- Centurion Clinic, Centurion was named Top Affiliate Award winner. They sent the most traffic from their website to the MediFin website for the prescribed period.
- Joint winners: Plastic Surgery Centre, Somerset West and Danel Cosmetic Clinic, Klerksdorp were named the winner of the Top Merchant Award. They sent the most client loan applications for the prescribed period.
- Dental Ladies, Roodepoort earned the Top Service Award, for being the partner who received the best Net Promoter Score, as rated by their patients, for the same period.
Awards co-ordinator Amy-Louise Louwrens shared the following message to the winners: “Working with our partners has been an incredible experience and we value our relationship with them. As such, we are keen to showcase their dedication and acknowledge them as deserving winners. I would like to wish them and all our partners the best of luck for the future, and thank them for trusting MediFin to assist in making their patients’ dreams come true.”
MediFin’s goal is to provide people with the opportunity and financial solution to “Be the best version of themselves”, particularly where they may not be in a position to afford the large, upfront capital investment required of most medical procedures. MediFin’s innovative finance solution provides clients with an alternative to rising medical-insurance tariffs and savings accounts, while medical aid providers also do not cater for elective procedures.
MediFin offers its clients:
- Zero deposit;
- Affordable repayments;
- Excellent customer service;
- Confidential medical finance;
- Direct payment to the selected practitioner;
- Preselected partners and other service providers;
- No early-settlement penalties; and
- Insurance options
This is how MediFin achieves these client offerings:
MediFin’s business-partner offering:
MediFin features more than 800 medical partners in its network, including dental practitioners, audiology and fertility specialists, and cosmetic surgeons — to name just a few categories. These medical practitioners have recognised the benefit of partnering with MediFin due to these unique value propositions:
MediFin does not charge a commission fee from their partners; instead they:
- Pay the medical practitioners 100% upfront:
- Decreasing their need for in-house collections;
- Decreasing the risk of non-payment; and
- Increasing the cash flow in their business.
Looking to the future:
In an effort to extend their reach, MediFin is looking to collaborate with businesses who are pioneers in the medical arena, as exhibited by their most recent partnerships with Unitron, Zoom Whitening and VisionWorks. MediFin’s online presence and business model continue to break ground as they partner with likeminded practitioners who share a common vision of putting the patient first.
Feel that you could benefit from MediFin’s services? Contact them at
, or call their friendly staff on 0861 000 808.
Poor collaboration at the right level, the lack of accountability and no proactive participation were identified as some of the stumbling blocks in the fight against malfeasance in the healthcare industry.
“The work that we do focuses on some of the elements on fighting fraud and money recoveries. We want also to extend that to successful prosecutions of the fraudsters. At the moment, there is a formalisation in the process of a relationship with the Special Investigations Unit (SIU). We have drafted a memorandum of understanding which will be signed off in the next few weeks,” Mothudi said.
The problem faced by the industry now is that it is thinking on fraud, waste and corruption is too small. Preventing fraud in the healthcare sector will make healthcare affordable and will also bring long-term benefits to the sector.
“Our expertise in the private sector on fighting fraud gathered over time could help in making sure that we also protect the funds that will be deployed in the National Health Insurance vehicle in collaboration with those resources that are currently in the state. So, it is a win-win situation,” Mothudi added.
Council of Medical Schemes (CMS) Senior Health Economist, Nondumiso Khumalo, said when looking at the impact and threats fraud poses to healthcare the industry needs to adopt a holistic picture that includes suppliers, manufacturers, providers and consumers.
“Impact is felt at a financial level when administrators incur costs. The quality of healthcare is affected because of the deviation of costs,” he said.
According to CMS in 2017 the proportion of claims attributed to fraud, waste and abuse amounted to R30.15bn. From a global perspective, the exposure rate to corporate fraud has risen by 28% since 2007 from an industry average of 8%. In South Africa, estimates range from 3 to 15% of claims.
Khumalo added that as a cost driver in medical schemes fraud contributes to the costs barrier to entry and has left the membership stagnated at 8.8-million lives.
Last year, medical aids lost at least R15-R20bn of total private healthcare industry spend to fraud, with the Board of Healthcare Funders of Southern Africa (BHF) reporting about 10 to 15% of all claims as fraudulent, abusive or wasteful. Approximately 3 to 4% of the R160-billion medical industry is pure fraud. The instances of medical fraud can be reduced, but it will take fundamental shifts in a number of areas, including the way medical schemes are structured and the efficiency of state health care.
You certainly don’t have to look far to find examples of medical fraud. From dietitians charging for ‘consultations’ on the quality of hospital food and a doctor claiming to see over 80 patients (several of whom were dead) in a day, to nurse-administered dialysis treatments out of dodgy garages and pharmacies colluding with clients to submit false claims.
One of the reasons for this pervasiveness is that people are not sufficiently informed to query recommended treatments – and no one wants to take a risk with their health. A good example is the C-section. South Africa’s Caesarean rate is 72% vs the 15% global rate. In private healthcare, cost isn’t usually taken as a factor when clinical decisions are made, and the worry is that the ethical responsibility may be blurred by financial incentives, such as the additional income a c-section brings to a gynae as opposed to a natural birth.
So how do we reduce this problem? Most critically, we need to change from a fee-for-service to a fee-for-value model, the latter meaning the healthcare provider will be remunerated based on the outcome of the treatment, regardless how many times the patient had to consult. The current fee-for-service model is quite contentious. As with all things, there are multiple nuances and discussions around it. Coming from a medical scheme perspective, we’ve seen how it can open the system to abuse, fraud and waste. At the moment, there are few regulations guiding what private practitioners charge. That’s one of the reasons why private healthcare has become so expensive.
Global fee arrangements are being investigated by medical schemes worldwide in an effort to constrain costs. This is effectively a ‘bundle’ fees model, where a healthcare provider receives a set sum to coordinate and distribute between all parties involved. The worry here is that an issue of underservicing may arise, with providers pocketing the profits. As with the fee-for-service model, a big issue is that a member may not be able to spot corruption, which is extremely disempowering. That’s where there’s a big education job to be done so the public becomes active watchdogs against corruption of any kind.
Additionally, to reduce medical fraud, state healthcare would need to reach global standards, in the process forcing competition in the private sector, which would bring costs down. Advancing tech – like wearables that monitor heartbeat, temperature, glucose and more – will also inevitably help streamline industry efficiencies and lower costs.
While structural changes will be necessary to significantly drop fraud rates, all members can play a role in reducing medical fraud by:
- Getting second opinions before procedures
- Questioning anything that seems suspicious
- Not resorting to anything unlawful when you feel the ‘contribution pinch’
- Seeing a GP before a specialist to ensure you get the right referral
- Making sure you invest in preventative care and explore non-invasive options if appropriate
- Trying not to view medical aid and severe illness cover as grudge purchases. Rather see them for the care they give you access to
Medical aid terms can be as difficult to decipher as your doctor’s handwriting. That’s why knowing medical aid speak is essential if you are going to understand your medical cover says Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund.
Medical schemes are not-for-profit and owned by the members of the scheme. In turn the scheme appoints a Board of Trustees to manage the affairs of the scheme to ensure that they are in the member’s best interests. This may also be known as medical aids or funds.
2. Medical scheme administrators
Medical scheme administrators are separate entities to the actual medical scheme and operate on a for-profit basis. The medical scheme may go out to tender for an administrator but an existing contract with the administrator may also exist for a certain number of years. The administrator is responsible for managed the administration of the scheme such as processing claims.
3. Medical scheme plans
There are usually a number of plans from which to choose. In general, more comprehensive plans are usually more expensive. The cover you need will vary according to your age, family size, dependents and income. It is important to look at your benefits holistically to ensure they offer you real value for money. Plans that offer more benefits in addition to your savings or benefits from risk generally offer more value.
4. Waiting periods when joining a medical aid scheme
If you have not been on a medical aid scheme or a hospital plan, there may be a waiting period, which means you will continue to pay premiums but are not covered for a period that is outlined by the scheme. The Medical Schemes Act outlines that medical aid schemes are entitled to impose waiting periods: These vary from a 3-month general waiting period or a condition-specific of up to 12 months.
5. What is a late-joiner penalty?
In South Africa, schemes can impose late-joiner penalties on individuals who join after the age of 35, who have never been medical aid members, or those who have not belonged to a medical aid 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 not contributed to the scheme).
These are ‘cost effective copycats’ of the original drug. The pharmaceutical company that develops the original drug spends millions on research and development and so take out a patent to protect themselves for a period of time. After the patent has expired other drug companies can make the generic equivalent without the initial clinical research costs. They have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety and strength as the original drug.
7. Gap cover
At times there may be a shortfall between what the medical scheme pays and what the hospital or specialist charges. As a member you are responsible for paying the difference. Even if you are on a top range medical aid plan, it doesn’t mean there will not be ‘gaps’ between the tariffs your scheme is prepared to pay and the amount your specialist charges.
There is an insurance policy called Gap Cover which you can take out to pay for this shortfall.
8. Prescribed Minimum Benefits (PMBs)
PMBs are a mandatory set of defined benefits that medical schemes must provide cover for all medical scheme members. These ensure members have access to a certain minimum level of health services, regardless of the benefit option chosen. It currently covers medical emergencies, 25 chronic and 270 medical conditions. PMBs are being reviewed by the Council of Medical Schemes (CMS) with a view to aligning them with the proposed National Health Insurance.
9. Designated Service Providers (DSP)
A DSP is a healthcare provider (doctor, pharmacist, hospital etc) that is the medical schemes’ choice for members to use. If you don’t use the DSP you may have to pay a portion of the bill as a co-payment. You can avoid co-payments and get more value for money by using preferred suppliers and DSPs.
10. Tariffs and rates of payment
Each Medical Schemes has a Rate of Payment ie the amount the medical scheme will pay for that service. Providers charge different rates known as the Scheme Tariff. Members often misunderstand that 100% of the Scheme tariff/rate doesn’t necessarily mean 100% of the account or what you will be charged. However, as a patient you can negotiate the best possible rate with your healthcare provider.
“Too often members do not understand what their medical aid option offers and are not familiar with the terminology,” says Van Emmenis. “The best advice I can offer is to be informed. Take the time to read all the information supplied, including the fine print, and compare plans. If you are unsure phone the scheme and ask questions, or check with your broker. Your health and that of your family is important so it is vital that you are comfortable with the choice you make and are confident your healthcare needs will be taken care of.”
Spectramed Medical Scheme and Resolution Health Medical Scheme (Resolution Health) have merged to form Health Squared Medical Scheme, as from 1 January 2019.
Health Squared will be administered by Agility Health, which is currently the managed care provider and administrator for both Spectramed and Resolution Health.
The launch of Health Squared forms part of an overall strategy to protect the interests of members while strengthening the service offering in the context of future developments in the South African healthcare landscape.
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Women’s health, men’s health, chronic disease management, innovative plans, catching criminals and a digital revamp – Bonitas reflects on 2018 and launches its 2019 plans and strategy.
Gerhard van Emmenis
“The past 12 months have been extremely trying, with a number of uncertainties and changes anticipated. In addition, consumers have been heavily impacted by the increase in VAT and escalating prices which resulted from this.”
In July Bonitas announced its financial results for 2017, the best in its 35-year history, with a solid surplus of R730.20 million, having recouped a deficit of R16.9 million from 2016. “This turnaround was due to several key cost saving strategies, says Van Emmenis, “and it bolstered our reserves from R3.1 billion to R4 billion which means that we are able to invest back into the Scheme and offer our members access to healthcare of the highest quality.”
The Fund has announced a number of additional benefits for its members for 2019, while keeping increases as low as possible. “We know that it’s not only the monthly premiums that affect the consumer’s pockets but the value they get out of their medical aid plan,” says Van Emmenis. “Some of the benefits have been tweaked, others increased, one plan has been discontinued and two new options have been introduced, all aimed at helping members take control of their health and lead better lifestyles.”
Working together to reduce healthcare costs
“We continue to seek partnerships with healthcare providers to ensure we are part of the same value chain, rather than being part of the supply and demand of the healthcare economy,” says Van Emmenis. “In addition, we are focused on educating role players to balance the triangle of affordability, quality and cost efficiencies. We are developing an incentive model to motivate service providers to eliminate activities that do not add value to members.”
Over the past few years, Bonitas has taken a multi-pronged approach to cost saving, focusing on:
Hospital claims account for half of Bonitas’ annual claims, around R6 billion a year. For this reason we negotiated a pricing structure with the main hospital groups, to deliver a savings of R242 million last year. We project that this saving will increase to approximately R550 million over the next two years in present value terms.
We place great emphasis on our Managed Care initiatives to help members, with chronic conditions, manage their health better. It takes into account the best clinical and treatment protocols while containing costs. Our back and neck, oncology, hip and knee and HIV/AIDS programmes respectively, continue to offer our members emotional, clinical and financial support.
The Council for Medical Schemes (CMS) cites chronic conditions – with diabetes in particular, as one of the key contributors to a rising disease burden in South Africa and escalating healthcare costs. 80% of the Scheme’s diabetic patients have associated chronic conditions such as high blood pressure and cholesterol, heart disease and depression which need to be managed on a unique basis. “Through our Diabetes Programme, hospital admissions related to diabetic patients having reduced by 11.6% year-on-year,” says Van Emmenis.
Prevention is better than cure
We have a keen focus on preventative care as early detection is a critical factor in ensuring our members get the support they need to manage any serious conditions timeously.
Last year, we kept a firm focus on women’s health introducing cover for pap smears on all our plans. Since cervical and breast cancer continue to be most prevalent, we have continued our efforts towards early detection by ensuring mammograms for women over 40 will be covered once every two years on all our plans from 2019.
In addition, we have placed the spotlight firmly on men’s health, especially in light of a prevalence of prostate cancer, by adding the prostate screening antigen test to all options for men aged between 45 and 69.
We have South Africa’s largest GP network which ensures our members get value for money and stretch their benefits. Our online provider locator tool has been enhanced so that members can find network hospitals, doctors and specialists in their area quickly and easily.
Fraud, waste and abuse (FWA)
Our ongoing efforts to reduce FWA have been successful, with a number of convictions and sentencings. This significant focus delivered recoveries of R31.2 million with a potential preventative savings of R75 million. We will continue to ensure that all outstanding money is successfully recovered and repaid to the Fund, so that it can be put to better use to benefit our members.
Digital remains a key driver for member and broker communication with Member, Broker and a newly introduced Corporate Zone available on the website. The online application has been revamped, we’ve introduced an electronic membership and a live chat function has been added to assist current and potential members with any questions they may have.
Besides enhancing the Member Zone as from January 1, 2019 members will have access to the Bonitas App – a revolutionary cell phone application that will offer the full benefits of the Member Zone. Making it easier for them to view their benefits and claims as well as submit claims, obtain authorisation, find a network provider, resolve queries and so much more while on the go.
As a value-add for members, Bonitas has aligned itself with strategic partners to offer a comprehensive and holistic solution to help members take care of their financial health and wellness, without paying anything extra. “This is not another loyalty programme,” explains Van Emmenis, “but rather real added value aligned to member needs, with no fee or points scoring.” The model includes a Multi-Insurer Platform offering Medgap, exclusive gap cover with a discount of up to 48% discount for Bonitas members and a wide range of life, funeral, disability cover products through Sanlam Indie with exclusive benefits in the form of free investments up to 110% of monthly contributions. And finally, a variety of free monthly discount vouchers from 30 participating partner retailers through Electronic Line.
In conclusion, Van Emmenis says, “Our plans have been restructured to meet market demand, consumers are looking for options that offer attractive benefits at a more affordable rate.”
Summary of key changes for the year:
- A weighted increase of 8.9%.
- A new multi-insurer platform with exclusive deals and offers for Bonitas members including gap cover.
- Two new plans introduced – Primary Select and BonEssential Select. These use dedicated networks and are both are priced around 15% lower than the Primary and BonEssential options respectively.
- The Hospital Plus plan has been discontinued.
- Mammograms for women over 40 will be covered once every two years across all the plans.
- Prostate screening antigen tests for men aged between the aged of 45 and 69 have been included across all plans.
- Childhood immunisations according to the EPI schedule, are now offered to members on BonClassic, Standard, Standard Select, BonComplete, BonSave, Primary, Primary Select and BonFit – paid from risk.
- The introduction of the My Family Model which contains a full suite of care – such as maternity consultations, 2D scans, antenatal classes, newborn hearing screening – all paid from risk.
- The day-to-day benefits on Primary has been increased by 15% for 2019.
- A family benefits of R31,500 has been introduced on BonEssential for internal prosthesis, it is also included on BonEssential Select.
- BonClassic has been re-aligned to fit in with other options with radiology and pathology combined into one benefit.
For more information on the range of medical plans available from Bonitas, or to compare options, go to www.bonitas.co.za.
An alternative reimbursement model has been launched that will benefit patients and encourage best practice among clinicians in the private healthcare sector.
EBC was spearheaded by the South African Society of Anaesthesiologists (Sasa) and rolled out to Discovery Health’s arthroplasty network. For example, a hip or knee replacement requires a team of professionals comprising a minimum of an anaesthetist, an orthopaedic surgeon, an appropriate hospital facility and a physiotherapist. The contract will cover the period for eligible patients from surgery into the recovery and rehabilitation period.
The model is the result of four years of extensive research and consultation with the healthcare sector, and is aligned with the Health Professions Council of South Africa’s (HPCSA’s) ethical rules and South African legislation.
“Sasa is committed to enhancing the delivery of healthcare services, ensuring that patient care is secured above all else. This led us to explore models that incentivise greater accountability and more collaborative work among clinicians, and offer both the funder and patient cost certainty, without compromising the patient’s care. The new contracting model achieves all of these goals,” says Natalie Zimmelman, Sasa chief executive.
Protects the patient without adding cost
It should not increase medical costs for patients and will, in fact, probably result in lower fees for private healthcare services over time, as all players in the healthcare system seek better efficiencies with good health outcomes, she adds.
Zimmelman says that the EBC is appropriate for the South African market – “which does not have the kind of sophisticated regulatory processes and active oversight seen in many other markets” – in that it promotes a greater level of transparency, and makes clinicians and facilities (clinics and hospitals) more accountable to each other and to their professional peers.
“This new patient-driven care model protects the patient without adding cost. Because the clinician contracts directly with the funder, they will share the risk, and it will drive collaborative care and information sharing, while keeping the patient at the centre. Ultimately, it’s always about putting patient safety first while ensuring the sustainability of the South African healthcare sector.”
Sasa also notes that this model can be used as an example of a mechanism for the procurement of private healthcare services under the National Health Insurance.
“The Sasa EBC is an example of a positive move towards enhancing and placing value on the integration of anaesthetic services in holistic patient care, supported by an innovative fixed-fee reimbursement model. The approach provides regulatory certainty and societal peer review, and entrenches quality-of-care principles through the monitoring of team processes and care outcomes,” says Darren Sweidan, Discovery Health’s head health professional unit.
The “startling costs” of South African private healthcare is at the heart of the Competition Commission’s Health Market Inquiry (HMI) draft report released in July. While cost is a key theme, the report also describes a sector lacking the vital force of authentic, robust competition.
Carl Grillenberger, Advanced Health CEO
Currently, the South African private healthcare sector is an opaque system dominated by a small handful of players. Members pay for medical scheme cover, and accept that they will also have to pay costs out of their own pockets.
The common refrain of the medical aid will pay is one that is inherently false. It is not the medical aid that pays, but the member. “The fact that so many people cling to this erroneous statement reveals two important facts about our business,” says Carl Grillenberger, CEO of Advanced Health.
“First, few consumers understand medical aid schemes, or are able to navigate them effectively. Second, the private healthcare economy routinely ignores the vital concept of value-based purchasing.”
He explains that the draft HMI report describes a fee-for-service model that reliably stimulates oversupply through wasteful expenditure and the provision of more services than are actually needed.
Competition is cosmetic
“Our private healthcare market is driven by supply induced demand, where competition mostly occurs mostly at a cosmetic level, and is based on a supposed choice between available products rather than value for money. The choice, of course, is often illusory. Consumers end up trying desperately to compare glossy medical aid scheme brochures and failing, despite their best efforts, to compare like with like,” Grillenberger says.
“The Competition Commission also tells us that lack of competition runs right through the market. Simply put, trustees and principal officers experience little pressure to hold scheme administrators to account for their actions – especially when it comes to procuring services based on value.
Runaway medical inflation
“Another key theme of the draft report is that there is very little incentive for change, because the South African private healthcare market is a de facto oligopoly where three hospital groups have a combined market share of 83% of the national private facilities market in terms of the number of beds. The same groups control 90% of all private healthcare admissions.
“All these are factors contributing to the most urgent issue facing our industry: runaway medical inflation,” he says.
There has been an average difference between medical inflation and CPI inflation of 4.2% over the last 10 years.
“In our calculations, we have projected an average differential of 4% for the coming decade. If today’s trajectory holds, by 2028 medical aid costs will be two and a half times their current value.
“In other words, the net income of an average income earner’s gross income increases at the CPI rate, but their medical aid contribution escalates at 9.6% per annum. If this trajectory continues, medical aid inflation will see private healthcare members experience a deteriorating net income in the coming years.
“The reality is that within 10 years a substantial number of medical scheme members will not be able to pay scheme contributions and will fall out of the market.
As the membership fall off accelerates, our industry is likely to shrink at a compounding rate. As this happens, more strain will be placed on a national health system that is clearly buckling in some places and broken in others. I think we all understand that our country cannot afford to further stress such a fragile system,” Grillenberger says.
“Many medical scheme administrators are much more concerned about the proposed implementation of National Health Insurance (NHI). The reality is that the NHI remains unlikely to achieve lift off any time soon. Not only is funding a major, unresolved issue, but the Department of Health still needs to dramatically improve services to resolve the fundamental distrust that still exists between state patients and provincial service providers. Without this key change, NHI won’t find the traction it needs to become operational.”
To resolve supply induced demand, the draft HMI report suggests serious consideration be given to alternative remuneration models (Arms).
“I think it’s clear that value-centric transformation of private healthcare is the only thing that will fully secure the long-term viability of our industry. By choosing to change we will make the private healthcare sector better for all players however it will also drive other crucial social contributions.
“Change will ensure our activities don’t destroy the South African public healthcare system, it will give patients better choice and value, lay the foundation for the long-term sustainability of the sector, the economy and the country.
“As an industry, we know what we need to do. We need to take the first step towards a value-centric structure, to change the market for the better, before it’s is too late,” Grillenberger says.