcare platform, DrConnect, which the company will be launching shortly. This is a predictive artificial intelligence (AI) engine which “glues doctors and patients together and provides contextual and meaningful information. AI is going to change doctors’ jobs. It’s patient-centric and allows them to manage their own care,” he says.

Practitioner retention is vital to sustainable health models

Substantial inroads have been made for funding healthcare in Africa in the last decade. Now, thanks to solid population risk management tools, the potential to attract and sustain medical talent and services in-country has never been better.

Insurers have been able to develop sustainable insurance models, delivering better income security for medical practitioners and attracting medical spend from multinational corporates, said Dr Numaan Mohamood, divisional director of member care at Liberty Health.

Speaking at the Association of Healthcare Funders of Zimbabwe conference, Mohamood stressed the importance of ongoing conversation and collaboration between funders, providers and regulators. “Funding healthcare and establishing quality systems requires sharing of insights, perspectives and protocols. While regulators and funders can play an oversight role in terms of value delivery and sustainability, healthcare providers are the stewards of patient health and must be active in the conversation.”

Income security

One of the challenges for medical professionals on the continent is income insecurity. The International Finance Corporation reports that 72% of African healthcare services are paid for out-of-pocket, which puts healthcare practitioners at huge financial risk, especially in times of economic downturn. This drives medical talent offshore and does not support the development of services in-country.

“Our core concerns as funders are sustainability and value – not just for patients, but for healthcare professionals too. They need to know that they will be paid fairly and timeously for services rendered,” he said.,

Trust

Insurers need to gain the trust of provider networks, and to ensure practitioners understand how fee structures and care protocols relate to the long-term sustainability of funders. In the past, small insurers have gone to market with selective membership products. Due to their less comprehensive product offering, these providers are unable to accommodate funding for secondary and tertiary services – this results in limited hospital coverage and reduced access to tertiary care.

The solution is population level clinical risk management and entrenching evidence-based medical protocols. To date, the required data, actuarial analysis and reporting has been scarce due to several factors, including pressured public health budgets and few systematic measures of population wellness, he explained.

Private sector skills and resources of enormous benefit to implementation of NHI

The achievement of universal healthcare coverage in South Africa could be thwarted by Cosatu’s opposition to the National Department of Health’s plan to allow the private sector to have a role in the implementation of National Health Insurance (NHI).

Private sector skills and resources

According to Dr Clarence Mini of the Board of Healthcare Funders of Southern Africa, the private sector supports the government’s calls for universal healthcare for all South Africans and has a wealth of expertise, processes, and systems that can give the implementation of NHI in South Africa a major boost.

“By far the most compelling reason is that the private sector comprising of medical schemes, administrators, hospitals and medical professionals have the resources that can contribute positively to the improvement of South African healthcare in general and to the improvement of healthcare provisioning in specific communities.

It is able to share its skills, experiences, research, and resources more meaningfully towards the achievement of affordable, equitable and quality healthcare. Medical schemes and administrators already look after 16% of South Africans and these skills will be of enormous benefit in the public sector which simply does not have this capacity yet.

Public and private participation crucial

The responsibility of the minister encompasses the entire healthcare value chain across public and private entities and how these are brought together to ensure the viability and security of quality healthcare provisioning in South Africa,” says Mini.

“Our healthcare sector has its problems and we must collectively take responsibility to address the difficulties in an effort to make quality universal healthcare a reality for all – it is a task that our government cannot achieve in isolation,” he adds.

“Of key importance is the fact that the extensive experience and capacity of the private sector, which already services millions of South Africans, are not lost to the South African national healthcare project. The Minister of Health, Dr Aaron Motsoeldi recognises the absolute gravity of the task of NHI implementation and its sustainability on the back of a shrinking economy and tax base and is being prudent in harnessing the assets and expertise that already exist in the private sector. The minister simply cannot ignore the resources that are at our disposal. Right now the focus must be on delivering a well-managed, functional and financially viable universal healthcare model for all South Africans that embraces public and private participation and buy-in,” concludes Mini.

Private healthcare environment compromised by unregulated fees

According to Patrick Masobe, chief executive officer of Agility Health, healthcare specialists are able to invoice patients and medical schemes in an unregulated fee-for-service environment – in which every service performed has a code and a price tag – with secondary healthcare expenditure eating away at the medical scheme benefits of South Africans.

“Among the biggest cost drivers in the healthcare funding sector are knock-on costs resulting from the way that the practice of medicine has evolved through the years, given costly new technologies and developments, which have rendered the cost of healthcare service provision prohibitively high. The more services the healthcare professional performs, the higher the bill will ultimately be,” he says.

“Add to this over-servicing due to clinicians practicing highly defensive medicine, which is often in response to the highly litigious environment healthcare professionals find themselves in. Doctors argue that they must test for all possible conditions in order to protect themselves from legal liability in the event that they could possibly have missed something. Unfortunately, this tends to drive overly cautious behaviour, which in turn increases healthcare expenditure.”

Unnecessary tests

According to Dr Jacques Snyman, director of product development at Agility Health, this means that doctors in an emergency setting may perform a range of tests to guard against the possibility that they could miss something of medical significance. “However, quite a number of the tests performed may, in fact, be quite unnecessary,” he adds.

Snyman cites a recent example of a patient who presented with chest pain and breathing difficulties. She lodged a complaint after receiving a R4,000 pathology account from a Pretoria emergency room. “As a known cardiac patient, she was rushed off to the emergency room for fear of a heart attack and received a physical examination, electrocardiogram (ECG), which is a test measuring the electrical activity of the heart, as well as blood tests checking heart enzymes. Given her history, these tests were all necessary and were appropriately performed.”

“In addition, however, a thyroid function, cholesterol, full liver, renal function as well as electrolyte tests were also performed. All of these were unnecessary within this context, thereby constituting over-servicing as they were done in the immediate past during normal follow-up. A host of other markers was also requested, again with no real relevance to this case. The patient was eventually diagnosed with inflammatory costochondritis, which is an inflammation of the cartilage in the rib cage. This condition can present as mild to severe chest pain, which in this case responded well to pain medication,” notes Snyman

“It is of particular concern that the patient was never asked to consent to the tests performed or informed of the costs thereof. This constitutes a serious breach of the ethical codes and rules of the Health Professions Council of South Africa (HPCSA), which require that the doctor or healthcare facility to obtain informed consent from a patient prior to performing tests and that they explain billing practices up front.”

PMB encourages opportunistic behaviour

Masobe explains that in terms of prescribed minimum benefit (PMB) regulations, all relevant tests that are done to exclude acute PMB conditions, such as a myocardial infarction, must be fully covered by a medical scheme. “It is important to note, however, that the scheme is only liable to fund this as a PMB condition until such time as a PMB condition has been excluded. In this case, it meant that the clinical examination, ECG and heart enzyme tests were funded as a PMB but not the additional, extraneous and medically unnecessary tests. This becomes a dilemma for the patient, who now becomes liable for paying these fairly expensive additional costs from medical savings or, worse still, out-of-pocket.”

Snyman cautions that medical schemes products, which dictate that certain services will only be funded in-hospital, can further drive opportunistic behaviour, both on the part of patients and providers. “In such instances, emergency consultations typically involve admitting the patient to ensure that costs are covered by the medical scheme. This is also highly convenient in terms of access for both patients and doctors, whose consulting rooms are located at the hospital.”

An additional driver of costs is the fact that specialist visits are often facilitated without a referral from a general practitioner. With specialists being in short supply, this type of behaviour is not only costly and unnecessary but also places a considerable burden on scarce healthcare resources. “There is an urgent need to return to a more primary care-focused healthcare model in the private sector. Medical scheme members should be channelled through GPs instead of going straight to specialists. However, the PMBs, in their current form, discourage such behaviour and instead tend to encourage hospitalisations,” he observes.

Creative billing practices

According to Snyman, non-adherence to medicine accounts for as much as 30% of hospital admissions in patients who suffer chronic conditions, yet some schemes have overly simplistic formularies that cannot provide the flexibility so desperately needed to effectively treat patients out of hospital.

“Some doctors invent creative billing practices to increase their earnings. In certain instances, they are encouraging patients to make full use of their gap cover policies to cover additional healthcare costs.”

“The implementation of PMBs and subsequent scrapping of the National Health Reference Price List (NHRPL) by the High Court exacerbated this problem. The establishment of a framework within which funders, as an industry could negotiate and agree on tariff structures with health service providers, will assist in controlling the rising costs associated with PMBs. If medical schemes need to pay for all PMB treatments and medications, it is important for schemes to be able to influence the costs of this by agreeing to an upfront Reference Price List (RPL) with hospital groups and healthcare specialists,” he says.

It has often been said that this situation has been exacerbated due to the pricing of PMBs not being regulated. Some providers are charging as much as 500% or more than the recommended tariffs for PMBs because they know the schemes are legally compelled to cover them. Providers are consequently not willing to contract at lower tariffs and are able to charge such high fees because of a shortage of, and great demand for, their highly specialised skills.

Regulatory model placing all medical schemes on an equal footing needed

Masobe notes that PMBs were intended to form part of a broader risk pooling exercise, which unfortunately never materialised. “As a result, we are now left with only one piece of a broader strategy, leading to escalating costs throughout the healthcare industry to the detriment of medical schemes and their members.”

“What is needed is a regulatory model that places all medical schemes on an equal footing so that schemes can, for example, reward GPs for quality outcomes. This would ensure that care is not compromised and significantly improved. “

“Implementing a patient-centred healthcare system, where schemes’ funds are freed up to cover more preventative care such as regular diagnostic tests and health screenings, would ensure that members require less hospitalisation. Schemes could still provide continuous care to members with fewer PMBs, or at least have the tariffs regulated for PMBs within specified limits,” he says.

A unique and integrated personalised patient management intervention, based on clinical and statistical insights per patient and not per disease, implemented by Agility Health since 2009 for medical schemes contracted to them, has reduced the number of hospital stays for patients living with chronic illnesses by 15.2%. “We found that, overall, hospital events decreased by 15.2% for high-risk patients following the implementation of the Patient Driven Care initiative. The reduction in costs that this represents is, naturally, a very welcome development for these patients and their medical schemes,” concludes Masobe.

Cost containment and quality healthcare need not be mutually exclusive

Health costs have climbed considerably over the past decade and yet, while healthcare cover remains a grudge purchase for many, talk of cost containment measures can make some consumers question whether this comes at the expense of quality.

Those of us who pay monthly medical scheme contributions to access private healthcare have vested interest in ensuring that healthcare funds are prudently managed to ensure that our needs are covered while promoting principles that optimise the quality of these services.

The risk management and managed care approach of each medical scheme is a reflection of this and informed healthcare consumers will vote with their feet and their wallets when evaluating whether their chosen scheme is adequately balancing this delicate equation.

South African healthcare system in transition

The South African healthcare system is in transition as we move towards the implementation of National Health Insurance (NHI). It is perhaps only natural that those who have been accustomed to private healthcare are concerned that concessions may have to be made on quality as the systems serving the ‘haves’ and ‘have-nots’ move closer to being amalgamated.

While there may be some areas of uncertainty, there is considerable opportunity for securing a brighter healthcare future for all. If we can secure foundations of rational containment of costs now, it will underpin appropriate access to quality healthcare for generations to come. In the evolution of any system of considerable public importance, there must be a little give and take in the short to medium term to establish consensus. This is the time to thrash out the details and consider what we have learned since the dawning of democracy to inform the next paradigm in South African healthcare funding.

Healthcare pricing

One aspect that needs to be urgently addressed is healthcare pricing. The Demarcation Regulations with regard to health insurance products and the proposed introduction of low-cost benefit options are likely to make inroads on healthcare pricing, however, other interventions will also be required to help contain spiralling healthcare costs.

One possible solution could be healthcare pricing ceilings, however, this could be seen as stifling competition between healthcare providers and it could potentially create an environment that is not optimally conducive to the promotion of quality services.

I would instead argue for the establishment of a framework within which healthcare funders can collectively negotiate a tariff structure with healthcare providers. In this way, both the healthcare funders and providers would be in a position to put their cards on the table and together find solutions that protect the integrity of South African healthcare in the interests of the people at the heart of the equation, and which both parties serve: their members and patients.

The triage system

The greatest cost driver in South African healthcare will also need to be addressed to moderate such negotiations, that is the high demand for scarce healthcare resources. There are no two ways about it, the demand for specialised healthcare will need to be urgently moderated if we are to conserve costs and promote quality.

Emergency medicine provides a practical model for ensuring that those in need are treated at the appropriate level of care, and this is the ‘triage system’, which prioritises patient care according to the severity of the condition of the patient. South Africa has a relatively well-developed primary healthcare system, which is equipped to serve the public’s day-to-day health needs as well as an array of preventative healthcare services. The time has come to put this system to optimal use, thereby alleviating some pressure at tertiary healthcare level.

If the power of primary healthcare could drive such a triage system to refer patients to the type of care most suitable to their needs, the more specialised health services would be in a better position to provide quality care where it is needed. A system of care coordination such as this could furthermore assist in closing existing gaps in continuity of patient care, particularly if it is supported with suitable information technology systems. Treating patients earlier will furthermore result in better outcomes and a healthier, more productive population.

A new era of healthcare consumer behaviour

In the run up to NHI, medical schemes have a considerable role to play in ushering in a new era of healthcare consumer behaviour through educating, motivating and encouraging members. Where members feel they are not obtaining true value in terms of access to quality healthcare, they will no doubt push back through exercising consumer choice.

I believe that these forces will help to shape all aspects of our healthcare system for the better through making healthcare funders more receptive to members’ needs, making healthcare providers more mindful of pricing while promoting quality care, and driving a sustainable future for the benefit of all who require healthcare, both now and in the future.

Is SA’s healthcare getting better?

Insight Survey’s latest South African Healthcare Industry Landscape Report 2017 provides a holistic understanding of the healthcare landscape in South Africa based on the latest information and research.

Globally, noncommunicable diseases were responsible for 70% of deaths in 2015, up from 60% in 2000. As illustrated by the graph below, ischaemic heart disease was the leading cause of death accounting for 8.8 million deaths in 2015, followed by stroke (6.2 million deaths) and lower respiratory infections (3.2 million deaths). Communicable (infectious) diseases, on the other hand, were the cause of 12 million deaths worldwide in 2015 (in total), especially in low-income countries. These diseases include lower respiratory tract infections, diarrheal diseases, HIV/AIDS, tuberculosis and malaria.

In South Africa, the number of deaths recorded in 2015 totalled 460,236 (compared to over one million births), indicating a 3% decline in deaths processed between 2015 and 2014. The majority of deaths were due to noncommunicable diseases (55.5% in 2015), an increase from 42.9% in 2005. Interestingly, when compared to the global situation, the graph below shows that the leading cause of natural deaths in South Africa in 2015 was tuberculosis (a communicable disease), accounting for 7.2% of all recorded deaths for that year, followed by diabetes mellitus (accounting for 5.4% of deaths) and cerebrovascular diseases (which accounted for 5.0% of deaths) – both of which are noncommunicable diseases.

In South Africa, the vision for health by 2030, according to the National Development Plan, is to achieve a health system that works for everyone and produces positive health outcomes. To achieve this 2030 vision, certain targets have been set, including progressively improving HIV/TB prevention and cure, reducing maternal and child mortality, and reducing prevalence of noncommunicable chronic diseases by 28%. Furthermore, due to the high prevalence of citizens living with HIV and/or TB in the country (7.05 million HIV/AIDS patients in 2016, for example), the National Strategic Plan (2017-2022) on HIV, STI’s and TB includes more specific objectives and goals.

The National Health Insurance (NHI) initiative was finally gazetted on 30 June 2017 and as per the gazette, the NHI is a health financing system that is designed to pool funds together to provide access to quality and affordable health services to all South Africans based on their health needs irrespective of their socio-economic status. The NHI will be implemented through the creation of a single fund that is publicly financed and publicly administered.

Several options are being considered for raising revenue to fund NHI and this funding will also occur through various sources. A large amount of funding will be generated from general taxes to support the NHI fund. Furthermore, all individuals earning above a set amount will be required by law to contribute directly. Employers will also be required to assist the NHI Fund by ensuring that their workers’ NHI contributions are collected and submitted in a manner similar to UIF contributions and employers will be required to match employees’ NHI contributions as well.

Healthcare consumers will be free to continue their medical scheme membership, but they will not be able to opt out from making contributions to the NHI Fund. Furthermore, Government will also no longer provide tax subsidies for medical scheme contributions.

However, the future success of the NHI will be based on achieving collaborative solutions to multiple issues. For example, in June 2017, there were more than 18,700 Medical Practitioners in the private sector versus only 5,325 Practitioners in the public sector and thus a clear necessity is for the NHI to include private medical practitioners through a win-win solution.

The South African Healthcare Industry Landscape Report 2017 (137 pages) provides a dynamic synthesis of industry research, examining South African Population Demographics, Global and SA Burden of Disease, Medical advancements in major chronic diseases, Healthcare Policy (NDP 2030, Strategic Plan 2017-2022, NHI as per government gazette), Healthcare Practitioner Stats, Hospitals and Clinics, Medical Aids, and the Pharmaceutical Services Sector.

Some key questions the report will help you to answer:

  • What is the burden of disease faced on a global and local scale?
  • Which examples of major chronic diseases are currently prevalent in South Africa, including their characteristics, treatments and medical advancements associated with these diseases?
  • What does the SA Healthcare Policy entail, including the Medium-term Strategic Framework 2014-2019, the National Strategic Plan on HIV, STIs and TB, and National Health Insurance?
  • What are the latest healthcare practitioner, hospital and clinics stats?
  • What are the characteristics of the South African medical aid landscape, including trends and details of medical aid beneficiaries, medical aid schemes, administrators, major company profiles, and benefits paid by medical aids?
  • What are the key characteristics of the South African pharmaceutical services?

Please note that the 137-page PowerPoint report is available for purchase for R25,000 (excluding VAT). Alternatively, individual sections can be purchased for R9,000 (excluding VAT). For additional information simply contact us at

az.oc.yevrusthgisni@ofni

or directly on (021) 045-0202 or (010) 140- 5756.

For a full brochure please go to: http://www.insightsurvey.co.za/south-african-healthcare-industry-report

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Insight Survey is a South African B2B market research company with more than 10 years of heritage, focusing on business-to business (B2B) market research to ensure smarter, more-profitable business decisions are made with reduced investment risk.

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HPCSA warns against global fee agreements

The Health Professions Council of South Africa (HPCSA) has urged healthcare practitioners to consult the council before signing any global fee or other financial or clinical arrangement with medical schemes, because these may violate the HPCSA’s ethical rules.

Since issuing a media statement in April warning against the practice, the council has been engaging with practitioners and different stakeholders since 16 May 2017 through roadshows held in Johannesburg, Durban, Cape Town and Bloemfontein and different meetings held with role players in global fee arrangements.

During the consultative process, the HPCSA has discovered that the alternative re-imbursement models are not limited to global fee arrangements and have advised its members not to enter into these contracts until all aspects relating to the law, ethics, clinical autonomy and funding mechanisms have been properly canvassed with all stakeholders

“While Council continues with a consultative process with the aim of providing a comprehensive guide to practitioners on alternative re-imbursement arrangements or models, practitioners are advised that until further guidance is provided, practitioners who are already involved in any form of alternative re-imbursement arrangements will be given ample and reasonable time to correct or amend any arrangements that are in contravention of the HPCSA’s ethical rules or to terminate such arrangements.

“Practitioners are advised to approach council for advice and guidance on Professionalpractice@hpcsa.co.za. Council commits itself to a turnaround time of 10 working days to respond to any request for guidance on global fees/alternative re-imbursement arrangement,” the HPCSA said in a statement.

Does SA’s private healthcare sector only provide care for 16% of the population?

At a press conference about South Africa’s National Health Insurance, the country’s health minister again said that private healthcare serves only 16% of the population. But his claim is misleading.

South Africa is regarded as an outlier in healthcare spend because it invests “huge amounts of money on few people”, the country’s health minister said at a media conference in June.

Minister Aaron Motsoaledi was announcing the gazetting of South Africa’s National Health Insurance white paper. A slide in his presentation repeated a frequent claim that “the private sector… only provides care to 16% of the population”, with the country’s public sector taking care of the rest.

8.8 million medical aid members in 2015

Motsoaledi’s spokesman, Joe Maila, told Africa Check that “the 16% is the people on medical aid” and that the figure comes from the Council for Medical Schemes.
The 2015/2016 annual report of the Council for Medical Schemes notes that “only 16% of the South African population belong to medical schemes while the rest of the population depends on an overburdened government sector”.

The percentage calculation was based on a medical scheme membership number of 8.8 million in 2015, Dr Elsabé Conradie, the council’s general manager for stakeholder relations, told Africa Check. She said that “for the past few years, the percentage varied between 16% and 17%” of South Africa’s population.
(Note: Statistics South Africa’s 2016 General Household Survey estimated that 17.4% of the population had medical aid.)

‘Many people use combination of both sectors’

But the number of people with medical aid does not equal the number of people using the private healthcare sector.

“It’s not as simple as either public or private as many people use a combination of both sectors depending on their health needs,” Dr Jacqui Miot from the Health Economics and Epidemiology Research Office (HE²RO) at the University of the Witwatersrand told Africa Check.

In 2016, Statistics South Africa estimated that 1,515,000 households with no medical aid normally used the private healthcare sector and 706,000 households where at least one member had medical aid used the public health sector.

In total, 4,679,000 households’ normal place of consultation was the private sector.

“The only way to get an estimate of the normal place of consultation on an individual level would be to make the assumption that all members of the household would act the same way,” Stats SA’s service delivery statistics manager, Niël Roux, told Africa Check.

Under this assumption – that is influenced by the household member’s age, sex and particular illness or injury, of course – an estimated 13,393,357 South Africans (24.3% of the population) normally used private healthcare in 2016.

41.5% saw a private healthcare provider at last visit

Another calculation is from the National Income Dynamics Study, conducted in 2014 by the Southern Africa Labour and Development Research Unit at the University of Cape Town. It surveyed a nationally representative sample of more than 28,000 individuals in 7,300 households.

The study found that 41.5% of the respondents went to see someone in the private healthcare sector at their last visit.

However, two limitations need to be kept in mind, NIDS communications manager Kim Ingle told Africa Check.

First, children younger than 15 weren’t included and only people “who didn’t know when they last consulted someone about their health or said they consulted someone in the last 12 months” were asked who they had last visited, she said.

GPs & retail pharmacy services paid for out-of-pocket most

In a 2010 discussion paper on private sector funding of health services, health economist Di McIntyre proceeded from a calculation based on a nationally representative survey of 4,800 households.

Called the South African Consortium for Benefit Incidence Analysis (SACBIA), it was carried out in 2008 and entailed repeat visits to the households sampled.
This analysis put the share of people without medical scheme coverage who use private providers for outpatient care at 20%. Based on a medical scheme membership of 15% of the population, up to 32% of South Africans were estimated to have used outpatient services in the private sector.

Non-scheme members paying for care in the private sector were “largely restricted to general practitioners and retail pharmacy services but sometimes specialists as well”, McIntyre told Africa Check.

According to the discussion paper, those with medical scheme coverage mostly use private healthcare services.

“However, medical scheme members do sometimes use public hospitals, particularly for inpatient care and often at the most highly specialised hospitals,” McIntyre wrote.

Conclusion: The claim is misleading

South Africa’s health minister, Aaron Motsoaledi, claimed that “the private sector… only provides care to 16% of the population”. This was based on the number of people in South Africa who are on medical aid.

But depending on their health needs, many people use a combination of private and public healthcare services. Shares vary, depending on how the surveys are carried out and the question asked.

For instance, in 2016, an estimated 4.7 million households (28% of the total) reported to Stats SA that they normally go to someone in the private healthcare sector. When people older than 15 were asked in 2014 where their last visit had taken place in the year before, 41.5% indicated the private sector.

While it is true that the majority of South Africans do not benefit from private healthcare, it is misleading to equate medical scheme coverage – or the lack thereof – with the exclusive use of a particular healthcare sector.

This report was researched by Africa Check, a non-partisan fact-checking organisation. View the original piece on their website here.

Are the demarcation regulations unconstitutional?

A consequence of the demarcation regulations coming into force is that up to two million policyholders using insurance products to access healthcare are now uninsured, meaning they have been deprived of their section 27 right to healthcare and their section 25 right to property.

Michael Settas of KaeloXelus and Patrick Bracher of Norton Rose Fulbright argue that the final demarcation regulations show a blatant disregard for the right of ordinary people to access healthcare and are based on the unsubstantiated claim that health insurance products are harmful to the medical schemes industry.

The demarcation regulations, that draw a line between medical insurance products and medical schemes, came into force on 1 April 2017. Existing policies will be eliminated from1 January 2018. Limited “gap cover” and “hospital cash plans” are allowed, but primary healthcare insurance policies are banned, says a statement by the Free Market Foundation (FMF)

“Drip by toxic drip, government is destroying the private healthcare sector to prepare the ground for the full introduction of National Health Insurance (NHI). With the demarcation regulations, government is making a concerted effort to attack the medical insurance sector by marginalising the funding vehicles as a means of removing lower income earners’ access to insurance,” it says.

Health products amount to property

“Accident and health products amount to ‘property’ under section 25 of the Constitution, making these regulations potentially unconstitutional. No-one should be deprived of property except in terms of the law of general application – not by a law targeted at some medical insurance policyholders. And no one should be deprived of property arbitrarily without compensation – there is no recourse for anyone who has paid a short-term premium for the last 15 years and is now deprived of their existing cover,” says Bracher,

The FMF maintains that the demarcation regulations are government interference in mutually-agreed private contracts between freely-consenting adults and insurers to minimise their risks of huge medical bills when catastrophe strikes. “Despite clear evidence that South Africa cannot afford NHI and that government infrastructure, sufficient numbers of medical practitioners, and the ability to effectively manage NHI are badly lacking, health minister Aaron Motsoaledi is pressing ahead in the face of opposition. Treasury struggled to raise R28bn in this year’s budget, so the estimated price tag for the NHI of R369bn (in 2017 prices) is pure fantasy. Yet, the private sector continues to be marginalised.”

Low-cost medical scheme benefit options

The Department of Health has requested that the Council for Medical Schemes (CMS) grant a limited two-year exemption period for primary healthcare providers who submit themselves to regulation under the Medical Schemes Act before existing primary healthcare insurance policies are banned so that the department can conduct further research into the development of low-cost medical scheme benefit options (LCBOs). However, the proposals contained in the NHI policy paper restrict medical schemes to merely providing “complementary cover” and each medical scheme will be permitted to provide only one benefit option. This raises serious doubt as to whether an LCBO will ever be developed and contradicts the government’s stated objective of removing the so-called “two-tiered” healthcare system.

If actuaries are allowed to develop policies that are economically sound, however, it will not only increase access to quality healthcare for low-income individuals but also relieve a large burden on the state so that it can concentrate scarce taxpayer resources on the truly destitute.

Settas poses fundamental questions for the architects of NHI, including why is the right to private healthcare being abolished and why is NHI being driven through without waiting for the outcomes of the Competition Commission’s healthcare market inquiry?

For Settas, NHI does not only face a formidable challenge in funding, but there is a severe shortage of healthcare providers, a massive disease burden, and a blundering healthcare bureaucracy. By extrapolating the existing, very poor dentist-to-patient ratios in the state sector, a dentist will have capacity to see the same patient only once every 16 years.

“Government should not attempt to provide free cover for all citizens but should focus on those who cannot afford medical insurance and leave those who can afford it, to pay for their own healthcare arrangements,” he says.