Medical Aids

MediFin announces its Top Loyalty Doctors for 2017

Dental-Ladies named the winner for Top Affiliate Award. They sent us the most traffic from their website during the calendar year.

Centurion Clinic named the winner for Top Merchant Award. They sent us the most client loan applications for the prescribed period.

Dr Charl Marais earned Top Service Award, for being the partner that received the best Nett Promoter Score as rated by their patients, for the same period.

Since inception in 2012, MediFin has financed hundreds of patients throughout South Africa using an online application process, allowing patients to apply from the palm of their hands and keeping the entire process completely confidential. Many patients need to have medical procedures done that fall outside the medical aid scope. This often results in delays on urgent procedures or the neglecting of one’s personal health due to the lack of savings – this is where MediFin assists. We offer finance for expensive procedures making important life decisions affordable, says CEO Tiaan De Jager.

Client offering:

MediFin’s goal is to provide people with the opportunity and financial solution to “Be the best version of themselves” where they may not be in a position to afford the large upfront capital investment of medical procedures. MediFin Financial Services was designed to offer clients a finance option with great flexibility, which includes payment to the doctor directly, a zero deposit, no early settlement penalties, and repayment structures of up to 48 months. Their innovative solution provides clients with an alternative to rising medical insurance tariffs and depleted savings plans and is one of the only options available for elective medical procedures.

This is done through the following means:

Business partner offering:
MediFin has over 400 Medical partners in its network, ranging from dental practitioners, to radiology and fertility specialists, to cosmetic surgeons – just to name a few categories. These medical practitioners have recognised the benefit of partnering with MediFin due to its unique value propositions:

  • We pay the practitioner 100% of the procedure cost upfront, improving their cashflow.
  • Higher conversion rates – financing patients who would otherwise have declined quotations due to no affordability.
  • Improved customer service by not having to turn clients away.

Looking to the future:
In 2017 MediFin increased their financial services offering to include various insurance products. In an
attempt to offer a more turnkey solution to their patients, it was a natural way to offer insurance against procedures that carried slightly more risk than others. They now offer travel insurance, GAP cover and emergency medical insurance which can be bought online in under five minutes – refer https://insurance.medifin.co.za/medifin.

In an effort to further extend their reach, MediFin is looking to partner with great businesses that are pioneers in the medical arena. This is evidenced by their most recent partnerships with Iyeza Health, Ear Institute, Cape Fertility Clinic and MediConnect. MediFin’s online presence and business model continues to prosper as they partner with likeminded companies that share a common vision of putting the patient first.

If you feel that you could benefit from MediFin’s services, kindly contact them on

az.oc.nifidem@ofni

or call their friendly staff on 0861 000 808.

Medical aid waiting periods and late-joiner penalties: What. How. Why?

The world of medical schemes in South Africa is a very different one to 25 years ago. There are strict rules and regulations governing the industry, there to protect both the members and the financial sustainability of the scheme. Now is the time of year when medical schemes announce their annual increases and benefit changes. It means people re-evaluate their existing medical cover and opt for new schemes, new plans or join a medical aid for the first time. Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund, discusses some of the important membership rules and regulations.

What are waiting periods?
According to the Medical Schemes Act, medical aid schemes are entitled to impose a three month general waiting period. This protects other members of the Fund by ensuring that individuals aren’t able to make large claims shortly after joining and then cancelling their membership.

Unlike other financial products, medical schemes are not-for-profit entities that are regulated to ensure they fulfil a social solidarity role, ie everyone benefits from the dependence individuals have on each other.

There are two types of waiting periods:
General waiting period (up to three months). A beneficiary is not entitled to any benefits, in some instances not even Prescribed Minimum Benefits (PMBs) during this period. If a beneficiary submits claims during a general waiting period, they will not be paid.

Condition-specific waiting period (up to 12 months). A condition-specific waiting period can last up to 12 months. During this time a beneficiary is not entitled to any benefits for a particular condition for which medical advice, diagnosis, care or treatment was recommended or received.

When do waiting periods apply?
Waiting periods generally apply if: You or your dependants were not on a medical aid for a period of at least 90 days before you joined Bonitas; you have never been a member of a medical aid or you chose to move from another medical aid to Bonitas.

When are they waivered?

  • To children born during membership, as long as they are registered within 30 days of birth
  • If application is made to register a foster or adopted child dependant within three months of the date on which fostership or adoption was granted
  • If application is made to register a spouse within three months of marriage
  • To a main member who has to join Bonitas due to a change in employment
  • If your employer moves to another medical aid and the change is made within a 90-day period
  • Active members on a medical scheme who have a break in membership of less than 90 days and a previous membership of less than 24 months

Do you pay premiums during this period?
You continue to pay your full premium during the waiting period.

Are PMBs covered during the waiting period?
A PMB is a common, life-threatening chronic condition for which cost-effective treatment would sustain and improve the quality of the member’s life. There are 27 PMB conditions and by law, the medical scheme has to cover the diagnosis, treatment and management of these. This can be confusing when waiting periods are imposed.

Van Emmenis explains, ‘Pre-existing conditions are not simple. There are a series of questions which are asked and factors taken into account when determining when to implement waiting periods. Underwriting is very much based on individual needs. If a potential member is concerned they can request pre-underwriting from Bonitas and engage on a one-on-one basis.’

What is a late-joiner penalty?
In South Africa, medical aid schemes can impose late-joiner penalties on individuals who join a medical aid scheme after the age of 35; those who have never been medical aid members, or those who have not belonged to a medical aid scheme for a specified period of time since April 2001. The reasoning for this is to ensure fairness (whereby members who have been part of a scheme for years are not subsidising newer members who have contributed to the scheme). In addition, it also ensures that medical schemes cannot deny members who wish to join.

These late-joiner penalties depend on age as well as the number of years the applicant was a member of a medical scheme or the number of years they had no cover at all. If you are over 35 and haven’t been on a medical aid then – depending on your age – you will be penalised and charged a surcharge between a 25% and up to 75% loading of your premium. It is outlined by CMS but at the discretion of the Scheme.

Does the loading reduce over time?
No unfortunately not, once you are paying a loaded premium, it remains in place.

Upgrading from a hospital plan
If someone has been on a hospital plan but decides to move to a medical aid and is over the age of 35, a loading will still apply.

Age and infirmity
Late-joiner penalties have been put in place to compensate for potentially increased claims by people who join a medical aid scheme when they’re already older or infirm and can range from 25% of contributions to 75%. These penalties are imposed at the discretion of the medical scheme and apply to all types of medical aid plans, including hospital plans.

Can you move directly from a hospital insurance to medical aid?
Even though hospital plans are now governed by the Medical Schemes Act and not as previously by the Financial Services Board, late-joiner penalties will now apply if you move from a hospital insurance to any form of medical aid (including a hospital plan).

Can a medical aim scheme ever refuse membership to the scheme?
Before 1998 medical aid schemes could refuse membership but this is no longer allowed, although they can now impose waiting periods and late-joiner penalties.

And for immigrants to South Africa?
If you belonged to a private medical aid abroad, the CMS and the scheme will evaluate each individual case, taking into account all the relevant circumstances and any pre-existing conditions.

Can you change your membership any time during the year, is there a penalty for doing this and/or a waiting period?
Yes you can change at any time (but usually this happens during open period with new contracts coming into place from the beginning of a new year). Waiting periods are not usually imposed unless for pre-existing conditions however, the savings allocated to a plan may be. Savings are allocated in advance for 12 months so, if you leave during the year and have used more than the appropriate portion of savings, you will have to pay this back.

What if you change from one Scheme to another?
A three-month waiting period will more than likely apply as well as limited PMB cover and a late-joiner penalties.

Expulsion from medical aid schemes
Van Emmenis says you can only be expelled from your medical aid scheme if you are found to have attempted to or defrauded the scheme. ‘You cannot be expelled on the basis that you have a high claim ratio, the Scheme cannot increase your premiums even if you are costing them a lot of money,’ he says. ‘However, non-disclosure or misrepresentation could result in your membership being cancelled and you being excluded from the scheme indefinitely.’

Van Emmenis says, ‘We encourage members to submit all their bills even if they might not be paid as it allows for a full record of medical expenses and you can assess your medical aid needs going forward.’

In conclusion, Van Emmenis says that he’d encourage people to compare policies across schemes before making a final decision about their medical aid future. ‘Our health is important and it makes sense to do some homework to see what is being offered, whether the plan provides the benefits you and your family needs, what will be paid from risk and the savings allocation and then weigh this up against the monthly premium.’

For more information on the options available from Bonitas you can go to www.bonitas.co.za.

Medical tax credits to go?

There has been talk for some time now about the National Health Insurance (NHI) and how it will be funded. In his Budget Speech in February 2017, former finance minister, Pravin Gordhan, alluded to an adjustment to medical tax credits to partly fund the system.

“The rationale behind replacing the tax deduction system with the credits/rebates was to address the inequality that the deduction system gave rise to,” says Somaya Khaki, South African Institute of Chartered Accountants (Saica) project director: tax. “In terms of the deduction system, higher income earners enjoyed a greater benefit through the effect of the progressive marginal income tax rates. With the more recently introduced medical credit system, lower income taxpayers now gain with the effect of reducing their overall tax liability with the medical tax credit, whilst higher income earners benefit less in comparison to the former regime, given that the rebate is a fixed amount regardless of earnings level.”

Medical tax credits reallocated

This was followed by the NHI White Paper in June this year, which proposes that the medical tax credits be ‘reallocated’ to fund the NHI to ensure an inclusive health system for all South Africans – that is, the credits currently enabling lower income earners access to private healthcare is likely to be scrapped. Whilst we hope to move to a society where all citizens have access to quality healthcare, one has to ask, how much revenue are we talking about and how much will it contribute towards the cost of NHI which will apparently only fully be implemented by 2025? Furthermore, what are the risks with increasing the tax liability on an already overburdened relatively small community of taxpayers?”

According to the 2017 Budget Review document released by National Treasury in February, the medical tax credits for the 2014/15 year amounted to approximately R18.5bn, approximately 7% of the R256bn estimated NHI cost in respect of the 2025 year (in 2010 pricing). According to Elize Rich from Econex, when adjusted to 2017 prices, the estimated NHI cost for 2025 is more in the region of R369bn. Considering these numbers, scrapping the medical tax credits will not make much of a dent in recovering such costs in the long term. These plans also appear contradictory to the state’s intent when it introduced the medical tax credits – namely to allow lower income earners access to high quality healthcare which the public healthcare system is not ready to provide and may not be ready for years to come.

Taxpayer morale

“One also needs to consider taxpayer morale and attitude to yet again increasing the tax burden on individual taxpayers, by taking away the benefit of the medical tax credit and possibly increasing other taxes to fund the NHI – such increases which are not considered in this article,” says Khaki. “If one has to consider that unlawful and wasteful expenditure in 2016 was, at R48bn, almost three times the amount expended on medical tax credits in 2014/15, according to the auditor general’s report, the question must be asked as to whether government is really acting responsibly and in the best interests of the citizens.

Addressing the unlawful and wasteful expenditure challenge would realise far more revenue than scrapping the medical tax credits and will go a long way to improving taxpayer morale and therefore taxpayer compliance and willingness to pay if there is a view that the monies are used responsibly.

This is supported by research performed by the Organisation for Economic Cooperation and Development as well as that presented at the recent International Symposium on Tax and Corruption hosted by the Saica, wherein it was identified that factors that influence tax morale amongst citizens especially in developing countries include: satisfaction with public services and expenditures; trust in government; and perceptions of corruption.

Tax increases unsustainable

Given the numerous service delivery protests, current media focus on corruption and the lack of trust that citizens have in general with respect to governance in South Africa – whilst taxpayers should always act ethically, the levels of unhappiness with the current state of affairs definitely raises the question: how much more tax will taxpayers be willing to pay before there is a revolt and will it be worthwhile to risk this for the additional R18bn a year?

The ongoing increase in taxes is clearly unsustainable and we anxiously await the medium-term budget policy statement where we will hopefully hear more on governments proposals for growing the economy, addressing the high unemployment rate, dealing with corruption and unlawful expenditure within state entities and increasing the tax base without overburdening the already overburdened taxpayers, all of which will go towards creating a more sustainable economy and sustainable funding,” concludes Khaki.

SA needs to rethink its healthcare model

It is into these limitations around healthcare budgets and resources that the value-based care model (VBC) steps, providing an alternative stance on medical care, the patient and costs.

No efficiencies of care

“The concept of fee-for-a-service is dead. Any provider delivering healthcare that charges for every step they take is rewarded financially, not by outcome. With value-based care and alternative reimbursement models, it is the outcome that is rewarded not the work done. It eliminates challenges around existing models where the more a practitioner does, the more they are paid, so there is no incentive to have efficiencies of care,” says Dr Jacques Snyman, CEO of Medical Specialist Holdings (MSH).

A good example of how this translates into reality would be to look at how a person services their car. There is an oil leak, the car is taken to the garage and the leak is repaired. The owner doesn’t pay until the issue has been resolved and the car fixed. The existing healthcare landscape works in the opposite direction – a patient sees a doctor about a bladder problem and has an operation, the doctor says that there may be the side effect of a leak afterwards and then charges again to fix the leak. Every time something breaks along the journey of this bladder operation, the patient has to pay for further repairs. With the alternative reimbursement model, this type of healthcare is turned on its head. The patient only pays the doctor when they are healed.

“The value equation in value-based care is defined by patient outcomes divided by the cost of delivery. If you don’t increase the cost of your treatment, but you improve patient outcomes, the value goes up. Conversely if you don’t improve patient outcomes, but the cost goes up, then the value comes down. It’s a simple formula, but implementing and measuring it is not as simple as it sounds as you can’t consider the clinical outcome,” explains Murray Izzett, MSH.

The goal of the alternative reimbursement and VBC model is to improve outcomes, but there are challenges around how existing models work and the ever-present need to satisfy the bottom line. In the pharmaceutical industry, new drugs place a high premium on the improvement of outcomes which pushes the cost up dramatically. In the oncology space, this challenge is particularly prevalent.

“There is a huge emotional interest in society to help people with cancer – it is a high-profile disease and there is a high willingness to pay. The pharmaceutical industry is a commercial entity so they are looking for a slight improvement in outcome for which they can charge a significant premium. The value equation around illnesses such as cancer introduces numerous elements that have to be assessed,” Izzett says.

Evidence-based medicine

To implement a quantifiable, reliable and sustainable VBC solution, every aspect of the healthcare industry must be taken into consideration. From the doctor, to the pharmaceutical industry to the patients. Measurement of outcomes and patient satisfaction is complex and objectivity hard to achieve, and the utilisation of these measurements must be assessed against cost and achievability.

“Currently we have a programme where we can show how evidence-based medicine can reduce costs for medical schemes. We work in concert with the medical schemes to develop a consistent methodology to showcase how we can reduce costs while ensuring patients achieve value-based care. Currently we have 18 quality assurance metrics which we will be expanding on in the future, using them to highlight that cost savings are not coming at the expense of appropriate care. The savings percentages are modest, but in light of existing inflationary increases, these are enough to make a significant impact,” he says.

‘Bogus’ online doctor to be probed

The Government Employee Medical Scheme has launched an investigation into claims it allowed staff at public relations firm Martina Nicholson Associates to give medical advice on its online column titled Dr Joe.

Dr Joe was an online service for members of the GEMS medical aid scheme who wanted to discuss health concerns with a doctor.

On September 26 The Times ran an article quoting former employees of Martina Nicholson Associates, who claimed that, with the help of Google, they answered questions sent to Dr Joe without a doctor’s advice. The column is no longer available on the GEMS website.

This week GEMS sent a response saying it was investigating the veracity of the claims.

GEMS principal officer Gunvant Goolab said: “GEMS is very concerned about this allegation and we have instituted an investigation and will respond as soon as the investigation has been concluded.

“GEMS takes the healthcare needs of our members seriously and will act without fear or favour against any conduct that places the scheme and industry in disrepute.”

Source: The Times

SOURCE

Dodgy ‘Dr Joe’ removed from Gems website amid HPCSA probe

The ‘House call with Dr Joe’ column on the Gems website has been taken down just days after TimesLIVE ran a story about how PR staffers from Martina Nicholson Associates were allegedly the ones offering medical health advice and not a qualified doctor as perceived.

“Apologies for the inconvenience, this page is currently under review,” was the message displayed on the page where dozens of questions and answers relating to a vast number of health issues from cancer, fertility and medication had been listed prior to the TimesLIVE story.

Health Professions Council of SA spokesperson Priscilla Sekhonyana said they were investigating the allegations about the column.

“The HPCSA is currently investigating the matter and once it has been finalised I will inform you accordingly,” she said.

The Government Employee Medical Scheme (Gems) had insisted that the answers had all been supplied by qualified medical practitioners.

Company owner, Martina Nicholson, had last week forwarded a response from Gems chief healthcare officer, Vuyo Gqola, who said: “All content is approved by medical doctors, both prior to being sent on to the member by Gems and also prior to being placed on the website by Gems.”

Nicholson herself had dismissed TimesLIVE claims that she used lay people to offer medical advice to Gems members, stating that the scathing allegations were made by a disgruntled former employee.

She later said her staffers only wrote the top and bottom of the answers.

“The work we do here at MNA is actually only a very small part of an extensive process,” she said.

Several doctors approached by TimesLIVE pointed out mistakes in numerous answers including one about the cancer risk associated with asymmetric breasts.

A pharmacist said some of the answers were also problematic because they suggested treatments.

Diagnosing and treating people over the internet without a full examination and medical history is illegal.

Bonitas announces annual increase and changes for 2018

Bonitas Medical Fund (Bonitas) has announced its lowest increase in six years. After a challenging year for the healthcare industry, the contribution increase for 2018 will be a weighted increase of 8.7%, with increases on the various options range from 7.9% to 9.9%.

Despite increasing healthcare inflation and economic pressures in the past year, robust cost-containment initiatives have enabled Bonitas to keep the weighted average contribution in single figures for 2018. The increase is the lowest seen from the fund in recent years – clearly signalling its good financial health. Last year, speculation was rife, following Bonitas’ amalgamation with LMS Medical Fund. However, the impact of this has been negligible.

Money saved through innovative strategic measures allowed Bonitas to emerge in a stronger financial position despite industry challenges. This resulted in a reduction in the overall net deficit experienced by the Fund, reducing it from R205.5m in 2015, to R16.9m in 2016.

“As one of the largest and most stable medical schemes in South Africa, our mission is to make quality healthcare more affordable and more accessible,” says Gerhard Van Emmenis, Principal Officer. “We have, therefore, focused on balancing costs while ensuring our members continue to receive rich benefits.”

It’s been a difficult few years for the healthcare industry, with medical schemes facing several challenges including economic pressures and escalating healthcare costs. In addition, medical schemes have to comply with the strict parameters of the Medical Schemes Act.

In spite of this, the Fund recently announced that its reserves have been bolstered to R3.1bn and it has also seen a significant growth in membership.

“Last year, we successfully concluded the largest amalgamation in the industry with LMS Medical Fund. This will continue to have a favourable impact on our membership as a whole, as a larger scheme is in a better position to negotiate tariffs in favour of our members,” says Van Emmenis.

The relatively low increase has not led to a reduction of benefits but rather an enhancement. “We’ve looked at the needs of our members and South Africa as a whole to introduce several new benefits in 2018. This includes a benefit for contraceptives and a mental wellness programme, among others.

“Increases are unfortunately inevitable given the high healthcare costs and inflation but we strive to keep premiums as affordable and accessible for all. Some of the benefits have been tweaked, others increased but all aimed at helping members take control of their health and lead better lifestyles and with South African socioeconomic factors in mind,” concluded Van Emmenis.

Mental health

In times of economic uncertainty and political instability, healthcare costs and claims tend to increase – particularly with regard to anxiety and depression. Recent studies show that over 17 million people in South Africa are dealing with anxiety disorders such as panic disorder, post-traumatic stress disorder and mood disorders. In addition, statistics from a global study presented at a recent mental health summit in Johannesburg revealed that mental disorders have increased by 22.7%. In South Africa, 30% of people report life-long psychiatric disorders, while one in three will be affected by a mental illness in their lifetime.

A mental wellness programme has been developed and available in 2018 to identified beneficiaries on four plans. It provides access to specialised mental health doctors as well as education on managing the condition and support for loved ones too.

More benefits for families

Earlier this year Babyline was introduced, the first dedicated toddler’s health advice line to its members. In 2018, further benefits will be made available for Bonitas babies, including screening for congenital hypothyroidism for newborns under a month old across on all options. Screening all newborns for hearing loss is internationally recommended and these tests will also be covered on all options (in or out-of-hospital).

A focus on wellness and preventative care

Benefits that help encourage positive lifestyle changes and focus on preventing serious conditions are one of the key elements to reducing chronic disease prevalence. The Wellness Extender benefit has been increased by 15% to give members access to more consultations with a GP, dietician or biokineticist or cover for a programme to stop smoking. Pap smears for women over 21 years will now be covered on BonEssential and BonCap, once every three years and mammograms for women over 40, will be covered once every two years on BonSave and Primary to strengthen the preventive care benefits on offer.

PMBs – making benefits last longer

In previous years, out-of-hospital tests and specialist consultations for the management of Prescribed Minimum Benefit conditions (PMBs) were paid for from day-to-day benefits first on Standard, Standard Select and Primary. In 2018, cover for PMBs will be paid for solely from risk – allowing members to get maximum value for money and stretch their day-to-day benefits.

Optimised online systems and services

A new website features information on benefits and plans to help current members understand more about what their plan offers while potential members can select and choose a plan to meet their specific needs. A facility allows you to compare up to three plans on a like-for-like basis.

Further cost-containment initiatives

  1. Negotiating rates with healthcare providers and hospital groups to encourage members to use preferred providers to extend their benefits, limit co-payments and ensure they receive quality healthcare. Hospital admissions account for half of Bonitas’s annual claims costs, around R6bn. Through renegotiated rates Bonitas saw healthcare savings of R32m, negotiations remain key to managing costs.
  2. Increasing focus on prevention and utilisation of managed care protocols in disease management and co-ordination of care and wellness through the Managed Care programme.
  3. Early detection and proactively managing the diseases are key components of this. This included using the Emerging Risk Model, an innovative tool to identify emerging risk members before they develop high risk conditions. Bonitas’s back and neck, oncology, hip and knee and HIV/AIDS programmes respectively, continue to offer members emotional, clinical and financial support. These initiatives have also worked from a cost-containment perspective – leading to savings of over R100m in 2016 alone.
  4. Fraud, waste and abuse in the healthcare industry are one of the main drivers of healthcare inflation and the increase in claims costs. The private healthcare funding industry spends over R150bn on private healthcare annually. A staggering 10-15% of these claims contained elements of fraudulent information – adding an estimated R22bn to the annual cost of private healthcare in South Africa.
    To curb the impact Bonitas introduced advanced analytical software into the live claims environment last year. Using this, software the Fund was able to identify over R79m in irregular claims in 2017 for medical practitioners alone. Money which could have been used to pay for around 57,000 more GP consultations or 18 lung or liver transplants. The model is now being extended to include all pharmacy and hospital claims.
  5. An increased prevalence of chronic conditions and diabetes in particular, is one of the key contributors to a rising disease burden. After reviewing the programme Bonitas developed the Diabetes Management Programme, in conjunction with the clinical team at Medscheme, to address diabetes as well as the specific comorbidities that it brings. This will allow for more holistic treatment and management of the condition which is tailored to a member’s specific needs.

Summary of changes for the year

  • A weighted increase of 8.7% will apply to 2018
  • A separate benefit for contraceptives will be added to all options
  • Newborn hearing screening tests will be covered on all options (in or out of hospital)
  • TSH test covered on all options for newborns
  • Pap smears for women over 21 years will be extended to BonEssential and BonCap
  • Mammogram screenings for women over 40, will be extended to BonSave and Primary
  • Bone Density Screenings available on BonClassic and BonComprehensive will now be available to men aged 70 and over
  • Children under 18 will no longer be required to complete the Health Risk Assessment to access the Wellness Extender.
  • The family limit for the Wellness Extender will increase by 15% in 2018.
  • Out-of-hospital tests and specialist consultations for PMBs paid from risk on Standard, Standard Select and Primary
  • A generous dentistry benefit package paid from risk to be added to BonFit
  • Unlimited terminal healthcare benefit introduced on all options
  • The corneal graft limit BonComprehensive, BonClassic, Standard, Standard Select, BonComplete and BonSave will increase from R22,000 to R30,000.
  • In addition, the sublimit for specialised drugs for retinal disorders will increase from R42,000 to R50,000 on BonComprehensive, BonClassic and Hospital Plus.
  • An internal prosthesis benefit of R30,000 per family (excluding joint replacement prosthesis) will be introduced to BonSave and Primary
  • Introduction of the Bonitas Mental Health Programme

For more information on the range of medical plans available from Bonitas, or to compare options, go to www.bonitas.co.za.

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.