Current medical aid models for end-of-life care will pay for costly in-hospital care but won’t pay for home-based care. But an all women fintech startup is offering an affordable and compassionate healthcare alternatives to SA’s medical schemes.
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Alignd is the brainchild of Dr Linda Holding, a palliative-trained doctor with 20 years of clinical risk management experience; Victoria Barr, a healthcare economist and senior director at FTI Consulting; and Shivani Ranchod, a healthcare actuary and academic. Its main intention is to provide alternative, more patient-centred and value-led healthcare models.
Metastaticised cancer in South Africa absorbs a disproportionately high percentage of funding from medical aids. The most recent estimates indicate that 8% of scheme expenditure is in the last year of life – a staggering R11.6bn in 2017 alone. The current focus of end-of-life care for these patients is on curative care and mostly in a hospital setting making it hugely expensive and geared to manage the patient’s medical costs in the final stages of their life.
“In current medical scheme approaches, healthcare costs in the last year of life are more than three times higher than in the second last year. This ramping up of cost represents the huge efforts to stave off death, efforts that are often invasive and non-beneficial,” says Ranchod.
“Using a combination of innovation, data analytics and a desire to bring the patient’s life to the fore, we believe we have a model that benefits all stakeholders and incentivises them to collaborate for the greater comfort of the patient and their wellbeing,” she says.
“Atul Gawande’s book, Being Mortal, talks about hospital-centric and aggressive treatment options at the end of life as a symptom of modern medical philosophy,” Ranchod says.
“There is little financial incentive or pressure for doctors to consider alternatives. A key moment in Gawande’s book is a discussion of a study where patients with complex and high-risk diagnoses had a consultation with a palliative specialist. The results were astounding – patients made dramatically different choices, costs came down and both the patient and their families reported higher levels of satisfaction,” she says.
The Alignd model brings to the healthcare system a carefully-constructed set of basic operating principles: a multi-disciplinary team naturally means that collaboration between role players lies at the heart of the business. It is also one that will be less costly to medical schemes.
Healthcare sector stakeholders have long advocated for a single regulator, believing that the current dual framework creates a regulatory arbitrage not conducive to offering the consumer maximum protection.
Butsi Tladi, MD of Alexander Forbes Health
Just as the public and private healthcare sectors need to work together for South Africa to achieve universal healthcare, the same applies to government departments and regulators. “A silo approach to these complex issues will only serve to detract the process and delay progress. The dual regulation of participants in the medical scheme industry is not ideal, and in some areas creates conflict,” says Butsi Tladi, managing director of Alexander Forbes Health.
The Conduct of Financial Institutions Bill (Cofi) Bill, aimed at regulating how the financial services industry treats its customers, was published by the minister of finance in December for public comments until Monday April 1. The Bill advocates removing core regulatory functions from the Council for Medical Schemes (CMS) and placing them with the Financial Services Conduct Authority (FSCA).
A form of insurance
Tladi says medical schemes are a form of insurance, “… even the CMS acknowledges this in their submission on the Cofi Bill. Greater alignment is in the interest of the industry. Because of the varied nature of insurance products, including health insurance products, The FSCA has had to develop a depth of skill to regulate this dynamic industry.
“Had we appreciated this fact, and allowed the best suited government entity to spearhead our National Health Insurance efforts, we would have made far more progress,” she says.
It is also clear to Tladi that the FSCA’s ability to regulate market conduct of financial institutions is more advanced. In fact, CMS already refers compliance relating to conduct to FSCA for consideration.
“Through related legislations such as the Financial Advisory and Intermediary Services (Fais) Act, FSCA has proven that it is far more capable of managing possible conflicts of interest in the provision of independent advice to consumers.
“The Cofi Bill approach is refreshing in that it sets out the specific intention of the law, rather than setting rules for compliance. Compliance with the spirit of the law, rather than narrow technical compliance will be important. If we appreciate the efforts of the Competition Commission’s Inquiry into Private Healthcare, then we must welcome efforts that support and facilitate better competition and innovation. Furthermore, Cofi aims to promote financial inclusion and transformation, particularly that of emerging black-owned financial institutions.”
The Special Investigating Unit (SIU) is awaiting the president’s go-ahead to investigate allegations that Health Professions Council of South Africa (HPSCA) employees may have taken bribes in exchange for medical registrations and board exam passes.
If allegations prove true, it may mean that people who were not qualified to provide medical care were fraudulently given HPCSA registration numbers that could have allowed them to masquerade as healthcare professionals and bill medical aids.
The HPCSA says it has already supplied the SIU with requested information and documentation pertaining to the allegations, according to HPCSA head of communications, Priscilla Sekhonyana. She declined to comment on how many officials were under investigation or whether any had faced disciplinary action.
Although allegations of bribery at the council are a revelation, it is not the first time the HPCSA has been under investigation.
In 2015, Health Minister Aaron Motsoaledi appointed a ministerial task team to look into maladministration, irregularities, mismanagement and poor governance at the council. The team concluded the council was in “in a state of multi-system organisational dysfunction” and that staff reported that some funds were unaccounted for in part because of a dysfunctional accounting system.
A year later, the body fulfilled one of the task team’s recommendations, parting ways with its CEO and a contract with a consultancy firm to help the HPCSA implement a turnaround strategy is expected to end later this year.
The proposed SIU investigation may be the latest signal from the state watchdog that it is getting serious about corruption in the healthcare sector.
In 2018, SIU head advocate Andy Mothibi announced that the body would create a special anti-corruption forum for the health sector, which he says would include civil society. An attorney with the public interest law organisation Section27, Nkululeko Conco, confirmed that the National Health Anti-Corruption Forum has been launched and now includes Section27 as well as the National Prosecuting Authority and the non-profit Corruption Watch. Pando says the forum has already received multiple complaints.
But Conco says it’s not enough that the newly created forum responds to complaints and cautions that we can’t always be reactive. He says once we’ve dealt with corruption, we need to ensure it doesn’t happen again, otherwise, it makes investigations into it meaningless.
Almost half the South African population has access to the internet, including 8-million Twitter users and 16-million Facebook users. This digital revolution has unlocked enormous opportunities for the creation of online communities for large-scale engagement around often complex topics like the management of health conditions.
E-patients are people that use digital resources such as the web, smartphones or other wearables to educate themselves about their condition and navigate the health system to track and manage their health. “In the age of consumerism, many e-patients, in managing their health, exhibit behaviours similar to that of people who research reviews before making online purchases, although the concept of an e-patient goes beyond that,” says Vanessa Carter, a Stanford University Medicine X e-patient scholar
A study conducted by the Office for National Statistics in the UK in 2018 found that 59% of women and 50% of men looked for health-related information online. In the US, 56% of people used websites and 46% used mobile phones to manage their health in 2018, according to Accenture Consulting’s 2018 Consumer Survey on Digital Health.
While there are no comprehensive statistics available for South Africa, Carter says the evolution of online resources and engagement has come a long way to empower patients. “Digital resources in the 21st century are going beyond the web and will include wearables and mobile applications that capture health data.”
Government involvement is key to driving the use of digital technology to improve the health of its citizens. E-health tech like electronic medical records, telemedicine and mobile electronic systems have been successfully used to improve health outcomes and empower populations. South Africa, however, has previously struggled to migrate traditional district health information systems to an electronic storage system that can be accessed by any health facility or practitioner. This has caused it to be ranked poorly in the global e-health maturity index.
Government initiatives to digitise healthcare have been evident in applications like MomConnect, a cell-phone based app that provides online resources to pregnant women. Since its creation, it has gained over 1.7-million users in over 95% of public health facilities to become one of the largest initiatives of its kind globally. NurseConnect is an extension of MomConnect for nurses to receive weekly information on aspects such as maternal health, family planning and new-born health.
Carter says that while these innovations are positive, governments could do more to bridge digital gaps and provide quality resources. “This includes wi-fi services in hospitals and clinics as well as websites for hospitals and clinics, both of which are fundamental resources that could empower patients and save time and money in researching online.”
She adds that a simple function on a hospital website notifying a patient about a medicine stockout for example, might save them an expensive trip to the hospital, long queues as well as reduce some of the heavy burden on overcrowded facilities.
Carter has no doubt that digital technology will be key in ensuring the sustainability of future healthcare provision, and that the e-patient will have a pivotal role to play.
“It is going to be a challenge to develop meaningful e-health systems if patients are not equal participants. Although e-patients are still evolving, especially in emerging countries like ours, they must not be undervalued as, in the future, they will be fundamental to collecting quality data in partnership with their medical professionals. Doctors can’t do this digital health transformation alone,” she adds.
The value of keeping proper written records of explanations, discussions and advice leading to the informed consent to avoid protracted legal proceedings for both doctors and patients was highlighted in the the Supreme Court of Appeal judgement in the case of Beukes v Smith.
What is informed consent?
The introduction to the ethical guidelines published by the Health Professions Council of South Africa succinctly describes informed consent in this statement: “Successful relationships between healthcare practitioners and patients depend upon mutual trust. To establish that trust practitioners must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention, even where a refusal may result in harm to themselves or in their own death. Patients must be given sufficient information in a way that they can understand, to enable them to exercise their right to make informed decisions about their care. This is what is meant by an informed consent.”
Medical treatment cannot be provided in the absence of consent. Our courts have held that, to give proper informed consent, a patient must be informed of all material risks associated with the treatment. What is material? If a reasonable person in the position of the patient, warned of the risk, would attach significance to the risk, it is material. To give proper informed consent, the patient must know, appreciate and, understand the nature and extent of the harm or risk.
The claim in the proverbial nutshell
Dr Smith performed a laparoscopic hernia repair on Mrs Beukes. She sued him for damages alleging that he had negligently failed to provide her with sufficient information so as to enable her to give informed consent for the surgery. Smith’s alleged failure was to inform her that the hernia repair could have been done by way of a laparotomy procedure. His failure caused her to give uninformed consent to the laparoscopy during which her colon was perforated and as a consequence of which she suffered complications and damages.
Beukes lost in the Gauteng Division of the High Court in Pretoria. The appeal was against that judgement.
Consultation, motivation, operation, complication
Against the backdrop of the surgery lay Beukes’ medical risk. She was a high risk patient which meant that because of her health, lifestyle and medical history the risk of her suffering complications related to surgery was high.
Beukes was referred to Smith who consulted with her on 21 February 2012. He admitted her to the hospital as surgery was inevitable if she did not respond to conservative treatment. The issue would then be which surgery to perform.
After having consulted the referring doctor’s report and radiological reports, Smith’s recommendation was that the laparoscopy would be the best option for Beukes in the circumstances.
Smith wrote a detailed motivation for approval for the laparoscopy to Beukes’ medical aid in which the reason for his recommendation for the laparoscopy was stated and the general and specific advantages of the surgery were listed.
The laparoscopy was performed by Smith on 23 February 2012. Beukes was discharged from hospital on 28 February 2012.
Three days post-discharge, Beukes was re-admitted to hospital with various complications associated with a perforation of her colon which included sepsis. She underwent three further surgical procedures and remained in hospital until 19 April 2012.
Trial and tribulation
According to Smith, Beukes gave him informed consent orally on 22 February 2012, after he had consulted with her and explained the nature of each of the two options available, being the contemplated laparoscopic surgery and the laparotomy, and the material benefits and risks associated with both. He had informed her that, in his opinion, the laparoscopy was the better option in the circumstances. He also testified that she had signed a written consent shortly before the operation on 23 February 2012 which formed part of the record and was a confirmation of the oral consent given the previous day following his explanation of both procedures.
Beukes, on the other hand, denied that Smith had explained both procedures to her. She insisted that, in her first consultation with Smith on 21 February 2012, he told her that he would first consult with the radiologists on her scans and thereafter perform a “quick ……. 15 to 20 minute operation” to repair her hernia with a mesh and in “two or three days” she would be home. On her version, Smith made the decision to do the laparoscopic hernia repair during the first consultation on 21 February 2012 before having consulted the radiologists. She also denied having signed the written consent. She testified that had she been informed that the hernia could also have been repaired through a laparotomy, she would have discussed her options with her family and would have opted for the less risky of the two procedures, but she trusted Smith and believed him when he told her that the laparoscopy was a simple procedure that would take 15 to 20 minutes and that she would be discharged from hospital in three days.
The specialist surgeons who gave expert testimony on behalf of Beukes and Smith agreed that Beukes was a high risk patient, that under the circumstances, the laparoscopy was the better option, the procedure had been performed by Smith without negligence, and that Smith’s post-operative management of Beukes was acceptable.
The only issue was whether informed consent had been obtained.
At the heart of Beukes’ contentions was the fact that there was no written record of the details of the informed consent discussion.
It was not disputed that no record had been made of the content of Smith’s explanation to Beukes.
Beukes’ version was that, in the absence of evidence on the detail of her consultation with Smith, the court had to conclude that Smith had not given Beukes the necessary information as he alleged and further, even if he had given her some information, it was not sufficient to enable her to make an informed decision
Smith’s evidence was entirely reliant on his memory of what had transpired over the relevant period. However, as found by the trial court, several aspects supported his version such as his demeanour and diligence which were more consistent with his version that all had been sufficiently explained. Added to this were the medical records which also supported his version as opposed to that tendered by Beukes. Her version was inconsistent with Smith’s undisputed caring and diligent nature. The medical records suggested that there had been a more substantive discussion between her and Dr Smith than she was willing to admit. The written representations made by Smith to Beukes’ medical aid after his consultation with her the morning before the laparoscopy were consistent with his version and revealed that the material risks and benefits of the medical procedures occupied his mind. Nothing in the medical records contradicted Smith’s evidence.
Fortunately for Smith, the Appeal Court found no basis upon which to overturn the factual finding by the trial court that Smith’s version was probable and that of Beukes was not.
The cost of not recording what is said
Unfortunately for Smith, as it would appear from what was stated in the judgement, he was subjected to lengthy cross-examination from which he might have been spared had there been a written record or other record of his explanation, discussion and advice leading to the informed consent. That is aside from the cost of the litigation to Smith and by cost, I don’t just mean legal costs. Litigation is stressful and takes one out of one’s day-to-day professional practice. It comes with a high personal and economic price tag.
Keeping record not only protects the patient which is primary. It also protects the practitioner and may well avoid the risk of becoming embroiled in costly and lengthy ‘he said – she said’ debates.
Image source: Getty/Gallo
The insights were drawn from the Alexander Forbes Health Medical Schemes Sustainability Index which tracks key performance metrics of medical schemes and aims to provide a comparative assessment of future sustainability between schemes. The index is calculated from a base year of 2006 and considers a scheme’s membership size, membership growth, average beneficiary age, operating results, accumulated funds per beneficiary, and trends in the scheme’s solvency levels.
“In the open schemes industry, the sustainability index for the top 10 schemes has improved since 2006, meaning that the medical schemes industry has become stronger,” says Zaid Saeed, senior actuarial specialist at Alexander Forbes Health.
Among restricted schemes, Polmed has been the top performer in the index over the 10-year period considered, although it was not the top performer for 2017. The scheme achieved an operating deficit for 2017 and saw a decline in its level of reserves. Transmed has consistently been one of the worst performers on the index because of its sustained loss of membership, worsening demographic profile, low solvency ratio and persistent operating deficits.
Other key findings include:
- The number of medical schemes reduced to 80 in 2017 driven by amalgamations and liquidations in the industry.
- The growth in principal members slowed to 0.5% from 2016 to 2017, compared to growth of 1% from 2015 to 2016.
- The average age of beneficiaries increased to 33.2 years at the end of 2017 (2016: 32.5 years), with the pensioner ratio rising to 8.4% (2016: 7.9%).
- Family size has consistently declined over the last 17 years. At 31 December 2017 the average family size was 2.21 compared to 2.59 at the end of 2000.
Saeed says affordability of medical aid cover was the reason behind decreasing family sizes. “For those in formal employment private medical cover is usually a condition of service, but in a struggling economy members are removing one or more of their children from cover before cancelling their own membership. Younger members of a household are generally healthier and therefore less in need of medical cover.”
The increasing average age and pensioner ratio of members indicates a worsening risk profile of the industry. “This is one reason why members’ contributions increase in excess of CPI inflation annually, as it requires a medical scheme to adjust its pricing to absorb a higher rate of benefit utilisation by its members.”
Operating results in the industry seem to follow a three-year cyclical pattern. “Due to volatility in claims experience, schemes tend to over- and under-compensate when correcting their pricing, which can cause peaks and troughs in operating results from year to year,” Saeed says.
The industry had been consistently generating operating deficits since 2014 but this trend reversed in 2017. “Overall, the demographic profile and financial strength of the industry remain stable.”
Pop symptoms of a headache into a search engine and it will come back with a myriad of diagnoses, varying from a sinus headache to a tumour. Dr Google has become the source of choice for self-diagnosis, a second opinion or to find out more about a diagnosed condition. While many healthcare practitioners caution very strongly against using the internet as a diagnostic tool, others say it does have its uses
Image source: Getty/Gallo
Unfortunately, self-diagnosing on the internet can sometimes cause more harm than good. Pew Research reports that 80% of internet users in the US search for health-related topics online.
While the stats aren’t similarly available for SA, in 2018 found that close to 60% of South Africans now have access to the internet. It seems we could be using this to self-diagnose. Certainly, South African doctors agree that more and more patients are Google-searching their symptoms before consulting a medical professional, according to Dr Marion Morkel, chief medical officer at Sanlam.
Access to medical information 24/7
Other than for ease of access, Morkel says people consult the internet for a second opinion, because they’re curious about health-related issues, or want clarity on a doctor’s advice. “It’s free, fast and available 24/7.”
She says that there is conflicting data on the ratio of accurate versus inaccurate medical information online. “A 2014 survey looked at 10 medical Wikipedia posts on popular medical topics, and cross-referenced them with evidence-based and peer-reviewed information. It found that nine out of 10 of these Wikipedia posts contained inaccurate medical information.On the other hand, also suggests that medical professionals confirm 41% of internet self-diagnosis.”
The doctor-patient icebreaker
Dr Sindi van Zyl, a medical doctor with a strong Twitter following, agrees that fighting the use of the internet in accessing medical information is a futile effort, “Instead, more medical professionals should embrace it. I find that patients announcing that they have looked up their symptoms online is a great ice-breaker – especially for those first few sessions where they might be a little nervous.
It’s also a great leveller of the patient-doctor dynamic – instead of them relinquishing their power completely, we become collaborative partners in addressing their health issues.”
Van Zyl shares medical information on Twitter in line with the HPCSA’s (Health Professions Council of South Africa) telemedicine guidelines and says that this provides an additional platform to make a real difference. “Due to the information I have shared on Twitter on the topic of prevention-of-mother-to-child transmission of HIV (PMTCT), for example, there is a young child in Nigeria who was born HIV negative, to a mother living with HIV.”
According to HPCSA regulations, medical professionals in South Africa are not allowed to provide diagnosis or prescribe any schedule 4 medication over the internet. Though Morkel says that doctors can often effectively conduct virtual follow-up consultations.
“Depending on the specific programme and aims, chatbots have become so sophisticated that they can function as virtual assistants. They can help simplify medical information and act as interpreters where there are language barriers,” she says.
The rise of cyberchondria
Morkel says there is no doubt that it has increased the incidence of the recently coined variation called cyberchondria. This can be tied to over-diagnosis, increase in psychological disorders (such as anxiety), incorrect diagnosis (as those who frequently look up medical symptoms online can often magnify the severity of their symptoms once presenting to the doctor), and doctor fatigue (doctors can also become hardened and convinced that clients quoting online references are cyberchondriac and have exaggerated symptoms).
Van Zyl argues that cyberchondria is not completely negative. Many people won’t consult a doctor or nurse until the symptoms are really bad. The internet is helping people be more vigilant. We can address hypochondria, but there’s little we can do for patients who present too late.”
The key is to ensure:
- That the medical information comes from a reputable site
- That the information is not outdated or irrelevant geographically
- That a medical professional is consulted as a result– whether a pharmacist for minor symptoms, or a nurse or doctor for persisting and serious symptoms
Morkel warns that people prone to cyberchondria should stop the online searches. “It is best to limit your exposure to stress-inducing medical information online. Rather follow your instinct and common sense. If your symptoms worsen seek professional medical assistance as soon as possible.”
The Gauteng Department of Health (GDOH), in partnership with medical aid schemes and their administrators, has officially signed a Memorandum of Understanding (MoU) on a public-private partnership.
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Through the MoU, medical aid schemes will support the GDOH in various activities associated with the provincial Health, Wellness and Happiness (HWH) campaign.
This initiative is aimed at scaling up efforts to curb rising mental health problems, lifestyle diseases and trauma cases.
“The parties [to the MoU] will advise or share ideas to craft and develop strategies for the Health, Wellness and Happiness campaign and ensure that relevant stakeholders and resources are availed to achieve its objectives,” said Health MEC, Dr Gwen Ramokgopa.
The three-year HWH campaign was launched in November 2018 in an effort to push back the prevailing disease burden ravaging communities.
The partnership was chosen for the parties to consider sharing, engage and co-develop the best management practices to improve the health and wellness of communities in Gauteng and society at large.
Furthermore, parties will share information to develop plans for addressing the health and wellness challenges in the province, as per the legislation pertaining to the Protection of Personal Information Act.
“It’s enshrined in the Constitution of the Republic of South Africa, Chapter 2 – Bill of Rights, section 27: people have the right to have access to healthcare services and section 24 enforces the right to an environment that is not harmful to the health and well-being of all South Africans,” said Ramokgopa.
The medical aid schemes and administrators, who are currently partnering with the department in this initiative, are GEMS, Discovery Health, Medscheme, and the Metropolitan Health Corporation.
“Through the Hospital Association of South Africa (Hasa), the GDOH is in the process of engaging several private hospital groups to partner on various initiatives to address the reduction of surgical backlogs and other areas of priority for the department,” said Ramokgopa.
National Health Insurance (NHI) is critical to creating a quality functioning healthcare system for all South Africans and it is good to see that Finance Minister Tito Mboweni’s Budget Speech covered areas such as increased funding for certain diseases and improved service delivery in the public sector.
Damian McHugh, head of marketing, Momentum health services.
Healthcare in South Africa can only work if the public and private sectors work in partnership – not one at the expense of the other. That is according to Damian McHugh, head of marketing at Momentum’s health solutions.
“By strengthening public health delivery, and with the private sector making sure that it is working towards a healthier South African healthcare sector by looking for opportunities to work with public entities, we can improve and safeguard the health of all South Africans,” says McHugh.
Mboweni unveiled several changes intended to improve the public health system and address funding for initiatives like the NHI.
Flat lining medical tax credits
To fund the NHI specifically, Mboweni announced a flat lining of medical tax credits, which is expected to generate additional revenue of R1bn in 2019/20. Spending on the NHI programme will increase at an average annual rate of 36.6%, from R1.2bn in 2018/19 to R3bn in 2021/22.
McHugh adds that it is further critical that resources are earmarked to help deliver a fully functioning, world-class public healthcare system, both in terms of infrastructure and service delivery. To this end, it is notable that the 2019 budget has allocated funds to combat diseases like malaria. Figures released by the World Health Organisation (WHO) show that the number of malaria deaths reached 435,000 globally in 2017, with the African region accounting for 92% of malaria cases and 93% of malaria deaths, during this period.
“The bad news as far as the consumer is concerned, is that you will not be able to claim more tax back for your medical aid contribution than in 2018, and it is unlikely that the 2020 budget will increase tax credits either. As the situation stands, principal members and the first dependent on a medical scheme continue to enjoy a monthly tax credit of R310, which reduces to R209 for additional dependents,” explains McHugh.
Impact of VAT increase
When VAT was increased last year, while not impacting medical aid contributions directly at the time, it did result in higher treatment costs, which increased claims costs and led to higher-than-inflation contribution increases among most schemes for 2019. Fortunately, this year’s budget didn’t include a further increase in VAT, which should bode well for 2020 medical aid increases.
“While South Africa finds ways to fund public healthcare, private healthcare consumers will increasingly need to use their health and active lifestyle as an asset, making use of innovative products in the market that assist one in making healthcare funding more affordable,” concludes McHugh.
Encouragingly, government is increasing funding for South Africa’s healthcare professionals, having acknowledged the need for more doctors and nurses. Mboweni announced that R2.8bn has been reprioritised for a new human resources grant and R1bn for medial interns. Another R1bn has been added to raise the wages of community health workers, who will earn R3,500 per month.
Fraud, waste and abuse is costing the private healthcare system more than R22bn, and if you submit false claims, you could face more than just being terminated from your scheme, the Council for Medical Schemes warned at its summit on fraud this week.
“We want independent investigations that are turned around quickly and submit and identify findings appropriately,” Mabuza said at the October gathering.
The CMS estimates that fraud, abuse or waste accounts for about 15% of the R160bn in claims that medical aids pay out annually.
The head of the SIU, advocate Andy Mothibi, said the body is working with the National Prosecuting Authority to help ensure that its investigations result in cases that can be prosecuted as it proactively targets healthcare fraudsters.
“Specifically with the SIU, when the investigations are done, there are not effective follow-ups to make sure action is taken. We have put in place measures now [to combat that],” he said.
The SIU is also trying to ensure investigations are followed from the point they start to the day they result in a conviction.
Last year, the public interest law organisation Section27 released the findings of an SIU investigation into corruption at the Gauteng health department. That report was only handed to former President Jacob Zuma’s office seven years after it was commissioned. The organisation says it, as well as the non-profit organisation Corruption Watch, have already joined a National Health Anti-Corruption Forum convened by the SIU.
Mothibi’s remarks come after a high profile win for his unit — a recent investigation led to the arrest of a prominent attorney in Mthatha in the Eastern Cape that relates to fraudulent medico-legal claims estimated to be over R100m, the government news agency SAnews reported on Monday.
But, the SIU isn’t in it alone
Some medical scheme administrators and funders have their own ways of uncovering irregularities. The Board of Healthcare Funders of Southern Africa now oversees the Healthcare Forensic Management Unit that allows medical aids to track suspicious activity by using healthcare professionals’ individual medical practice numbers.
Discovery Health uses a case management system that gives them insights into their members’ claim trends. Based on these trends, Discovery is able to pick up on suspicious activity. Their system has led to R2bn in direct savings; since 2013, it has helped the scheme to recover more than R5bn.
“It’s not only about money,” Marius Smith, head of Discovery Health’s forensics, explains. “It’s about the quality of care. The health of patients is jeopardised by fraud, waste and abuse. We shouldn’t lose sight of that.”
So, who’s behind all of this fraud?
“It’s not [just] a doctor issue,” Smith says. “Discovery has seen an equal spread of fraud, waste and abuse between healthcare professionals, medical aid members and hospital groups.”
But is it all illegal? Not always
Paul Midlane, general manager of Medischeme’s healthcare forensics, says sometimes perpetrators are technically not doing anything illegal — but it doesn’t make their actions ethical or less costly.
Catching out the bad guys is going to take teamwork and larger pools of data would need to be combined to detect trends sooner, says Lynette Swanepoel who works for the commercial firm, Southern African Fraud Prevention Service.
What does weeding out fraud mean for the average person?
Simon Magcwatywa, the principal officer of Sizwe Medical Fund, says combating fraud could lead to more affordable private healthcare.
But only if the money lost to corruption is returned.
CMS’s chief executive Sipho Kabane warns terminating people who fall foul of the law from schemes is not combating corruption. Instead, he says, they should be rehabilitated through penalties, including making them refund schemes for the money lost.