BUSSINESS DAY
Africa’s biggest generic drug maker, Aspen Pharmacare, has lost its appeal against the €5.2m fine levied by the Italian Competition Authority over the price of some of its cancer drugs, a development that comes hard on the heels of Tuesday’s news that it is to be investigated by the Competition Commission in SA.

The Italian case relates to the prices of a portfolio of off-patent cancer drugs that Aspen acquired from GlaxoSmithKline several years ago, and that it recently increased. Aspen’s conduct relating to the price of these drugs is also under the microscope in SA, although the prices of the drugs in question have remained relatively stable as they are regulated tightly by the Department of Health.

Aspen said on Wednesday it had noted the abridged judgment handed down by the Italian court and was awaiting the release of the full reasons for the judgment to determine whether it would appeal to the Italian Council of State appeal court.

Aspen’s head of strategic trade, Stavros Nicolaou, said the cancer drugs in question had not had price increases in Italy for the past 40 to 60 years, despite increases in the cost of production, and were typically used as drugs of last resort by a small number of patients. The list price of a generic equivalent of one of these drugs was more than double the Aspen product’s, he said.

On Tuesday, the South African Competition Commission said it was launching an investigation into the price of cancer drugs, homing in on Aspen and multinational pharmaceutical manufacturers Roche and Pfizer.

Commissioner Thembinkosi Bonakele said the commission had not discussed the investigations with the Department of Health, which regulates private sector drug prices. "It is a sensitive matter, and we need to be independent," he said.

The commission said it was investigating Aspen for alleged abuse of market dominance for its off-patent cancer drugs Myleran, Leukeran and Alkeran, which had no generic rivals.
Aspen acquired these drugs in a portfolio of products it bought from GlaxoSmithKline in December 2009.

Nicolaou said Aspen had not driven up the price of these drugs after their acquisition and had only instituted the increases permitted by the Department of Health. For example, the price of a pack of 25 x 2mg Leukeran tablets was R241.61 (excluding VAT) in February 2009, when it was still sold by GlaxoSmithKline, and now cost R369.79 (excluding VAT), said Nicolaou.

The price increases introduced by Aspen were in line with the medicine-pricing regulatory framework and averaged 6% a year from 2009 to 2017, he said.

SA’s medicine pricing regulations stipulate that pharmaceutical manufacturers must sell their products at the same price to all their customers in the private sector, regardless of the volumes bought.
They also control the permitted mark-ups at every stage of the supply chain. Typically manufacturers get one price increase a year, which is approved by the health minister.

Nicolaou said Myleran, Leukeran and Alkeran were affordable, fully reimbursed by medical schemes and had a combined yearly turnover of just R3.2m. A month’s supply of Leukeran cost R2,000-R4,000 (excluding VAT).

There were no generic rivals in SA because this was a very small market for these products, with limited prospects. "It don’t think any other player would see a market for them," he said.

Roche is being investigated on the price of its breast cancer drugs Herceptin and Herclone, while Pfizer is under scrutiny for the price of its lung cancer drug Xalkori.

The Fix the Patent Laws coalition, which recently campaigned for lower breast cancer drug prices, welcomed the commission’s investigation.

"In SA, the annual price currently charged by Roche in the private sector for trastuzumab [Herceptin] is R516,700, while the few public facilities which can access it do so at a lower price of around R211,920 per year," the coalition said.

"[Roche] maintains its high prices in every way possible and it holds multiple ever-greened patents on trastuzumab in certain countries.

"In SA, for example, multiple patents extend Roche’s monopoly until 2033," Fix the Patent Laws said.

IOL
Hospitals are facing their worst nursing crisis in 20 years after a sudden drop in new arrivals from Europe, experts warn.

Numbers coming from the EU have ‘crashed’ by 96 per cent in nine months.

There were just 46 new registrations of European nurses in April – down from 1,304 in July last year. Academics said the situation was bleak while nursing leaders warned of ‘severe consequences’ for patients.

Hospitals have become increasingly reliant on European nurses in recent years because of a failure to train enough home-grown staff.

Many NHS trusts have targeted staff from Spain, Portugal and Italy, where job prospects are poor and salaries are significantly lower. But many overseas nurses are being deterred by the uncertainty following the Brexit vote and the introduction last June of tougher English language checks, say experts. The latest figures were obtained by the Health Foundation think-tank and published by the Health Service Journal as part of an ongoing analysis into the state of the NHS workforce.

Lead author Professor Jim Buchan, of Queen Margaret University in Edinburgh, said: ‘It is a crash. Clearly something has happened in that period, and that something was most likely the Brexit vote and the uncertainty that has created. It has led to a change in the choices being made by individual EU nurses and midwives.

‘Non-EU nurse inflows have increased but not by enough to offset the decrease from EU nurses.’ Janet Davies, of the Royal College of Nursing, said: ‘We rely on the contributions of EU staff and this drop... could have severe consequences for patients and their families.

‘Across our health service, from A&E to elderly care, this puts patients at serious risk. These figures should act as a wake-up call to the Government as they enter Brexit negotiations.’

In 2015/16, almost a third of nurses – some 9,389 – registering with the Nursing and Midwifery Council came from the EU. There were 19,133 from the UK and 2,145 from outside Europe. The figures for 2016/17 have not yet been published but are likely to be much lower. Only last month the Royal College of Nursing warned that one in nine nursing posts were vacant, equivalent to 40,000 nurses.

Shadow health spokesman Jonathan Ashworth said: ‘Theresa May’s weak and unstable government has pushed NHS services to the brink and it is patients who will pay the price. Our health service has always relied on the contribution of overseas workers yet these staff are being forced out by this Government’s neglect and disregard.’
A Department of Health spokesman said more than 52,000 nurses were being trained, adding: ‘We understand the need to give valued NHS staff from the EU certainty – which is why we have made clear that the future of those EU nationals working in our health and care system should be a priority in Brexit negotiations.’

BUSINESS DAY
Africa’s biggest generic drug maker Aspen Pharmacare, already under investigation by European authorities over the price of its cancer drugs, is now under similar scrutiny from SA’s Competition Commission.
On Tuesday, the commission announced it was investigating Aspen and multinational pharmaceutical manufacturers Roche and Pfizer for suspected excessive pricing of their cancer drugs.
If the Competition Commission’s investigation uncovers abuses, the matter will be referred to the Competition Tribunal for prosecution. The maximum penalty the tribunal can levy is 10% of annual turnover.
Aspen is being investigated for allegedly abusing its dominant market position to charge excessive prices for three cancer drugs — Alkeran, Leukeran and Myleran — which are used for treating leukemia, bone marrow cancer and lymphoma.
Roche is in the cross-hairs for the price of its breast cancer drugs Herceptin and Herclon, while Pfizer is to be scrutinised for the price of its lung cancer medicine Xalkori.
“This investigation is crucial. It is a matter of national importance,” said commissioner Thembinkosi Bonakele.
Aspen is being investigated by the European Competition Commission for steep rises in the price of five off-patent cancer drugs it bought from GlaxoSmithKline several years ago.
It also faces probes by competition regulators in Spain and the UK, and is appealing against a price-hiking fine in Italy.
“Given that Aspen supplies similar products in SA, the commission has reasonable grounds to suspect Aspen may be engaging in similar conduct locally,” Bonakele said.
“Moreover, Aspen appears to be either the only supplier or at least a dominant supplier of these products in both the South African and European markets.
“Given that Aspen’s products are listed as generic products, it is of concern that none of the markets has observed significant entry of other generic products by competing pharmaceutical companies,” he said.
Aspen investors appeared unperturbed by Tuesday’s developments and its share price closed flat at R275.
“I think Aspen is very confident that in SA, they didn’t do anything with respect to price-gouging,” said Aeon Investment Management’s chief investment officer, Asief Mohamed.
Aspen said it had not increased the price of any of its products outside the regulatory framework approved by the Department of Health, which sets a maximum price for medicines sold in the private sector and controls annual price increases.
The commission believed Roche was using an “ever-greening” strategy to prolong the patents it held on its breast cancer drugs to delay competition from generic alternatives, Bonakele said. Roche charged different prices to state and private-sector patients, which may amount to price discrimination, in contravention of the Competition Act, he said.
Roche’s Aadila Fakier said Roche had yet to be formally notified of the Competition Commission’s investigation, but would co-operate with the authorities and provide any information required.
The commission said Pfizer’s Xalkori had initially cost R152,000 for 250mg and had then dropped to less than half that amount.
Pfizer SA country manager Jennifer Power said the R152,000 price quoted by the commission was wrong.
“We await the opportunity to be contacted by the commission to clarify the pricing for this product. We respect the process initiated by the commission and Pfizer shall fully co-operate with the authorities,” she said.

MAIL AND GUARDIAN
In a recent opinion piece for The Mail & Guardian, Health Minister Aaron Motsoaledi argued that the legal system has created perverse incentives for lawyers in the form of commission-based fees and that this is increasingly driving lawyers to pursue medicolegal litigation even when some cases have no merit. He said this rise in litigation is not only pushing some gynaecologists out of practice but also threatens to collapse the public health system: “Nobody in their right mind would argue that victims of medical harm should be ignored. The problem we are faced with, though, is the ugly shape that medico-legal litigation has taken,” Motsoaledi said. If one is to accept the Health Minister’s proposition that medico-legal litigation is out of control - which is a proposition that may require more formal investigation and study - then, perhaps, the most appropriate government reaction is to map legislation to deal with such circumstances. Maybe a legislative solution is needed to cap damages in legitimate claims against medical practitioners.
This kind of solution could set out - in a manner consistent with existing legislation as well as the right to access courts in terms of the Bill of Rights and the Constitution - an appropriate dispute resolution mechanism for legitimate claims for when negligence occurs, and the claim is neither frivolous nor vexatious. It may be that medico-legal litigation has increased over the past years and it may be that such legal action has shifted to medical practitioners as opposed to the Road Accident Fund (RAF) because of the latter’s financial state. But the conclusion that healthcare workers are now the focus of legal action as a result of the RAF’s financial status is not the only plausible or reasonable conclusion that can be drawn in respect of a supposed increase in medico-legal litigation. Patients are also consumers. Since 2004, with the coming into effect of the 2003 National Health Act, patients have been provided with additional legislative rights concerning, among other principles, informed consent and the legal right to participate in decisions affecting their healthcare and treatment. Also, the 2008 Consumer Protection Act endowed patient-consumers with greater rights to understand the goods and services that they purchase, including medicines and medical treatments.
The coming into legislative existence of those rights coincided with information about medical treatments and options becoming more widely available to patients through the internet and social media. Patient-consumers are now better informed than ever before not only about their rights but also about concomitant obligations of medical personnel. The corollary to the empowerment of the patient-consumer is that, when matters go wrong, they are also aware of the numerous options available to remedy or redress such circumstances. It may be easy to lay the blame for increased litigation at the feet of alleged avaricious lawyers, but it is worth remembering that lawyers are - first and foremost - officers of the court. We are charged in society with the administration of justice along with the judiciary. Lawyers are a constituency that is not without the unscrupulous, but the checks and balances inherent in the legal system operate to eject frivolous and vexatious claims. Judges do not simply hand out cheques and lawyers - in the vast majority - do not pursue claims without merit to achieve a contingency payment of one percentage or another. It is also readily apparent that the quality of healthcare will affect the outcomes of medical and legal interventions. Poor quality healthcare inevitably leads to adverse but otherwise avoidable medical outcomes that, in turn, sponsor legal interventions and encourage medico-legal litigation.
Patient-consumers expect more for less and, when they receive less for more, they quite rightly turn to the legal system for help. One should therefore not underestimate the prowess of the patient-consumer in the context of today’s legislative framework and the rights afforded to them to access adequate and reasonable healthcare services as contemplated by the Bill of Rights. Patient-consumers will continue to enforce their rights by whatever legal means is available to them, especially where they are the recipients of inadequate medical services or treatment, which is the genesis of the harm that is legally actionable.
Neil Kirby is the director of health and life sciences practices at Werksmans Attorneys

EHEALTH NEW
A COHSASA accreditation award means the healthcare organisations was scrutinised while it underwent a rigorous quality improvement programme.

Healthcare facilities in Nigeria and Botswana, as well as in South Africa have been awarded accreditation by the Council for Health Service Accreditation of Southern Africa (COHSASA), a body that assists a range of healthcare facilities meet and maintain quality standards and so provide safe, quality services.

A COHSASA accreditation award means the healthcare organisations was scrutinised while it underwent a rigorous quality improvement programme, which it has been assessed against and complied with according to the standards of the International Society for Quality in Health Care (ISQua).

COHSASA itself is accredited by ISQua, the global body overseeing accreditation and quality improvement programmes in healthcare organisations in 70 countries around the world, as are its standards and its surveyor training programme.

Mediclinic’s Morningside hospital in Johannesburg received accreditation for three years while the Western Cape’s Worcester Hospital was accredited for four years.

Other accredited hospitals include Botswana’s Nkoyaphiri Clinic, Nigeria’s Chevron Hospitals in Gbagda and Warri, and the Shell Petroleum Development Company Hospital Port Harcourt, as well as the Cure Day Clinics in Bellville, Cape Town and Somerset West.

COHSASA also awarded the Graded Recognition Awards (Progress, Entry, Intermediate)  to Sekgoma Memorial Hospital and Selebi Phikwe Hospital in Botswana although they do not yet meet all the standards, COHSASA says facilities that are awarded this level usually go on to achieve full accreditation.

The two facilities in Ghana (C and J Medicare Hospital and Diagnostic Centre) and Botswana (Block 6 Clinic and Botshelo Diabetes Clinic) that have been awarded intermediate level with a focus survey will undergo a further onsite visit to assess their compliance.

The accredited hospitals will have to undergo vigorous testing again when their accreditation ends to ensure quality standards are maintained.
In the past 21 years of operation, the COHSASA has worked in over 600 facilities in both the public and private sectors in South Africa and several other African countries including Lesotho, Rwanda, Nigeria, and Kenya.

PERSONAL FINANCE
Regulations concerning choice of health insurance products, the benefits they offer, and the consumer-protection measures to which they must adhere, came into effect at the beginning of April. If you are using these products, either as a substitute for medical scheme cover or to supplement it, or are looking at using them, you need to know what has changed and the type of products that are now available. The regulations under the Long-Term and Short-Term Insurance Acts, known as the demarcation regulations, were instituted in an effort to forge a clear boundary between medical scheme cover, which is governed by the Medical Schemes Act, and other types of health insurance, which are governed by the two insurance Acts.

Certain types of insurance policies that superficially resembled medical scheme cover will be phased out. The reasons for the regulations are twofold:

• They make sure consumers are better informed of the differences between health insurance and medical scheme cover; and,

• They ensure that the cross-subsidisation within medical schemes between healthy and sick members, which is critical for schemes’ well-being, is not undermined.

All new health policies have had to comply with the new requirements since April 1. Existing long-term insurance policies will have to align to the regulations as and when such contracts are changed or renewed. Existing short-term insurance policies will have to align by January 1 next year. Product providers are obliged to communicate clearly that health insurance policies, particularly hospital cash plans, are not a substitute for medical scheme membership. Roseanne Murphy Harris, the president of the Actuarial Society of South Africa, said the regulations were much needed. She said confusion over the benefits offered by health insurance policies versus medical schemes has unfortunately resulted in consumers inadvertently sacrificing adequate medical cover by opting for products not appropriate for their circumstances. This confusion also restrained medical schemes from developing a broader and more sustainable membership pool, which is crucial for the financial well-being of schemes. These views are echoed by Gerhard van Emmenis, the acting principal officer of Bonitas Medical

Fund welcomed the demarcation, as it is designed to protect consumers and will assist in stabilising the medical schemes industry. He said the demarcation will further aid in clearing the misperception that exists between health insurance products and medical schemes. The main types of health policies affected are:

• Gap over which is used to supplement medical scheme cover. It makes up the difference between what your scheme pays out for hospitalisation and inhospital specialists and what hospitals and specialists actually charge.

• Hospital cash plans which are often taken out by people who cannot afford medical scheme cover but need some sort of cover for healthcare expenses.

These policies pay out a fixed amount per day for each day you are in hospital.

• Primary healthcare policies which are policies from insurers that resemble basic medical scheme cover, paying for certain medical consultations and procedures.

These will be phased out over the next two years while the Department of Health and National Treasury look at ways of integrating them into the medical scheme framework as low-cost medical scheme options.

Van Emmenis said one needs to remember that health insurance products are sold by insurance companies, which are for-profit organisations. Medical schemes, on the other hand, are non-profit (although the administrators of such schemes are for-profit). Also, insurance contributions are not tax-deductible, whereas tax credits are received for medical scheme contributions. Murphy Harris said medical scheme cover outweighs what one gets from a short-term insurance policy. It helps to pay for a comprehensive range of healthcare needs and expenses, offering different levels of benefit options. It also provides guaranteed prescribed minimum benefits, which provide for full cover for treatment in medical emergencies, 270 life-threatening conditions and 25 common chronic conditions.

Gap Cover Policies

Gap cover policies, which have become popular as a way of supplementing medical scheme cover, have been allowed to continue under the demarcation regulations.

Whereas gap cover limits were determined by individual insurers in line with industry norms (you could buy cover of up to R1 million a year), the new regulations limit cover per individual to R150 000 a year. Murphy Harris said the benefit cap on gap cover may help to counter escalating healthcare expenses, because in the past some healthcare specialists may have increased their fees according to how much insurers paid, contributing to medical inflation. Mike Settas, the director of Kaelo Xelus, a provider of gap cover, disagrees with this view. He said there are many reasons for the high fees specialists charge, and capping benefits will have no effect on medical inflation. First, Settas said, it is simply a matter of supply and demand: specialists in short supply in a particular discipline will charge more for their services. Second, specialists face escalating costs, particularly for liability insurance - gynaecologists and obstetricians now pay about R1-million a year to cover themselves when faced with malpractice suits.

He said isolated practitioners may have charged more if a patient had gap cover insurance, but this was the exception. Settas said the new regulations will not have much of an effect on business, and very few claims in the past exceeded the now imposed R150 000 annual limit. He expects the gap cover market to grow now that the uncertainty surrounding the future of these products has been removed and, more pertinently, because medical costs will continue to soar. Van Emmenis said you should be aware of the following when you buy gap cover:

• Cover differs from policy to policy in terms of the percentage pay-out, as well as any waiting periods (how long you must wait before you are covered) or exclusions (events or circumstances in which you are not covered);

• You may need gap cover even if you have a top-of-the-range medical scheme option, because there might still be gaps between what your scheme pays and the amounts specialists charge; and,

• Never assume that all costs will be covered.

He said gap cover is by no means a cure-all solution to avoid co-payments.

Hospital Cash Plans

Hospital cash plans are intended to pay a daily amount towards non-medical expenses that might arise when you are hospitalised, such as childcare or loss of income.

However, Murphy Harris said, these policies are often used as low-cost cover by people who mistakenly believe that the benefits will cover the costs of hospitalisation, leaving them without adequate medical protection. Moreover, she said, many hospital cash plans pay benefits only after policyholders have spent as many as four or five days in hospital, which happens only in rare cases. Hospital cash plans have therefore been limited to paying up to R3 000 for each day spent in hospital to a maximum of R20 000 a year. The new regulations further stipulate that benefits should be paid after two days spent in hospital, and must be calculated from the first day on which you are hospitalised. In other words, if you spend only a day in hospital, you will not be covered, but if you are in hospital for longer than that, you will be paid out for all days, including the first day, up to the maximums.

Primary Healthcare Policies

Primary healthcare policies offer a limited range of healthcare benefits, such as visits to general practitioners and emergency medical care. Because they are considered to perform the business of a medical scheme, these products will be phased out. Murphy Harris said insurers are able to apply for a two-year exemption under the regulations in order to protect the rights of policyholders, as these policies target low-income earners. Consumer Protection Requirements Murphy Harris said rules introduced by the demarcation regulations for the protection of consumers include the following:

• Commission payable to insurance brokers on health insurance policies has been limited to prevent mis-selling. Commission is now set according to monthly premium bands, ranging from a maximum of 20 percent of premiums less than R300 a month, to a maximum of five percent of premiums above R1 200 a month.

• Insurers are prohibited from discriminating against individuals by refusing them cover or increasing their premiums on the basis of their state of health, because they have a disability or because they are pregnant. However, insurers may price premiums based on the age of the policyholder when taking out a contract, provided that this pricing affects all new policyholders of the same age.

• Insurers may impose a general waiting period of up to three months on policyholders before they can submit a claim, as well as a condition-specific waiting period of up to 12 months. This will apply to individuals who have been diagnosed with or sought treatment for an illness or condition in the year preceding the date on which they take out a new policy.
• As part of the Treating Customers Fairly principles adopted by the financial services industry, the terms of policies, the premiums payable, as well as any restrictions on benefits, must be disclosed when a policy is taken out.

NEWS24.COM
Knysna - Green Valley in Plettenberg Bay and Buffalo Bay next to Brenton-on-Sea was evacuated on Saturday morning as windy conditions complicated firefighting efforts in the area.
The suburbs were temporarily evacuated as a precautionary measure, municipal spokesperson Fran Kristen said.
The George local municipality deployed five Go George busses to assist with evacuations.
Social media reports suggest that Sedgefield has also been evacuated, but Knysna municipality denied evacuations taking place and said fires are being monitored in the area.
On Friday afternoon fires in the Eden district were 85% under control. Several flare-ups have however occurred on Friday evening and Saturday morning which was sustained by windy conditions.
In a statement, SANParks said winds of up to 42km/h were expected at 11:00 on Saturday morning.
Western Cape Local government spokesperson James-Brent Styan said an additional South African National Defence Force (SANDF) helicopter has been deployed.
Eleven helicopters have been deployed to the Eden District by Saturday morning with an additional helicopter from Working on Fire on its way to the area.
George municipality said fires caused no structural damage in the municipality.
Seriously ill patients from the Geneva clinic were evacuated to the Mediclinic due to serious smoke inhalation, but fires did not damage the clinic building, municipal spokesperson Chantel Edwards-Klose told News24.
Local authorities confirmed that 300 buildings have been destroyed by the fires since Wednesday and roughly 4 000 people remain displaced.
Knysna municipality urged residents to use water sparingly as water infrastructure has been stretched to its capacity.
The municipality was declared a drought disaster zone in May.
Kirsten said heat created by recent fires caused many pipes to burst and increased water leaks. She requested residents to reports leaks to the municipality by phoning 044 302 6300.
"Some residents have noticed the brown colour of the water. This is purely aesthetic and is still safe for use," Kristen said.
The municipality is also experiencing sporadic power outages due to kilometres of electricity lines destroyed.
The municipality appealed for donations of mattresses, sleeping bags, bottled water and sanitary products to be used specifically for the elderly people in the area.
Donations can be dropped off at DHL centres across South Africa.
News24 earlier reported that local police has not received any reports of missing people and encouraged residents to report missing people to police as soon as possible. Missing people can be reported to 044 302 6687 or 08600 10111.
Seven people have been arrested for looting following the blaze.
Local historian Phillip Caveney said the last time a fire of this magnitude hit the district was in 1869.
This type of blaze occurs in 150 year cycles, he said.

MAIL AND GUARDIAN
Medico-legal litigation has exploded. As of March 2016, claims against the health department from the previous five years stood at more than R37billion. By October that year, the figure had jumped to R51billion — or a third of the whole public healthcare budget if we had to pay every cent.

The medico-legal litigation pandemic threatens not only our health system but also the very existence of our mothers and children. When some see these figures, their first reaction is to condemn the health department and accuse it of absolute carelessness. Please be careful before drawing such conclusions.

Ask yourself first: But what has changed? It is common knowledge that, over the decades, an overwhelming number of medico-legal litigation cases were lodged against the Road Accident Fund (RAF). The RAF has since been litigated into a state of near bankruptcy and is finding it difficult to even pay legitimate claims.

The minister of finance has tried to raise the fuel levy to fund the RAF, to no avail. Lawyers who used to make a living out of the RAF are now focusing on the healthcare system. There is a perception, a wrong one, that only the public healthcare system is being sued. Let me inform you that lawyers are pursuing both the public and the private healthcare systems.

This litigation has grown exponentially. The relentless pursuit of cases is not necessarily about what is happening currently: most cases are based on incidents that happened 20 to 25 years ago. It is an inherent problem of any healthcare system that undesirable outcomes such as negligence, malpractice or adverse events could occur. Nowhere in the world does a healthcare system aim for such incidents of "medical harm" to happen. But they do. Nobody in their right mind would argue that victims of medical harm should be ignored.

The problem we are faced with, though, is the ugly shape that medico-legal litigation has taken. Not all doctors are experiencing litigation to the same extent. Obstetricians and gynaecologists are the prime targets, followed by neurosurgeons, neonatologists (specialists dealing with babies during the first 28 days of life) and orthopaedic surgeons.

Why is this so? They work in areas where adverse events or complications are more likely to happen. No child deserves to arrive in this world with a condition such as cerebral palsy (brain damage that results in a physical disability that affects movement and posture). We believe that such children deserve compensation.

The health department does not have a problem with the concept of compensation but rather with the way in which it is being conducted. Some lawyers literally raid schools for the disabled, sniffing for children born with cerebral palsy, in order to litigate against the hospital or the obstetrician who delivered the baby.

Such claims increase by the day, because South Africa's law system allows lawyers the option to operate on a commission basis instead of charging clients fees. At the conclusion of a case, the lawyer takes a cut of the amount awarded to the victim, also known as a "contingency fee". Lawyers are allowed to take up to 25%. In some RAF cases, however, unscrupulous legal practitioners have taken advantage of uninformed patients and family members and awarded themselves up to 80% in contingency fees.

The contingency fee system is an American one and is part of the reason why the United States spends 18% of its gross domestic product on health. It is also leading South Africa to a precipice. When a snake, in the form of medical harm, enters your house, you do not bomb the whole house with your children inside; you try to find a better way to rescue your children. In order to practise medicine in the private sector, doctors have to buy indemnity or insurance, which will pay out in legal cases where they are found guilty of negligence.

Those in the state sector don't have to, because it is the minister of health who gets sued. About eight years ago, obstetricians and gynaecologists paid R78 000 a year for insurance. This year, the Medical Protection Society's insurance costs R800 000 — an increase of 925%. The South African Society of Obstetricians and Gynaecologists has pleaded with the Medical Protection Society to reduce this amount. But its response was along the lines of: "You're not being litigated against for what you are doing now or what you may do in the future, but mostly for what you did in the past. We have to charge a high premium if we are going to be able to settle your litigation debt." The result?

Obstetricians and gynaecologists are closing their practices and leaving the profession. Many of those who are brave enough to continue — or who have no option because they are too old to change professions — refuse to deliver babies and refer pregnant women to public hospitals. Young doctors are refusing to specialise in obstetrics and gynaecology. Where will pregnant women go? How is the country going to secure safe pregnancies for mothers and bring healthy babies into this world when doctors who are supposed to perform such functions are being litigated out of existence? Lawyers argue that litigation is being pursued as a form of social justice for the victims of medical harm, and is done solely in their interest.

The more they litigate, they say, the more pressure there is on doctors to provide better quality services. The pursuance of social justice sounds noble but why, then, charge such high contingency fees? Is it in the interest of victims that practices are now being closed down? When your child commits mistakes, do you take a sledgehammer and bludgeon him or her out of existence or do you devise decent and civilised corrective action? As the health sector, we accept that the best solution for this explosion of litigation is for health workers and systems to reduce incidents that may lead to litigation.

When health workers or hospitals are found guilty of negligence however, victims should be compensated. But our country can no longer continue with a compensation mechanism that allows the health sector to be wiped out. We are looking at designing a better system, such as the one that Denmark uses, where medical injury claims aren't handled by the courts but by medical and legal experts who review cases at no charge to patients. The outgoing director general of the World Health Organisation, Margaret Chan, once said to me: "Minister, your country needs a better mechanism of compensation. The contingency fee system is the worst that America ever bequeathed to the world." Aaron Motsoaledi is the health minister.

Comment by Aaron Motsoaledi

BIZCOMMUNITY
South Africans are faced with the constant increases in the cost of living and an ailing economy, forcing consumers to cut down on spending across the board. For a small percentage of the population, healthcare costs are covered by medical aid, but only an estimated 16 percent of South Africans have such coverage while the rest rely on an already overburdened healthcare system. Continuing downward pressure on the economy is pushing even those with medical cover to either reduce it, or outright terminate their membership just to make ends meet, leaving more and more South Africans vulnerable. While there are several factors contributing to the increase in private healthcare costs, including the volatile exchange rate and its impact on the cost of importing medical equipment, the rising costs of medication, doctors’ fees, the increasing average age of principal members on the schemes, the biggest culprit is private hospital costs. According to the Council for Medical Schemes’ 2014-2015 report, hospital fees constitute the bulk of fees paid by medical schemes with total hospital expenditure amounting to 37.6 percent, of the R124.1-billion that medical schemes paid to all healthcare providers in 2014.

This was an 11.6 percent increase in expenditure on hospitals from the previous year and this trend has not abated. Whether we like it or not, the reality is that healthcare costs in SA - especially private hospitals - have become too expensive. The compound hospital cost escalation of 15 percent per annum is unaffordable and is not sustainable in our healthcare environment. However, some 70 percent of surgical procedures, currently done in acute hospitals, can safely be performed in a day surgery facility. In South Africa, day hospitals offer significant opportunities to improve the efficiency of private hospitalisation. Locally, only approximately 13 percent of all surgical procedures are attended to in day hospitals, an extremely low figure compared with the almost 70 percent international utilisation of day hospitals.

The potential to increase the use of day hospitals is significant, bringing clear benefits to both patients and medical schemes. Several factors influence the cost model of day hospitals: no large catering facilities, no ICU or specialised theatre, no overnight beds to cater for and no after-hours staff costs, no emergency unit and more reasonable per minute theatre fees compared to an acute facility. We have moved on since the early 1980s where day case surgery was more focused on dental care and minor procedures. Day hospitals across the world are transforming the surgical experience for millions of patients by providing them with a more convenient alternative to hospital-based surgery. It’s time for South Africans to take advantage of the many benefits of this option.

FA NEWS
Recent calls by the Health Professions Council of SA (HPCSA) to its members not to enter into agreements with medical schemes specifically on Global Fees and similar arrangements have raised an important discourse across the healthcare funding industry.

The Board of Healthcare Funders of Southern African (BHF) supports the NHI policy direction and refers to the green and white papers that place emphasis on alternative reimbursement models, stating that in this context, global fees are important tools in the achievement of accountable and affordable healthcare, and the establishment of guidelines in the implementation of such alternative reimbursement models is vital. When one considers that the private sector will play an important role in National Health Insurance (NHI) delivery and can help SA’s NHI leapfrog many of the challenges experienced in other geographies, the need for new models of reimbursement that drive quality outcomes and not utilisation is crucial.

The implementation and adoption of alternative models of provider reimbursement is crucial to the sustainability of the healthcare sector. South African consumers have faced unavoidable medical scheme tariff increases far beyond inflation and as a result, an erosion of benefits for the past decade.

“Relevant healthcare stakeholders need to find common ground and collaborate through mature leadership on the issues of spiralling benefit utilisation and costs, finding agreeable ways to reimburse providers that are premised on quality outcomes for patients, transparency and accountability for patient outcomes by providers,” says Dr Ali Hamdulay, Chairperson of the Board of Healthcare Funders of Southern Africa (BHF).

Alternative Reimbursement models such as Global Fee models provide a single payment to a healthcare team to cover all the tests, procedures, drugs, devices and rehabilitation needed for a patient’s condition and are premised on accountability for the quality of care provided by each team member— a vastly different approach to the current fee-for-service model.

The Board of Healthcare Funders has emphasised that it’s not about imposing models on healthcare providers, and that it’s essential that funders and healthcare providers work collaboratively to find the right reimbursement models that work towards better managing risks and costs, serve the interests of the patient and the health professional’s ability to act in the best interests of the patient.

“The alternative reimbursement models also stimulate the creation of centres of excellence by increasing competition and accountability between healthcare providers – teams with consistently better healthcare outcomes are likely to receive more patient referrals from schemes based on quality outcomes. This will also have the effect of driving more competition between healthcare providers, which in turn drives better outcomes, and which will have the effect of improving pricing as well. All of this ultimately equates to the best care and outcome for the patient and medical scheme member,” explains Dr Hamdulay.

The BHF adds that the concerns raised by healthcare providers that global fee models will create an environment of underservicing which compromises patients are moot. “Within such a model, there is little room to underservice since the focus is on outcomes and most crucially, an increased demand for accountability by the healthcare provider for such outcomes. Essentially a global fees arrangement paves the way for schemes to contract with specific suppliers because they offer the best quality, transparency and outcome, and not the lowest fee,” adds Dr Hamdulay.

Ultimately, how the reimbursement models of the future are built is important, and this must be done collaboratively. “We have strong leadership in the healthcare sector, but what we need is stronger leadership that is pulling towards what should be our shared objectives – patient care and quality healthcare outcomes. If we can collaboratively solve these challenges with funders, specialists and patient advocacy groups, we can work towards creating models that represent fair outcomes for all parties and solve some very real and fundamental challenges in the private healthcare industry. The interconnected nature of the entire healthcare supply chain emphasises the need for a strategic approach that involves all role players to find a way to standardise benefits in a manner in which we can measure the quality and cost of care, and in turn use the outcomes data to better define the future healthcare model for the country and all South Africans,” concludes Dr Hamdulay.

MAIL AND GUARDIAN
Discussions and debate are focused on state capture and its effect on the economy, but there is another beast eating away at productivity, hurting the economy and undermining our health system. South Africa is open for medical fraud business. Medical fraud manifests in two ways: bogus doctors in practice and bogus medical certificates issued to rob employers by keeping an employee away from work while earning a salary. The phenomenon of suspiciously qualified or unqualified doctors opening practices in some townships and attracting unsuspecting patients has become a concerning norm. Just recently a bogus doctor was caught and arrested at his Mpumalanga surgery in front of patients, some of whom he had prescribed highly regulated schedule 4+ drugs.

These bogus doctors - and even dentists and specialists - are found not only in township surgeries but also in hospitals. Although one may argue that the responsibility rests with the patient to ensure that they visit qualified doctors, it is difficult to check the credentials of the doctor before a consultation.

Up to now, what our medical field seems to lack is a robust, impenetrable system to vet medical professionals before employing or certifying them as good to practice. Issuing a medical certificate to keep an employee away from work without need is fraud and both the doctor and the patient need to be held accountable.

Albeit with very little remedial action taken, fraudulent medical certificates have been a problem for years. Worse still, if you are sick of work or have a hangover, you can but an authentic medical certificate on a street corner. At a tavern in the North West, you can buy a drink and a sick note at the same time. Depending on how long you wish to stay away from work, it will cost anything between R60 to R200 without even visiting the doctor’s rooms. The economy loses R55.2-billion annually to sick leave, according to an article in September 2013 quoting Adcorp Holdings’ employment index of that year.

There is an IT solution aimed at combating the issuing of fraudulent medical certificates. It was designed and developed by young entrepreneurs from QwaQwa in the Free State. What the system does is to allow only a qualified doctor - verified by the Health Professions Council of South Africa as good to practice - to issue a medical certificate with limitations to changing the date of the consultation and the number of days the doctor recommends for the employee to be off duty. The employer will receive the medical certificate from the doctor’s rooms on the day and at the time the employee had a consultation. The system ensures that:

• Only registered practitioners and those authorised to issue medical certificates do so
• The date and time of issue (and examination) is not manipulated
• The medical certificate is only issued in the presence of the patient
• Bogus doctors don’t have access to the system.

This will help combating medical aid fraud through doctor registration verification and an electronic and paperless prescription system.

Ezra Ndwandwe works for Dual Point Consulting

BUSINESS DAY LIVE
Mediclinic has hardly been a safe-as-houses investment since muscling out rival bidder NMC to secure a £1.4bn reverse takeover of Abu Dhabi’s Al Noor in 2015, becoming Mediclinic International in the process. While Al Noor was touted as an earnings-neutral investment in the first year, it has proved a drag on profit and "gradual recovery" is now the message from management. Business Day spoke to CEO Danie Meintjes.

Was your due diligence thorough enough?

What I would have preferred – but it was not permissible and it was not possible at that time due to the circumstances — was to do a deep due diligence at operational level as well. If we knew more, would we still have done the transaction? Undoubtedly yes, but maybe at a lower price.

Margins in the Middle East are 11%, in Southern Africa 21% and in Switzerland 20%. Will they ever reach the level of your other businesses?

Two answers: we’ve told the market that in Dubai we are happy with the margins, we said there’s no reason why the Dubai business can’t get to the same margins as SA, about 20%. In Abu Dhabi, we had different circumstances, we had headwinds and you need to take into account that our tariff structures in Abu Dhabi are slightly lower than Dubai, we also do more basic patient [care] that has a much lower price point and we are doing tactical changes to get that mix of generally insured and basic insured patients to be more enhanced.

[In SA] if you start a new hospital, your start-up costs are related to your own staff – there’s no cost in terms of doctors. If you come to this part of the world, then you must recruit doctors at huge cost, bring them in, set them up with housing and pay a salary while they haven’t seen one patient yet, so that ramp-up in this part of the world takes longer than in SA.

I want to make one point very clear: we are long-term players – we’ve got a 30-year plus track record and that is what we focus on. I’m very comfortable with the potential of the Middle East.
What caused the doctor shortage at the Al Noor hospitals and how acute is it still?

To get doctors to work in the Middle East is not the issue. It is easier to get doctors to work [there] than in SA … but you have to find doctors and that takes longer. [Al Noor] lost doctors before we got involved. We don’t pay doctors to do more radiology, more pathology, to write out more scripts, etc.
That’s not our style, and we changed the remuneration model … we took a lot of staff out of the system to get our cost base right, but now we are on a solid foundation that we need to build up. What we’re telling the market is: don’t expect wonders of ramping up just because the Thiqa co-payment fell away. There are structural changes that we made.

How worried are you about regulators squeezing you on costs? What do regulators view as a reasonable margin?

I don’t think the regulator can tell you at what margin you should run your business. You must look at the capital investment and the return on capital, the risks, etc. But regulatory interference in the hospital business, is par for the course. Governments must ensure that their citizens do have access to reasonable facilities. The private sector can make quicker decisions, has access to capital and whether you do it for electricity generation or running airlines, or whatever, I believe the private sector is in a position to be more cost efficient, but then you must do a proper cost comparison with the alternatives, that is, the government. The reality is that healthcare is getting more and more expensive as a percentage of the economy.

Why?

If you think of an ageing population, you consume more healthcare in the last 10 years of your life than most of your life before that. New technology, new medicines that enhance quality of life come at a price.

But that is what is so great about this industry from an investment point of view — there are few industries where you can say the demand for your services will grow year by year. The challenge will be how to keep it sustainable.

What about capricious regulation – especially in the Middle East, where they introduced co-payments and then reduced them again?

I can only work on what I know and, yes, in the Middle East they take decisions quicker — that is the nature of that part of the world, but what is positive is that the governments of the United Arab Emirates are very pro private investors. The crown prince who announced the abolishment of [insurance co-payments] very explicitly said they didn’t want to send a negative message to private investors.

Are you still committed to SA?

We are totally committed to SA but we cannot ignore the macro environment. Political uncertainty, the lack of investment, lack of new jobs created – it’s tough and it wouldn’t be wise if you use shareholders’ money to invest if there’s no demand for your services. So we are cautious to create new capacity. 

PAARL POST
Mediclinic Paarl het onlangs begin met 'n bou en opgraderingsprojek aan die hospitaal.

Die projek sal na raming ongeveer drie jaar duur en die eindresultaat behels 'n nuwe teaterkompleks, twee nuwe sale met meer privaatkamers en die opgradering van die fasiliteit.

Tans word nuwe stormwaterpype gele wat tot gevolg het dat 'n groot gedeelte van die bestaande parkeerarea nie gebruik kan word nie. Alhoewel addissionele parkering orkant die pad van die hospitaal geskep is is dit ongelukkig nie voldoende om in parkeerbehoeftes te voorsien nie.

Daar word tans met die munisipaliteit gesprekke gevoer om tydelike parkering naby die hospitaal te skep. Oelof Dippenaar, algemene hospitaalbestuurder, doen namens Mediclinic 'n beroep op die publiek om asseblief geduldig te wees met die proses wat die volgende paar weke gaan duur. 

BIZCOMMUNITY
Proud members of the Mediclinic Cape Gate nursing team gathered in the hospital's board room in May 2017 to receive the Katrin Kleijnhans Quality Trophy from Quality Advisor and Surveyor, Riel le Roux, of the Council for Health Service Accreditation of Southern Africa - COHSASA. Mediclinic Cape Gate is the third hospital in the Mediclinic Group to receive the award.

The Nursing Department at Mediclinic Cape Gate won the annual Katrin Kleijnhans Quality Award from COHSASA. Far left is General Manager of the Mediclinic Cape Gate, Carol Defty. COHSASA Surveyor and Quality Advisor, Riel le Roux, (middle back row), handed over the trophy.

The Nursing Department at Mediclinic Cape Gate won the annual Katrin Kleijnhans Quality Award from COHSASA. Far left is General Manager of the Mediclinic Cape Gate, Carol Defty. COHSASA Surveyor and Quality Advisor, Riel le Roux, (middle back row), handed over the trophy.

The Quality Trophy is awarded to an individual, a unit, a department or a discipline in a healthcare facility that has made the most impressive or substantial contribution to quality improvement during the COHSASA accreditation process. The recipient is not selected by COHSASA but is chosen by peer review at the healthcare facility.

The flame-shaped trophy, echoing the COHSASA logo to inspire quality, honours the memory of COHSASA colleague, Dr Katrin Kleijnhans, who died on 28 September 2016 after a long illness. It is intended that the trophy carry forward her legacy and encourage others to share her enormous passion for ensuring quality and safety in healthcare.

It is hoped that after its initial presentation, the trophy will become an annual internal floating trophy, given to a deserving recipient at Mediclinic Cape Gate in the future.

Mediclinic Cape Gate General Hospital Manager, Carol Defty, said: “I am very proud of the entire team at Mediclinic Cape Gate as they are passionate about constantly improving on providing safe patient care to all the patients that entrust themselves to our care.”

NEWS24
Cape Town - Henri van Breda was emotional when his uncle saw him on the day his parents and brother were murdered, Andre du Toit testified in the Western Cape High Court on Tuesday.

Du Toit, Teresa van Breda’s older brother, said when Henri returned from the Stellenbosch detective’s office with Marli’s then-boyfriend James Reade-Jahn, James’ father Ron and Henri’s friend, their reunion was emotional.

"We didn’t talk a lot. We know when he speaks fast, he stutters. He speaks slowly. We hugged and cried," he told Judge Siraj Desai.

He agreed that this was in contrast to the testimony of Dr Michelle van Zyl who later examined him and described Henri as calm.

Henri, 22 is on trial on charges of murdering his parents Martin, 54, and Teresa, 55, and brother Rudi, 22, with an axe, attempting to murder his younger sister Marli, and defeating the ends of justice.

He has pleaded not guilty, claiming a balaclava-clad man attacked the family in their home in the De Zalze Estate, Stellenbosch, in the early hours of January 27, 2015, before escaping.

Broke down

The Du Toits are the Van Breda family’s only relatives in the province, and Du Toit has been attending proceedings regularly.

He said on the morning of the murders, he was contacted by the estate manager to go to De Zalze as quickly as possible.

When he arrived, he found a number of police vehicles outside 12 Goske Street.

The property was surrounded by yellow police tape.

Du Toit broke down when he told the court that he found out at the scene that Teresa, Martin and their son Rudi had died.

Station commander Colonel Damon Beneke introduced himself to him while he stood outside the house, and the first question he was asked was what the family’s relationship was like, Du Toit testified.

“I replied that I don't know of any problems,” he recalled.

He later heard that Henri had been taken to the police station and Marli to the Mediclinic Stellenbosch.

He and his wife, who later joined him, were not allowed to see Marli at the hospital and were told that she was being transferred to Mediclinic Vergelegen.

"[At the hospital they told me] there were better doctors for her there and they didn't want us to see her in that condition," Du Toit said.

They then went to the Stellenbosch police station and asked to see Henri. They weren’t allowed to and apparently weren’t given a reason for this.

They didn’t give Henri any food or clothes, he said.

Emotional reunion

Du Toit said they then contacted the Reade-Jahns and went to their home in Somerset West, and Henri later arrived, later followed by his then-girlfriend Bianca van der Westhuizen.

Their reunion was also very emotional.

Du Toit later left with the family dog, Sasha, and Henri decided to stay behind that so that he could be close to Marli and go and see her in hospital the next day.

Henri had requested this himself, Du Toit said.

Du Toit said his wife had seen Henri’s wound and had told him that the cut looked deep, encouraging him to go to hospital for stitches.

He didn’t agree with district surgeon Dr Lizette Albertse and Dr Van Zyl’s opinion that it wasn’t required.

Du Toit’s testimony formed part of a trial-within-a-trial to decide the admissibility of Henri’s initial statement given to police shortly after the murders.

Defence advocate Pieter Botha argued that police had already seen his client as a suspect and that he was entitled to be warned that he did not have to make a statement had the right to consult a lawyer, and to remain silent.

Sergeant Clinton Malan, who took the statement on the day, said Van Breda was not informed of his rights as he was being questioned as a witness, not as a suspect.

Closing arguments in the trial-within-a-trial are expected on Wednesday.