Tag: medical aid schemes

Categories : Medical IndustryTags :

GEMS Hosts its 14th Annual Symposium, Bringing Together Key Healthcare Industry Stakeholders and Policymakers

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The Government Employees Medical Scheme (GEMS) will, on November 2nd, 2023, host its 14th annual GEMS Symposium under the theme: “Advancing Health Equity by Addressing the Social Determinants of Health”. Experts, thought leaders and specialists in healthcare will engage in discussions towards a better understanding of the societal determinants of health in South Africa. 

For this hybrid event, delegates will attend both in person at Sandton and virtually.

Dr Moloabi states that the “Symposium is an important event on the GEMS calendar, providing a platform for academic, clinical, government and business minds to discuss what social issues are at play in determining the nation’s health status and how to improvements in health equity can be realized”. Moreover, he also highlights the need to remove practical obstacles that make us an unequal society if we are to achieve collaborative and cohesive solutions to our healthcare challenges.”

Speakers will include: 

  • Dr Ingrid Pooe – Chief Operations Officer, Government Employees Medical Scheme (GEMS),
  • Dr Sebayitseng Millicent Hlatshwayo – Chairperson, Government Employees Medical Scheme (GEMS),
  • Dr Chana Pilane-Majake – Deputy Minister of Public Service and Administration (DPSA),
  • Professor Mcebisi Ndletyana – Professor of Political Science, Department of Politics and International Relations, University of Johannesburg,
  • Dr Selaelo Mametja – Chief Research Officer, Government Employees Medical Scheme (GEMS),
  • Mr Barry Childs – Joint Chief Executive Officer Insight Actuaries & Consultants,
  • Dr Vuyo Gqola – Chief Healthcare Officer, Government Employees Medical Scheme (GEMS),
  • Mr Louis Botha – Chief Executive Officer, Health Quality Assessment (HQA),
  • Ms Yoliswa Makhasi – Director General, Department of Public Service and Administration (DPSA),
  • Mr Frikkie de Bruin- General Secretary, Public Service Coordinating Bargaining Council (PSCBC),
  • Dr Pali Lehohla – Director of Economic Modelling Academy (EMA), 
  • and
  • GEMS Principal Officer Dr Stanley Moloabi.

Dr Pilane-Majake, the Deputy Minister for the Department of Public Service and Administration (DPSA) will deliver the keynote address, elucidating, amongst other insights, the crucial relationship between the DPSA as employer and GEMS as an implementor of a mandate to ensure access to health and wellness by government employees and thus contributing towards the attainment of the ideals of Universal Healthcare Coverage.

Media personality Ms. Faith Mangope will facilitate conversations as the panel covers key discussion points, including:

  • Achieving the Sustainable Development Agenda 2030.
  • Beyond Healthcare: Addressing health equity and social determinants of health.
  • Policy Interventions for Addressing Social Determinants of Health: Lessons and best practices.
  • Value-Based Care and Social Determinants of Health: Integrating social context into healthcare delivery.
  • Advancing health equity by addressing social determinants of health; and
  • Exploring the interplay between healthcare quality and social determinants.

At GEMS, we are dedicated to fulfilling our responsibilities towards our members and the people of South Africa. The Symposium is a testament to our commitment to Universal Healthcare Coverage, and we are eagerly anticipating a productive outcome that will be memorable and provide an insightful experience for all involved, Dr. Moloabi” concludes. 

To learn more about the GEMS Symposium, visit www.symposium.gems.gov.za. 

Categories : Expert Opinion Medical IndustryTags :

Opinion Piece: The Rise of Affordable Medical Insurance

On By ModernMedia

Reaching the masses with quality healthcare services

Photo by Hush Naidoo Jade Photography on Unsplash

By Sandra Sampson, Director at Allmed Healthcare Professionals

With its two-tiered, highly unequal healthcare system, only 14.86% of South Africa’s population can currently afford private healthcare, and rising costs are making it difficult for many to keep paying their monthly medical aid premiums. There are plans to implement National Health Insurance (NHI) to fund healthcare in the public and private sectors, although this process which began in August 2011 has been slow, and the NHI Bill is still under consideration in the National Assembly.

Despite concerns about the state’s ability to implement the NHI effectively and competently, delivering quality medical care to the population must continue to be a priority for every healthcare provider. This is where a specialist Temporary Employment Services (TES) provider can assist – delivering a flexible, competent, quality workforce on demand for institutions in both the public and private sectors.

Increasing access to quality healthcare

The public healthcare sector is primarily intended to serve those who are unable to access private medical aid and is currently accessible to all, regardless of immigration status or nationality. Significant funding is a massive drawcard for specialists in the private sector, which has resulted in a widening gap between public and private healthcare facilities in much of the country. The impending NHI is intended to address this gap and enable greater access to specialist care and more free services for all, while improving the quality of public healthcare by establishing a national fund that will allow for the purchasing of healthcare services on behalf of users. Estimates for funding this national health initiative range from R165bn to R450bn, and the government has been given the go-ahead by the Gauteng High Court to continue its recruitment drive before the bill has even passed.

Access starts with affordability

In line with this move, affordable healthcare insurance is on the rise. This trend starts with partnerships between healthcare and financial services providers, and has already been seen in the likes of Dischem, Clicks and Tyme Bank’s TymeHealth, all offering medical insurance, enabling access to high-quality healthcare specialists to a market that was previously woefully under-serviced. As the demand for quality healthcare increases, there will be a proportionate increase in the need for healthcare professionals.

Practical resourcing alternatives

It is not economically or practically feasible for healthcare institutions (whether in the private or public sector) to hire more medical professionals permanently, which means they will have to explore other resourcing options. This is becoming increasingly difficult in South Africa, as many skilled medical staff are seeking work elsewhere as a result of poor working conditions created by loadshedding, corruption, and incompetent administration. Although the Department of Home Affairs has added new skills to our country’s critical skills list (many of which include medical practitioners and individual specialisations) the healthcare industry is still severely understaffed. Hospital groups are only growing more frustrated with the government’s inability to address the decreasing number of medical practitioners, particularly nurses. The Hospital Association of South Africa (HASA) has reported that nurses in the country are reaching retirement age without the necessary inflow of younger employees. In 2020, there were more than 21,000 nurses in training, but South Africa still needs as many as 26,000 additional nurses to meet the growing demand.

Meeting the demand flexibly

TES providers in the healthcare sector have the potential to meet the demand of healthcare institutions for nurses and specialists, without these institutions having to commit to the responsibilities and costs associated with full-time employment. TES providers are on hand to supply the vetted and highly-skilled workers so desperately needed. Every healthcare institution can be supplied with the resources necessary on a shift-by-shift basis. So, if, for example, there is a deficit of five ICU nurses at a certain hospital, a TES provider can meet this with very short notice. If, on the other hand, patients are discharged or rerouted, these additional nurses can be cancelled at short notice, and the TES provider picks up the hospital’s slack and answers it with flexible resources on demand. Additionally, when it comes to meeting the fluctuating demand for speciality staff, a TES partner will become indispensable.

Equitability and affordability depend on agility

Ultimately, regardless of when the NHI comes to fruition, healthcare institutions should begin partnering with a TES provider if they haven’t already. Along with providing medical professionals on demand, this comes with cost-saving benefits for the hospital or clinic. Not having to employ full-time staff to meet fluctuating needs is a cost-saving exercise. Not only from a wage standpoint but also from an HR perspective in terms of payroll, industrial relations and skills development. The TES partner is responsible for all aspects of the employment relationship, while the healthcare institution gains access to qualified healthcare professionals as needed, at a fixed rate on flexible terms. This means that as soon as hospitals decide to invest in making their wards and spaces bigger and more efficient, they will have access to the medical resources necessary to staff them in a manner that enables equitable access to quality healthcare.

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

National Health Insurance Bill: Will it Wipe out Medical Insurance?

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The NHI Bill does not contain any clarity on how South Africa’s large and complex medical schemes and insurance industry will be affected.

Photo by Bill Oxford on Unsplash

By Lenee Green, Partner, Mateen Memon, Associate & Mariam Ismail, Trainee Attorney at Webber Wentzel

On 12 June 2023, the National Health Insurance Bill (the Bill) was passed by the National Assembly and is currently with the National Council of Provinces for consideration. Its laudable aim is to make primary healthcare widely accessible.

The Bill has been closely scrutinised by various stakeholders in the healthcare sector. Concerns have been raised by medical schemes and insurers about the effect the Bill will have on their current businesses.

The Bill, among other things, covers:

  • who will be able to access health care services;
  • how these services will be funded;
  • the establishment of a board and advisory committees to achieve the objectives of the Bill;
  • general provisions applicable to how the fund will operate;
  • complaints about and appeals of decisions made by the fund; and
  • the source of income of the Fund and transitional arrangements.

Clause 33 of the Bill states that once the National Health Insurance (NHI) is fully implemented, medical schemes can only offer complementary coverage for services not reimbursed by the NHI. Clause 6(o) of the Bill allows individuals to purchase services not covered by the NHI through voluntary medical insurance schemes. This means medical schemes cannot cover services already covered by the NHI, potentially jeopardising their existence. This approach may face constitutional challenges related to the right to access healthcare, property rights of medical schemes, and freedom of trade and profession.

It is contemplated that the Minister of Health will introduce regulations limiting benefits to services not reimbursable by the Fund.  We have not yet seen any indication when these regulations will be published.

Current regime

Broadly, four main categories of business will be impacted by the Bill:

  • business of a medical scheme as defined in the Medical Schemes Act 131 of 1998 (MSA);
  • insurers licensed to conduct insurance business pursuant to the Insurance Act 18 of 2017 (the Insurance Act);
  • insurers who offer products pursuant to section 8(h) of the MSA (the Exemption Framework); and
  • insurers who offer products pursuant to the regulations published under each of the Long-Term Insurance Act 52 of 1998 and the Short-Term Insurance Act 53 of 1998 (the Demarcation Regulations).

Medical schemes

Presently, only medical schemes may carry on the “business of a medical scheme” as defined in the MSA. The “business of a medical scheme” involves undertaking liability for the provision of obtaining “relevant health services”, defraying expenditure for “relevant health services” or rendering health services by the medical scheme itself or by any supplier of a “relevant health service” in return for a premium or contribution.

A “relevant health service” under the MSA is very wide. It includes “any health care treatment of any person by any person registered in terms of any law, which treatment has as its object…” The objects include a broad range of medical services, including the physical or mental examination of a person, the diagnosis, treatment or prevention of any physical or mental defect, illness, or deficiency, ambulance services and hospital or similar accommodation.

Insurers

Medical schemes must be distinguished from medical insurance provided by insurers. Insurers may provide medical insurance under, among other dispensations, the Insurance Act. Schedule 2 to the Insurance Act provides for various classes and sub-classes of insurance business for which life insurance companies and non-life insurance companies may be licensed. Schedule 2 allows insurers to provide health and disability benefits under the risk class of business for life insurance and accident and health and travel insurance under the classes for non-life insurance.

Health insurance is provided upon the happening of a health event. A health event is defined in the Insurance Act as one that relates to the health, mind or body of a person or an unborn, other than a disability event. The disability event is defined and includes circumstances where a person loses a limb or becomes physically or mentally impaired. It is apparent that there is an overlap of products provided for in the Insurance Act and offered under the MSA.

The Demarcation Regulations provide for the demarcation between insurance business and medical schemes business. The regulations provide that a benefit that would otherwise have been a medical scheme benefit, but meets the exact requirements (definitions) set out in the tables in the Demarcation Regulations, is classified as an insurance product.

In March 2017, the Counsel for Medical Schemes (CMS) issued an exemption framework for insurers as a transitional arrangement while the development of a low-cost benefit option (LCBO) for medical schemes was developed (Exemption Framework). To the extent that an exemption was granted to an insurer in terms of section 8(h) of the MSA, and subject to the conditions of the exemption, the insurer was permitted to continue to underwrite those products until the expiry of the exemption. On 25 January 2022, the CMS granted insurers that had previously been granted an exemption in terms of the Exemption Framework an extension of a further two years.

The background to the LCBO is that a ministerial task team on social health insurance launched the low-income medical scheme consultative process in 2005. In 2015, the CMS issued a circular that considered introducing a guideline to allow medical schemes to introduce LCBOs in response to the growing number of working South Africans who did not have medical scheme coverage because they could not afford it. Following various engagement processes, the LCBO Framework Advisory Committee issued a Report in May 2022 (the Report). The Report states that LCBOs still have the potential to “alleviate pressure in the public healthcare system and allow resources to be redirected to the poor”. This process has progressed quite slowly, and it remains to be seen what comes of it if anything.

While the Bill is a piece of framework legislation, it does not provide clarity on what will become of insurance under the current regime. The fate of medical schemes is dealt with in a very cursory manner, without considering the nuances of the current regime.

The LCBO could have been a path to make healthcare more accessible, but the process has become stifled, and it may never come to fruition. What is left in the wake of the Bill is a great deal of uncertainty. Industry participants and stakeholders will have to keep abreast of the process and ensure that their comments are taken into account as the system evolves.

Categories : Injury & Trauma Medical IndustryTags :

Legal Review – Subrogation: Medical Schemes Act on Motor Vehicle Accidents Payments

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Photo by Pixabay

John Letsoalo – Senior Manager; Legal Services

Mpho Sehloho – Senior Analyst – Benefits Management

In the ensuing court battle between Discovery Health and the Road Accident Fund (RAF) over reimbursements to be paid on motor vehicle claims, medical schemes members had always sought clarity or a position from the Council for Medical Schemes regarding this. In normative terms, the CMS is not obliged to release commentary on matters remote to its mandate, however, as a responsible regulator, it became a necessary act to clear any anomality.

Medical scheme members usually do not always have the full understating of the arrangements between RAF and medical schemes. At best, members sometimes have difficulty engaging with their scheme’s rules or RAF due to language barrier or be it of a technical nature of the matter.

In terms of the Medical Schemes Act 131 of 1998 (the “MSA”), Medical Schemes undertake liability in return for a contribution by among others granting assistance in defraying expenditure incurred in connection with the rendering of any relevant health services.

MSA further obliges medical schemes to pay for Prescribed Minimum Benefits (PMB), which include any emergency medical condition, under which motor vehicle claims could fall, in full. Unless a claim is specifically excluded in terms of the schemes’ rules and/or does not meet the criteria in terms of the definition of relevant healthcare, the medical scheme must still pay.

Most medical schemes provide for the handling of motor vehicle claims in their rules, wherein members of medical aid can claim compensation from the Road Accident Fund (the “RAF”) for such claims and any future healthcare services which may arise due to such motor vehicle accident. 

It is also common cause that where RAF is responsible for claims, which a medical scheme has paid in terms of its rules and the MSA, that the RAF should refund to such medical scheme the amounts paid. Members of medical schemes who would have claimed directly from the RAF and received compensation for such claims, must also pay such amounts back to the medical scheme. This is commonly known as subrogation.

Should a member not receive any compensation from the RAF even after claiming, the scheme remains liable for the costs of the treatment subject to the registered scheme rules and must not be required to repay/refund such funds to the scheme.

The scheme may, however, attempt to recover such amounts paid from the RAF for the benefit of its members.

Subrogation allows medical schemes to minimise losses as a result of these claims and keep members’ contributions reasonable, by holding responsible parties accountable. It also prevents members from being “overcompensated” or unjustifiably enriched for the loss since they should not receive double compensation from both the medical scheme claim payout and the recovery from the RAF.

It must be emphasized that the financial risk associated with health interventions for which the need is uncertain is equitably shared within the covered population through a risk pool managed by medical schemes under the Medical Schemes Act. Therefore, CMS cannot condone a situation where members of medical schemes are forced to be out of pocket due to the non-payment of medical costs by RAF where these have since been paid out by medical schemes.

In line with our mandate under Section 7 of the Medical Schemes Act, it is not in the members interest if medical schemes are required to claw back payment made on behalf of members due to non-payment of these costs by RAF.

Moreover, the non-recovery of these costs by medical schemes negatively and unfairly withdraws from the entire risk pool that is aimed at benefitting the whole membership.

The World Health Organization (WHO) defines pooling as “…accumulation and management of revenues in such a way as to ensure that the risk of having to pay for healthcare is borne by all members within the pool, not by each contributor individually…” (WHO, 2000).

By implication, the refusal to refund medical schemes by RAF leads to the unfair deterioration of the entire risk pool funds.

Within this background, CMS believes that the refusal to refund medical schemes by RAF is not in line with the provisions of the Medical Schemes Act and it is not in the interest of beneficiaries of medical schemes.

DISCLAIMER: COUNCIL FOR MEDICAL SCHEMES. 2023

This document has been prepared by the author(s) from the Council for Medical Schemes Legal Services Unit and Benefits Management Unit. The views and information expressed in this article are for information purposes only. CMS cannot be held liable for any incorrectness of statements and statistical errors. Recommendations and conclusions are based on the author(s) research outcomes/findings and does not necessarily espouse or state as a CMS policy stance. The information is subject to change without notice. Companies and individuals wishing to use the information must reference the CMS in company reports, news reports, interviews, panel discussions etc.

Categories : Healthcare Politics and RegulationsTags :

CMS Provides Clarity over BHF’S Court Challenges

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Various stakeholders within the medical schemes value chain have sharply raised concerns over the unending court challenges brought by the Board of Healthcare Funders (BHF) against CMS. As an agile regulator, the CMS endeavours to clarify any misconception and confusion over BHF’s court challenges.

Chronology of Events

Initially, the main issue brought by BHF in this case was to request the court to grant them a general exemption for medical schemes to offer low-cost benefit options and to declare an alleged moratorium unlawful by the CMS and Ministry of Health in order to prevent medical schemes from offering low-cost benefit options.

In response, the CMS vehemently opposed the application on the basis that there was no moratorium as alleged by BHF and it would be thus unlawful to grant BHF a general exemption for medical schemes to offer low costs benefit options.

“It must be noted that while the main case/dispute was still ongoing (even after CMS submitted an extensive record of documents that were compliant with relevant information and documents having been exchanged between CMS and BHF), surprisingly BHF brought an interlocutory application alleging that CMS and the Minister were hiding certain information.”

Accordingly, the interlocutory application requested CMS and the NDOH to release an exhaustive list of documents which the CMS believed were irrelevant and had no bearing on the main application.

Despite CMS’s vehement contestation to the court on the additional requested documents by BHF, Judge Botha granted the BHF the order they sought, and the CMS, as well as the Minister of Health were ordered to produce the documents listed in Notice in terms of Rule 30A within 10 (ten) days of the Court Order, being 24 July 2023. 

Before the expiration of rule 18 of the superior court, CMS filed leave to appeal the court order of Judge Botha as CMS believed that the order was flawed in law and that the judge had no reasons for ordering CMS and the Minister to produce those documents.

While the CMS legal team was studying the order, BHF concurrently lodged a contempt of court on an urgent basis.

CMS, through its attorneys, moved swiftly and wrote to BHF urging them to withdraw the contempt application as the CMS had already lodged its leave to appeal the court order of Judge Botha and this meant that the court order by Judge Botha would been suspended. 

BHF refused to withdraw the contempt application and the application was heard on 8th August 2023 and the court dismissed BHF’s application on 10 August 2023 with costs in favour of CMS and Minister.

Citing Judge E van der Schyff who emphasised that “in the Practice Manual of the Gauteng High Court Division that while an application maybe urgent, it may not be sufficiently urgent to be heard at the time selected by an applicant” and also strongly highlighted that it does “not mean that applicants can indiscriminately approach the urgent court on the basis of extreme urgency without having regard to the context and facts of each individual application.”

Based on this order, the contempt application is now in our view moot or rather has been overtaken by the leave to appeal lodged by CMS and the Minister and CMS/NDOH. The leave to appeal will be heard somewhere September 2023.

The main application brought by BHF is likely to be heard in later parts of 2024.

Categories : Healthcare Politics and RegulationsTags :

High Court Ruling for Affordable Medical Scheme Benefits in South Africa not Adhered to

On By ModernMedia
Photo by Tingey Injury Law Firm on Unsplash

In the recent judgement handed down by the Pretoria High Court in favour of Board of Health Funders (BHF), the Council for Medical Schemes (CMS), Registrar of Medical Schemes and the Minister of Health were ordered to deliver a complete record, which will shed light on the moratorium on granting exemptions to medical schemes to provide LCBO benefits.  The order directed the CMS and the Minister of Health to deliver all documents or information requested under Rule 30A within 10 days of the order, but all the respondents failed to meet the deadline.

After the ten-day deadline had passed and noting that the documents were still not produced and there was no appeal to the court order, the BHF was forced to return to court to seek answers. The BHF filed a contempt of court order on an urgent basis. In this application, the BHF highlighted that no complete record had been submitted even though the deadline for the Minister of Health and CMS to do so was on 24 July 2023. In response, the CMS and the Minister of Health opposed the contempt of court action and appealed the rule 30A judgement delivered on 10 July 2023. The Minister of Health, acting through his attorneys, allowed his own team to submit certain documents in terms of rule 30A, and the attorneys have stated that the delivery of the documents demonstrates good faith. This is despite the appealing of the judgement and order delivered in the rule 30A application.

The legal battle against the CMS and Minister of Health not only highlights their failure to comply with the court’s order, but also raises concerns about transparency and accountability within the healthcare system. This delay not only hampers the progress towards implementing affordable healthcare solutions, but also undermines public trust in the decision-making process of these regulatory bodies.  This lack of adherence to court orders highlights the urgent need for effective enforcement mechanisms to ensure that court decisions are respected and implemented by the relevant parties.

Categories : Healthcare Politics and RegulationsTags : 1 Comment

Council for Medical Schemes Approves 5% Increase – but no Details on Low-cost Options

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In a media briefing on Tuesday, 8th August, the Council for Medical Schemes (CMS) sought to clarify its process and recommendations over the approved 5% increase to medical aid scheme contributions, levels above which the medical schemes must motivate for. As for low-cost benefit options (LCBO), the CMS indicated that they would only provide a report to the Health Minister by the end of the month. This could prevent medical schemes from applying for new LCBOs in 2023.

Mr Mondi Govuzela, Senior Manager of Benefits Management, explained that the 5% approved increase is based on the Consumer Price Index (CPI) for 2022, which indicated a 4.9% increase. Schemes therefore may raise contributions by 5%, in line with the Reserve Bank’s inflation prediction for 2024. A prudent percentage markup should be incorporated to take into account cost increases and demographic changes, he advised. Before COVID, contribution increases have typically been 2.4–5% above CPI. The years 2020 to 2022 saw contribution increases dip below CPI.

One of the cost drivers that Mr Govuzela noted in the media briefing was supplier pressure stemming from fewer doctors and specialists, who were pushing for higher remunerations. Increased costs elsewhere in the healthcare industry. On the member side, growing rates of chronic diseases, membership ageing and coverage for medical services also added pressure.

LCBO would appear to be a solution for many individuals to access private healthcare for at least some urgent conditions, but the CMS has yet to comply with a Pretoria High Court ruling ordering that they provide a report on their moratorium on granting exemptions to medical schemes to provide LCBO benefits. The case was brought by the Board of Health Funders (BHF).

As to what the CMS’s response to the LCBO ruling was, CMS Registrar Dr Sipho Kabane said that the CMS was preparing a report that would be delivered to the Health Minister “by the end of the month”, but would not be drawn on what it might say. The deadline for registering new benefit options is September 1.

In their circular explaining the decision increase, the CMS acknowledged the persistent macroeconomic headwinds facing medical schemes and their members, with a meagre 1% increase predicted for SA’s GDP next year. “Against the backdrop of the current adverse macroeconomic conditions characterised by multi-year higher interest rates due to stubbornly higher inflation rate, volatile domestic currency and surging energy prices and overall lacklustre economic growth, it is evident that most household budgets will remain constrained for a foreseeable future, leaving most consumers under a precarious financial position. To cushion members of medical schemes against further financial distress and the probable risk of losing their health insurance cover due to affordability constraints, medical schemes are advised to limit their cost increase assumptions for contribution increases for the 2024 benefit year to 5.0%, in line with CPI.”

Categories : Healthcare Politics and RegulationsTags :

High Court Ruling Paves the Way for Affordable Medical Scheme Benefits in South Africa

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Photo by Bill Oxford on Unsplash

The recent judgement by the Pretoria High Court in favour of the Board of Health Funders (BHF) carries substantial implications for medical schemes in South Africa. This follows BHF’s court application, which sought to compel the Council for Medical Schemes (CMS) to give a complete record, providing light on the LCBO’s decision-making process thus far.

The Court ordered the Minister of Health and the CMS to provide all of the papers listed in Rule 30A within 10 days of receiving the applicant’s notice of motion. The completion of this crucial milestone hinges on the provision of several documents, which we eagerly await.

This significant victory brings us closer to the ultimate goal of granting Medical Schemes exemptions to offer Low-Cost Benefit Options (LCBOs), which aim to provide greater access to affordable medical scheme benefits for low-income earners. The BHF’s success aligns with the mission of improving
healthcare accessibility and advancing progress towards universal healthcare coverage (UHC) in the country.

In the main application lodged on 8 August, the BHF requested the High Court to:

  • Lift the moratorium that prevents medical schemes from offering LCBOs when the Council for Medical Schemes (CMS) refuses to grant applications for exemptions to medical schemes, pending the finalisation of LCBO guidelines.
  • Declare the failure by the respondents to develop and implement LCBO guidelines as irrational, unreasonable, and unlawful, as per Section 6 of the Promotion of Administrative Justice Act and Section 1(c) of the Constitution.

The BHF represents the majority of the country’s medical schemes and healthcare funders, encompassing schemes and administrators serving nearly 4.5 million individuals.

According to Charlton Murove, the protracted process of crafting a framework for Low-Cost Benefit Options has taken over seven years and is yet to be finalised. Many policymakers have criticised medical schemes for their lack of affordability. The proposed solution aims to address these concerns and move closer to the principles of UHC, ensuring that the healthcare system grants everyone access to quality and affordable healthcare.

Murove stated, “This application seeks to drive a progressive agenda for the public and private healthcare sectors, fostering collaboration to alleviate the current challenges in our healthcare system. The Council for Medical Schemes and the Minister have pivotal roles in implementing policies that enhance access to healthcare. However, progress with LCBOs has been hindered by the CMS’s failure to take the necessary steps for reform, despite the publication of demarcation regulations in 2016.”

The BHF’s victory in the High Court represents a significant step forward in the pursuit of affordable and accessible medical scheme benefits. By addressing the current burdens faced by the state and ensuring that medical scheme premiums remain affordable, we can strive towards a healthcare system that benefits all South Africans.

Categories : General Interest Medical IndustryTags :

AcciCare and Standard Bank Partnership Makes Private Medical Care Accessible to all Commuters

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Public transport is used by more than 10 million commuters in South Africa every day. It’s how people get to work, how they get to the grocery store, how they get their children to school. It’s quite simply a way of life.

For many of these commuters, there is no alternative to minibus taxis. They are an indisputably dominant pillar of the informal public transport system, but they are also notoriously unsafe. The constant threat of an accident is a real concern for commuters, especially those who cannot afford private medical aid.

“We live in a country where 73% of the population doesn’t have access to private medical aid. Couple this with the high number of road accidents in South Africa, and what recourse do the vast majority of commuters have if they are involved in a road accident?” asks Rikus Scheepers, managing director at AcciCare Medical Service Providers.

AcciCare is a medical funding company that assists people who do not have medical aid, to get access to private hospital care when they are involved in a motor vehicle accident. Scheepers started AcciCare in 2017, with the intention of making private medical care accessible to all commuters.

“We started AcciCare in a few hospitals and had limited capital to work with but soon realised the extensive need for this type of service. As a start-up without a long trading history, it became impossible to grow the business to meet the demand. We needed a business partner who shared our vision to supply this essential service throughout the country, and so we approached Standard Bank,” says Scheepers.

“AcciCare is a unique concept not offered in South Africa,” says Jocelyn Hamilton at Standard Bank. “When they approached us for finance we had to apply some out-the-box thinking in order to provide a working capital solution that would enable the business to grow and expand into more provinces in the country.”

In the event a person is injured in a motor vehicle accident, AcciCare will assist treating doctors and hospitals to collect and complete the correct documentation in order for medical costs to be claimed back from the Road Accident Fund (RAF). AcciCare provides financial assistance to these service providers, so they don’t carry the costs while waiting for the RAF to settle accounts.

“We firmly believe that all commuters should have access to private medical care when they need it the most. Through our partnership with Standard Bank we are expanding our footprint and we have exciting initiatives in place for 2023, to educate more people about the reliable private care that is available to them,” says Scheepers. “Together with Standard Bank, AcciCare has saved countless lives and has significantly improved the quality of life of those who have unfortunately been involved in a motor vehicle accident.”

“Our business banking model is centred on partnering with clients to grow their businesses in the communities in which they exist. While we came in as a working capital solution that would see AcciCare achieve their vision, in return we indirectly partnered in improving the long-term quality of life for those unfortunate enough to be in need of medical care at critical times. We hope to continue with this partnership, as they take their business to new heights,” says Hamilton.

Categories : Expert Opinion Medical IndustryTags :

Act Now to Stop the Bleed on Medical Schemes Industry

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By Junior Biola

Last year, fraud and abuse of medical aids resulted in a loss of R22 billion for medical scheme funds according to The Board of Healthcare Funders – a loss which could be avoided with the implementation of fraud mitigation services.

Medical aid fraud is certainly nothing new: for years, medical schemes have railed against members collaborating with medical practitioners – from doctors to pharmacists – for personal gain. There are the members who convince practitioners to admit them to hospital, for example, and pocket the monies received from their hospital cash back plans; the pharmacists who bill their customers for ‘medicine’, when their baskets are in fact filled with non-medicinal items; or even the practitioners who bill patients for treatments which never take place.

Since the advent of the Covid pandemic, such activities have escalated. In fact, it is no longer rogue pharmacists or practitioners taking advantage of medical aids; the industry is now affected by dishonest members and criminals using stolen cards to deplete medical savings accounts or take advantage of benefits.

The results are catastrophic for an industry which is frequently accused of charging members exorbitant fees. In truth, players are under siege from the steeply rising costs of healthcare, and while they are doing their best to limit the impact on members, this is no easy task when those very members are, in effect, stealing from the scheme through fraudulent claims.

The impacts are far-reaching for all stakeholders. Medical funds have no choice but to raise the price of contributions – after all, they need to maintain a steady pool of funds in order to be able to pay out claims, and if members are dipping into that pool for illicit reasons, it needs to be replenished. Naturally, this affects members severely, especially as many are already challenged by the rising cost of living. On the other side of the equation, practitioners also take a hit: when the pool of medical funds decreases, a less profitable practice is inevitable.

The prevalence of fraud is understandable when you consider that few controls are in place to prevent it. Think of the average consumer entering a retail chain pharmacy, for example: they may be asked to present their loyalty card, and while this may be considered a form of identification, the reality is that it is rather ineffective as a verification tool. The absence of an identification photo means that the purchaser could well be someone besides the patient for whom the script was written; nor is there anything to stop them from adding over-the-counter items to purchase and claiming them from their savings.

The good news? Fraud mitigation is both effective, and simple to implement. Establishing a ‘safety net’ of identity and biometric recognition makes it possible for medical schemes to ensure that members claim only for medicines and treatments they have been prescribed, while also protecting against scripts that have been falsified.

The result? A healthier medical aid industry – for the benefit of all.

Junior Biola is CEO of Johannesburg-based fintech company, Bitventure, a provider of state-of-the-art real-time automated verification and payment solutions. www.bitventure.co.za