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2019/03/18 02:25 PM

There has been a lot of hype around the proposed National Health Insurance Bill, 2018 (NHI Bill) and the numerous implications for South African citizens. Little has been said, however, about how the NHI Bill will impact on the provision of medical aid benefits in the employee context.

The NHI Bill aims to enable access to free, universal, high quality healthcare for all, by creating a single national health insurance fund. The NHI Bill will, once promulgated, centralise the procurement of medical supplies by the State. A key feature of the NHI Bill is the establishment of the National Health Insurance Fund (NHI Fund).

Membership of the NHI Fund will be mandatory for all South African citizens. Currently, the NHI Bill is silent in relation to how the contributions towards the NHI Fund will work, but the Department of Health has indicated that everyone that can afford to do so will be liable to contribute towards the NHI Fund. It appears that contributions to the NHI Fund would be in addition to any medical aid scheme premiums, if individuals should choose to remain members of a private scheme.

It is envisaged that all healthcare will be accessed free of charge through the NHI Fund.

It has been suggested that one of the options for funding the NHI would be via a withholding tax, similar to Pay as You Earn (PAYE). This would then be paid over to the NHI Fund by the employer.

Accordingly, once the NHI Bill is promulgated, employers will most likely have to contribute towards the NHI Fund and it appears that they would no longer be expected to contribute to private medical aid schemes on behalf of their employees, unless they elect to make both contributions.

Where an employer chooses to cease making private medical aid contributions on behalf of its employees, as a result of the introduction of the NHI Fund, this may result in a unilateral change to the employees' terms and conditions, or a potential unfair labour practice relating to the withdrawal of benefits. This is especially the case if the changes are not effected in the appropriate manner.

For those employees who decide to stay on a private medical aid scheme in addition to contributing to the NHI Fund, the draft Medical Schemes Amendment Bill has made several changes to the current system, which appear to be advantageous for medical scheme members. It abolishes co-payments, requires medical aid schemes to make full payment of the patient's expenses, and removes medical aid brokers.

If these amendments are passed, medical aid scheme members who have raised concerns about above inflation premium increases and exposure to co-payments should see immediate improvements. However, the changes could also potentially cause medical aid schemes to raise member contributions to cover their increased obligations.

While a substantial amount of detail is still to be fleshed out in the regulations, implementation of the NHI is currently targeted for 2025. In the interim, employers should consider whether they would want to cease contributions to their employees' private medical aid scheme.

In order to potentially cap their (future) liability and curb any headaches associated with trying to escape double contributions later, employers should consider building the present value of their contributions into their employees' gross remuneration packages, requiring them to facilitate their own medical aid membership in the future. The effect of this will, at the very least, mitigate financial risk concomitant with increased premiums following the promulgation of the NHI Act.
2019/03/18 02:15 PM

It’s not an obvious association, but Afrocentric, the listed BEE healthcare investment company that owns Medscheme, has quietly become the biggest dispenser of medicines by script volumes in the country.

Through a deal with the department of health in 2018, the company’s pharmacy courier unit Pharmacy Direct now dispenses more than 1-million scripts a month in KwaZulu-Natal for chronic medicines to public collection points.

At the same time, it has leapt feet-first into drug manufacturing with the deal to buy the 74 percent it did not own in Activo Health, a SA-based generics pharmaceutical manufacturing company that makes ARVs and over-the-counter products under the Plusssz range, among others. While manufacturing generics is not an obviously high-profit business, Afrocentric’s CFO Hannes Boonzaaier argues that in the health “value chain”, manufacturers are “still making good money”.

But the company’s increasing reach in all aspects of the healthcare business has yet to truly materialise in its earnings. For the six months ended December, fully diluted headline earnings per share were only 2.4 percent better, at 22.18c. It was slightly more generous with the dividend, raising that 6.25 percent, to 17c a share.

Admittedly, the results don’t include Activo, for which Afrocentric paid R588-million, as the deal was only signed off on March 1. While its empire building in the healthcare sector may pay off, for investors this share are likely to require patience.
2019/03/152019/03/18 02:23 PM

Almost daily, our news reports are marred by statistics about gender based violence, such as one in three women are assaulted, physically or sexually. According to the World Health Organisation WHO, South Africa has one of the highest rates of violence inflicted on women and girls in the world.

A baseline study with 2 600 men, conducted in Diepsloot by the University of the Witwatersrand's school of public health as part of the Sonke Change Trial, revealed alarming levels of violence. Fifty six percent of the men interviewed reported they had either raped or beaten a woman in the preceding 12 months. Of those, 60% also violently assaulted women many times during that period.

This has a devastating effect on the emotional, physical and mental health of people and on the economy and health systems. A KPMG study estimated that gender based violence cost the economy a minimum of between R28.4 billion and R42.4 billion, or 0.9% and 1.3% of gross domestic product, in the year 2012 2013. An estimated 1.75 million people annually seek healthcare for injuries resulting from physical and sexual violence.

One study also cites how more than a third of women who have been raped develop post-traumatic stress disorder, which, if untreated, persists in the long term and leads to depression, suicide and substance abuse.

An Avert (A Very Early Rehabilitation Trial) study estimated that 16% of all HIV infections in women could be prevented if women did not experience domestic violence. Women and girls bear the brunt of these injustices because of unequal treatment and poor access to quality sexual reproductive health and abortion services in the public healthcare system.

When women face an unwanted pregnancy resulting from rape, they are more than twice as likely to choose to terminate that pregnancy, even if safe and legal abortion options are unavailable. This puts them at a high risk of complications, including injuries and death.

If violence occurs when women are pregnant, there are several potential complications, including an increased likelihood of miscarriage, stillbirth and premature labour. Additionally, violence is a leading cause of injury and death among pregnant women.

To tackle this issue, the government must finalise and implement the recommendations that arose from the gender based violence and femicide presidential summit held in November last year. It was convened after thousands of women marched under the banner i#TotalShutDown to the Union Buildings in August last year to highlight the plight of women and girls.

A declaration was issued by President Cyril Ramaphosa, which included renewed commitments to address and eradicate gender based violence and the toxic patriarchal structures in our society. Some of these commitments were repeated in the president's State of the Nation address on February 7.

Reproductive health services are vital to address gender based violence. The provision of timely and confidential access to emergency contraceptives can prevent women and girls from becoming pregnant because of sexual violence. Likewise, increasing access to information about HIV and confidential testing, counselling and early treatment services, such as post exposure prophylaxis, can reduce the risk of infection.

There is a need to improve post trauma care in public health facilities to address disproportionate access to basic sexual reproductive health services and thwart the perpetuation of gender inequality in our society. Another response should include access to safe abortion should the need arise. Despite a progressive abortion law, many victims of sexual violence resort to unsafe abortion services, which can lead to death or disability.

The government must ensure that a comprehensive bouquet of post-trauma sexual reproductive health services are provided at the primary, secondary and tertiary levels under the proposed National Health Insurance scheme.

It needs to further capacitate and financially support nongovernmental organisations already involved in providing psychosocial services to gender based violence survivors.

It is also imperative for chapter nine institutions, the custodians of the Constitution, policymakers and citizens, to demand government accountability regarding the implementation of recommendations and related policies.

Civil society, faith based organisations and traditional leaders also have the responsibility to create more opportunities for dialogue and awareness of gender based violence issues to destigmatise the shame and guilt experienced by survivors.

Gender based violence is no longer a private and domestic affair. It has become a human rights violation of national proportions that requires our urgent response.

Angelica Pino is the director of Sonke Gender Justice
2019/03/152019/03/18 02:24 PM

Die skerp styging in mediesefondspremies is nie jou dokter of hospitaal se skuld nie –
dié diensverskaffers het verlede jaar hul tariewe net met die inflasiekoers verhoog.

Die eintlike rede is dalk eerder dat lede van mediese fondse ouer en sieker word én dat duurder tegnologie en medisyne ontwikkel word.

Dié dinge het die vraag na mediese dienste verlede jaar met die meeste tot nog toe laat styg sedert dit gemeet word – met 5,9%.

Saam met die 5,2%-styging in mediese tariewe beteken dit mediese inflasie was 11,1%.

Dis volgens Discovery Health se nuutste indeks van mediese inflasie, ’n maatstaf van hoeveel méér die Discovery Health Medical Scheme (DHMS) aan eise moes uitbetaal.

Die styging in eise het ’n regstreekse impak op lede van mediese fondse omdat nagenoeg 90% van premies gebruik moet word om eise te betaal.

Die mediese inflasie van 11,1% is effens laer as die gemiddelde mediese inflasie oor tien jaar (van 2008 tot 2018), wat 11,3% beloop het.

Dis egter meer as dubbeld die jaar se gemiddelde verbruikersprysinflasiekoers van 5,1%.

Discovery wys daarop dat die koste van mediese dienste verlede jaar met gemiddeld 5,2% gestyg het. Dokters en hospitale het hul tariewe met net 5,1% verhoog – dieselfde as die inflasiekoers – en voorskrifmedisyne het met net 1,3% duurder geword. Die verhoging van 1 persentasiepunt in belasting op toegevoegde waarde in April het ook bygedra om mediese tariewe te laat styg.

Die styging in mediese inflasie is dus nié dokters of hospitale se skuld nie: Die groot rede is die styging in die vraag na dienste.

Die 5,9%-styging in die vraag na dienste verlede jaar was baie meer as die gemiddelde styging van 4,8% van 2008 tot 2018.

Die vraag na dienste word op sy beurt onderverdeel in twee faktore: vraagkant- en aanbodkant-inflasie.

Vraagkant-inflasie, wat 2,9% beloop het, word volgens Discovery Health grootliks veroorsaak omdat mense wat aan mediese fondse behoort, al hoe ouer word.

“Met elke jaar wat lede gemiddeld ouer is, styg eise met nagenoeg 2% tot 3% per jaar omdat ouer individue meer gereeld siek word en meer gesondheidsdienste gebruik.”

Mediese skemas se lede verouder omdat die swak ekonomi beteken minder jong mense kry vaste werk. Baie jong mense mét werk stel ook uit om lid to word van ‘n mediese fonds omdat dit so duur is.

Volgens Discovery het net 5 000 mense (hooflede en hul begunstigdes) in die nege maande van Januarie tot September 2018 by oop mediese fondse in die land aangesluit. Dis die netto aansluitings, dus aansluitings minus die mense wat uit fondse bedank het of wat gesterf het.

Om die probleem te vererger, is daar ’n skerp styging in chroniese siektes, insluitend diabetes en hoë bloeddruk, en ernstige siektes soos kanker onder lede van mediese fondse.

Discovery sê een uit vier DHMS-lede is vir een of meer chroniese toestand geregistreer. Dit is 61% méér as in 2008.

Mense met chroniese toestande eis byna vier keer meer as mense sonder chroniese toestande.

DHMS-lede met kanker het sedert 2010 verdubbel.

Aanbodkant-inflasie het verlede jaar 2,4% beloop. Dié styging word aangedryf deur die opening van nuwe hospitale, maar ook deur nuwe, duurder tegnologie en medisyne.

Discovery noem as voorbeeld die koste vir die behandeling van melanoom (velkanker). In die verlede is dit met chemoterapie behandel teen ’n koste van R6 500 per kursus. Deesdae is ’n soort immunoterapie, Yervoy, beskikbaar, maar een kursus daarvan kos R880 000.

“Die bekendstelling van dié soort hoëkostemedisyne het daartoe gelei dat drie keer meer mense per jaar meer as R1 miljoen per jaar van DHMS eis in die afgelope vyf jaar.”

’n Meer omstrede aspek van aanbodkant-inflasie is die skerp styging in die getal private hospitale in die land. In die bietjie meer as twee jaar van Januarie 2016 tot Maart 2018 het 2 200 meer hospitaalbeddens beskikbaar geword; dis dieselfde getal beddens as in die ses jaar van 2010-’15. Dit het DHMS R855 miljoen méér gekos.

Die indeks is bereken op grond van die eise van DHMS se nagenoeg 2,8 miljoen lede, wat 32% van alle lede van mediese fondse in die land verteenwoordig en 56% van alle oop mediese skemas.
2019/03/18 02:25 PM

Health Minister Dr Aaron Motsoaledi has paid tribute to Professor Mashudu Tshifularo and his team at the University of Pretoria (UP) for a pioneering surgical procedure which uses 3D printed middle ear bones for conductive hearing loss rehabilitation.

On Wednesday Tshifularo led the team in successfully performing a nearly two hour transplant operation on their first patient, Thabo Moshiliwa, 40, who damaged his middle ear bone in a car accident.

The minister urged donors, development partners and the business community to support the innovation, which he described as "South Africa's scientific breakthrough".

“As the department of health, we shall do everything in our power to assist and mobilise resources to make sure that Professor Tshifularo gets all the help he needs,” Motsoaledi said.

The groundbreaking surgery was done at the Steve Biko Academic Hospital in Pretoria.

The department of health says the procedure, which can also be performed on newborns, may be the answer to conductive hearing loss, a middle ear problem caused by congenital birth defects, infection, trauma or metabolic diseases.

It uses 3D printing technology to effectively replace the hammer, anvil and stirrup, the ossicles – the smallest bones in the body – that make up the middle ear.

Tshifularo, head of the department of Otorhinolaryngology at UP, said this innovation posed less risk than others.

"By replacing only the ossicles that aren't functioning properly, the procedure carries significantly less risk than known prostheses and their associated surgical procedures," he said."

This 3D technology is allowing us to do things we never thought we could. But I need sponsors and funding for this invention to take off the ground," he added.
2019/03/142019/03/18 02:15 PM

The country’s biggest nurses’ union has called on President Cyril Ramaphosa not to retain Health Minister Aaron Motsoaledi in his Cabinet after the May polls.

On Wednesday, Denosa president Simon Hlungwani said the health system had collapsed under Motsoaledi’s watch and the minister had failed to prepare the country for the implementation of the National Health Insurance (NHI).

Speaking at Denosa’s national ­conference in Durban, Hlungwani said the health system was in a crisis.

“We want people who are proactive and who plan beforehand,” he said.

On failing to prepare the country for the implementation of the NHI, Hlungwani said: “The current minister has reached the pinnacle of his career, and there is nothing more he can offer the department of health.”

However, he said, Cosatu still sees Motsoaledi as a good and capable ­comrade, “but (one) who should be deployed elsewhere”.

“After the elections, we want a different minister, and that is what this conference is going to deliberate.

“We have not invited the minister as we just don’t want him any more, and I can confirm that even with the MEC in KZN, a similar stance had been taken by the province, as they have had enough of him,” he said.

Hlungwani accused KZN health MEC Dr Sibongiseni Dhlomo of not sharing information with health employees and the public about the extent of oncology problems in the province.

“We are calling for an investigation on how many people died during that saga of not having cancer treatment, because some doctors are saying there were 460 (deaths).

“Now tell me, who in his conscious mind can bring such a person back when something like that could happen under his leadership?” he said.

Motsoaledi’s spokesperson, Popo Maja, said allegations that the minister had collapsed the health system were “outrageous”.

“In as far as we are aware, there is nothing supporting that. The minister has been the champion of the NHI,” said Maja.

ANC KZN spokesperson Nomagugu Simelane-Zulu said the relevant authorities would assess Dhlomo’s performance.

Simelane-Zulu said before deploying its leaders, the deployment committee and party’s provincial leaders would first assess them.

When asked if the ANC was happy with Dhlomo’s performance, she said: “Once the assessment is done, the ANC will take a decision.”
2019/03/142019/03/18 02:16 PM

According to the Competition Commission’s (CC) enquiry into the private healthcare market in South Africa, the private health industry is characterised by a lack of competition, rising prices, minimal transparency and disempowered users.

Yet the quality of care in the public sector is often lacking, despite the efforts of dedicated doctors and nurses. Along with the challenges faced in both the public and private healthcare industries, plans to create National Health Insurance (NHI) limp along.

Conducted over four and a half years with a preliminary report published in July 2018, the CC recommended altering the range of medical scheme benefit options to increase comparability between schemes and increase competition in the market. A supply-side regulator to implement this change was another of its recommendations.

National Health Insurance
The proposed NHI will also affect the medical scheme industry. The NHI Bill was sent back to the Health Department for another rework in December 2018. The Bill has begun a process of far-reaching health reforms that should create universal health coverage (through the NHI fund that would buy services on behalf of patients that are then free at the point of care). How medical schemes (which currently provide cover for around nine million people) will fit into the NHI system is unclear.

Changes to the Medical Schemes Act (MSA) are also being made, especially related to co-payments, prescribed minimum benefits, and the proposed abolition of broker fees.

Additionally, the medical scheme industry is not supposed to be profit-making, which legislative changes hope to make clear. Brokers, for example, will have to work to prove that their fees – previously constituting as much as R90 of a member’s monthly contribution – are justified in relation to value.

Balancing act
Around 80% of South Africans are currently dependent on state healthcare. A balance between curbing high costs in the private sector and improving the quality of care in the public sector must be struck. Finalising the two draft Bills will bring some clarity. But 2019 is an election year, so the battle of ideologies regarding a national healthcare system may be delayed further.

We are not ready for the NHI
The country is not in a position to implement the NHI as was originally contemplated, and certainly not on the timing that was initially proposed. Legislators have a huge job because the health industry is embedded in a tangle of at least 12 pieces of legislation, of which the MSA is just one.

Medical negligence
There is also the discussion document from the Law Reform Commission’s inquiry into medical negligence and related litigation to consider. It highlights the significant medico-legal challenges faced by the public health sector.

Proposed amendments to the State Liability Act – allowing for payment of damages awards in instalments, under certain conditions – was met by substantial opposition in submissions made to Parliament.

Even if funds were available to implement the NHI, the huge backlog of medico-legal cases against public healthcare institutions must be urgently dealt with, along with an increase in the quality of healthcare provided in the public sector. The contingent liabilities faced by government for damages claims in the healthcare industry means that billions of rands are spent on court awarded damages or on settlements annually.

Money that could be better spent on improving healthcare quality and the facilities that provides them. However, with money diverted to the backlog of claims, less is available to improve the current state of affairs, and we are left in a cycle of poor service delivery, leading to even more claims against the State.

While the biggest tally of medical negligence cases heard by the Supreme Court of Appeal in the latter part of last year was in keeping with the trend that obstetricians and gynaecologists make up the most litigated against medical speciality, the court has reiterated in a number of judgments that an adverse health outcome – even a birth injury – does not, necessarily, imply causative negligent conduct on the part of the health professional.

The balanced approach of the courts is a bright spark in a healthcare industry fraught with challenges, pending changes and disagreement as to how to bring about reform for the benefit of all.
2019/03/142019/03/18 02:17 PM

Sign up for the most basic plan if money is tight

SA's health system is under immense strain. While some public and academic hospitals have state-of-the-art equipment and top specialists, and thousands of doctors and nurses who care deeply about their patients, the entire system is under resourced and over-crowded.

The government has prioritised health and its national health insurance (NHI) may have the best of intentions, but it will be many years before you can rest assured you will have quality care and are covered sufficiently in the case of a medical emergency.

If being able to use private healthcare facilities is important to you because you want to be sure you will be treated professionally, sufficiently and timeously, medical scheme cover will allow you to sleep at night knowing you are covered in the event of a medical expense or accident.

You could be injured or fall ill at any time. Without medical scheme cover, you could face steep medical bills that could ruin you financially. You could even be denied admission to or, after being stabilised, a continued stay in a private hospital if you or your family can't pay upfront.

"An unexpected hospital event or procedure or accident could leave you seriously out of pocket and in debt if you had to take out loans to pay for it, and could therefore have a crippling effect on your family's finances and future," Jeremy Yatt, principal officer of Fedhealth, says.

"Taking out the most basic medical scheme product such as an entry level hospital plan is preferable over leaving one's health to chance," Yatt says.

Even if you are prepared to make use of a state hospital, depending on what you earn, you may have to pay, as state hospitals are expected to charge households with an income of more than R72,000 a year.

Many employers offer a subsidy of a percentage of your medical scheme contributions as an employment benefit. If you have this option, it is a no brainer to grab it. Many employers don't offer this, and if you are self-employed, you will be responsible for your own contributions.

You also get a tax credit that reduces your tax if you pay for your own and dependants' membership of a scheme. The cost of living is high, budgets are harder to manage and medical scheme member ship is expensive and typically increases each year at more than inflation.

Deon Kotze, head of research and development at Discovery Health, suggests you consult a financial adviser for an analysis of your financial and medical needs so you can keep appropriate cover at a lower cost.

There are various types of medical schemes and some are better for tight budgets.

A hospital plan probably won't cover your day to day medical expenses such as visiting a GP, getting medicine from the pharmacy or visiting a dentist or optometrist.

But as Yatt points out by law, even the most basic medical scheme plans have to cover the prescribed minimum benefit PMB conditions: a set list of 25 common chronic conditions and 270 hospital conditions. This means you'll be covered for these conditions, even with the most basic plan.

A savings plan is essentially a hospital plan with a savings account to which you contribute each month. Whatever you contribute, you can spend on your day to day healthcare needs.

A way to contain costs is to agree to limit your choice of hospitals, doctors, pharmacies and other providers by joining a plan that restricts you to using providers in a network the scheme's list.

"The contributions for network-based plans are lower than plans that cover all hospitals and doctors," Kotze says.

If your budget is tight, you should join a scheme with contributions that are based on your income.

Another option is to agree to pay a co-payment for certain services, such as hospital admissions. This is like a high excess on your car insurance. If you agree to pay this amount should you need to go to hospital, you will enjoy lower monthly premiums.

Medical scheme vs hospital cash plan
Be sure you know the difference between a medical scheme and medical insurance. Some insurance products have confusingly similar names – a hospital cash plan is not the same as a medical scheme hospital plan.

"Although medical insurance is priced at a much lower rate and might therefore seem like a more attractive option when compared to a medical scheme, it does not provide you with the same level or type of cover," Fedhealth's Jeremy Yatt explains.

"It usually starts paying out a set amount per day after a few days in hospital, so you often might not even get any payout if your hospital stay is not long enough, or the amount might not cover all the hospital costs."

A private hospital may not even admit you if you only have a hospital cash plan as the payout may fall far short of the costs of treating you.
2019/03/18 02:17 PM

Take care as cover for private doctor day-to-day healthcare needs varies widely

Standardised benefits for low-cost medical scheme options are unlikely to be introduced for another two years.

Insurers will, in the absence of a standardised package, be allowed to offer you a confusingly wide range of plans that start at around R160 a month and offer cover for your day to day healthcare needs through private practitioners, but leave you relying on state hospitals for most admissions.

If medical scheme membership is too expensive for you, you could consider one of these so called primary healthcare plans, as in return for a low premium they can give you access to a private general practitioner, basic medicines, x-rays and blood tests and sometimes even optometry and dentistry.

But without a standard set of benefits helping you to know what you are buying and to make meaningful comparisons, you have to stay wised up to the potential differences in cover.

The plans cost between about R160 and R550 a month and the benefits are as diverse as the cost of the premiums. To protect medical schemes the definition of the business of a medical scheme has been tightened up and these plans are now regarded as doing the business of a medical scheme.

The Department of Health, however, set the medical scheme regulator, the Council for Medical Schemes, the job of drawing up a standardised benefit package to allow these plans to continue under a general exemption from the Medical Schemes Act. The idea was to exempt them from providing the prescribed minimum benefits as many of these benefits are expensive ones that cover in hospital treatment.

While it considered what should be in this benefit package and how it should fit in with the government's future National Health Insurance plans, the council granted exemptions to a number of primary healthcare plans.

The exemptions expire at the end of this month, but the council has now instructed insurers providing these plans to apply for a further exemption that will last another two years.

This means you need to take care when you compare these plans as the benefits vary greatly. For example, some offer unlimited GP visits while others offer a set number of visits, or a set number of visits per year, after which you must pay a co-payment.
Most plans only pay for GPs who belong to a GP network – be sure you are happy to use those doctors. Many exclude specialist visits.

Cover for medicines may be limited to a rand amount and or may exclude chronic or over the counter medicines.

Blood tests, x-rays, dentistry and optometry are usually strictly limited.

Some plans are combined with insurance policies that offer some strictly limited benefits for private hospital cover, such as stabilisation after an accident.
2019/03/142019/03/18 02:18 PM

While technological advances in healthcare have the potential to become a massive game changer in the way healthcare service are delivered, healthcare professionals’ fear that it could reduce their role in providing care and impact on their earnings, and regulatory limitations are hampering optimal implementation in South Africa.

This was one of the messages coming out of this week’s Business Dialogue on the future of healthcare hosted by Life Healthcare and Business Day in Johannesburg.

Conceding that advancements in healthcare technology could drive the provision of more accessible, better quality healthcare services at a reduced cost, Deputy Director-general for NHI in the Department of Health, Dr Anban Pillay cited issues such as a lack of infrastructure and connectivity, outdated regulation and some healthcare providers’ belief that it could make them redundant, as some of the obstacles impeding the rollout of new technologies.

He cited the current implementation of a patient registration system in the state sector, e-scripting, ATM pharmacies and the introduction of pill-packing robots in some government hospital pharmacies as examples where technology is already making a big difference in streamlining healthcare services in the public sector.

“Where it is possible, there are huge opportunities. However, we will need to find a way of convincing all role players of the benefits and take them along in the decisions to prevent those who are benefitting from the current system and who are reluctant to embrace new technology from creating obstacles to implementation,” Dr Pillay said.

Life Healthcare CEO, Dr Shrey Viranna noted that South Africa is still stuck in the “paradigm of brick and mortar” that is not needed to implement innovative technologies. There is also a need to relax regulation that prevents the implementation of services such as virtual consultations and the use of non-clinical skills to augment those of physicians such as radiologists, enabling them to diagnose and triage patients remotely.

Axel Bauer, Senior Partner of McKinsey and Company’s Hong Kong office cited technological developments in the areas of Artificial Intelligence (AI)-based diagnostics and molecular biology such as liquid biopsy as some of the biggest advances in detecting diseases much earlier and with more precision.

He pointed out the advantages of digital platforms such as the “GoodDoctor” application developed in China that gives more than 400 million people access to 24/7, online consultations which are supported by systems that allow patients who need emergency care to quickly access services. In addition, so-called mini-clinics have been introduced where patients can access machine-driven imaging services that allow them to be scanned without the presence of a healthcare professional to establish whether they need to see a physician. However, he cautioned that without end-to-end online-off-line systems that ensure continuity of care, the advantages of these technologies won’t be achieved.

Referring to South Africa’s dire shortage of doctors, Accenture CEO, Vukani Mngxati, emphasised the huge role mobile digital technologies can play in expanding healthcare services to rural areas.

“As the country is going through health reforms such as the NHI, we have an absolute opportunity to put the basics in place that will allow us to “leapfrog” existing technologies and introduce new technologies to the advantage of the millions of patients who still don’t have access to a doctor,” Mngxati said.

According to Dr Pillay, regulation should be dynamic and move to accommodate new technologies but that it requires evidence that it is affordable and will provide the right outcomes and broaden access.

“We need to ensure that everyone understands where we are going, especially those who see innovation as an obstacle. If we don’t, it could create a culture of fearmongering, causing a negative spiral of resistance,” Dr Pillay said, citing the example of ATM-dispensing pharmacies that took more than 18 months to get the approval of the Pharmacy Council because of a perception that it could leave pharmacists without jobs.

Panelists concluded that the private sector, healthcare providers, funders and regulators should work together in ensuring that the opportunities new technologies can bring are achieved in a way that is patient-focused while allowing for healthy competition.
2019/03/142019/03/18 02:19 PM

Nursing union, DENOSA has called on President Cyril Ramaphosa to ditch Health Minister, Dr Aaron Motsoaledi after the May elections, according to a report in The Star this morning.

Speaking at the national DENOSA conference in Durban, the union’s president, Simon Hlungwani said the health system had collapsed under Motsoaledi’s watch and that the Minister had failed to prepare the country for the implementation of the National Health Insurance (NHI).

According to Hlungwani, the Minister has reached the pinnacle of his career, and there is nothing more he can offer the Department of Health. Hlungwani also accused KZN health MEC Dr Sibongiseni Dhlomo of not sharing information with health employees and the public about the extent of oncology problems in the province.

He said Denosa is calling for an investigation on how many people died during that saga of not having cancer treatment, because some doctors are saying there were 460 deaths.

Motsoaledi’s spokesperson, Popo Maja, said allegations that the Minister had collapsed the health system were “outrageous”. He said there is nothing to support that, adding that the Minister “has been the champion of the NHI”.
2019/03/142019/03/18 02:20 PM

In a bid to address surgical backlogs, Gauteng Health MEC Gwen Ramokgopa has sent a letter of request to facilitate a handover of the site where Soshanguve District Hospital will be built.

Once built, the hospital is set to alleviate a backlog at Dr George Mukhari Academic Hospital (DGMAH).

“This initiative will enable the hospital to reduce backlog of surgical procedures and help more patients who are awaiting their turn to be operated, especially in the obstetrics and gynaecology, cardiothoracic surgery and orthopedics departments,” said the MEC.

According to the MEC, the Soshanguve District Hospital is progressing slowly due to land issues.

Public private partnership
In the interim, the department has collaborated with private hospitals to make use of their theatres, through the Hospital Association of South Africa, Mediclinic in particular, which has signed a memorandum of understanding with the department. The partnership has been successfully tested and ready to be expanded.

“Private hospitals will provide theatre time mainly with the department having to supply consumables and the workforce for these operations.

“I’m happy that our management, specialists, registrars and nurses are happy about this arrangement and are also prepared to make the intervention work best for their patients,” said Ramokgopa.

Of the four central hospitals – Steve Biko, DGMAH, Chris Hani Baragwanath Academic Hospital (CHBAH) and Charlotte Maxeke Academic Hospital – the program will prioritise the two situated in townships being DGMAH and CHBAH.

“The population in Gauteng over the past 25 years of democracy has doubled and patient visits have more than tripled. The over 40 primary healthcare facilities and seven hospitals constructed in this period have proved not enough to meet demands.

“The progress being made with the Polokwane Academic Hospital will both help the patients from Limpopo access specialized quality services closer to home and on the other hand relieve the high demand on DGMAH,” said Ramokgopa.
2019/03/142019/03/18 02:22 PM

The Durban University of Technology’s (DUT’s) Faculty of Health Sciences hosted a Public Lecture under the Executive Dean’s Lecture Series. The lecture was delivered by the Faculty of Health Sciences Research Co-ordinator, Professor Champaklal Jinabhai on Wednesday, 13 March 2019 at DUT’s Indumiso Campus in Pietermaritzburg.

The lecture was titled: ‘Promoting and Protecting the Nation’s Health through the National Health Insurance Programme’.

Prof. Jinabhai defined the National Health Insurance (NHI) as a fund which will ensure that all citizens of South Africa (and legal long-term residents) are provided with essential healthcare, regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.

He touched on various national and international policy and constitutional frameworks that underpin the NHI, including the South African Constitution, the National Development Plan, National Department of Health’s Strategic 10-point Plan and United Nations Sustainable Development Goals.

“The supreme law of South Africa, the Constitution through Section 27 of the Constitution provides that every person has the right to have access to health care services, including reproductive health care. United Nations Sustainable Development Goal 3, which talks about ensuring healthy lives and promoting well-being for all is the most important policy that underpins the NHI. It says by 2030 the health system should provide quality health care to all for free at the point of service or paid for by publicly or privately funded insurance. It further says we must achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all,” explained Prof. Jinabhai.

He said the NHI is the proposed mechanism that South Africa will use as a vehicle to achieve targets that are outlined by these national and international policies.

Prof. Jinabhai said the NHI is not yet at the implementation phase. “The National Health Insurance Bill is still a White Paper, and Parliament still needs to pass it as an Act.

Government has not yet shared much details in terms of the implementation plan of the NHI including clarity on its funding model,” he added.

Students and staff members in attendance lauded the NHI but expressed their reservations about the lack of details in terms of its implementation. This prompted a suggestion from the audience that there should be a follow – up seminar that will be addressed by a senior official from the Department of Health, to provide more clarity on the implementation of the NHI.
2019/03/122019/03/18 02:13 PM

Even if there are funds to implement National Health Insurance (NHI) as envisaged, Donald Dinnie, well-known medico-legal practitioner, has predicted that the scheme will be “stillborn” due to the large list of historical and current medico-legal claims faced by the Department of Health.

“The scheme will be stillborn if the huge historical medico-legal exposure of public healthcare institutions is not resolved urgently together with the quality of healthcare provided,” Dinnie has warned in his 2018 Medico-Legal Year in Review paper.

“Starting with a clean slate – or at least a substantially clean slate – is necessary to avoid the situation where billions of rands are taken from the health budget annually to resolve a large historical list and current list of medico legal claims,” he stressed. Such an eventuality, he noted, would mean that money would not be spent on delivering and improving healthcare quality and facilities thereby creating a spiral of ongoing claims “which the public sector will have difficulty in escaping”.

Dinnie, CEO of Natmed Medical Defence who also spoke at the Gynaecology Management Group/SASOG Private Practice Weekend seminar, said that the action required would be the large number of claims being dealt with innovatively, aggressively and urgently: “Every month delay makes it more and more difficult to resolve existing and new claims cost effectively because, with the passing of time, records are lost, witnesses disappear or memories fade, expectation of the claimants harden and the cost of medical interventions which may be needed to assist deserving claimants increase significantly.”

Discussing the current state of the healthcare sector in general, Dinnie reiterated that the Health Market Inquiry (HMI) report, coupled with the NHI and Medical Scheme drafts have done little to reassure “an already skittish private healthcare industry” whose relationship with government has not been comfortable for years.

“Although having recently shown signs of improvement, this relationship is likely to remain challenging due to ideological differences and different views on funding. Everyone,” Dinnie acknowledged in his review, “is agreed on the desirability of quality universal healthcare and accessibility of affordable healthcare for all.

“It is in how that is to be achieved, as we now well know, where the differences arise.” 
2019/03/122019/03/18 02:13 PM

SA’s tight regulatory environment poses a challenge to the roll out of new health technology, putting a damper on initiatives that could provide cheaper care to more people, a senior government official conceded on Tuesday.

It took more than 18 months for the health department to obtain approval from the SA Pharmacy Council for its medicine-dispensing ATMs, the health department’s deputy director-general for National Health Insurance (NHI) Anban Pillay told a discussion hosted by Business Day and private hospital group Life Healthcare.

“SA has a deficit of pharmacists, but the Pharmacy Council saw it as a threat to jobs,” he said.

Gauteng and NGO Right to Care launched an ATM “pharmacy” that provides medication to patients with chronic illness in less than three minutes last year, in an effort to reduce congestion in public health facilities.

Panelists highlighted the potential of new technologies, such as artificial intelligence (AI)-assisted diagnosis and robotics, to improve access to healthcare services, but warned that resistance from healthcare professionals and red tape could throttle innovation.

“Regulatory hurdles are an impediment to the kind of step change we would like to see,” said Life Healthcare CEO Shrey Viranna.

There were opportunities for SA to “leap-frog” existing technologies and introduce innovative new digital health products, but they require an enabling regulatory environment, he said.
He cited Chinese company Ping An’s mobile medicine application “Good Doctor” as an example of innovative digital healthcare that could not be readily mirrored in SA due to the current regulatory environment. Good Doctor provides round-the-clock, online consultations and reaches more than 48-million people.

The Health Professions Council of SA has previously said that services offering online consultations breach patients’ rights to confidentiality, and the practitioner-patient relationship.
2019/03/122019/03/18 02:14 PM

Government promises free universal healthcare to all Mzansi people.

This means anyone who needs quality medical care gets it for free – it’s not only available to people who can afford it.

But who pays the costs of universal healthcare?

Kelly du Plessis, CEO and founder of Rare Diseases SA, said access to quality healthcare will only become popular if it is addressed at the highest political level.

The South African Health Products Regulatory Authority, the Council for Medical Schemes, Innovative Pharmaceutical Association South Africa, and other medical organisations met to discuss some disputed prescribed minimum benefits clause.

One in particular is the access and cost of orphan drugs in Mzansi. Orphan medicine is developed to treat or cure rare disease. They are often extremely expensive and excluded from cover provided by medical aid schemes.

Patricia Matseke, principal consultant at Elsabe Klinck Associates, said: “We see that our current medical schemes are unwilling to fund orphan medicines.

“We have to find what medical scheme system can’t afford orphan medicines and close the funding gap.”

Other orphan medicine issues
• How to determine a fair price for orphan medicines.
• Making patient outcomes and not money the most important factor in these decisions.
• What rare diseases and appropriate drugs must be considered.

Dr Shyamli Munbodh, acting director clinical evaluations and trials at the products regulator, said: “Our orphan drug policy guidelines with a rare disease and drug list and registry suggestions should to be released after June.”
2019/03/112019/03/18 02:12 PM

The prospect of a bargaining chamber to settle tariff negotiation issues, as recommended in the Health Market Inquiry (HMI) report, is ‘risky’, Discovery Health CEO, Dr Jonny Broomberg, told Gynaecology Management Group (GMG)/SASOG Private Practice
Weekend delegates on Saturday.

He was, however, encouraged generally by the HMI supply-side regulator concept to facilitate structures for providers and funders to negotiate tariffs as well as allowing for certain negotiations to take place outside the structure: “This is something like we had before.”

But the problem, Broomberg warned, will arise when there is no agreement and a maximum rate set by the proposed bargaining chamber will be enforced. This, he said, would have to be watched carefully as ‘we can’t control what’s going on in the bargaining chamber’

This, he said, was potentially very risky: “Someone like the minister comes in and rules, but if it works properly, gives a proper voice to the providers and funders and we don’t have politicians coming in calling the shots when there is deadlock, then it should be fine but still a real issue to keep our eyes on.

“My view,” he added, “based on discussions I have had with officials in government, is that it needs a whole new bureaucracy. But being pragmatic I have to ask the question: when will it see the light of day? I don’t think it will see the light of day at least for the next few years – if ever.

“If there is going to be a structure like this emerging, it will come out of collaboration in the private sector with funders and people like yourselves, management groups,  going to the  competition  authorities and asking them to ‘give us permission to do this ourselves for the benefit of all stakeholders’. Only reason we can’t do it today is because of the Competition Commission.” 

Another HMI point raised by the Discovery CEO was its “strong views” on the Health
Professions Council of SA (HPCSA) rules – rulings that doctors can’t work or bill in teams, and more specifically, can’t be employed by hospitals.

“I know from the various discussions I have had on this is that there are divisions on the doctor employment issues. As far as I am concerned, it is a 200-year-old debate and therefore very out of date. Everywhere else in the world there are entities employing doctors. Doctors are even setting up organisations to employ themselves – doesn’t have to be a hospital that employs them. But here they are not even allowed to do that which to me is very old fashioned.

“To run modern healthcare, people do have to work in teams. Employment is spreading out and if the terms are right employment is a very safe alternative. In the US, for example, 90% of graduates are seeking employment.

“So we support the HMI on this and it will be interesting to see what comes of it.”

On a related point, Broomberg noted that what was also missing in South Africa were corporate structures to support private practitioners.

NHI – ‘high road to catastrophe!’
As expected, Broomberg spent some time on issues pertaining to developments and the current status of National Health Insurance (NHI), alluding specifically to the “public spat” between the Department of Health and Treasury on “where’s the money coming from?” and “what will happen to medical schemes under NHI”.

On the latter, he indicated “that the small group in the presidency” advocating amendments to what was believed to be the final proposal – resulting in the Bill bouncing in and out of  Cabinet  – was most concerning. These changes, said Broomberg, represented a “high road to catastrophe” – changes which included preventing medical schemes from providing cover for conditions already covered by NHI.

An example he gave was ante-natal care, delivery, and post-natal care, all covered by NHI: “so you can claim from a clinic in Dobsonville” but not if carried out privately in the northern suburbs of Johannesburg.

In is SONA address, said Broomberg, President Cyril Ramaphosa announced that the NHI Bill would be “coming to Cabinet soon”: “What did he mean? We just hope that when it finally reaches parliament all that is in it is reasonable. If not, there will have to be a public effort to prevent it from destroying the private sector.”
2019/03/18 02:12 PM

That the Sunday Times and its associated publications are against National Health Insurance (NHI) is very clear for all to see. After all, they are no longer doing this in the form of normal reporting but in their editorial comment, affirming their position on the NHI.

In their opposition to the NHI, they are throwing mud from every direction, at every available opportunity, even linking things that are otherwise not connected. Perceived opposition to the NHI by the private sector, undocumented migrants, the presidential war room and many others are put together to prepare a case against the NHI.

The NHI is a flagship programme of the state (and the President of the country stated so on many occasions, including during the State of the Nation Address), and an international programme of the UN (goal 3.8 of the 17 Sustainable Development Goals).

Despite this, the Sunday Times has done it best to caricature the NHI as a pet project of one individual, the Minister of Health. That the concept of NHI is a resolution of the ruling party – adopted at the Polokwane conference of 2007, further endorsed in 2012 in Mangaung and in 2017 at Nasrec – does not matter in its quest to characterise it as an ill-informed project of the minister of health.

The editorial comment of March 3, “Health minister’s diagnosis will keep our health system sick”, was so riddled with conjecture, half-truths and plain lies that it would be irresponsible to allow such a malicious narrative to go unchallenged.

The first accusation against me as the minister of health is that I have alienated the private sector and put its existence in doubt. I, as the health minister, have worked very well with various stakeholders in the private sector. Apart from having worked with them very well in the Presidential Health Summit and in the subsequent launch of the summit report, I have also been working very well with the private sector on social responsibility projects for the good of the country.

Since 2013 we have worked together in the Public Health Enhancement Fund (PHEF), whereby the private sector contributes huge amounts of money to help the department build the human capacity of the country. Through this project, we have produced 40 PhDs (90 percent) and master’s (10 percent). This year and next year, another 35 will graduate, bringing the number to 75. In addition, the PHEF funds medical students from the poorest and most rural parts of the country. A total of 79 are doing internships this year.

We would like the Sunday Times to inform us which particular group in the private sector the newspaper is speaking for, because those who were at the summit and at the launch of the summit report spoke for themselves without being censored by anybody.

The second accusation is to lump together the problems of undocumented migrants and the NHI and shout “xenophobia!” to taint the department in general and the Minister in particular, and create an impression that migrants are not being treated in our public health facilities.

In fact, a huge number of them, including pregnant women, receive free treatment in our hospitals and clinics all over SA on a daily basis. We do not understand why an unauthorised circular, issued by a junior official, and which the department withdrew after being made aware of it, should be used as a measure of the position of the department, and in the process drag NHI into the quagmire.

The Sunday Times and its sister publications have persistently, directly or indirectly, questioned the right to exist of the presidential war room, which was established to give direction to the NHI process. In the process, they also demonise the adviser to the President on social and health matters, Dr Olive Shisana, who is in charge of the war room. Sinister, clandestine and irregular activities, which never existed, are invented and blamed on her. They even invented a frosty relationship and poor working relations between Dr Shisana and me. This approach creates the impression that there is secrecy around the NHI and that the Presidency has imposed itself on unsuspecting health department officials.

I have come out clearly and repeat here that I am the one who asked the President to take control of the NHI process. NHI is not just a health project, but is a project that seeks to change the direction of the nation and is an equaliser between the rich and the poor. It is bound to affect all government departments and entities. Only the President has oversight over all state institutions.

To tarnish such a structure and subject its activities to innuendo is exactly the same method the newspaper used against a South African Revenue Service unit established in the interests of the country. We are aware that the Sunday Times apologised and withdrew its scathing articles about the unit. We are bound to start doubting the sincerity of the apology in the light of similar methods being applied in its fight against NHI.

Dr Motsoaledi is the minister of health
2019/03/18 02:26 PM

Slow uptake stifles Advanced Health's SA growth prospects

When Advanced Health began building its day hospital business in SA about five years ago, it had one goal: to provide an alternative to expensive hospital stays for patients and, in turn, medical aids.

SA faces rising health care costs and a growing divide between the one fifth of the population who can afford private health care and the rest, who rely on a strained public health system.

Despite high health care costs so high, they have triggered a market inquiry the Pretoria based company's cheaper alternative to overnight hospital stays hasn't gained as much traction as it has enjoyed in the Australian market.

Day hospitals have been a tough sell in SA as patients and doctors are used to most surgeries taking place in acute hospitals. Advanced Health's lack of market penetration has seen its Alt X listed shares tumble more than 57% in the five years since listing. It now trades at about 59c.

With shares under pressure and cash running out, the company is struggling to open new facilities.

This has put it in a tight spot because its clinics take three years to break even, said Anthony Clark, an analyst at @Smalltalkdaily Research.

And "if they don't open new hospitals they can't expand their footprint, but if they expand their footprint they lose money".

According to its most recent interim results, to end-December, the company is sitting with cash of R50m and has managed to open only one hospital in the past six months.

Clark said that though Advanced Health's model is "noble and admirable" in a country that is in need of day hospitals, it will take a long time for the industry to buy into the concept.

"As it stands right now, I don't think they'll be around long enough to see the benefits. The company that generally innovates first is never the company that in the long run makes the money.

"It's always the second or third entrants in the marketplace because the people who lead generally always go bust or lose money, and the people who come after them learn from their mistakes."

Advanced Health's COO, Bibi Goss-Ross, conceded at the group's last results presentation that it had made a mistake in anticipating how long it would take to turn a start-up business into a profitable venture.

However, she was upbeat about its prospects, saying that the change that had taken place in other countries with regard to uptake was now happening in SA.

The country's major private hospital groups, such as Netcare, Life Healthcare and Mediclinic, aren't in a healthy position either in an economy that has remained in a low-growth territory for five years – during which private medical aid membership has levelled off. International expansion projects have also failed to deliver as regulation in developed climes such as the UK bite.

Netcare, the largest of the majors, has seen its stock fall more than 43% from its March 2015 peak.

But, though international expansion has proved difficult for leading hospital groups, Advanced Health has fared well in Australia.

It has been operating Down Under for 22 years as Presmed Australia, whose five facilities contributed 68% of the group's overall revenue in the six months to December. In the same period losses in the SA business deepened.

Marc Resnik, MD and CEO of Presmed, said the group's South African business is young and has not yet matured. The Australian business has long standing doctor support and operates in a big day hospital market that has about 340 private day hospitals, accounting for 54% of private hospitals in Australia.

In SA, Resnik said, the market is dominated by about 220 private hospitals, and there are about 80 day hospitals.

The strategy for the South African business is to focus on stabilising the new facilities and gaining doctor support.
2019/03/092019/03/18 02:11 PM

After a second provincial circular instructing health facilities to charge non-citizens in full for services came to light this week, the National Department of Health (NDoH) vehemently denied it was fuelling xenophobic sentiments.

“The Health Minister (Aaron Motsoaledi) never said that anyone should be attacked to say we are xenophobic is going too far,” deputy director-general for National Health Insurance (NHI) and the NDoH, Dr Anban Pillay said.

Earlier this week, Pillay said no other provincial health department other than Gauteng, acted on a bogus directive issued by a junior official from the NDoH almost two months ago.

But a second circular came to light later in the week, this time from KwaZulu-Natal, instructing non-citizens to pay for services including “emergency treatments”, which many have pointed out is unconstitutional.

“Whilst the NDoH claims that this circular was released in error, such actions have serious ramifications including furthering anti-foreigner sentiments within, and beyond, the public health-care system,” said Professor Jo Vearey of the African Centre for Migration and Society at Wits University.

Towards the end of last year, Motsoaledi came under fire for comments he made regarding the burden foreign nationals were placing on the health system.

According to Vearey, non-citizens make up only between 5% and 8% of provincial populations and are not the root cause of the crippling of the health system.

“The NDoH has a worrying track record of scapegoating foreign nationals for the poor performance of the national health-care system. Denying access to foreign nationals is a public health disaster, with negative public health implications for all in South Africa and the SADC (Southern African Development Community) region,” said Vearey.

Section 27’s Sasha Stevenson said the KwaZulu-Natal circular was withdrawn as of Thursday night, five weeks after it was sent.

Writing in public health magazine Spotlight, Stevenson asked how a junior official in the department would have come up with the content contained in the national communiqué sent in mid-January in the first place.

“The sentiment didn’t come from nowhere.” According to Stevenson, the Constitution and the National Health Act gave everyone, regardless of documentation, the right to free primary health care, antenatal care and HIV and tuberculosis treatment.

Neither could anyone be denied access to emergency care.

Stevenson said this “move to exclude foreign nationals from the health system is not without precedent”, and that the “NHI Bill envisages drastic reductions in access to care for foreign nationals, and so the war is far from won when it comes to unconstitutional regression in access to care”.
2019/03/082019/03/11 09:36 AM

With the publication of the National Health Insurance Bill, proposed amendments to the Medical Schemes Act, and the anticipation of amendments to another 12 or so pieces of legislation needed to implement National Health Insurance, a review of the funding of medico-legal claims would also be useful.

National Health Insurance is the proposed funding model for universal health care. Nowhere does the draft deal with the financing of, and financial provision for, and management of medico-legal exposure. 

The state has massive exposure to claims running into the billions of rand in many provinces. Private health facilities and health care practitioners also have their contingencies for medical-malpractice claim exposure, although not at the same level as the state.

Presumably, the hope is that once National Health Insurance is fully operational there will be universally properly functioning state health care facilities delivering good quality health care and the masses of medical malpractice claims against the state will be a thing of the past. And the incidence of claims in the private sector will also be reduced because of the increased use of good quality state facilities.

This is pure speculation because if there is a national detailed plan to deal with medico-legal exposure in state facilities, beyond the platitudes of a commitment to deliver quality care and put the patient first, that has not been communicated, nor, based on the ever-increasing media reports of claims successfully actioned.

Some provinces are doing better than others in their attempts at dealing with and resolving historical claims. Those are legal responses to existing claims. Not clinical responses to improving patient outcomes and dealing decisively with patient communication, record keeping and informed consent.

Perhaps reliance is being placed on the outcome of the Law Reform Commission’s investigation into medico-legal reform and the recommendations that arise from that. An Issue Paper was published by the Commission last year. A discussion paper is awaited.

If private medical facilities and health care practitioners are to have their fees capped, or regulated in any way, will that take into account the (in the case of a number of specialisations not insignificant) medical malpractice insurance premiums required to be paid and the risk exposures to claims of the different areas of specialisation?

In resolving what has been labelled a medico-legal crisis the opportunity does present itself in finalising a National Health Insurance framework to include an appropriate funding model to deal with medico-legal claims.

At the moment the state does not, and cannot because of the Public Finance Management Act apparently, budget separately for medico-legal claims or insure for that exposure. That creates the problem that a health budget for any year is in effect not the health budget in the sense of funds available for the delivery of health care because medico-legal settlements and court awards are required to be paid from that budget as well. And anecdotally it seems that because in part of that budgeting anomaly, in decision making structures and authority, is it often easier for an official to await judgment in a claim to action payment than to be proactive and resolve as soon as possible.

At a state level, there is a need and opportunity to focus on and structure financial accountability for medico-legal exposure and claims in a far better way than has been done before. The authority to insure that exposure (the ability to do so is another question including a market appetite for massive exposures) is another avenue worth exploring. Any insurer would want the comfort of knowing that they could implement appropriate risk control processes and reward programmes including reduced premiums and/or deductibles in return for appropriate risk reduction and control behaviours. But it is silly not to at least have the ability to engage, collaborate with and capitalise on the skill and expertise of local and international insurers steeped in medical malpractice experience.

National Health Insurance also creates the opportunity of debating whether a no-fault regime for avoidable adverse medical outcomes is desirable and practicable.

A number of jurisdictions around the world have no-fault legislation. Some allow the option of going a no-fault route for a speedy but perhaps limited payment if certain criteria are met, without removing the right as an alternative to litigating with all the issues and costs that come with litigation. In other jurisdictions no-fault resolution is mandatory and the right to litigate is removed. Some jurisdictions provide for no fault resolution in all types of medical outcomes, others have limited categories.

The states of Florida and Virginia have birth-related neurological compensation legislation financed by a fund contributed to by participating hospitals and doctors who contribute on a sliding scale depending on their participation time period. To be eligible for payment, certain criteria need to be met. That includes the suffering of a birth-related neurological injury as defined in the governing legislation.

A universal and national no-fault system would be dependent on political will both at government level and in the private sector to drive that innovation, an appropriate financial model and funding and the willingness and ability to deal with the legal challenges, including constitutional challenges such a system would bring. In funding and running the model, there is a role for medical malpractice insurers to play given their expertise and experience in the field.

Even if not legislated for there may well be a role for a voluntary no-fault system offered by state and private facilities and practitioners alike. Patients may be given the option of a speedy but limited no-fault resolution to an avoidable adverse outcome without the delays, costs and destructive processes of attributing blame, in return for abandoning further legal recourse.

A bolder step, and one which would avoid legal debates about the correctness of giving up the right to resolve a claim in court, would be to provide a no-fault payment on certain criteria without requiring abandonment of any further rights of recourse. It may well be that in most cases the matter is taken no further.

There are, of course, many permutations possible for a no-fault offering. It may be limited to certain types of medical interventions or outcomes only, or quantum of costs for example. And there is a significant role for insurers to play in such a voluntary no-fault system – in respect of funding, managing, risk control and pro-active interventions.

The reality is that there will always be medico-legal claims, despite the best intentions of health practitioners, and National Health Insurance needs to take that into account and deal with the management and financing thereof.
2019/03/082019/03/11 09:38 AM

A Durban-based private hospital group is in a legal war with 13 medical aid schemes that it claims are refusing to pay R27-million it is owed for hundreds of “preauthorised” hospital visits. If this is not resolved, the patients could be sued for the money. City Hospital Pty Ltd, which owns City Hospital and Ascot Park Hospital, claims that administrator Medscheme is behind the payment ban because it raised “anomalies” in admission patterns at the two hospitals. It says Medscheme claims that certain directors of the group, who are doctors, are enriching themselves through admissions. The group claimed Medscheme refused to provide full details of the allegations. The two biggest debtors are Bonitas, which owes R14.5-million, and Polmed, which owes just under R10-million. The hospital group says it is being financially crippled by the non-payment and wants a court to direct that the registrar and the Council for Medical Schemes (CMS) undertake an urgent inquiry into the matter.

Undesirable business practice
It wants CMS to declare the conduct of medical aid schemes as an “undesirable business practice” and to probe who at Medscheme motivated for the medical aids to withhold payment and “to what extent is the type of behaviour is prevalent against others and who they are”. But CMS CEO Dr Sipho Kabane, in an affidavit filed with the Durban High Court, said that the complaints process is governed by legislation. He said it is inappropriate for the applicant to seek that this court direct how an investigation should be conducted. Paul Midlane, GM of healthcare forensics for Medscheme, said an audit had revealed that doctors with the highest admission rates were also shareholders in the group. He said that while it is not unlawful, admitting doctors have an ethical duty to notify patients of this potential conflict of interest.

Admitted without screening
Midlane said the majority of patients were admitted directly into the hospital without screening, adding that it was clear that doctors were admitting the vast majority of patients and then only consulting for the first time. Midlane said pre-authorisations were issued in good faith and were not a guarantee of payment. He said that in the past two years, Medscheme had paid the hospitals R323-million and he believed a substantial portion of that could have been avoided if it were not for unnecessary admissions. In his affidavit, the group’s GM Vishnu Rampartab, pinned the blame for the non-payment on Medscheme manager Mcdonald Marabo who he said “lacks objectivity” and “has an agenda”. In disputing claims that doctors are enriching themselves, he said the sole shareholder of the group is Joint Medical Holdings “which in turn has two corporate shareholders whose shareholding exceeds 490 different shareholders of which the applicant’s directors constitute a minority”.

Payments on hold
Rampartab said he was contacted by Marabo in June 2018 who said he had concerns about admission patterns. He did not define them but said all payments would be put on hold. The initial complaint was against Ascot Park, but in November the allegations were repeated against doctors at City Hospital. Rampartab said that Marabo had met one doctor privately “and had threatened to withhold payments to him unless he abandoned significant amounts of his claim”. The group sought the opinion of Deborah Pearmain, an expert in liability of medical schemes, who confirmed that “withholding payment on the grounds of alleged unethical conduct by medical practitioners who work at hospitals is unlawful”. Attorney Aneesa Mahomed, for Bonitas, said the scheme, upon the furnishing of the claims by City Hospital, would analyse them “and then take a view regarding their validity”. Mahomed said while Medscheme has a duty to check for possible fraud, it is subservient to the medical aid schemes and Bonitas can act independently of it. She said it was possible that should payments not be made, the hospital could make claims against patients “but they will have to prove that the claims are valid”. Polmed principal officer Neo Khauoe said they were opposing the application. He said the scheme has a duty to protect interests of members, including not paying for potential overservicing or overcharging.
2019/03/072019/03/11 09:33 AM

More than 8.8 million South Africans brace themselves for the rising annual cost of medical scheme cover to ensure their families receive quality healthcare services should the need arise.

However, it is not just consumer price inflation that sees you forking out more for your health plan each year but also the rise in medical aid fraud.

"Up to 25% of the money you pay for your medical aid is lost to fraud, waste and abuse, costing the private healthcare sector between R22-billion and R28-billion every year," explains Dr Katlego Mothudi, managing director at the Board of Healthcare Funders.

What is medical aid fraud?
According to the Council for Medical Schemes, medical aid fraud refers to an intentional deception or false statement of facts in a claim that could result in a benefit or payment that would otherwise not get authorised, including:

• Non-disclosure of pre-existing conditions by the member to the scheme;
• Allowing your healthcare provider to charge for services not provided;
• Loaning your medical scheme card to unregistered dependents, including family and friends;
• Providing your medical scheme or policy details to a healthcare provider to submit a false claim for a financial kickback;
• Buying non-medical goods with your medical aid card from doctors and/or pharmacies; and
• Being admitted to hospital for a non-existent ailment to benefit from the cashback payment from your insurer.

Other examples include claiming for fillings when cosmetic dental work was done, ordering unnecessary blood tests or even obtaining sunglasses where a claim for prescription spectacles have been processed.

A major criticism faced by medical schemes in SA is that they do not communicate effectively and enough with their members regarding the issue of fraud and when a member could potentially be committing an offence.

It is therefore important that all stakeholders understand what constitutes inappropriate behaviour as well as the consequences that may result from such conduct.

"Look, we understand that communication from a medical scheme to a member is usually thrown in the trash unless it contains a cheque, but more effort needs to be made to ensure that consumers remain informed and educated at all times to make quality healthcare more accessible to more South Africans," says Paul Midlane, general manager of healthcare forensics at Medscheme.

Dr Simon Mangcwatywa, principal officer at Sizwe Medical Fund says the best way to keep members informed is for the medical scheme to constantly share content with its members. Education places power back in the hands of members and gives them the incentive to use their medical aid card responsibly and play their role in reducing the cost of medical aid fraud by:

• Seeking second opinions before any procedures;
• Questioning any and everything to pick up unlawful acts by service provides;
• Seeing a GP before a specialist to ensure the right referral is given;
• Investing in preventative care and exploring non-invasive options where possible; and
• Viewing medical aid cover as a necessity that gives access to quality care as opposed to a grudge purchase.

Imagine for a moment a world with no medical aid, where you would have to pay for all medical and associated costs from your pocket.

Most people would not be able to afford it, so inevitably if the cost of care dropped, it would be to the benefit of all South Africans, whether they're on medical aid or not.

Industry experts who recently met at the Sandton Convention Centre for the Council of Medical Schemes' Fraud, Waste and Abuse Summit agree that though medical aid fraud is a complex form of financial fraud that is often hard to detect, monitor and prevent, industry collaboration and members blowing the whistle on detected fraud can go a long way in diverting the loss from where it hurts the most - your pocket.
2019/03/072019/03/11 09:35 AM

A recent article in the Sunday Times “Better not to know total NHI cost” is reflection of the Minister of Health being totally disingenuous and denialist of what is required in South Africa’s aims to achieve Universal Health Coverage (UHC).

Although the World Health Organisation (WHO) is alluded to in the White Paper as cautioning that while costing assumptions and scenarios may be useful for raising core policy issues regarding the sustainability of reforms, it is not useful to focus on getting the exact number indicating the estimate costs. The WHO, however, clearly states in the quoted document that costing assumptions and scenarios may be useful for raising core policy issues regarding the sustainability of reforms. It is a concerning failing to assume that one does not need to do a costing of the NHI in order to implement it, as affordability cuts to the core of the implementation potential of the policy.

Radically overhauling the entire system is definitely a core policy issue, which needs to be considered. The original NHI Cost projections were based on state care costs in 2010. That was inflated up to 2026. So, it is not a “thumb suck”, as the Minister has previously stated, it is what state services will cost in 2026, irrespective of whether NHI gets implemented or not. So, South Africa will face this funding shortfall in state care by 2026. What the estimate failed to consider was the private sector spend, which equals the public sector spend, even though it covers a smaller portion of the population. One cannot, however, assume you can render services to the private scheme population without incurring any additional spend, no matter how you structure the system.

The quoted Irish example is painfully relevant to SA, and the same costing and scrapping exercise should be happening here. Instead, we keep denying that we should do a costing and carrying on with planning. NHI is purely a political ideology which cannot be practically implemented. If one approves the NHI Bill, the project is set in motion, without any idea of future costs. That is a failure in due diligence. There will be massive costs in setting up the administration of the NHI Fund in offices and staff costs, which South Africans will have to fund, irrespective of whether NHI is ever fully rolled out or not. The NHI fund will be a state payment body, twice the financial size of Eskom. The three state bodies currently fulfilling a similar role to the NHI Fund (i.e. disseminating government funds to the population in one form or another) are SASSA, the RAF and the Compensation Fund. All three are in a dire financial and administrative state and assuming that the NHI fund will be any different is obtuse thinking.

If we can do a costing exercise now and realise that NHI in its current format is unaffordable, we can start looking at alternatives. But there is a lack of political will to do this. South Africa has 8.8 million medical scheme beneficiaries who currently pay for their own healthcare at minimal expense to the state, and 5.7 million taxpayers. NHI wishes to have healthcare for everyone funded by 5.7 million taxpayers, including healthcare of the 8.8 million people currently self-funding. If one takes state employer subsidies and tax credits out of the equation, South Africa would have to raise an additional R105 billion in taxes annually to replace the voluntary private spend which is currently the norm. 

The Minister’s indication that private prices are inflated, was the reason for the establishment of the Health Market Inquiry. The one glaring absence in their interim HMI report, was an indication that private healthcare is costly due to provider tariffs being too high. Utilisation is driving costs, because the population is getting sicker and older. The medical scheme population grew by 0.67% in the last three years and the number of pensioners by 14.4%. South Africa therefore faces a utilisation crisis and a different systems design is not going to reduce the costs of the private sector by 30%. If services are purchased from the private sector at rates that are not reflective of the costs of running the system, the system will not continue to function. While doctors can work longer hours to cover costs when seeing patients at lower rates, this saving is limited by the available hours and reflects the assumption that private doctors are not already working very long hours and close to full capacity.

Countries with single payer UHC models all have large tax bases and co-payments (along, of course, with massive waiting times for service). The research provided by DoH does not explain why South Africa decided on a single payer model. What does explain it, is current testimony in front of the Zondo Commission. Did we create a healthcare funding model to ensure easy central access to the contained funding for politically connected individuals, who were busy expanding a business empire into healthcare? We need a South African solution for a uniquely South African problem, which includes a much more pragmatic approach and recognition that the administration expertise that would be required by an NHI Fund does not exist in government. The shining ray of hope at this stage, is the announcements by the Finance Minister, who is painfully clear in admitting that there are no public funds for any large projects, including NHI.

South Africa needs to increase the size of medical schemes by making membership mandatory for employed individuals. If SA can mandate minimum wage, medical scheme membership should follow the same route. Increasing voluntary health spend in the private sector, will reduce the burden on the public sector, creating an opportunity to improve quality. It will also reduce the costs of private healthcare premiums by 20%. The reasons given for NHI? To reduce costs in the private sector and improve quality in the public sector. This explains the lack of political will to fix the current system, because a repaired system will negate the need for NHI, which is purely a political ideology and not a pragmatic attempt to address the issues in SA Healthcare.

Dr Johann Serfontein is a Healthcare Consultant and published novelist, under the pseudonym Jean Cerfontaine
2019/03/11 09:29 AM

Error: Dept. ‘mistakenly’ tells provinces noncitizens ‘must pay’
Migrants do not constitute a significant burden on health resources – report

The Gauteng department of health issued a circular, backed by the national department, last week that instructed the reclassification of all non South African citizens to "full paying patients".

But when Health-e News contacted Dr Anban Pillay, deputy director general for National Health Insurance at the national department, he said senior officials, including Minister of Health Aaron Motsoaledi, first caught wind of this communication, dated January 15, last weekend.

Pillay said the error had been traced to national department official Ursula le Roux, director of revenue management, who is responsible for sending out communications to provinces regarding the uniform patient fee schedule on an annual basis.

According to Pillay, Le Roux issued the communique "without the authority" necessary for such a substantial change for health policy and "misunderstood talks between government departments". She then created the document because "she thought it was a good thing to do", but "it was her own interpretation and does not reflect any official version".

The Gauteng directive, dated February 20, instructed that noncitizens must now "pay for all healthcare services including emergency treatment, confinement maternity and basic health services etc... The cost of services rendered must be paid up front".

"This circular is hugely worrying because it is in contravention of both the constitution and the National Health Act, and even in contravention of the Gauteng department's own existing policy," said Jo Vearey from the African centre for Migration & Society at Wits.

One of the most concerning aspects in the circular was the reference to "basic services", which includes the provision of HIV and tuberculosis (TB) treatment, she said.

"If access to HIV and TB care is explicitly being removed, it would constitute a public health disaster and goes beyond simply the right to health which remains paramount but has serious implications for controlling HIV across the whole region," she said.

A Lancet Commission report published in December notes the need to prioritise migrant health in any discussion relating to universal health coverage.

Research has shown that migrants do not constitute a significant burden on health resource and that denying these groups ac cess to services undermines population wide health, it said.

Professor Steve Tollman, from Wits, who served as one of the 20 commissioners for the Lancet report noted: "Clearly, we want to take care of our citizens but clearly, we want to take care of others who cared for us pre ‘90s.

Resources are finite but the answer is simply not to reject those who are not 'us'. Universal health coverage does not mean 'but not I you're not one of us'."

Despite being a mistake, man: are worried about the implications of this messaging in term of the treatment experienced be noncitizens in health facilities. Pillay said Le Roux would be undergoing "a formal process" to "manage" the internal system so that "she doesn't make this kind of error again". Pillay said the Gauteng department had been given an urgent instruction to retract the circular.
2019/03/062019/03/11 09:29 AM

Doctors and medical schemes clashed in discussions during the Council of Medical Schemes’ inaugural Fraud, Waste and Abuse Summit, which was boycotted by the Hospital Association of SA.

Medical doctors have hit back against the commonly held narrative that they are the main drivers of fraud, waste and abuse in the private health sector – throwing the blame right back at their accusers, the medical schemes. City Press reports that the not-so-subtle blame-shifting formed part of discussions held during the Council of Medical Schemes’ inaugural Fraud, Waste and Abuse Summit – held recently.

The report says the two-day gathering was aimed at bringing together health practitioners, medical aids, policy makers and other industry stakeholders to discuss strategies to deal with such misrepresentation – which costs the industry between R22bn and R25bn a year. According to the council’s latest report figures, released last year, the annual claims paid out by schemes in 2017 amounted to R172bn – and 15% of those claims were as a result of fraud, waste and abuse.

The report says noticeably absent from the discussion was the Hospital Association of SA – the representative body for the majority of private hospitals in South Africa – to detail the role played by its sector.

According to the council’s report, most of the industry’s healthcare benefits went to covering hospital expenditure amounting to R59bn.

The report says first to address the attendees was the Special Investigating Unit (SIU) head, advocate Andy Mothibi. He revealed that in some provinces, such as the Eastern Cape, investigations unearthed how lawyers were colluding with doctors to make fraudulent medico-legal claims, with one lawyer having claimed R90m for six cases and got doctors to sign off on the cases – yet the injured were actually healthy. Then Ishmael Mogapi, operations risk manager at the Government Employees Medical Scheme (Gems), added this body’s experience of a fraud committed that was linked to doctors. He spoke of a psychologist who claimed to have worked 490 hours in a day and reprimanded hospital groups which admitted patients to help them claim back from their cash-back plans.

And, the report says, Paul Midlane, the GM of healthcare forensics at Medscheme, cited the example of an obscure, run-down surgery claiming R1m from the scheme for medicines dispensed in 11 months. Midlane gave examples of how pharmacies and suppliers also contributed to fraudulent practices in the industry, with one pharmacy having claimed R1.2m from Medscheme, yet on inspection, its shelves stood almost empty.

But, the report says, doctors at the conference did not take the finger being pointed at them lying down. “We do not promote fraud, we actually stand against it,” said Dr Prudence Buthelezi, secretary-general of the National Health Care Professionals Association. “And we have said to medical aids that ‘if you do suspect our members, open criminal cases’. But also, when it comes to the reimbursement of healthcare practitioners, we are not paid (by schemes) what we are worth. A dentist will be paid R250, a GP R450 and a specialist R700, so we have to look at whether that, too, is not contributing to fraud.

“This issue of designated service providers (DSP) that medical aids work with is also unethical by law as it leads to healthcare professionals being controlled by the medical aid, and not looking at what service would best suit the patient.

“Also, as doctors under that DSP, you have to prescribe the medication that the scheme wants you to … it is about cost for the scheme and not about the patient,” she said.

Dr Elijah Nkosi, CEO of the Independent Practitioners Association Foundation – representing 5,000 doctors – is quoted in the report as saying medical aid schemes were also guilty of conducting underhanded “probes” of doctors’ practices to avoid paying out their claims. “Doctors are forced to sign acknowledgments of debt under duress and their claims are held back, yet the numbers they present are thumb-sucks. We are against forensic units (in schemes). If there is an ethical matter against the doctor, report it to our regulator, the Health Professions Council of SA. If it is a criminal matter, report it to the SA Police Service,” he said.

Mogapi denied that Gems conducted probes on doctors’ practices.

Dr Mvuyisi Mzukwa, board vice-chair of the SA Medical Association, said in the report that the narrative that doctors drive fraud, waste and abuse was incorrect and incomplete as there were a number of other drivers. “Chief among those drivers are the benefit plans that allow members to bypass their family doctors and result in duplicate services. We caution strongly against this simplistic narrative and call for transparency, fairness and equity in dealing with the matter,” he said.

Marius Smit, the head of forensic services at Discovery Health, also cautioned against only blaming doctors. “This is not a doctor issue. We need to be careful of that narrative … it includes doctors, member fraud and corporate fraud. It is all evenly spread.

“Obviously, the money component is important in terms of what fraud costs the industry, but there is also a quality of care component. Hospitals are a great place to be if you’re sick; not so much if you’re not,” he is quoted in the report as saying.

At the summit’s conclusion, the various schemes, health practitioners and industry bodies agreed on key definitions related to fraud, waste and abuse, and signed an industry charter pledging to work against them.
2019/03/062019/03/11 09:31 AM

Recent national and Gauteng memos demanding all foreign patients pay in full for services likely fell foul of the law.

Directives recently issued by the national and Gauteng health departments requiring foreign nationals to pay in full for healthcare at public facilities weren’t only a threat to public health, they may have been downright illegal.

Walk into a public hospital, and you may be asked to fill out a form stating just how much you earn. That’s because many services in the public sector are billed for on a sliding scale based on a means test: You pay what you can for the treatment you need. At least in theory.

In mid-January, a national health department circular reportedly instructed clinics and hospitals to begin billing foreign nationals the full rate for public health services. Low-income refugees, the memo said, would be the sole exception and would be means tested, Business Day reported.

Only Gauteng passed these instructions onto its clinics and hospitals, specifying that all non-South Africans other than documented refugees should be charged full fees for all services including emergency treatment, maternity care and “basic health services”. The national health department has now said that the circular should have never gone out.

Speaking to Business Day, Gauteng Health MEC Gwen Ramokgopa said “the province had aligned itself with national policies” but had withdrawn its circular to public facilities.

As a public interest law organisation, we believe that Gauteng’s circular was unlawful in that it had the potential to withhold previously available services from patients, contravened the National Health Act and could have led to violations of people’s constitutional rights. It also threatened to derail progress towards HIV targets contained in the country’s latest national plan that require 90% of all people to know their HIV status and 90% of those to be on antiretrovirals.

Section 27 of the Constitution says that everyone has a right to have access to health care services, including reproductive health care services and that no one may be denied emergency medical treatment.

What does this mean? Here’s a breakdown of who is entitled to what in South Africa’s public sector.

1. Who is entitled to free healthcare in South Africa?
Section 4(3) of the National Health Act provides for certain free health care services for people who don’t have medical aid. It does not limit access to these services based on nationality or immigration status, meaning that these services are available to all, South African and not; documented and not.

It says:
1. Everyone is entitled to free primary health care services at government facilities. This means that clinics are free to all;
2. All women are entitled to free abortion at government facilities. Under South African law, anyone can terminate a pregnancy up until 12 weeks for whatever reasons and between 13 and 20 weeks if the pregnancy endangers the woman's mental, physical or socioeconomic health;
3. All pregnant and breastfeeding women and children under the age of six are eligible for free health care services at public clinics or hospitals.

Until a health minister publishes conditions to the contrary, this is the law that applies. In the future, if this happens, a health minister won’t just be able to impose whatever conditions they like. They’ll have to show their proposals take into account the free services already available and how changes would impact access to health care services and the needs of vulnerable populations such as women, children, the elderly and people with disabilities.

A 2007 national health department directive also guarantees free HIV and TB care and treatment to anyone regardless of status.

2. What health services do foreigners pay for?
Refugees, asylum seekers as well as undocumented migrants from Southern African Development Community (SADC) states including Lesotho, Mozambique and Zimbabwe who need hospital care – should be treated like South African citizens. That means they’ll have to take the means test given to South Africans to determine how much they have to pay for hospital care.

Undocumented people from countries outside SADC who attend hospitals — except pregnant or breastfeeding women, children under six and women seeking an abortion — are expected to pay the full fees as laid out in the national schedule.

Nationally, what people pay for hospital services is defined by a patient fee schedule that lists fees for procedures such as dialysis for patients with kidney failure, for which the state bills full paying patients about R2000 per session.

But health MECs can impose additional criteria and procedures concerning this, including fees for different groups of people. For instance, the Gauteng Hospitals Ordinance Amendment Act 4 of 1999 provides that the CEO of a hospital may require identification documents before admission to a hospital except where deferring treatment may have "dangerous or detrimental consequences" to the person seeking treatment.

The vagueness of the legislation’s wording leaves it open to a broad interpretation, meaning that this may be more widely used than it was intended to be. Hospitals need some proof of identification to see a patient, and they may also require proof of income. But the failure of staff to communicate what they need and how it can be provided can sometimes lead to patients being turned away when they are unable to offer a South African ID book or an asylum document or a refugee permit.

Patients that can’t produce these documents can, however, submit foreign passports or an affidavit.

A 2008 Gauteng health department memorandum also says that “no patient should be denied access to any health care service, including access to antiretrovirals, irrespective of whether they have a South African identification document or not”.

Finally, no one may be refused emergency medical treatment, including on the basis of ability to pay. This means that it doesn’t matter who you are or where you seek care, if it’s emergency treatment you need, you may be charged for it after it has been provided (based on the provisions above), but you can’t be required to pay for it before it is delivered.

3. What do you need to know?
Basically, everyone regardless of their documentation is entitled to free primary healthcare, antenatal care, abortions as well as HIV and TB treatment. Pregnant, breastfeeding, under the age of six? Then your healthcare at clinics or hospitals should be free too.

If you’re not from here but are from a SADC country, or you’re a refugee or asylum seeker, you should be treated just like South Africans at public hospitals and will be assessed to see how much you can afford to pay.

Everyone else? You’re looking at paying full price but just for hospital services.

Sasha Stevenson is the head of healthcare at Section27.
2019/03/11 09:31 AM

While South Africa has made tremendous progress in the provision of health care including vaccinating more than 1,9 million girls against cervical cancer, the only sustainable way to give quality health care to all is through the implementation of the NHI, writes Health Minister Dr Aaron Motsoaledi

As a young medical doctor, I met an elderly woman in my home village of Glen Cowie in Limpopo. The elderly woman knew that I was a medical practitioner and she approached me for help. She pleaded with me that I should assist her to deal with her unending "menstruating" problem.

I knew immediately what the problem was. She had advanced stage of cervical cancer.

For most African women, especially those who live in rural areas, they are only diagnosed with cervical cancer when the disease has advanced to stage 4, when they are basically left with very short time to live. Many of them find it hard to talk about it as they consider it taboo that they could be menstruating when they are in their seventies.

Of course that elderly woman died a short while after our contact.

As tragic as it is, the agony of the elderly villager is not an isolated case. According to 2017 figures, there are 5 743 new cases of cervical cancer that are reported each year in South Africa. Each year, more than 3 000 women die from this disease.

But there is hope. The current generation of young women have a fighting chance to escape this killer disease. Today, girls aged 9 years have the benefit of HPV vaccination that protects them from developing cervical cancer.

Sadly, this protection was not yet available in the eighties, which is why the elderly woman from my village had developed cervical cancer.

Cervical cancer is the second biggest type of cancer that kills women. The biggest cancer killing women is breast cancer.

South Africa started providing HPV vaccination to young girls in 2014. As part of the prevention of diseases, the Department of Health has been in the forefront of the campaign to ensure that young girls are prevented from suffering the same fate as my elderly relative. From 2014, more than 1,9 million girls have received Dose 1 of HPV vaccination. A total of 1,2 million have received both Dose 1 and Dose 2 HPV vaccination. An individual requires both doses of HPV to prevent her from developing cervical cancer.

The HPV vaccination programme has huge benefits. The obvious one is that it prevents millions of women from developing cervical cancer, thus making them to live long and healthy productive lives. There are also benefits to the economy in that they would not be confined to their hospital beds but would be engaged in productive activities.

The other benefit is that the vaccination program reduces the burden of diseases in the health care facilities. In other words, fewer people would need hospital beds and all the required care associated with hospitalisation.

The other benefit is that the programme has been able to save money for the state. When we started it, we projected, based on the prices of HPV vaccine, that we would spend about R1,2 billion a year on it. Because of the huge number of the girls that require the vaccine, we used our economic of scale to negotiate better prices with the suppliers. This has resulted in huge savings. Instead of spending R1,2 billion, we are spending R200 million.

Our vision is to aggressively fight the spread of cervical cancer in our country so that the next generation of our elderly women would not experience "menstruation" at the advanced age of 75 years.

This is an expensive programme which can only be sustainable in the long term by the implementation of the National Health Insurance (NHI). Many countries around the world have embraced the concept of Universal Health Coverage (UHC). The basic idea behind the concept is that everybody should have access to quality health care regardless of their economic or social status. In other words, nobody should be denied health care because he or she cannot afford to pay.

In our country, our adopted UHC plan is the NHI. The NHI will be implemented in stages because there are many things that should happen before it could be implemented in full. We would need a total overhaul of the health care system because we cannot just super impose the NHI on the current health care system. Even our economic blue print, the National Development Plan (NDP) has identified two things that should be dealt with to improve the country's health system. These are the high cost of health care in the private sector and the quality of health care in the public sector. In essence, before we could roll out NHL we should attend to these main factors that the NDP has identified.

But NHI is not an event that will have a big launch date. It is a long process that that has already started. As we continue to build the foundation of NHL there are things that we have already started doing.

We have consistently stated that the heartbeat of NHI is Primary Health Care. And Primary Health Care has three major components. The first is prevention of diseases, the second is promotion of a healthy life-style and the third is that when a patient gets sick, the first point of call should be a Primary Health Care facility such as a clinic and not a tertiary hospital.

Our long term vision is to reduce the burden of disease and to contribute in making our people live a longer and healthy life.

This page is in partnership with the Department of Health
2019/03/052019/03/11 09:26 AM

Limpopo’s senior medics allege unlawful promotion of juniors to managerial posts

Senior medical doctors in Limpopo are up in arms over claims that the province’s health MEC, Phophi Ramathuba, is desperate to curry favour with union bosses – and, as a result, has allowed inexperienced individuals to be appointed irregularly and unlawfully to senior management positions in various Limpopo hospitals.

The disgruntled doctors allege that Ramathuba appointed these junior doctors based either on their relative proximity to her or on the fact that the doctors are close to union bosses, particularly those affiliated with the SA Medical Association (Sama).

“Ramathuba only appoints those [junior doctors] close to her and union leaders, particularly those from Sama,” said Dr Stephen Ntlhane a senior practitioner at Mokopane Hospital.

“She does this because she seeks to silence the union bosses from raising sharply the health issues in the province.”

Among the doctors affiliated with Sama who were alleged to have been appointed irregularly is Dr Sizeka Maweya, Sama’s current chairperson in Limpopo.

He was appointed to the post of clinical executive director.

“Dr Maweya did not have the eight years of experience required to be a clinical manager or the required three years as senior clinical manager – meaning that he was not even supposed to be short-listed,” said Ntlhane.

Dr Mvuyisi Mzukwa, the national vice-chairperson of Sama, confirmed that Maweya was Sama’s chairperson in Limpopo.

But, she added: “Sama’s national leadership is not aware of any irregularities in his appointment because the association was not part of the process that led to his appointment, nor has Sama received any complaints about it.”

Mzukwa went on to make a request that anyone with information to the contrary should make it available to the association.

“Sama currently has the biggest market share among unionised doctors; it is therefore possible to randomly pick up a Sama member when appointing a doctor to management positions, especially in smaller provinces such as Limpopo,” said Mzukwa.

However, she conceded that Sama did not know why these individuals would be appointed to such positions if they did not meet the work experience requirements.

Still, she remained resolute about Sama not being involved in appointing people: “Sama was not part of the process of appointments and was not privy to any information regarding these appointments.”

Ntlhane argued that the appointment of less experienced doctors came at the expense of “better-qualified and more experienced candidates” like him, adding that he had been overlooked numerous times.

In response, Ramathuba denied allegations that she was appointing doctors to senior positions based on their proximity to her or based on unions’ affiliation with Sama.

She went on to argue that there were more “highlights in appointing young clinical managers and the chief executive officer” than there were disadvantages.

“At Mankweng Hospital, many specialists had left and it had become difficult for the institution to operate as a tertiary hospital. But since the change of leadership here, specialists are coming back.

“One of the greatest highlights in the recruitment of specialists is Dr Thato Moabelo-Monareng, who is the only ophthalmologist in the province assisting the department in dealing with eye operation backlogs.”

Ramathuba added that it was thanks to youthful creativity and the passion of this new management that Mankweng Hospital “has opened the first-of-its-kind optic laboratory in the province, where we are able to test, prescribe and assemble spectacles while a patient waits”.

She did not dispute the fact that the doctors being appointed to these senior positions did not meet the work experience requirements, but maintained that “bringing young, vibrant and passionate people into positions of leadership means that more and more specialists are accepting to come and work in Limpopo”.

Ntlhane, however, refuted this, saying older and more experienced doctors were leaving the province over the appointments of these junior doctors.

He reported the matter to Health Minister Aaron Motsoaledi, but said he had yet to receive any feedback from the minister’s office.

City Press has seen the numerous emails that Ntlhane has sent to the minister’s office.

He and two other doctors, who spoke to City Press on condition of anonymity, said they were now seeking recourse from the media, “seeing that the MEC and the unions, which are supposed to take up such matters, are the ones embroiled in the scandalous appointments”.

The disgruntled doctors said the minimum requirement for the senior clinical manager position, as stipulated in the 2017 advertisement, was eight years’ appropriate experience as a medical officer after registration with the Health Professions Council of SA.

They added that there were many other cases where junior doctors without the prerequisite eight-year experience had been appointed.
2019/03/042019/03/11 09:25 AM

Hitting back, they accuse schemes of unlawful probes, underpayment and ignoring patients’ needs

Medical doctors have hit back against the commonly held narrative that they are the main drivers of fraud, waste and abuse in the private health sector – throwing the blame right back at their accusers, the medical schemes.

The not-so-subtle blame-shifting formed part of discussions held during the Council of Medical Schemes’ inaugural Fraud, Waste and Abuse Summit – held last week at the Sandton Convention Centre.

The two-day gathering was aimed at bringing together health practitioners, medical aids, policy makers and other industry stakeholders to discuss strategies to deal with such misrepresentation – which costs the industry between R22 billion and R25 billion a year.

According to the council’s latest report figures, released last year, the annual claims paid out by schemes in 2017 amounted to R172 billion – and 15% of those claims were as a result of fraud, waste and abuse.

Noticeably absent from the discussion was the Hospital Association of SA – the representative body for the majority of private hospitals in South Africa – to detail the role played by its sector.

According to the council’s report, most of the industry’s healthcare benefits went to covering hospital expenditure amounting to R59 billion.

First to address the attendees was the Special Investigating Unit (SIU) head, advocate Andy Mothibi.

He revealed that in some provinces, such as the Eastern Cape, investigations unearthed how lawyers were colluding with doctors to make fraudulent medico-legal claims, with one lawyer having claimed R90 million for six cases and got doctors to sign off on the cases – yet the injured were actually healthy.

Then Ishmael Mogapi, operations risk manager at the Government Employees Medical Scheme (Gems), added this body’s experience of a fraud committed that was linked to doctors.

He spoke of a psychologist who claimed to have worked 490 hours in a day and reprimanded hospital groups which admitted patients to help them claim back from their cash-back plans.

And Paul Midlane, the general manager of healthcare forensics at Medscheme, cited the example of an obscure, run-down surgery claiming R1 million from the scheme for medicines dispensed in 11 months.

Midlane gave examples of how pharmacies and suppliers also contributed to fraudulent practices in the industry, with one pharmacy having claimed R1.2 million from Medscheme, yet on inspection, its shelves stood almost empty.

But doctors at the conference did not take the finger being pointed at them lying down.
“We do not promote fraud, we actually stand against it,” said Dr Prudence Buthelezi, secretary-general of the National Health Care Professionals Association.

“And we have said to medical aids that ‘if you do suspect our members, open criminal cases’. But also, when it comes to the reimbursement of healthcare practitioners, we are not paid [by schemes] what we are worth. A dentist will be paid R250, a GP R450 and a specialist R700, so we have to look at whether that, too, is not contributing to fraud.

“This issue of designated service providers (DSP) that medical aids work with is also unethical by law as it leads to healthcare professionals being controlled by the medical aid, and not looking at what service would best suit the patient.

“Also, as doctors under that DSP, you have to prescribe the medication that the scheme wants you to … it is about cost for the scheme and not about the patient,” she said.
Dr Elijah Nkosi, chief executive of the Independent Practitioners Association Foundation – representing 5 000 doctors – said medical aid schemes were also guilty of conducting underhanded “probes” of doctors’ practices to avoid paying out their claims.

“Doctors are forced to sign acknowledgments of debt under duress and their claims are held back, yet the numbers they present are thumbsucks. We are against forensic units [in schemes]. If there is an ethical matter against the doctor, report it to our regulator, the Health Professions Council of SA. If it is a criminal matter, report it to the SA Police Service,” he said.

Mogapi denied that Gems conducted probes on doctors’ practices.

Dr Mvuyisi Mzukwa, board vice-chairperson of the SA Medical Association, said the narrative that doctors drive fraud, waste and abuse was incorrect and incomplete as there were a number of other drivers.

“Chief among those drivers are the benefit plans that allow members to bypass their family doctors and result in duplicate services. We caution strongly against this simplistic narrative and call for transparency, fairness and equity in dealing with the matter,” he said.

Marius Smit, the head of forensic services at Discovery Health, also cautioned against only blaming doctors.

“This is not a doctor issue. We need to be careful of that narrative … it includes doctors, member fraud and corporate fraud. It is all evenly spread.

“Obviously, the money component is important in terms of what fraud costs the industry, but there is also a quality of care component. Hospitals are a great place to be if you’re sick; not so much if you’re not,” he said.

At the summit’s conclusion, the various schemes, health practitioners and industry bodies agreed on key definitions related to fraud, waste and abuse, and signed an industry charter pledging to work against them.
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