Heidi Kruger

PREVENTATIVE and primary care are in some respects two sides of the same coin.

Primary care involves visiting an appropriate healthcare practitioner when an illness first starts for first-line treatment — before the illness progresses.

Preventative care is incredibly important, and is necessary to prevent conditions or illnesses from getting worse or needing radical treatment, according to Heidi Kruger, the Board of Healthcare Funders head of corporate communications.

And though it may cost a medical scheme more money while it is putting a disease management programme together for diabetes, HIV or another chronic condition, it’s going to save medical scheme members, as well as the scheme itself, money in the long term.

BOARD of Healthcare Funders CEO says move demonstrates the government’s commitment to making private healthcare more affordable, writes David Jackson.

Health Minister Aaron Motsoaledi has announced that he is launching an inquiry into prices in the private healthcare sector through the vehicle of the Competition Commission, with a view to proposed legislation to establish a regulated pricing framework for the industry.

Reacting to news of this development, Dr Humphrey Zokufa, CEO of the Board of Healthcare Funders (BHF), says: "We believe the government is demonstrating a commitment towards making private healthcare more affordable.

MEDICAL scheme fraud, estimated at about R15bn annually, is not declining, despite greater sharing of information by medical schemes and a zero-tolerance approach by some of the bigger medical schemes such as the Government Employees Medical Scheme and Discovery Health.

Michelle David, a medical scheme specialist at law firm Eversheds, said on Friday although it had been estimated that fraud cost SA’s schemes between R4bn and R15bn, she believed it to be more than R15bn.

She said few medical schemes took part in surveys to determine the extent of fraud — only about eight schemes on average, and not the larger ones .

Medical scheme members could be left out in the cold if gap cover products were scratched because medical aid benefits were constantly shrinking, health insurance experts said last week.

Over the years, the gap in cover between benefits provided by medical schemes and what providers charge has widened not only for specialists’ consultations, but for in-hospital procedures as well.

Medical schemes have said their reduced reimbursement rates on hospital cover could be blamed on specialists who charged higher rates. This has left members to pay more from their pockets because of co-payments, sub-limits and deductibles, among other things.

Private healthcare prices in South Africa have to be regulated, Health Minister Aaron Motsoaledi said.

Speaking at the Board of Healthcare Funders conference at Sun City, Motsoaledi called for a pricing negotiation forum, saying healthcare in South Africa was "predatory".

He said the health structure was worse now than during apartheid.

"There is a tendency to believe that a long and healthy life is the right of those that can afford it and that is totally wrong," he said.

"The reality is that our people are dying in large numbers. We are running a healthcare system in this country that is not working."

The solution lay in re-engineering the primary healthcare system.

Motsoaledi announced a plan to introduce three streams of care, which would have a particular impact in rural areas.

Board spokesman Heidi Kruger welcomed Motsoaledi's comments, saying: "I think it's brilliant. The sooner it comes through the better. We can't have a situation where there is no containment on costs."

Kruger said private healthcare providers charged whatever they wanted, "pushing up" medical aid premiums.

The current system was an "open-ended liability for funders" so medical schemes could not budget properly.

Regulating healthcare costs would be "very constructive" and "provide certainty", Kruger said.

Motsoaledi is hoping to begin setting up the pricing forum by the end of the year.

However, he told delegates at the conference that hospitals were creating a stumbling block in the process because that sector did not want to have its prices regulated.

Motsoaledi accused the public and private health sectors of "engaging in destructive, unsustainable practices". He was particularly outspoken about the high cost of private hospital treatment and called for a stronger emphasis on primary care, rather than the present curative system with its "rapidly escalating" costs.

"The public health system is in a crisis of quality and I am going to deal with it head on, but it is not an excuse for profiteering," he said.

"Our country is going in the wrong direction . all of us, public and private," he said. "We have a predatory healthcare system where the sick and the vulnerable are the ones who get attacked."

The Board of Healthcare Funders (BHF) has asked the Competition Commission to exempt medical schemes from provisions in the Competition Act that stop them from working as a collective on matters such as setting tariffs and defining patient benefits. The BHF, which represents 85% of SAs medical schemes, said its application was intended to deal with a host of unintended consequences arising from a ruling by the Competition Commission in 2004 that banned collective bargaining in the sector. The ruling was aimed at fostering competition, but was undermining schemes ability to safeguard their economic future, it said .

During this month (April) new proposals will be released by Cabinet which could alter the entire foundation of South Africa's healthcare system by changing the way health is financed. The proposals for a social health insurance scheme, which will be part of a wider plan for social security, will be released for wider consultation before the final recommendations are made, said Fezile Makiwane, deputy DG for Social Development and a key member of the committee of inquiry into social security. The Ministers of Health, Social Development, Transport, Labour and Finance have all been briefed by the committee and, as their sectors are all affected by these proposals, they are taking the process forward and making a joint submission to Cabinet. Cabinet will release the proposals in early April, said Makiwane. Social health insurance is seen as one component of a potential future social security system. In addition to health, the committee considered how to provide social security benefits in relation to unemployment, retirement and old age, disability, poverty and social assistance, injuries and diseases arising from employment, and road accidents. A social health insurance scheme is regarded by its proponents, mostly health economists, as the answer to the crisis in South Africa's overburdened state hospitals and it is being eagerly awaited by the medical aid industry which will double its business if the proposals go through. But the unions are against the plan and are ready to fight it. Nearly a decade after social health insurance was first proposed as a mechanism for extending health care coverage and promoting equity in South Africa - and after investigation by three government committees since 1994 - the plan could finally be coming to fruition. Its proponents are confident it will have a better chance of getting through this time because for the first time it is part of a wider social security plan. The proposal is that everyone in South Africa who is in formal employment, but who is not already on medical aid, should become part of a compulsory social health insurance scheme. It will be an earmarked tax which will go into a state fund, but it may be administered by the medical aid schemes. Also, by reducing the number of people whose health care has to be funded out of the public budget, or by contributing to the public budget through fees paid directly to public services, it has the wider effect of improving equity across the entire health care system. Professor Di McIntyre, director of the University of Cape Town's Health Economics Unit, said the plan rested on the ability of medical aids to contain costs. McIntyre said the original proposals were that everyone who is insured, including those who currently have medical aid, would fall under the social health insurance scheme - which would promote a wider distribution of resources. But under the present proposals, the medical aid schemes and the state fund will be completely separate, which rules out cross-subsidisation between high income and low income groups. She said this would limit the extent to which the original objectives of the social health insurance proposals could be met - it was envisaged that the social health insurance could extend health insurance cover in South Africa, as there would be substantial cross subsidisation and lower income groups would pay relatively little in contributions to the fund. The other potential landmine, said McIntyre, is that government would now have to pay for the contributions of all civil servants. At present, government spends a considerable amount of money on the medical scheme contributions of civil servants. However, only half of all civil servants are currently covered by medical schemes, and if the new fund is introduced, then government spending on contributions for health insurance cover could double - and questions are being raised as to whether this is affordable. (Source: Health-e, 3 April 2002)