In a statement, the association says that in light of the fact that the investigation took almost four years to complete and runs to hundreds of pages, it is, on first review, somewhat disappointed in the overall analysis of the private healthcare sector.

Doctor-induced moral hazard

Sama is particularly concerned about the allegations that doctors increase demand of unnecessary services, including increased admissions to hospitals, says chairperson, Dr Mzukisi Grootboom.

“The HMI reached this conclusion after analysing claims data. We are of the considered view that the methods used by the HMI were not robust enough to conclude that many admissions are unexplained and thus constitute a doctor-induced moral hazard,” he says.

In 2017, the Medical Research Council presented to Parliament the top 10 diseases that kill South Africans. These included HIV and Aids, cerebrovascular disease, lower respiratory tract infections, ischaemic heart disease, tuberculosis, diabetes mellitus, hypertension, interpersonal violence, other trauma-related injuries, liver disease and diarrhoeal illnesses. In 2015, Statistics South Africa reported cancer to be the fifth cause of death in the country.

“Typically the private sector uses the Prescribed Minimum Benefit Chronic Conditions List (PMB CDL list) to define chronic conditions. The list only includes three of the conditions which kill South Africans. The HMI can therefore not conclude that there are unexplained admission after adjusting only for chronic diseases and age. Sama believes the increase in admission can be explained by high prevalence of injuries, acute infections, cerebrovascular accidents, cancer, tuberculosis, and substance abuse, amongst other factors,” says Grootboom.

Disregard of mental health

Dr Grootboom says it is also concerning that the HMI assumed all psychiatry and paediatric admissions are discretionary. This is patently wrong.

“This cannot be true given the recent developments in mental health. If psychiatry admissions are really discretionary, we would not have witnessed the development of the Life Esidemeni crisis. No doctor will choose to admit a mental health patient if an option for community-based care exists. In a country where high causes of mortality rates in children include lower respiratory tract infection and diarrhoea, assuming that all paediatric admissions are discretionary is quite flawed,” Grootboom notes.

The HMI analysed the proportion of discretionary admissions in 10 specialities. He says it is astounding that all cardiology and cardiothoracic admissions appear to have been considered discretionary against the backdrop of ischaemic heart disease being responsible for a significant proportion of deaths in the country.

He notes that almost all of urology and orthopaedics admissions were also considered discretionary.

“Treatment of hip fracture with arthroplasty or early prostate cancer is not discretionary; these are the standards of care,” he says.

In addition Grootboom notes that black men in South Africa are more likely to suffer aggressive forms of malignancies or cancer and that a watch and wait strategy is therefore clinically not appropriate in our setting.

Further to the report’s findings that unpaid claims should be construed as unnecessary care, Grootboom says schemes typically do not fund clinically appropriate care if they judge it is not a prescribed minimum benefit and not covered by plan type.

“Unfortunately, the allegations of doctor-induced demand can erode the patient-doctor trust. As a profession we will continue doing our level best to care for and save the lives of all South Africans. We will also further engage with the HMI after a complete analysis of this lengthy document.”