Tag: medical aid schemes

BHF Annual Conference Concludes with Key NHI Insights and Roadmap for SA’s Healthcare Future

Photo by Pexels on Pixabay

After what was an insightful and collaborative meeting of the minds of healthcare professionals and experts at the 2024 BHF Annual Conference, the final day concluded by providing crucial insights into regulatory reforms shaping the future of healthcare in South Africa, as well as the legalities surrounding the controversial NHI Bill.  

Facilitated by Nomo Khumalo, BHF Director and Head of Solutions at MMI Health, part one of the discussion comprised the key regulatory responses essential for building a resilient health system capable of navigating beyond current barriers. 

Among the notable delegates participating in the discussion were Vincent Tlala, Registrar and CEO of the South African Pharmacy Council; Dr Magome Masike, Registrar of the Health Professions Council of South Africa; Dr Thandi S Mabeba, Chairperson of the Council for Medical Schemes; Dr Mark Blecher, Chief Director of Health and Social Development at the National Treasury; Yoliswa Makhasi, Director General of DPSA; and Dr Sandile Buthelezi, Director-General of the National Department of Health. 

Their expertise across the healthcare regulatory sector added invaluable insights into the state of the sector, where they explored the current policy landscape, analysed the intent of reforms versus the realities, and discussed necessary changes for policymakers to ensure healthcare sustainability. 

While all dignitaries note the need for Universal Health Coverage (UHC) to bridge the gap in access to healthcare in South Africa, Dr Sandile Buthelezi, acknowledged the complexity of implementing the NHI and the need for a phased approach. To this end, Buthelezi cited that significant work is required to establish the fund, develop regulations, and set up administrative structures.

“Apart from this, optimising healthcare delivery requires prioritising resource utilisation through proper management and spending, and addressing managerial issues to utilise available resources effectively,” suggests Buthelezi. 

“Regulatory reforms are essential for advancing healthcare, encompassing standardised data collection, quality enhancement, and informed policy evolution. Moreover, the integration of digital health strategies is paramount, leveraging technology to bolster comprehensive health information systems and elevate healthcare delivery.”

Amidst the discussions, a common thread resonated among all dignitaries: the vital importance of collaboration. Here, Buthelezi stressed the necessity for stakeholders within the healthcare sector to unite in pursuit of shared goals, emphasising the need to improve health outcomes and effectively tackle challenges through collaborative efforts.

Following this, the conversation swung to the legalities of the impending NHI Bill in a session chaired by Michelle Beneke of Michelle Beneke Attorneys Inc, and featured industry experts Neil Kirby, Director at Werksmans Attorneys, and David Geral, Partner at Bowmans.

The conversation focused on the several facets of the implementation of the Bill, including its constitutionality, lack of government response to engagement efforts, and the broader regulatory challenges facing the healthcare industry.

According to Kirby, Werksman Attorneys, as legal representatives of BHF, have closely monitored the evolution of the NHI Bill, thoroughly scrutinising its alignment with South Africa’s constitutional principles.

“Regrettably, the implementation process hasn’t yielded a bill that adequately addresses our constitutional concerns. Despite incremental progress and assurances of future adjustments, the current iteration falls short of meeting the constitutional litmus test. 

“As stakeholders directly impacted by the bill’s implications, we cannot afford to overlook constitutional shortcomings. Our obligation demands rigorous adherence to constitutional standards, ensuring that any legislation enacted upholds the rights and principles enshrined in our constitution,” he says. 

To this end, Geral adds that the Bill introduces significant changes to the healthcare system, which may potentially affect tax policy and revenue sources. 

In closing the conference, Dr Katlego Mothudi, Managing Director at BHF, emphasised the success of the conference in addressing industry challenges while promoting sustainability across the healthcare sector. 

“As we conclude this enlightening conference, we reflect on the breadth of topics covered, from disease burden to the transformative potential of digitisation and AI in healthcare. Our discussions underscored the necessity of embracing change, combating fraud, and fostering regional collaboration. 

“With a firm focus on healthcare reform, particularly the intricacies of the NHI Bill, our gathering has propelled us toward a future marked by innovation, resilience, sustainability and collective action. In the words of Edgar Tan – we can have what we need if we use what we have,” he concludes.

Useless Antibiotic Prescriptions are Getting out of Hand

Photo from Pixabay CCO

According to a massive new medical insurance database study, the U.S. is going the wrong way with antibiotic stewardship, with 1 in 4 prescriptions going to patients who have conditions that the drugs simply won’t work on. In fact, the percentage of all antibiotic prescriptions given to treat conditions they’re useless against was even higher in December 2021 than it was before the pandemic began, the study shows – increasing the rate of antibiotic resistance development.

The percentage inappropriate prescriptions actually fell slightly in the early months of the pandemic, when far fewer people sought medical care for infectious or non-infectious reasons, the new research shows. But this trend was soon reversed.

The study, published in the journal Clinical Infectious Diseases by a team from the University of Michigan, Northwestern University and Boston Medical Center, is based on data from more than 37.5 million children and adults covered by private insurance or Medicare Advantage plans from 2017 to 2021. Patients received antibiotic prescriptions from both in-person and telehealth visits.

The team looked back at any new diagnosis given to each patient on the day they received a prescribed antibiotic or in the three days before getting the prescription. If none of these diagnoses justified the use of antibiotics, they classified the prescription as inappropriate.

Key findings:

  • In all, 60.6 million antibiotic prescriptions were dispensed in the five years of the study period from January 2017 to December 2021. The share that were inappropriate rose from 25.5% to 27.1% during this period.
  • The proportion of people getting inappropriate antibiotics was 1.7% in December 2019, dipped to 0.9% in April 2020 – largely because fewer people get antibiotics in general – and returned to 1.7% by December 2021.
  • Some groups of people were more likely to receive inappropriate antibiotics. At the end of 2021, 30% of antibiotics for older adults with Medicare Advantage coverage were inappropriate, compared with 26% of antibiotics for adults with private health insurance and 17% of antibiotics for children with private insurance.
  • Among the diagnoses listed for people who received antibiotics for inappropriate reasons, “contact with and suspected exposure to COVID-19” was one of top two most common reasons from March 2020 through December 2021. There is no evidence that taking antibiotics after an exposure can reduce risk of developing COVID-19.
  • Of all the inappropriately prescribed antibiotics dispensed in the last half of 2021, 15% were for a COVID-19 infection. And COVID-19 infections accounted for 2% of all antibiotic prescribing – regardless of appropriateness – from March 2020 through December 2021.
  • Telehealth appointments accounted for 9% of all inappropriate antibiotic prescriptions in the latter half of 2021, down somewhat from 2020. There were almost no telehealth-based antibiotic prescriptions before March 2020.
  • For 28% to 32% of the antibiotic prescriptions filled by patients in the study period, there was no diagnosis available to judge appropriateness, potentially because the patient received the prescription at an appointment that didn’t get billed to their insurance, or it was a refill of a past prescription. The percentage was especially high in the first months of the pandemic.
  • 45% of all the patients in the study received antibiotics at least once in the five years, and 13% received them four or more times.

Source: University of Michigan

News24 Awards Name Bestmed as ‘Medical Scheme of the Year’

The News24 Business Awards – focused on areas such as costs, client service and claims – has named the largest self-administered medical scheme in SA as the nation’s best

Photo by National Cancer Institute on Unsplash

Bestmed Medical Scheme, the fourth largest open medical scheme and the largest self-administered medical scheme in the country, has been honoured with the News24 Medical Scheme of the Year award, at the 2024 News24 Business Awards.

These awards recognise client satisfaction scores surveyed from more than 4 000 subscribers, along with their assessment of the offering, among other criteria, and cover multiple sectors, including banking, insurance, and healthcare.

Focused on a range of criteria, including customers’ satisfaction with key issues like costs, and client service and claims, the awards also consider the company’s transparency / communication with clients, overall contribution to South Africa, shareholder value creation and business performance. These elements are also evaluated by News24’s financial reporters, as well as fund managers and analysts – with results ultimately audited by an actuarial consultant.

This year, Bestmed took the coveted Medical Scheme Award notably because of the outstanding feedback from its clients in a survey of thousands of News24 readers, especially when it came to its claim process and communication. News24 journalists also gave Bestmed a very high score for how easy it is to understand what is covered and for value for money.

“Bestmed is truly proud to be named Medical Scheme of the Year, particularly based on criteria that are so client-focused,” says Leo Dlamini, CEO and Principal Officer of Bestmed Medical Scheme. “These awards celebrate the best in corporate South Africa, and we are pleased to have been recognised for our efforts in this space. We have always believed in great member experience, value for money offerings and making a difference in the communities in which we operate.”

Awards of this nature are nothing new to the Scheme, which has received many similar accolades in recent years. Bestmed was voted, for a second successive time, as the leader in the South African medical scheme industry when it comes to customer satisfaction, according to the most recent SA Customer Satisfaction Index (SA-csi). Last year, Bestmed also received the Board of Health Funders’ Titanium Award for Excellence in Creating Access to Quality Healthcare – this, for the third consecutive time. Bestmed was also voted first in 2020 and 2022, and second in 2023, for customer experience in the Ask Afrika Orange Index® benchmark’s medical aid category.

“Members are at the centre of everything that we do. Our ‘Personally Yours’ promise is a commitment to consistently providing our members with the highest quality service, while also offering value for money. This award affirms our conviction and energises us to maintain the focus on member experience and value-for-money offerings. This will continue to set Bestmed apart as a healthcare funder of choice,” concludes Dlamini.

About Bestmed

Bestmed Medical Scheme is the largest self-administered medical scheme in South Africa. Bestmed’s “Personally Yours” philosophy leads the way in the medical aid industry. Bestmed’s membership offerings include 14 unique plans, designed to suit the needs of members. Beneficiaries have access to a network of more than 18 000 healthcare professionals countrywide. The Scheme’s head office is based in Tshwane (Gauteng). Bestmed has satellite offices in Nelspruit, Durban, Cape Town, Gqeberha (Port Elizabeth) and Polokwane.  For more information visit www.bestmed.co.za

Does NHI Spell the End for Medical Aid and Gap Cover?

Photo by National Cancer Institute on Unsplash

South Africa’s National Health Insurance (NHI) Bill would, if passed in its current form, completely disrupt the medical sector in the country and would inevitably reshape the role of medical schemes as well as gap cover.

However, the implementation of NHI does not necessarily mean that medical aid and gap cover will no longer have a role to play, because there are many possible scenarios in which they will continue to be an important part of the landscape. It is important to understand your current coverage from both a medical aid and gap cover perspective so that when the NHI does come into effect, you can make an informed decision that will be best for your needs.

A long road ahead

Given the potential for the current NHI Bill to face legal challenges, we are driven by a shared responsibility to safeguard the health and well-being of all citizens. The risk of lengthy court battles cannot be underestimated, as they may inadvertently prolong the uncertainty and affect the timely implementation of essential healthcare reforms. According to Andre Jacobs, Marketing Manager at The People Company and Vice Chair of the FIA Health Exco, these challenges include constitutional, funding, affordability, policy and supply-side demand issues.

“There are also conflicting points of information within the current Bill that need to be resolved. For example, in Section 33, the Bill states that once NHI is implemented, medical schemes can play a top up role, which could mean different things. It could imply that they may only provide cover for anything that is not primary care, or that they may only provide specialised dentistry cover or advanced oncology treatment,” says Jacobs. 

“However, if one reads the definition of a health service and a health product with section 2(a) of the NHI Bill, it states that all health services will be provided by the NHI Fund and that they are the single purchaser and provider of health services. Therefore, whilst section 33 provides a role for medical schemes, it would be impossible to operate,” he adds.

A matter of speculation

The reality is that it is yet to be determined what benefits the NHI Fund will provide. This means that the role of medical schemes, and therefore the role of gap cover, is a matter of speculation at present. The structure of the current medical scheme and gap cover range may need to be adjusted to align with the NHI offering that is enacted.

This may lead to the design of products moving toward a defined benefit structure where a particular medical intervention, such as a broken leg, has a defined benefit that is paid out irrespective of the amount of cover provided by the NHI. This amount could then be utilised to pay for a private procedure. It is also likely that high-cost treatments such as specialised dentistry or advanced cancer treatment or biological medicine will not be provided by the NHI Fund. However, the regulations post-NHI will dictate what can be offered.

“If we use overseas experience by way of example, there will be a role for both National Health and private insurance products, where the private cover will provide additional benefits to complement the base offering of the NHI. For example, we often see this as providing a fast track for certain elective procedures that a person may need to address due to personal circumstances,” says Tony Singleton, CEO of Turnberry Management Risk Solutions. 

Make sure you are covered in any eventuality

“The goal of expanding universal healthcare should be supported, but rather than abolishing private healthcare, South Africa should leverage the private sector to expand the level of universal health cover. We can develop a dualistic healthcare system with the same universal coverage elements based on social solidarity principles, with a healthcare system that is accountable to the communities it serves. Transitioning to a more equitable healthcare system demands not only sound policy decisions, but also a shared commitment to overcoming societal attitudes and cultural beliefs that might hinder progress,” says Jacobs.

Private medical schemes are an asset that should be leveraged to drive healthcare innovation and foster advancements for the broader healthcare sector, and the healthcare system needs to provide meaningful choices through an accessible, inclusive, and adaptable system that caters to the diverse needs and preferences of the population.

Gap products currently play an important role in protecting your financial wellbeing in the event that medical expenses exceed what medical schemes will reimburse. In the current landscape, where the future state of the NHI is uncertain, there is still a definite need for both medical aid and gap cover to ensure access to quality private healthcare. In addition, gap cover for the use of non-Designated Service Providers (DSPs) will continue to be important even after a National Health product comes into effect.

“Before making any decisions, it is important to understand the cover provided by your medical aid and to understand any limitations that your plan may have. To assist you with this, it is useful to have your financial advisor review your medical aid coverage. They will be able to identify the type of gap product that will be most complementary to your Medical Aid plan whilst at the same time understanding your family’s unique health and financial situation,” Singleton concludes.

About Turnberry Management Risk Solutions

Founded in 2001, Turnberry is a registered financial services provider (FSP no. 36571) that specialises in Accident and Health Insurance, Travel Insurance, and Funeral Cover. With extensive experience across healthcare and insurance industries in South Africa, Turnberry offers unsurpassed service to Brokers and clients. Turnberry’s gap cover products are available to clients on all medical aid schemes, as they are independently provided and are therefore transferable in the event of a change in the client’s medical aid scheme. Turnberry is well represented nationally, with its Head Office based in Bedfordview, Johannesburg with Business Development Managers in Cape Town and Durban. The Turnberry Team’s focus on outstanding client service comes from having extensive knowledge and experience in the financial services sector and is underwritten by Lombard Insurance Company Limited. Lombard Insurance Company Limited is an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.

GEMS is Again Recognised as a Top Employer 2024 in South Africa

The 2024 Top Employers have been announced and GEMS (Government Employees Medical Scheme) has again been recognised as a Top Employer in South Africa. 

Being certified as a Top Employer showcases an organisation’s dedication to a better world of work and exhibits this through excellent HR policies and people practices. 

GEMS Principal Officer, Dr Stan Moloabi says this of the accolade, “The Scheme takes immense pride in this achievement as we believe in the adage, ‘batho pele’– people first.” He adds, “It is our focus on investing in our more than 400 employees that enables us to fulfil our mission to provide all members with equitable access to affordable and comprehensive healthcare; promoting member wellbeing.”

The Top Employers Institute programme certifies organisations based on the participation and results of their HR Best Practices Survey. This survey covers six HR domains consisting of 20 topics including People Strategy, Work Environment, Talent Acquisition, Learning, Diversity, Equity & Inclusion, Wellbeing and more.

To the Scheme, it is heartwarming that it is the third year in a row that it has received this recognition.

Top Employers Institute CEO David Plink says: “Exceptional times bring out the best in people and organisations. And we have witnessed this in our Top Employers Certification Programme this year: exceptional performance from the certified Top Employers 2024. These employers have always shown that they care for the development and well-being of their people. By doing so, they collectively enrich the world of work. We are proud to announce and celebrate this year’s group of leading people-oriented employers: the Top Employers 2024.” 

The programme has certified and recognised over 2 300 Top Employers in 121 countries/regions across five continents. 

Medshield Medical Scheme And Clicks Strengthen Their Partnership to Enhance Access to Quality Care Through Medshield’s Smartcare Benefits

Medshield Medical Scheme, a prominent medical aid scheme, and Clicks, a leading retail pharmacy chain and Designated Service Provider on the Medshield Pharmacy and SmartCare Networks, are pleased to announce the expansion and enhancement of their partnership. This partnership aims to empower members with even greater access to quality care through Medshield’s SmartCare benefit, allowing access to a network of Clicks clinics for professional nurse and nurse-led virtual Family Practitioner (GP) consultations. This further cements their commitment to delivering healthcare excellence through technology.

Expanding the SmartCare Network

Medshield and Clicks have partnered to add 123 Clicks clinics to the existing 255 clinics in the SmartCare Network. This expansion guarantees that Medshield members can conveniently and efficiently access their SmartCare benefits at these selected Clicks clinics.

SmartCare: The Gateway to Modern Healthcare

Medshield’s flagship member benefit, SmartCare, is leading the charge in digital innovation in healthcare. By utilising the power of technology, SmartCare provides access to pharmacy clinics that offer a one-stop-shop for members to access professional nurse consultations, health risk assessments, sick notes, specialist referrals, medication and nurse-led virtual access to Family Practitioners (GP) when required. This benefit is redefining the way healthcare services are accessed and delivered, making it more convenient and efficient for both healthcare providers and members.

Medshield members have access to an unprecedented level of convenience through Clicks clinics, which are powered by the Udok telemedicine solution. These consultations cover prevention, diagnosis, and treatment, focusing on connecting patients, nurses, doctors, and medication for fast and convenient care.

Kevin Aron, Principal Officer at Medshield, explains, “When we introduced SmartCare, we aimed to offer a cutting-edge solution that would add more value for our members. Medshield was the pioneer medical scheme in South Africa to integrate this service as a new benefit for all members, without additional costs.”

The Medshield SmartCare Benefit

SmartCare offers a multitude of benefits to Medshield members, providing them with a holistic approach to healthcare:

  • Enhanced Access to Care: SmartCare provides Medshield members with easy access to quality care led by professional, licensed nurses at pharmacy clinics. The nurse will facilitate a virtual Family Practitioner (GP) consultation depending on the patient’s ailment. Once the patient has been diagnosed and treatment prescribed, the relevant medication is easily obtained from the pharmacy.  
  • Stretch day-to-day medical aid benefits:  Healthcare services offered by SmartCare pharmacy clinics such as Clicks are cost-effective, and enable members to receive quality care and their medication as a complete solution. Utilising the SmartCare benefits allows the member to receive quality care whilst minimising the use of their day-to-day benefit.
  • Improved Health Outcomes: SmartCare services implemented by pharmacy providers allow members to manage and receive preventative care through wellness checks and health risk assessments, providing access to early intervention services and ultimately leading to better health outcomes. 

The Vision of Collaboration

“We are excited to announce our enhanced partnership with Clicks, a valued partner on the Medshield DSP Network. With the addition of 123 Clicks clinics to the SmartCare Network, we are reinforcing our commitment to provide Medshield members with access to high-quality healthcare services,” said Kevin Aron, Principal Officer at Medshield. “SmartCare is revolutionising healthcare delivery, and we are proud to offer this innovative solution to our members.”

The Medshield SmartCare way of adding value:

  • A Medshield member can visit any Clicks clinic on the SmartCare network for primary healthcare needs such as acute conditions, wellness checks, health risk assessments, vaccinations, or chronic medication prescriptions as prescribed by a Family practitioner (GP).
  • A registered nurse performs a thorough medical history and examination of the patient.
  • The nurse can advise the patient on over-the-counter medication available at the pharmacy.
  • A virtual consultation with a family practitioner is requested by the nurse through Clicks clinic’s Udok technology when further treatment is necessary. The doctor then completes the consultation with the assistance of the nurse.
  • The nurse can print the doctor’s written documentation, and the patient can fill their prescription at the pharmacy immediately.

Accessible Medications and Comprehensive Care

In addition to SmartCare consultations, Clicks pharmacies are available on all Medshield plans, making access to prescription medication convenient for members.

Rachel Wrigglesworth, Clicks’ Chief Healthcare Officer stated, “This partnership between Clicks and Medshield focuses on the wellbeing of our customers, which is our top priority. The collaboration has expanded to include Clicks clinics powered by Udok, a solution that offers real-time access to registered family practitioners through our Nurse-led consultations on the SmartCare benefit, funded by Medshield Medical Scheme. As a leader in the healthcare market, this partnership perfectly aligns with our commitment to increasing access to affordable primary healthcare for all South Africans. We are committed to the continued success of this collaboration.”

Embracing the Future of Healthcare

As the healthcare industry continues to evolve in the digital age, SmartCare stands as a shining example of how technology and innovation come together to provide added convenience and efficiency in healthcare. It empowers nurses to provide additional care for Medshield members through accessible technology. Unless it is a trauma situation, members can visit a Clicks clinic on the SmartCare network for acute and chronic conditions. By embracing the future of healthcare through the SmartCare benefit, Medshield members can expect to experience efficient and reliable medical consultations to enhance their wellbeing.

“Medshield is continuing to reinvent healthcare the smart way. The SmartCare benefit offers our members a new level of convenience, connecting members with nurses, doctors and medicine like never before,” concluded Aron.

A Strengthened Partnership

Expanding the Medshield and Clicks partnership demonstrates a solid commitment to providing excellent healthcare services and a shared vision of creating a more accessible and convenient healthcare experience for Medshield members. It is a testament to the excellent collaboration between Medshield and Clicks, ensuring that quality care is always easily accessible.

Opinion Piece: Prostate Cancer is One of the Most Common Male Cancers in South Africa – How Would You Deal with a Diagnosis?

Credit: Darryl Leja National Human Genome Research Institute National Institutes Of Health

By James White, Head of Sales and Marketing at Turnberry Management Risk Solutions

According to the National Cancer Registry (NCR) of South Africa, prostate cancer is the most commonly diagnosed cancer among men in South Africa. In 2020, it accounted for more than 22% of all male cancers, with the average age of diagnosis being 65 years old. While prostate cancer is more common among older populations, it can affect men of any age, and although the disease is often treatable, the success of treatment and survival rate depends heavily on an early diagnosis and access to appropriate treatment. The last thing anyone wants to think about after a diagnosis is how they will pay for the treatment, or if they can even afford it, which is why gap cover has become an essential weapon in the fight against cancer.

Key points about prostate cancer

While the exact cause of prostate cancer is unknown, there are several risk factors that increase a man’s likelihood of developing the disease. These include age, family history, and lifestyle factors such as diet and exercise. However, if it is caught early, prostate cancer can often be successfully treated, so it is important for men to get regular check-ups and prostate cancer screenings starting at age 50 (or earlier if they have a family history or other risk factors). Regular screenings can help detect prostate cancer before it has a chance to spread, giving men the best chance of a favourable outcome.

It is also important to know that help and support are available. Prostate cancer can be a difficult diagnosis for men and their families, but there are many resources available for support, including support groups like the Machi Filotimo Cancer Project, as well as online forums, and counselling services. These resources can help men and their families cope with the emotional and practical challenges of a prostate cancer diagnosis and treatment. When it comes to the financial side, it is important to understand your medical aid scheme and plan option, and how treatments will be covered.

Shortfalls and PMB conditions

Prostate cancer is a Prescribed Minimum Benefit (PMB) condition, which means that medical aid schemes in South Africa are required by law to provide cover for diagnosis, treatment, and care, in line with that which is available at a state hospital. However, this does not mean that medical expense shortfalls will not occur. Co-payments may still apply for certain aspects of treatment and making use of a non-Designated Service Provider (DSP) may attract penalties. Depending on the scheme and plan option a patient has, there may also be other limitations on the cover received for cancer treatment.

For example, a PMB will cover the treatments that are available as per the protocols of a state hospital, including surgery, chemotherapy, immunotherapy, radiation, and hormone therapy. There are also next-generation biological cancer drugs that are used to successfully treat prostate cancer while being minimally invasive and having fewer side effects. These drugs, however, are not part of the basket of PMB care, and will be covered according to the cancer benefits of a patient’s medical aid scheme and plan. There is significant potential for shortfalls here, as these drugs are expensive, are not often fully covered, and need to be administered multiple times to be effective.

A significant gap

As with all cancers, early detection saves lives, and the sooner a patient can start to get the treatment they need, the better their prognosis. However, having to think about the financial implications can add strain to an already stressful situation. Having the right gap cover policy can be invaluable in ensuring that you can receive the best treatment, quickly, to give you the highest chance of surviving and thriving after a prostate cancer diagnosis.

At Turnberry, prostate cancer claims make up a significant 17% of all cancer-related claims, and the amounts claimed for are substantial sums of money. In 2022 alone, we paid out several high-value claims related to prostate cancer – a shortfall of R29 530 from a total bill of R84 889.50; a shortfall of R31 496.60 from a bill of R47,244.90; a claim of R54 555.50 from a total charged amount of R84 899.50; a claim of R53 722 from a total bill of R80 583; and a shortfall claim of R26 765.86 from a total bill of R39 392.80. Without gap cover, these patients would have had to fund these shortfalls out of pocket, which could significantly impact their financial wellbeing long after they received a clean bill of health.

Always talk to your broker

Medical aid schemes and the various plan options within the schemes vary in the coverage they provide as well as the way in which their cancer benefits are structured. In addition, different gap cover policies have different coverage options, which means that it is important to talk to your broker or financial advisor to find the best gap cover policy to augment your medical aid cover. Ultimately, gap cover is a small price to pay for the peace of mind it offers, that you will be covered for cancer treatments and that the financial burden of shortfalls will not fall on your shoulders, or on those of your family members either.

About Turnberry Management Risk Solutions

Founded in 2001, Turnberry is a registered financial services provider (FSP no. 36571) that specialises in Accident and Health Insurance, Travel Insurance, and Funeral Cover.

With extensive experience across healthcare and insurance industries in South Africa, Turnberry offers unsurpassed service to Brokers and clients. Turnberry’s gap cover products are available to clients on all medical aid schemes, as they are independently provided and are therefore transferable in the event of a change in the client’s medical aid scheme.

Turnberry is well represented nationally, with its Head Office based in Bedfordview, Johannesburg with Business Development Managers in Cape Town and Durban. The Turnberry Team’s focus on outstanding client service comes from having extensive knowledge and experience in the financial services sector and is underwritten by Lombard Insurance Company Limited. Lombard Insurance Company Limited is an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.

GEMS Hosts its 14th Annual Symposium, Bringing Together Key Healthcare Industry Stakeholders and Policymakers

The Government Employees Medical Scheme (GEMS) will, on November 2nd, 2023, host its 14th annual GEMS Symposium under the theme: “Advancing Health Equity by Addressing the Social Determinants of Health”. Experts, thought leaders and specialists in healthcare will engage in discussions towards a better understanding of the societal determinants of health in South Africa. 

For this hybrid event, delegates will attend both in person at Sandton and virtually.

Dr Moloabi states that the “Symposium is an important event on the GEMS calendar, providing a platform for academic, clinical, government and business minds to discuss what social issues are at play in determining the nation’s health status and how to improvements in health equity can be realized”. Moreover, he also highlights the need to remove practical obstacles that make us an unequal society if we are to achieve collaborative and cohesive solutions to our healthcare challenges.”

Speakers will include: 

  • Dr Ingrid Pooe – Chief Operations Officer, Government Employees Medical Scheme (GEMS),
  • Dr Sebayitseng Millicent Hlatshwayo – Chairperson, Government Employees Medical Scheme (GEMS),
  • Dr Chana Pilane-Majake – Deputy Minister of Public Service and Administration (DPSA),
  • Professor Mcebisi Ndletyana – Professor of Political Science, Department of Politics and International Relations, University of Johannesburg,
  • Dr Selaelo Mametja – Chief Research Officer, Government Employees Medical Scheme (GEMS),
  • Mr Barry Childs – Joint Chief Executive Officer Insight Actuaries & Consultants,
  • Dr Vuyo Gqola – Chief Healthcare Officer, Government Employees Medical Scheme (GEMS),
  • Mr Louis Botha – Chief Executive Officer, Health Quality Assessment (HQA),
  • Ms Yoliswa Makhasi – Director General, Department of Public Service and Administration (DPSA),
  • Mr Frikkie de Bruin- General Secretary, Public Service Coordinating Bargaining Council (PSCBC),
  • Dr Pali Lehohla – Director of Economic Modelling Academy (EMA), 
  • and
  • GEMS Principal Officer Dr Stanley Moloabi.

Dr Pilane-Majake, the Deputy Minister for the Department of Public Service and Administration (DPSA) will deliver the keynote address, elucidating, amongst other insights, the crucial relationship between the DPSA as employer and GEMS as an implementor of a mandate to ensure access to health and wellness by government employees and thus contributing towards the attainment of the ideals of Universal Healthcare Coverage.

Media personality Ms. Faith Mangope will facilitate conversations as the panel covers key discussion points, including:

  • Achieving the Sustainable Development Agenda 2030.
  • Beyond Healthcare: Addressing health equity and social determinants of health.
  • Policy Interventions for Addressing Social Determinants of Health: Lessons and best practices.
  • Value-Based Care and Social Determinants of Health: Integrating social context into healthcare delivery.
  • Advancing health equity by addressing social determinants of health; and
  • Exploring the interplay between healthcare quality and social determinants.

At GEMS, we are dedicated to fulfilling our responsibilities towards our members and the people of South Africa. The Symposium is a testament to our commitment to Universal Healthcare Coverage, and we are eagerly anticipating a productive outcome that will be memorable and provide an insightful experience for all involved, Dr. Moloabi” concludes. 

To learn more about the GEMS Symposium, visit www.symposium.gems.gov.za

Opinion Piece: The Rise of Affordable Medical Insurance

Reaching the masses with quality healthcare services

Photo by Hush Naidoo Jade Photography on Unsplash

By Sandra Sampson, Director at Allmed Healthcare Professionals

With its two-tiered, highly unequal healthcare system, only 14.86% of South Africa’s population can currently afford private healthcare, and rising costs are making it difficult for many to keep paying their monthly medical aid premiums. There are plans to implement National Health Insurance (NHI) to fund healthcare in the public and private sectors, although this process which began in August 2011 has been slow, and the NHI Bill is still under consideration in the National Assembly.

Despite concerns about the state’s ability to implement the NHI effectively and competently, delivering quality medical care to the population must continue to be a priority for every healthcare provider. This is where a specialist Temporary Employment Services (TES) provider can assist – delivering a flexible, competent, quality workforce on demand for institutions in both the public and private sectors.

Increasing access to quality healthcare

The public healthcare sector is primarily intended to serve those who are unable to access private medical aid and is currently accessible to all, regardless of immigration status or nationality. Significant funding is a massive drawcard for specialists in the private sector, which has resulted in a widening gap between public and private healthcare facilities in much of the country. The impending NHI is intended to address this gap and enable greater access to specialist care and more free services for all, while improving the quality of public healthcare by establishing a national fund that will allow for the purchasing of healthcare services on behalf of users. Estimates for funding this national health initiative range from R165bn to R450bn, and the government has been given the go-ahead by the Gauteng High Court to continue its recruitment drive before the bill has even passed.

Access starts with affordability

In line with this move, affordable healthcare insurance is on the rise. This trend starts with partnerships between healthcare and financial services providers, and has already been seen in the likes of Dischem, Clicks and Tyme Bank’s TymeHealth, all offering medical insurance, enabling access to high-quality healthcare specialists to a market that was previously woefully under-serviced. As the demand for quality healthcare increases, there will be a proportionate increase in the need for healthcare professionals.

Practical resourcing alternatives

It is not economically or practically feasible for healthcare institutions (whether in the private or public sector) to hire more medical professionals permanently, which means they will have to explore other resourcing options. This is becoming increasingly difficult in South Africa, as many skilled medical staff are seeking work elsewhere as a result of poor working conditions created by loadshedding, corruption, and incompetent administration. Although the Department of Home Affairs has added new skills to our country’s critical skills list (many of which include medical practitioners and individual specialisations) the healthcare industry is still severely understaffed. Hospital groups are only growing more frustrated with the government’s inability to address the decreasing number of medical practitioners, particularly nurses. The Hospital Association of South Africa (HASA) has reported that nurses in the country are reaching retirement age without the necessary inflow of younger employees. In 2020, there were more than 21,000 nurses in training, but South Africa still needs as many as 26,000 additional nurses to meet the growing demand.

Meeting the demand flexibly

TES providers in the healthcare sector have the potential to meet the demand of healthcare institutions for nurses and specialists, without these institutions having to commit to the responsibilities and costs associated with full-time employment. TES providers are on hand to supply the vetted and highly-skilled workers so desperately needed. Every healthcare institution can be supplied with the resources necessary on a shift-by-shift basis. So, if, for example, there is a deficit of five ICU nurses at a certain hospital, a TES provider can meet this with very short notice. If, on the other hand, patients are discharged or rerouted, these additional nurses can be cancelled at short notice, and the TES provider picks up the hospital’s slack and answers it with flexible resources on demand. Additionally, when it comes to meeting the fluctuating demand for speciality staff, a TES partner will become indispensable.

Equitability and affordability depend on agility

Ultimately, regardless of when the NHI comes to fruition, healthcare institutions should begin partnering with a TES provider if they haven’t already. Along with providing medical professionals on demand, this comes with cost-saving benefits for the hospital or clinic. Not having to employ full-time staff to meet fluctuating needs is a cost-saving exercise. Not only from a wage standpoint but also from an HR perspective in terms of payroll, industrial relations and skills development. The TES partner is responsible for all aspects of the employment relationship, while the healthcare institution gains access to qualified healthcare professionals as needed, at a fixed rate on flexible terms. This means that as soon as hospitals decide to invest in making their wards and spaces bigger and more efficient, they will have access to the medical resources necessary to staff them in a manner that enables equitable access to quality healthcare.

National Health Insurance Bill: Will it Wipe out Medical Insurance?

The NHI Bill does not contain any clarity on how South Africa’s large and complex medical schemes and insurance industry will be affected.

Photo by Bill Oxford on Unsplash

By Lenee Green, Partner, Mateen Memon, Associate & Mariam Ismail, Trainee Attorney at Webber Wentzel

On 12 June 2023, the National Health Insurance Bill (the Bill) was passed by the National Assembly and is currently with the National Council of Provinces for consideration. Its laudable aim is to make primary healthcare widely accessible.

The Bill has been closely scrutinised by various stakeholders in the healthcare sector. Concerns have been raised by medical schemes and insurers about the effect the Bill will have on their current businesses.

The Bill, among other things, covers:

  • who will be able to access health care services;
  • how these services will be funded;
  • the establishment of a board and advisory committees to achieve the objectives of the Bill;
  • general provisions applicable to how the fund will operate;
  • complaints about and appeals of decisions made by the fund; and
  • the source of income of the Fund and transitional arrangements.

Clause 33 of the Bill states that once the National Health Insurance (NHI) is fully implemented, medical schemes can only offer complementary coverage for services not reimbursed by the NHI. Clause 6(o) of the Bill allows individuals to purchase services not covered by the NHI through voluntary medical insurance schemes. This means medical schemes cannot cover services already covered by the NHI, potentially jeopardising their existence. This approach may face constitutional challenges related to the right to access healthcare, property rights of medical schemes, and freedom of trade and profession.

It is contemplated that the Minister of Health will introduce regulations limiting benefits to services not reimbursable by the Fund.  We have not yet seen any indication when these regulations will be published.

Current regime

Broadly, four main categories of business will be impacted by the Bill:

  • business of a medical scheme as defined in the Medical Schemes Act 131 of 1998 (MSA);
  • insurers licensed to conduct insurance business pursuant to the Insurance Act 18 of 2017 (the Insurance Act);
  • insurers who offer products pursuant to section 8(h) of the MSA (the Exemption Framework); and
  • insurers who offer products pursuant to the regulations published under each of the Long-Term Insurance Act 52 of 1998 and the Short-Term Insurance Act 53 of 1998 (the Demarcation Regulations).

Medical schemes

Presently, only medical schemes may carry on the “business of a medical scheme” as defined in the MSA. The “business of a medical scheme” involves undertaking liability for the provision of obtaining “relevant health services”, defraying expenditure for “relevant health services” or rendering health services by the medical scheme itself or by any supplier of a “relevant health service” in return for a premium or contribution.

A “relevant health service” under the MSA is very wide. It includes “any health care treatment of any person by any person registered in terms of any law, which treatment has as its object…” The objects include a broad range of medical services, including the physical or mental examination of a person, the diagnosis, treatment or prevention of any physical or mental defect, illness, or deficiency, ambulance services and hospital or similar accommodation.

Insurers

Medical schemes must be distinguished from medical insurance provided by insurers. Insurers may provide medical insurance under, among other dispensations, the Insurance Act. Schedule 2 to the Insurance Act provides for various classes and sub-classes of insurance business for which life insurance companies and non-life insurance companies may be licensed. Schedule 2 allows insurers to provide health and disability benefits under the risk class of business for life insurance and accident and health and travel insurance under the classes for non-life insurance.

Health insurance is provided upon the happening of a health event. A health event is defined in the Insurance Act as one that relates to the health, mind or body of a person or an unborn, other than a disability event. The disability event is defined and includes circumstances where a person loses a limb or becomes physically or mentally impaired. It is apparent that there is an overlap of products provided for in the Insurance Act and offered under the MSA.

The Demarcation Regulations provide for the demarcation between insurance business and medical schemes business. The regulations provide that a benefit that would otherwise have been a medical scheme benefit, but meets the exact requirements (definitions) set out in the tables in the Demarcation Regulations, is classified as an insurance product.

In March 2017, the Counsel for Medical Schemes (CMS) issued an exemption framework for insurers as a transitional arrangement while the development of a low-cost benefit option (LCBO) for medical schemes was developed (Exemption Framework). To the extent that an exemption was granted to an insurer in terms of section 8(h) of the MSA, and subject to the conditions of the exemption, the insurer was permitted to continue to underwrite those products until the expiry of the exemption. On 25 January 2022, the CMS granted insurers that had previously been granted an exemption in terms of the Exemption Framework an extension of a further two years.

The background to the LCBO is that a ministerial task team on social health insurance launched the low-income medical scheme consultative process in 2005. In 2015, the CMS issued a circular that considered introducing a guideline to allow medical schemes to introduce LCBOs in response to the growing number of working South Africans who did not have medical scheme coverage because they could not afford it. Following various engagement processes, the LCBO Framework Advisory Committee issued a Report in May 2022 (the Report). The Report states that LCBOs still have the potential to “alleviate pressure in the public healthcare system and allow resources to be redirected to the poor”. This process has progressed quite slowly, and it remains to be seen what comes of it if anything.

While the Bill is a piece of framework legislation, it does not provide clarity on what will become of insurance under the current regime. The fate of medical schemes is dealt with in a very cursory manner, without considering the nuances of the current regime.

The LCBO could have been a path to make healthcare more accessible, but the process has become stifled, and it may never come to fruition. What is left in the wake of the Bill is a great deal of uncertainty. Industry participants and stakeholders will have to keep abreast of the process and ensure that their comments are taken into account as the system evolves.