Category Archives: Medical Aid

Information on Medical Aid schemes in South Africa

Mind the gap: Demarcation Regulations and universal healthcare

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A healthy nation is a cornerstone of socioeconomic growth, and besides ensuring basic services such as clean water and sanitation, quality healthcare is also a right. Therefore, a proper approach is ultimately required, and the government is responsible for creating the framework within which healthcare is promoted and and delivered.

In the National Health Plan (NHP), Government has considered these objectives. The National Development Plan (NDP), which provides the long-term strategic plan of the government, also recognises quality healthcare as one of its goals.

There are various health insurance products which are closely linked to the provision of healthcare. One of these is medical expense shortfall insurance, also referred to as gap cover, an insurance product underwritten in terms of the Short-term Insurance Act. This product is designed to cover the shortfall between medical scheme benefits and the rates that private medical care providers may charge. Gap cover is typically only available to those that already belong to medical schemes.

Medical schemes operate on the core principle of social solidarity. These schemes cross-subsidise risk by pooling members from a wide spectrum of the population, for instance young, old, healthy and sick individuals. The contributions of members are universal, depending on the plan you select, the monthly contribution of each member is the same. This is what is referred to as community rating. The benefits within medical schemes are also pre-determined, and includes a list of prescribed minimum benefits, or the conditions (such as hypertension or diabetes) that the medical aid has to cover by law. Anyone that applies for membership can join the scheme no matter their age, health status, race or gender. These mechanisms contribute to the affordability of schemes and provide access to quality private healthcare.

In contrast, gap cover is underwritten by insurers that apply normal underwriting principles in pricing these products, meaning that risk factors such as age, health status, etc. are taken into account to arrive at a price which aligns with the insurer’s risk appetite.

The dilemma is that the availability of gap cover encourages younger and healthier, and therefore less risky, members of medical schemes to ‘buy down’ or opt out of schemes entirely and cover the gap between the benefit under the scheme option and the actual medical expense. The loss of these less risky members from medical schemes tips the scales towards an older and less healthy average member remaining in the scheme and thus impeding on the principles of cross-subsidisation which ordinarily improves the affordability of medical schemes. As a result, medical cover for the older and less healthy members left in the scheme becomes more expensive.

This problem has been amplified, amongst others, by the following:

  • Financial advisors earning higher commissions for selling gap cover as opposed to medical schemes products, and
  • advisors misleading customers by marketing health insurance policies as alternatives to medical schemes cover.

This ultimately led to the National Treasury (NT) and the Department of Health (DoH), in conjunction with the Financial Services Board (FSB) and Counsel of Medical Schemes (CMS) – collectively referred to as the regulators – putting their heads together to come up with a solution.

There is, however, an alternate view that the target market for health insurance products is in fact those in society who are not able to afford traditional medical aid cover and that consumers take up health insurance products because they cannot afford medical schemes or their existing scheme does not cover their medical expenses in full, leaving them out of pocket to settle outstanding medical expenses.

The Demarcation Regulations

As a starting point, the Financial Services Laws General Amendment Act widened the definition of the “business of a medical scheme”, resulting in the inclusion of some health insurance products. Affected insurers would therefore need to be registered as a medical scheme and need to comply with the Medical Schemes Act (MSA).

As a result, the Demarcation Regulations, made under the Long- and Short-term Insurance Acts, became effective on 1 April 2017. These specify the types of contracts regulated under the Long- and Short-term Insurance Acts and therefore which contracts are excluded from the MSA.

The regulations will allow insurers to continue to provide gap cover products but they must be structured in a manner that complements medical schemes and will be subject to strict underwriting and marketing conditions. Thereby, effectively levelling the playing field for those health insurance products that pose a threat to the medical scheme environment and those products issued by medical schemes.

This includes:

  • A policy benefit limit of R150,000 per insured person per year must be applied across all gap cover products.
  • The commission which advisors will receive will also be adjusted. The new regulations provide a sliding scale with 5% being the lowest commission level and 20% the highest commission level. The maximum percentage will apply to monthly premiums less than R300.
  • Gap cover has to be underwritten on a group basis, meaning no individual risk rating is applied, and therefore no discrimination based on race, health status, etc., against an individual policy holder is allowed.
  • No variation to an individual’s policy can be made as a result of claims experience. Variations can only be made on a group basis as whole.
  • There are stricter marketing rules aimed at ensuring that customers are not misled.

Current developments

The Treasury agrees that more needs to be done to lower the high medical schemes costs for consumers and supports the Competition Commission inquiry into the high costs of private healthcare. The inquiry is essentially an investigation into the state, nature and form of competition in the market and was initiated to determine features of the private healthcare sector that prevent, distort or restrict competition. The NT and the FSB are also working together to improve market conduct practices in medical schemes.

The DoH and CMS are taking concrete steps to develop a low-cost medical schemes option that can be provided under the MSA, in order to ensure that more low-income households can access medical schemes and the government through the DoH and the NDP has realised that it is time for the country to move to universal health coverage where everyone receives the quality healthcare regardless of their economic status and this universal health coverage is envisaged by the National Health Insurance system.

Stay healthy on holiday

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December and the annual migration down to the coast or overseas will soon be a reality for the majority of South Africans as the summer holiday shutdown begins. Most of us are vigilant about our preparations ahead of going away.

We make sure our car has been serviced and also make arrangements for our animals and homes to be looked after and might event double-check our household insurance policies. But, the majority of us are not as good when it comes to checking whether we have cover for medical emergencies while away, especially when travelling outside of South Africa.

Consider travel insurance to ensure you are fully covered in the event of a health scare while travelling. If you are unfortunate enough to have an accident in a foreign country the last thing you and your family need to be worrying about is the cost of hospitalisation.

“Holidays are part of living a healthy lifestyle and we encourage our members to de-stress from the daily grind of life by taking some well-deserved time out,” says Gerhard van Emmenis, Principal Officer of Bonitas Medical Fund. “We urge all our members to ensure they take their medical aid cards with them when they travel locally to ensure that will be taken care of in the case of an emergency. For those travelling internationally, we offer an International Travel on all our plans, except BonCap.”

Medical expenses that you might encounter when travelling abroad can be prohibitively expensive, especially with a fluctuating exchange rate. Van Emmenis says that to avoid having your holiday and finances totally ruined, look at what your current medical aid scheme offers in terms of medical travel cover and, if necessary, top this up with additional travel insurance.

The International Travel Benefit, offered by Bonitas covers medical emergencies when you travel outside the borders of South Africa. Cover is:

  • Provided for up to 90 days per trip, irrespective of the number of trips made during the year
  • Limited to R5 million per person, up to a maximum of R10 million per family
  • Subject to certain exclusions (such as pre-existing conditions which is limited to R100,000 and certain dangerous sports activities)

The benefits include cover for:

  • Mandatory vaccine expenses (i.e. when a country you’re travelling to requires certain vaccinations)
  • Emergency medical expenses
  • Medical evacuation and transport
  • Hospitalisation
  • Out-patient and in-patient treatment
  • Optical and dental expenses
  • Travel assist services

What does your medical aid cover?

It is important to check with your medical aid scheme to see what you are covered for and, just as vital, is notifying them of your travel plans. “Members need to activate the international travel cover when they are planning to travel out of the country,” explains Van Emmenis. “The Bonitas cover is underwritten by an authorised financial services provider who need time to activate the policy. Ensuring you have cover prior to leaving will allow the medical aid to provide members with the necessary information needed in terms of vaccinations, as well as who to contact in case of an emergency abroad.”

Paying for travel by credit card

Almost all credit card providers have some form of automatic travel insurance if you use your credit card to book your air tickets. However, this doesn’t necessarily mean that the medical benefits offered will be adequate. Make sure you know what is covered, what the total monetary value for the cover is and where there might be a shortfall.

Travel insurance policies

There are a host of insurance companies and travel organisations – including the AA – who offer travel insurance. Often these are affordable as a form of ‘topping up’ on your existing cover that you have via your credit card insurance or medical aid.

However, if is wise to shop around for a plan that covers all bases, don’t assume that because you have travel insurance you are covered for every eventuality. In addition, check what the claim process is as you might have to keep all records, bills and payment receipted while travelling.

Cover for the adventurous

Although there are various policies you can take out for a short term period, i.e. for the duration of your holiday, you do need to also consider the type of holiday you are going on and the country you are visiting. Good advice to follow to us to check whether there are any travel warnings or restrictions around the city or country you are visiting and plan accordingly. Make sure you have natural disasters covered on your travel plan.

Often perceived dangerous adventure trips for the adrenalin junkie-seeker will not be covered or there will be a surcharge. This means you will need to specifically look at taking out “hazardous activity cover”, designed to cover accidents that could happen but there are limits here too.

“In all honesty, none of us want to think about ill health or possible disasters when we are excitedly planning a holiday,” says Van Emmenis. “But there is nothing worse than being unprepared and in the case of an accident or medical emergency, not only will the holiday be ruined but financially it can be devastating too.”

Life is unpredictable so the best thing you can do before your next holiday is be prepared. Find out what your existing medical aid policy covers, research additional travel insurance options and make sure you have adequate cover and, above all, read all the fine print. Stay healthy and safe these holidays!

Hat trick for Bonitas Medical Fund

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Bonitas Medical Fund was recently awarded the Ask Afrika Orange Index for service excellence. This makes it a hat trick for the fund this year, having earlier received both the Kasi Star Brand Award and the ICON Brands Survey award – both for the medical aid category.

The Ask Afrika Orange Index, which started in 2001, measures service within and across 32 industries, using 10 of the most relevant service benchmarks and ranks 165 companies. This ensures a 360 degree view of the service performance of the company while measuring customer and emotional satisfaction and loyalty.

According to Ask Afrika service expectations have changed significantly over the past five years. “Consumers are more sophisticated and have higher service expectations. This, in conjunction with more choice and service channels, elevated access to information and less customer loyalty, not only shapes what consumers know and expect from brands but also how they engage with brands”.

Gerhard Van Emmenis, Principal Officer of Bonitas, says, “As a South African brand that has been around for over 35 years we conduct regular interactions and surveys with members and financial advisors. Through this, we gauge customer satisfaction in order to improve on the delivery of services.

“We appreciate that we need to differentiate ourselves not just through our product offerings but on delivering an efficient service and outcome for our members. We are pleased that our members are positive about both the product and service they receive from us. The increase in satisfaction can be directly attributed to claims being dealt with quickly and efficiently as well as clear, simple, easily understandable communication.”

The fund’s call centre was recently upgraded and additional staff training rolled out to ensure member that queries are dealt with timeously. Earlier this year Bonitas enhanced their website and digital platforms to offer members and brokers more support.

MediFin announces its Top Loyalty Doctors for 2017

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Dental-Ladies named the winner for Top Affiliate Award. They sent us the most traffic from their website during the calendar year.

Centurion Clinic named the winner for Top Merchant Award. They sent us the most client loan applications for the prescribed period.

Dr Charl Marais earned Top Service Award, for being the partner that received the best Nett Promoter Score as rated by their patients, for the same period.

Since inception in 2012, MediFin has financed hundreds of patients throughout South Africa using an online application process, allowing patients to apply from the palm of their hands and keeping the entire process completely confidential. Many patients need to have medical procedures done that fall outside the medical aid scope. This often results in delays on urgent procedures or the neglecting of one’s personal health due to the lack of savings – this is where MediFin assists. We offer finance for expensive procedures making important life decisions affordable, says CEO Tiaan De Jager.

Client offering:

MediFin’s goal is to provide people with the opportunity and financial solution to “Be the best version of themselves” where they may not be in a position to afford the large upfront capital investment of medical procedures. MediFin Financial Services was designed to offer clients a finance option with great flexibility, which includes payment to the doctor directly, a zero deposit, no early settlement penalties, and repayment structures of up to 48 months. Their innovative solution provides clients with an alternative to rising medical insurance tariffs and depleted savings plans and is one of the only options available for elective medical procedures.

This is done through the following means:

Business partner offering:
MediFin has over 400 Medical partners in its network, ranging from dental practitioners, to radiology and fertility specialists, to cosmetic surgeons – just to name a few categories. These medical practitioners have recognised the benefit of partnering with MediFin due to its unique value propositions:

  • We pay the practitioner 100% of the procedure cost upfront, improving their cashflow.
  • Higher conversion rates – financing patients who would otherwise have declined quotations due to no affordability.
  • Improved customer service by not having to turn clients away.

Looking to the future:
In 2017 MediFin increased their financial services offering to include various insurance products. In an
attempt to offer a more turnkey solution to their patients, it was a natural way to offer insurance against procedures that carried slightly more risk than others. They now offer travel insurance, GAP cover and emergency medical insurance which can be bought online in under five minutes – refer https://insurance.medifin.co.za/medifin.

In an effort to further extend their reach, MediFin is looking to partner with great businesses that are pioneers in the medical arena. This is evidenced by their most recent partnerships with Iyeza Health, Ear Institute, Cape Fertility Clinic and MediConnect. MediFin’s online presence and business model continues to prosper as they partner with likeminded companies that share a common vision of putting the patient first.

If you feel that you could benefit from MediFin’s services, kindly contact them on

az.oc.nifidem@ofni

or call their friendly staff on 0861 000 808.

Medical aid waiting periods and late-joiner penalties: What. How. Why?

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The world of medical schemes in South Africa is a very different one to 25 years ago. There are strict rules and regulations governing the industry, there to protect both the members and the financial sustainability of the scheme. Now is the time of year when medical schemes announce their annual increases and benefit changes. It means people re-evaluate their existing medical cover and opt for new schemes, new plans or join a medical aid for the first time. Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund, discusses some of the important membership rules and regulations.

What are waiting periods?
According to the Medical Schemes Act, medical aid schemes are entitled to impose a three month general waiting period. This protects other members of the Fund by ensuring that individuals aren’t able to make large claims shortly after joining and then cancelling their membership.

Unlike other financial products, medical schemes are not-for-profit entities that are regulated to ensure they fulfil a social solidarity role, ie everyone benefits from the dependence individuals have on each other.

There are two types of waiting periods:
General waiting period (up to three months). A beneficiary is not entitled to any benefits, in some instances not even Prescribed Minimum Benefits (PMBs) during this period. If a beneficiary submits claims during a general waiting period, they will not be paid.

Condition-specific waiting period (up to 12 months). A condition-specific waiting period can last up to 12 months. During this time a beneficiary is not entitled to any benefits for a particular condition for which medical advice, diagnosis, care or treatment was recommended or received.

When do waiting periods apply?
Waiting periods generally apply if: You or your dependants were not on a medical aid for a period of at least 90 days before you joined Bonitas; you have never been a member of a medical aid or you chose to move from another medical aid to Bonitas.

When are they waivered?

  • To children born during membership, as long as they are registered within 30 days of birth
  • If application is made to register a foster or adopted child dependant within three months of the date on which fostership or adoption was granted
  • If application is made to register a spouse within three months of marriage
  • To a main member who has to join Bonitas due to a change in employment
  • If your employer moves to another medical aid and the change is made within a 90-day period
  • Active members on a medical scheme who have a break in membership of less than 90 days and a previous membership of less than 24 months

Do you pay premiums during this period?
You continue to pay your full premium during the waiting period.

Are PMBs covered during the waiting period?
A PMB is a common, life-threatening chronic condition for which cost-effective treatment would sustain and improve the quality of the member’s life. There are 27 PMB conditions and by law, the medical scheme has to cover the diagnosis, treatment and management of these. This can be confusing when waiting periods are imposed.

Van Emmenis explains, ‘Pre-existing conditions are not simple. There are a series of questions which are asked and factors taken into account when determining when to implement waiting periods. Underwriting is very much based on individual needs. If a potential member is concerned they can request pre-underwriting from Bonitas and engage on a one-on-one basis.’

What is a late-joiner penalty?
In South Africa, medical aid schemes can impose late-joiner penalties on individuals who join a medical aid scheme after the age of 35; those who have never been medical aid members, or those who have not belonged to a medical aid scheme for a specified period of time since April 2001. The reasoning for this is to ensure fairness (whereby members who have been part of a scheme for years are not subsidising newer members who have contributed to the scheme). In addition, it also ensures that medical schemes cannot deny members who wish to join.

These late-joiner penalties depend on age as well as the number of years the applicant was a member of a medical scheme or the number of years they had no cover at all. If you are over 35 and haven’t been on a medical aid then – depending on your age – you will be penalised and charged a surcharge between a 25% and up to 75% loading of your premium. It is outlined by CMS but at the discretion of the Scheme.

Does the loading reduce over time?
No unfortunately not, once you are paying a loaded premium, it remains in place.

Upgrading from a hospital plan
If someone has been on a hospital plan but decides to move to a medical aid and is over the age of 35, a loading will still apply.

Age and infirmity
Late-joiner penalties have been put in place to compensate for potentially increased claims by people who join a medical aid scheme when they’re already older or infirm and can range from 25% of contributions to 75%. These penalties are imposed at the discretion of the medical scheme and apply to all types of medical aid plans, including hospital plans.

Can you move directly from a hospital insurance to medical aid?
Even though hospital plans are now governed by the Medical Schemes Act and not as previously by the Financial Services Board, late-joiner penalties will now apply if you move from a hospital insurance to any form of medical aid (including a hospital plan).

Can a medical aim scheme ever refuse membership to the scheme?
Before 1998 medical aid schemes could refuse membership but this is no longer allowed, although they can now impose waiting periods and late-joiner penalties.

And for immigrants to South Africa?
If you belonged to a private medical aid abroad, the CMS and the scheme will evaluate each individual case, taking into account all the relevant circumstances and any pre-existing conditions.

Can you change your membership any time during the year, is there a penalty for doing this and/or a waiting period?
Yes you can change at any time (but usually this happens during open period with new contracts coming into place from the beginning of a new year). Waiting periods are not usually imposed unless for pre-existing conditions however, the savings allocated to a plan may be. Savings are allocated in advance for 12 months so, if you leave during the year and have used more than the appropriate portion of savings, you will have to pay this back.

What if you change from one Scheme to another?
A three-month waiting period will more than likely apply as well as limited PMB cover and a late-joiner penalties.

Expulsion from medical aid schemes
Van Emmenis says you can only be expelled from your medical aid scheme if you are found to have attempted to or defrauded the scheme. ‘You cannot be expelled on the basis that you have a high claim ratio, the Scheme cannot increase your premiums even if you are costing them a lot of money,’ he says. ‘However, non-disclosure or misrepresentation could result in your membership being cancelled and you being excluded from the scheme indefinitely.’

Van Emmenis says, ‘We encourage members to submit all their bills even if they might not be paid as it allows for a full record of medical expenses and you can assess your medical aid needs going forward.’

In conclusion, Van Emmenis says that he’d encourage people to compare policies across schemes before making a final decision about their medical aid future. ‘Our health is important and it makes sense to do some homework to see what is being offered, whether the plan provides the benefits you and your family needs, what will be paid from risk and the savings allocation and then weigh this up against the monthly premium.’

For more information on the options available from Bonitas you can go to www.bonitas.co.za.

Medical tax credits to go?

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There has been talk for some time now about the National Health Insurance (NHI) and how it will be funded. In his Budget Speech in February 2017, former finance minister, Pravin Gordhan, alluded to an adjustment to medical tax credits to partly fund the system.

“The rationale behind replacing the tax deduction system with the credits/rebates was to address the inequality that the deduction system gave rise to,” says Somaya Khaki, South African Institute of Chartered Accountants (Saica) project director: tax. “In terms of the deduction system, higher income earners enjoyed a greater benefit through the effect of the progressive marginal income tax rates. With the more recently introduced medical credit system, lower income taxpayers now gain with the effect of reducing their overall tax liability with the medical tax credit, whilst higher income earners benefit less in comparison to the former regime, given that the rebate is a fixed amount regardless of earnings level.”

Medical tax credits reallocated

This was followed by the NHI White Paper in June this year, which proposes that the medical tax credits be ‘reallocated’ to fund the NHI to ensure an inclusive health system for all South Africans – that is, the credits currently enabling lower income earners access to private healthcare is likely to be scrapped. Whilst we hope to move to a society where all citizens have access to quality healthcare, one has to ask, how much revenue are we talking about and how much will it contribute towards the cost of NHI which will apparently only fully be implemented by 2025? Furthermore, what are the risks with increasing the tax liability on an already overburdened relatively small community of taxpayers?”

According to the 2017 Budget Review document released by National Treasury in February, the medical tax credits for the 2014/15 year amounted to approximately R18.5bn, approximately 7% of the R256bn estimated NHI cost in respect of the 2025 year (in 2010 pricing). According to Elize Rich from Econex, when adjusted to 2017 prices, the estimated NHI cost for 2025 is more in the region of R369bn. Considering these numbers, scrapping the medical tax credits will not make much of a dent in recovering such costs in the long term. These plans also appear contradictory to the state’s intent when it introduced the medical tax credits – namely to allow lower income earners access to high quality healthcare which the public healthcare system is not ready to provide and may not be ready for years to come.

Taxpayer morale

“One also needs to consider taxpayer morale and attitude to yet again increasing the tax burden on individual taxpayers, by taking away the benefit of the medical tax credit and possibly increasing other taxes to fund the NHI – such increases which are not considered in this article,” says Khaki. “If one has to consider that unlawful and wasteful expenditure in 2016 was, at R48bn, almost three times the amount expended on medical tax credits in 2014/15, according to the auditor general’s report, the question must be asked as to whether government is really acting responsibly and in the best interests of the citizens.

Addressing the unlawful and wasteful expenditure challenge would realise far more revenue than scrapping the medical tax credits and will go a long way to improving taxpayer morale and therefore taxpayer compliance and willingness to pay if there is a view that the monies are used responsibly.

This is supported by research performed by the Organisation for Economic Cooperation and Development as well as that presented at the recent International Symposium on Tax and Corruption hosted by the Saica, wherein it was identified that factors that influence tax morale amongst citizens especially in developing countries include: satisfaction with public services and expenditures; trust in government; and perceptions of corruption.

Tax increases unsustainable

Given the numerous service delivery protests, current media focus on corruption and the lack of trust that citizens have in general with respect to governance in South Africa – whilst taxpayers should always act ethically, the levels of unhappiness with the current state of affairs definitely raises the question: how much more tax will taxpayers be willing to pay before there is a revolt and will it be worthwhile to risk this for the additional R18bn a year?

The ongoing increase in taxes is clearly unsustainable and we anxiously await the medium-term budget policy statement where we will hopefully hear more on governments proposals for growing the economy, addressing the high unemployment rate, dealing with corruption and unlawful expenditure within state entities and increasing the tax base without overburdening the already overburdened taxpayers, all of which will go towards creating a more sustainable economy and sustainable funding,” concludes Khaki.

SA needs to rethink its healthcare model

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It is into these limitations around healthcare budgets and resources that the value-based care model (VBC) steps, providing an alternative stance on medical care, the patient and costs.

No efficiencies of care

“The concept of fee-for-a-service is dead. Any provider delivering healthcare that charges for every step they take is rewarded financially, not by outcome. With value-based care and alternative reimbursement models, it is the outcome that is rewarded not the work done. It eliminates challenges around existing models where the more a practitioner does, the more they are paid, so there is no incentive to have efficiencies of care,” says Dr Jacques Snyman, CEO of Medical Specialist Holdings (MSH).

A good example of how this translates into reality would be to look at how a person services their car. There is an oil leak, the car is taken to the garage and the leak is repaired. The owner doesn’t pay until the issue has been resolved and the car fixed. The existing healthcare landscape works in the opposite direction – a patient sees a doctor about a bladder problem and has an operation, the doctor says that there may be the side effect of a leak afterwards and then charges again to fix the leak. Every time something breaks along the journey of this bladder operation, the patient has to pay for further repairs. With the alternative reimbursement model, this type of healthcare is turned on its head. The patient only pays the doctor when they are healed.

“The value equation in value-based care is defined by patient outcomes divided by the cost of delivery. If you don’t increase the cost of your treatment, but you improve patient outcomes, the value goes up. Conversely if you don’t improve patient outcomes, but the cost goes up, then the value comes down. It’s a simple formula, but implementing and measuring it is not as simple as it sounds as you can’t consider the clinical outcome,” explains Murray Izzett, MSH.

The goal of the alternative reimbursement and VBC model is to improve outcomes, but there are challenges around how existing models work and the ever-present need to satisfy the bottom line. In the pharmaceutical industry, new drugs place a high premium on the improvement of outcomes which pushes the cost up dramatically. In the oncology space, this challenge is particularly prevalent.

“There is a huge emotional interest in society to help people with cancer – it is a high-profile disease and there is a high willingness to pay. The pharmaceutical industry is a commercial entity so they are looking for a slight improvement in outcome for which they can charge a significant premium. The value equation around illnesses such as cancer introduces numerous elements that have to be assessed,” Izzett says.

Evidence-based medicine

To implement a quantifiable, reliable and sustainable VBC solution, every aspect of the healthcare industry must be taken into consideration. From the doctor, to the pharmaceutical industry to the patients. Measurement of outcomes and patient satisfaction is complex and objectivity hard to achieve, and the utilisation of these measurements must be assessed against cost and achievability.

“Currently we have a programme where we can show how evidence-based medicine can reduce costs for medical schemes. We work in concert with the medical schemes to develop a consistent methodology to showcase how we can reduce costs while ensuring patients achieve value-based care. Currently we have 18 quality assurance metrics which we will be expanding on in the future, using them to highlight that cost savings are not coming at the expense of appropriate care. The savings percentages are modest, but in light of existing inflationary increases, these are enough to make a significant impact,” he says.

‘Bogus’ online doctor to be probed

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The Government Employee Medical Scheme has launched an investigation into claims it allowed staff at public relations firm Martina Nicholson Associates to give medical advice on its online column titled Dr Joe.

Dr Joe was an online service for members of the GEMS medical aid scheme who wanted to discuss health concerns with a doctor.

On September 26 The Times ran an article quoting former employees of Martina Nicholson Associates, who claimed that, with the help of Google, they answered questions sent to Dr Joe without a doctor’s advice. The column is no longer available on the GEMS website.

This week GEMS sent a response saying it was investigating the veracity of the claims.

GEMS principal officer Gunvant Goolab said: “GEMS is very concerned about this allegation and we have instituted an investigation and will respond as soon as the investigation has been concluded.

“GEMS takes the healthcare needs of our members seriously and will act without fear or favour against any conduct that places the scheme and industry in disrepute.”

Source: The Times

SOURCE

Dodgy ‘Dr Joe’ removed from Gems website amid HPCSA probe

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The ‘House call with Dr Joe’ column on the Gems website has been taken down just days after TimesLIVE ran a story about how PR staffers from Martina Nicholson Associates were allegedly the ones offering medical health advice and not a qualified doctor as perceived.

“Apologies for the inconvenience, this page is currently under review,” was the message displayed on the page where dozens of questions and answers relating to a vast number of health issues from cancer, fertility and medication had been listed prior to the TimesLIVE story.

Health Professions Council of SA spokesperson Priscilla Sekhonyana said they were investigating the allegations about the column.

“The HPCSA is currently investigating the matter and once it has been finalised I will inform you accordingly,” she said.

The Government Employee Medical Scheme (Gems) had insisted that the answers had all been supplied by qualified medical practitioners.

Company owner, Martina Nicholson, had last week forwarded a response from Gems chief healthcare officer, Vuyo Gqola, who said: “All content is approved by medical doctors, both prior to being sent on to the member by Gems and also prior to being placed on the website by Gems.”

Nicholson herself had dismissed TimesLIVE claims that she used lay people to offer medical advice to Gems members, stating that the scathing allegations were made by a disgruntled former employee.

She later said her staffers only wrote the top and bottom of the answers.

“The work we do here at MNA is actually only a very small part of an extensive process,” she said.

Several doctors approached by TimesLIVE pointed out mistakes in numerous answers including one about the cancer risk associated with asymmetric breasts.

A pharmacist said some of the answers were also problematic because they suggested treatments.

Diagnosing and treating people over the internet without a full examination and medical history is illegal.

Bonitas announces annual increase and changes for 2018

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Bonitas Medical Fund (Bonitas) has announced its lowest increase in six years. After a challenging year for the healthcare industry, the contribution increase for 2018 will be a weighted increase of 8.7%, with increases on the various options range from 7.9% to 9.9%.

Despite increasing healthcare inflation and economic pressures in the past year, robust cost-containment initiatives have enabled Bonitas to keep the weighted average contribution in single figures for 2018. The increase is the lowest seen from the fund in recent years – clearly signalling its good financial health. Last year, speculation was rife, following Bonitas’ amalgamation with LMS Medical Fund. However, the impact of this has been negligible.

Money saved through innovative strategic measures allowed Bonitas to emerge in a stronger financial position despite industry challenges. This resulted in a reduction in the overall net deficit experienced by the Fund, reducing it from R205.5m in 2015, to R16.9m in 2016.

“As one of the largest and most stable medical schemes in South Africa, our mission is to make quality healthcare more affordable and more accessible,” says Gerhard Van Emmenis, Principal Officer. “We have, therefore, focused on balancing costs while ensuring our members continue to receive rich benefits.”

It’s been a difficult few years for the healthcare industry, with medical schemes facing several challenges including economic pressures and escalating healthcare costs. In addition, medical schemes have to comply with the strict parameters of the Medical Schemes Act.

In spite of this, the Fund recently announced that its reserves have been bolstered to R3.1bn and it has also seen a significant growth in membership.

“Last year, we successfully concluded the largest amalgamation in the industry with LMS Medical Fund. This will continue to have a favourable impact on our membership as a whole, as a larger scheme is in a better position to negotiate tariffs in favour of our members,” says Van Emmenis.

The relatively low increase has not led to a reduction of benefits but rather an enhancement. “We’ve looked at the needs of our members and South Africa as a whole to introduce several new benefits in 2018. This includes a benefit for contraceptives and a mental wellness programme, among others.

“Increases are unfortunately inevitable given the high healthcare costs and inflation but we strive to keep premiums as affordable and accessible for all. Some of the benefits have been tweaked, others increased but all aimed at helping members take control of their health and lead better lifestyles and with South African socioeconomic factors in mind,” concluded Van Emmenis.

Mental health

In times of economic uncertainty and political instability, healthcare costs and claims tend to increase – particularly with regard to anxiety and depression. Recent studies show that over 17 million people in South Africa are dealing with anxiety disorders such as panic disorder, post-traumatic stress disorder and mood disorders. In addition, statistics from a global study presented at a recent mental health summit in Johannesburg revealed that mental disorders have increased by 22.7%. In South Africa, 30% of people report life-long psychiatric disorders, while one in three will be affected by a mental illness in their lifetime.

A mental wellness programme has been developed and available in 2018 to identified beneficiaries on four plans. It provides access to specialised mental health doctors as well as education on managing the condition and support for loved ones too.

More benefits for families

Earlier this year Babyline was introduced, the first dedicated toddler’s health advice line to its members. In 2018, further benefits will be made available for Bonitas babies, including screening for congenital hypothyroidism for newborns under a month old across on all options. Screening all newborns for hearing loss is internationally recommended and these tests will also be covered on all options (in or out-of-hospital).

A focus on wellness and preventative care

Benefits that help encourage positive lifestyle changes and focus on preventing serious conditions are one of the key elements to reducing chronic disease prevalence. The Wellness Extender benefit has been increased by 15% to give members access to more consultations with a GP, dietician or biokineticist or cover for a programme to stop smoking. Pap smears for women over 21 years will now be covered on BonEssential and BonCap, once every three years and mammograms for women over 40, will be covered once every two years on BonSave and Primary to strengthen the preventive care benefits on offer.

PMBs – making benefits last longer

In previous years, out-of-hospital tests and specialist consultations for the management of Prescribed Minimum Benefit conditions (PMBs) were paid for from day-to-day benefits first on Standard, Standard Select and Primary. In 2018, cover for PMBs will be paid for solely from risk – allowing members to get maximum value for money and stretch their day-to-day benefits.

Optimised online systems and services

A new website features information on benefits and plans to help current members understand more about what their plan offers while potential members can select and choose a plan to meet their specific needs. A facility allows you to compare up to three plans on a like-for-like basis.

Further cost-containment initiatives

  1. Negotiating rates with healthcare providers and hospital groups to encourage members to use preferred providers to extend their benefits, limit co-payments and ensure they receive quality healthcare. Hospital admissions account for half of Bonitas’s annual claims costs, around R6bn. Through renegotiated rates Bonitas saw healthcare savings of R32m, negotiations remain key to managing costs.
  2. Increasing focus on prevention and utilisation of managed care protocols in disease management and co-ordination of care and wellness through the Managed Care programme.
  3. Early detection and proactively managing the diseases are key components of this. This included using the Emerging Risk Model, an innovative tool to identify emerging risk members before they develop high risk conditions. Bonitas’s back and neck, oncology, hip and knee and HIV/AIDS programmes respectively, continue to offer members emotional, clinical and financial support. These initiatives have also worked from a cost-containment perspective – leading to savings of over R100m in 2016 alone.
  4. Fraud, waste and abuse in the healthcare industry are one of the main drivers of healthcare inflation and the increase in claims costs. The private healthcare funding industry spends over R150bn on private healthcare annually. A staggering 10-15% of these claims contained elements of fraudulent information – adding an estimated R22bn to the annual cost of private healthcare in South Africa.
    To curb the impact Bonitas introduced advanced analytical software into the live claims environment last year. Using this, software the Fund was able to identify over R79m in irregular claims in 2017 for medical practitioners alone. Money which could have been used to pay for around 57,000 more GP consultations or 18 lung or liver transplants. The model is now being extended to include all pharmacy and hospital claims.
  5. An increased prevalence of chronic conditions and diabetes in particular, is one of the key contributors to a rising disease burden. After reviewing the programme Bonitas developed the Diabetes Management Programme, in conjunction with the clinical team at Medscheme, to address diabetes as well as the specific comorbidities that it brings. This will allow for more holistic treatment and management of the condition which is tailored to a member’s specific needs.

Summary of changes for the year

  • A weighted increase of 8.7% will apply to 2018
  • A separate benefit for contraceptives will be added to all options
  • Newborn hearing screening tests will be covered on all options (in or out of hospital)
  • TSH test covered on all options for newborns
  • Pap smears for women over 21 years will be extended to BonEssential and BonCap
  • Mammogram screenings for women over 40, will be extended to BonSave and Primary
  • Bone Density Screenings available on BonClassic and BonComprehensive will now be available to men aged 70 and over
  • Children under 18 will no longer be required to complete the Health Risk Assessment to access the Wellness Extender.
  • The family limit for the Wellness Extender will increase by 15% in 2018.
  • Out-of-hospital tests and specialist consultations for PMBs paid from risk on Standard, Standard Select and Primary
  • A generous dentistry benefit package paid from risk to be added to BonFit
  • Unlimited terminal healthcare benefit introduced on all options
  • The corneal graft limit BonComprehensive, BonClassic, Standard, Standard Select, BonComplete and BonSave will increase from R22,000 to R30,000.
  • In addition, the sublimit for specialised drugs for retinal disorders will increase from R42,000 to R50,000 on BonComprehensive, BonClassic and Hospital Plus.
  • An internal prosthesis benefit of R30,000 per family (excluding joint replacement prosthesis) will be introduced to BonSave and Primary
  • Introduction of the Bonitas Mental Health Programme

For more information on the range of medical plans available from Bonitas, or to compare options, go to www.bonitas.co.za.