Tag: medical aid schemes

Categories : CancerTags :

Breast Cancer Knows no Gender: the Rising Need for Awareness, Early Detection, and Financial Preparedness

On By ModernMedia
Breast cancer cells. Image by National Cancer Institute

Breast cancer is a significant health issue in South Africa, being the most common cancer among women, with a lifetime risk of 1 in 27. However, while breast cancer predominantly affects women, it is crucial to acknowledge that men can also develop the disease, and awareness needs to span genders. Early detection is key in improving outcomes, but the financial implications of treatment can be significant, as many medical aid schemes do not fully cover the extensive costs associated with treatment, including surgeries, chemotherapy, and follow-up care. Having gap cover in place can significantly ease the burden of out-of-pocket expenses, providing peace of mind for patients and their families.

Incidence on the rise

The latest statistics from the National Cancer Registry (NCR) indicate that breast cancer remains the most prevalent cancer among women in South Africa. According to the 2022 NCR report, breast cancer accounted for 20.4% of all cancers diagnosed in females, with a significant increase in incidence rates over the years. Although not very common, men also get breast cancer; approximately 1% of all breast cancer cases occur in men, and this number is also increasing.

Steve Kelly, a male breast cancer survivor, has been cancer-free for five years. “In December 2018, my partner spotted a lump in my right breast. It was painless, and I did not feel ill. It was diagnosed as stage 3 grade 3 breast cancer. I had surgery the following week, followed by six months of chemotherapy and six weeks of radiation therapy,” he explains.

While Kelly is one of the lucky ones, the reality is that many men who receive a diagnosis of breast cancer are not, because it is typically diagnosed late, which increases the mortality rate and also means that treatment has to be more aggressive. The increasing prevalence of breast cancer, along with the challenges of late-stage diagnoses, underscores the importance of early detection and education. Initiatives aimed at promoting regular screenings and self-examinations are vital for improving outcomes for all individuals affected by breast cancer in South Africa, including men.

Awareness is crucial

“Men do not scan and are generally poor at self-examination. More significantly, research shows that up to 33% of men would not seek medical attention if they found a painless lump in their breast. Because of embarrassment or ignorance, men would often present later with a more advanced breast cancer and a worse prognosis,” Kelly says.

Awareness campaigns need to evolve to become more inclusive. However, they also need to evolve to effectively target women, given the growing prevalence of breast cancer as well as the fact that it is increasingly affecting women at younger ages. Regular self-examination is a critical element in the early detection of breast cancers in both women and men, and having appropriate testing in place is essential.

Joanne Stroebel is another breast cancer survivor, and she credits her early diagnosis and successful treatment to her healthy lifestyle and her regular self-screenings. “Have your screenings done regularly and make sure to self-examine at least once a month. Once you have been diagnosed, involve your medical aid broker (or get one that knows the systems) and let them help you with the claims. The healthcare system can be very daunting when you have a new diagnosis, and extra stress is the last thing you need,” she recommends.

Easing the financial strain

Having medical aid is important in covering the cost of breast cancer treatment, but the reality is that many medical aid schemes do not fully fund treatments. There are many areas where you could potentially incur out-of-pocket expenses. Surgery is typically involved, which often comes with shortfalls on doctors’ accounts, such as surgeons and anaesthetists.

Prophylactic bilateral mastectomy (the preventative removal of both breasts) is generally not covered, and neither is reconstruction. Making use of a doctor who is not in a Designated Service Provider (DSP) network means additional shortfalls and co-payments. Medical aids also cover cancer in one of two ways: they either have an annual limit for cancer treatment, and once this is depleted you will only have access to Prescribed Minimum Benefits (PMBs); or they will cover you up to a certain Rand value, and once this is depleted you will incur a 20% co-payment on anything related to oncology treatment as well as the treatment itself.

Gap cover can go a long way toward alleviating the financial burden of breast cancer treatment. If your medical aid pays a lump sum, once this is depleted, then gap cover can assist with funding ongoing treatment, including in-hospital as well as outpatient treatment, pathology, and biological drugs, if these were covered by your medical aid. Gap cover can also help to pay the 20% co-payment, which can add up to significant sums, especially around biological drugs.

“Nearly a quarter (23.3%) of all Turnberry cancer claims are for breast cancer, and the highest individual claim we have seen is in excess of R80 000 resulting in a total treatment cost of more than R170 000. This is not an outlying number either – individual claims are frequently in the tens of thousands of Rands, and total treatment cost is usually over R100 000,” says Brian Harris, GM: Operations at Turnberry Management Risk Solutions.

Stroebel concludes, “Being a medical aid specialist, I was fortunate that I had the best cover available for cancer treatment. I never thought that I would need to try and raise funds for treatment, as I was confident that my medical aid and gap cover would cover any shortfalls, which was absolutely the case. I also had a dread disease policy that paid out, and being financially secure meant I never had unnecessary stress. Talk to your broker to make sure you have the best cover to suit your needs.”

Categories : Medical IndustryTags :

Mega Gap Claims Show Deep Cuts in Medical Scheme Benefits

On By ModernMedia

Analysis of top 20 mega gap claims shows massive erosion of medical scheme benefits and huge cover shortfalls for members

Photo by cottonbro studio

An analysis of the top 20 gap claims (by Rand value) paid by Sirago Underwriting Managers during 2024 highlights an alarming reality for medical scheme members – the erosion of medical scheme benefits is resulting in members facing huge financial shortfalls for in-hospital treatment not covered by their medical scheme benefits. 

Without gap cover in place, these 20 claims alone would see these medical scheme members having to collectively pay R3 million from their own pockets for in-hospital treatment. In many instances, the gap provider is paying more than the medical scheme – a complete misalignment if one considers the significant difference in premium/contribution between the two.

Gap cover is a supplementary insurance to a medical scheme benefit that covers the difference that arises from the rate that healthcare specialists charge for in-hospital procedures versus what a medical scheme pays.  

A breakdown of Sirago’s 20 mega gap claims paid in 2024 follows:

ConditionAge groupGap paid% paid by GapMedical scheme paid% paid by medical scheme
Circulatory system50-65 yearsR191 00067%R94 04233%
Blood/Neoplasm50-65 yearsR191 00039%R304 51561%
Circulatory system66-75 yearsR191 00063%R111 37337%
Musculoskeletal50-65 yearsR175 70968%R82 55332%
Musculoskeletal66-75 yearsR173 89468%R80 02032%
Blood/Neoplasm50-65 yearsR163 19871%R66 34729%
Circulatory system66-75 yearsR154 91127%R563 27073%
Circulatory system30-49 yearsR152 36064%R85 28836%
Musculoskeletal50-65 yearsR152 35030%R352 34770%
Musculoskeletal10-29 yearsR142 66047%R176 70553%
Circulatory system66-75 yearsR136 63124%R425 63176%
Musculoskeletal50-65 yearsR129 39636%R229 98564%
Circulatory system66-75 yearsR129 34064%R72 74936%
Musculoskeletal30-49 yearsR126 77182%R27 57318%
Circulatory system30-49 yearsR125 81123%R427 84877%
Circulatory system66-75 yearsR125 47943%R289 37857%
Neoplasm66-75 yearsR123 67526%R344 60474%
Circulatory system30-49 yearsR123 00122%R415 23778%
Musculoskeletal76+ yearsR121 27651%R120 23049%
Musculoskeletal50-65 yearsR119 68544%R151 36156%
Total: R2 948 38340%R4 421 05660%
  • Of these 20 gap claims, all shortfalls were in excess of R100 000, while three reached the maximum overall annual limit of R191 000 that a gap policy may cover, per member.
  • In almost half of the claims, gap cover paid more than the medical scheme paid. In one particular instance, gap cover paid R126 771 while the medical scheme paid just R27,573 – just 18% of the entire treatment bill was paid by the medical scheme.
  • Of the total healthcare cost across all 20 claims, gap covered 40% of the total cost, while medical schemes covered only 60% of the total costs for in-hospital treatment.

“These are massively concerning statistics and demonstrate just how financially devastating the shortfalls are for in-hospital treatment that medical schemes are not paying for. It is indicative of how medical scheme benefits are being eroded as schemes try to limit premium increases – members are getting less cover and lower benefit limits, despite the premium increases in their medical scheme benefit every year. Secondly, specialist fees and healthcare cost inflation is out of control and certainly not aligned with what schemes or consumers can afford. In the absence of any price regulation, and the absence of any competition as medical specialists are in short supply, things can only get worse.  Providers are free to charge any rate they wish, often many more times the rates that medical schemes reimburse at,” explains Martin Rimmer, CEO of Sirago Underwriting Managers. 

This continued acceleration of mega claims is putting the premium under pressure which inevitably will result in high premium increases every year. Sirago points to its gap claims trends over the last four years, which clearly demonstrate that being on a medical scheme option – even a comprehensive one – is no guarantee that your bills for in-hospital treatment will be paid for in full by your medical scheme.  And the shortfalls are growing rapidly in financial quantum.

“Of these 20 mega claims alone, the shortfall paid by gap cover was between R120 000 to R191 000.  These are huge numbers that very few people can afford to fork out from their savings, or go into debt for – which they would have to do if they did not have gap insurance in place. Just consider the implications for a 30-year old with a growing family to support and serious financial constraints, or a 70-year old having to fund such a cost from their retirement savings,” adds Rimmer.

Healthcare financial planning is critical

Medical scheme members will have until the end of November to make any changes to their medical scheme options which will take effect from 1 January 2025.  Given the affordability constraints, many are looking to cut back but still want access to private healthcare for any hospitalisation or serious health crisis they may face in future. Sirago advises that you work with your professional healthcare financial advisor to do the sums, take you through a comparison of the various benefit options and then devise the best plan to ensure that your healthcare needs and access to private healthcare are covered, as best possible. 

“If you’re on a medical scheme benefit, then adding gap cover to your healthcare plan is a non-negotiable if you want to protect yourself from shortfalls on in-hospital treatment and specialist charges which can be anything from a few thousand Rand, to over R190 000.  If you’re on a medical scheme option that covers 100% or 200% of tariff charged, you are going to face shortfalls when you consider that many specialists charge upwards of 500% of the medical scheme tariff. You will be liable to pay those shortfalls from your own pocket if you do not have gap cover.  Make sure to discuss this with your healthcare advisor.

“Always engage the advice and services of an accredited, skilled, and experienced healthcare broker/ advisor who will help you make informed decisions when needed most, as well as support you through the administration processes with getting your cover in place,” concludes Rimmer.

Categories : IT in HealthcareTags :

AI in Healthcare: From Hype to a Game Changing Reality  

On By ModernMedia

By Margot Brews, Head Health Risk Management Strategy at Momentum Health Solutions

The healthcare sector has been on the cusp of substantial reform for quite some time. However, the introduction and application of artificial intelligence (AI) across various healthcare disciplines will surely stand out as one of the most revolutionary eras in the industry.

This rapidly evolving field has been lauded as the key to unlocking greater quality in healthcare services, introducing more efficient protocols and treatment pathways, as well as considerably increasing access to healthcare across all demographics.

When we place this in a local context, taking into consideration that steps to implement the NHI are already in motion, AI will be critical in helping implement specific elements, such as public health interventions. If we are to refer to the Covid-19 pandemic and its immense scale, AI was leveraged across various countries around the globe to predict the spread of the virus. In doing so, this allowed governments to implement protocols to curb its spread, as well as provide citizens with critical information in an effort to decrease its proliferation.

Looking at the medical schemes sector in South Africa, the industry aims to ultimately improve health outcomes for members and in doing so, encourage and maintain a better quality of life. AI has assisted Momentum Health Solutions in evaluating the delivery of healthcare in the future with clear goals that include increasing access to quality healthcare, and utilising the unmatched innovation that AI offers in assessing member profiles more comprehensively. This is to ensure that we are not only providing a service, but actually understanding in the broadest terms possible what type of care a member requires and partnering with them on that journey.

An example of this is closely analysing commonalities within a member’s treatment pathway. When we review clinical data such as doctors’ consultations, the discipline of the doctor and their particular field of expertise, along with the medication prescribed, we can more timeously start to see patterns developing. This indicates and therefore informs us that the member may have a more serious illness or chronic disease that requires clinical support on a more extensive scale, which we can then discuss with the member and facilitate.

To ensure we are providing tailored healthcare solutions that steer away from offering members generic benefits, we have partnered with Amazon Web Services (AWS), which provides the most comprehensive services, tools, and resources in artificial intelligence today. Through this partnership we have been able to provide members with unique services and individualised care that ultimately ensures their healthcare is a priority.

While AI is indeed key to creating a more efficient healthcare system, ethical considerations remain a concern for many when evaluating factors such as the protection and privacy of data and its ownership, as well as the accuracy of its outputs and conclusions. Having said this, risk mitigation protocols have been implemented to ensure that personal data is protected, and ethical standards are maintained at the highest level.

AI is certainly the most effective solution in the 21st century when investigating ways to solve the ongoing healthcare crisis, particularly in South Africa, where immense disparity exists between the public and private sectors. Leveraging AI, both from a medical scheme provider perspective and more broadly, will not only empower current and future workforces within the sector, but will also create greater opportunity for improved healthcare services that can be sustained. When implemented and utilised for the benefit of all, AI has the potential to be South Africa’s healthcare redeemer.

Categories : Medical IndustryTags :

Spiralling Costs Squeezing Medical Schemes – and Where does This Leave NHI?

On By ModernMedia
Photo by Towfiqu barbhuiya on Unsplash

Pressure from ageing populations, stagnant growth and growing medical costs will mean that medical aid schemes will make above-inflation rate hikes, reveals Momentum Health marketing officer Damian McHugh. He made the comments at Momentum Health Solutions’ virtual Healthcare Insights Summit on Tuesday (30 July), where he also noted that the same demands on medical funds are serving to put NHI even further out of reach, estimating a budget of some R1.3 trillion.

If one take’s McHugh’s figures and projects into the coming years, these above-inflation hikes make the target an ever increasing-one, steadily sending the current estimates even further from the realms of affordability. This is a situation which national health schemes of far wealthier countries are now encountering.

This comes as the Council for Medical Schemes advised the 1st of August of inflation plus “reasonable utilisation estimates” resulting in a recommendation to keep under 8.5%. But it given the pressures on medical aid schemes, this is unlikely to be adhered to, as last year already saw increases in excess of this.

Medical aid cost pressures

The CMS acknowledged that above-inflation medical cost increases are inevitable due to “unique industry factors such as technological advancement, the ageing population, and the increasing prevalence of chronic diseases.”

Last year, Discovery Health Medical Scheme (DHMS) announced a weighted average increase of 7.5%, for 2024 – but its comprehensive “premium” segment rose by 13%. Both Momentum and BestMed announced weighted increases of 9.6% for 2024, while Bonitas managed to contain its increases to 6.9% (though its comprehensive cover rose to 9.6%). MediHelp surged to 15.96%, though it justified this increase as its options were the lowest-priced on the market.

Medical aid scheme growth is slow, at best around 0.5% per annum, while there is considerable pressure on subscriber income. Low income brackets only spend around 4% on healthcare, while middle and high income brackets spent 6% and 7%, respectively.

But with claims on the increase, many medical aids are having to tap into reserves and reducing solvency. Many medical aids are running close to 100% claims ratio – obviously a very bad situation for them to find themselves in.

These cost pressures result in a reduction in benefits, with the burden being shifted by reducing day-to-day benefits and members moving to Efficiency Discount Options (EDOs) – in turn, reducing the risk contribution income received by the schemes.

Rate hikes inevitable

In its recommended guidelines for 2025 released in Circular 35 of 2024, the CMS advised that medical aid schemes limit their contribution increases in line with CPIThis was based on the Reserve Bank’s latest inflation forecast which expects headline inflation to average 4.4% and 4.5% in 2025 and 2026, respectively. With last year’s estimated of an additional 3.2% to 3.8%, that works out to about 8.5%. But the CMS noted that medical aid schemes have historically had increases in excess of CPI+4%.

The COVID pandemic bucked the trend, resulting in – though many medical aid schemes saw record profits as procedures were deferred. Price increases were deferred, with increases kept below inflation for 2021 and 2022, with an uptick in 2023.

McHugh pointed out that growth in medical aid schemes has remained largely flat, and the ageing of the insured lives was linked to increasing claims costs as health problems became more complex. He revealed that claims costs per life had risen from about R15 000 in 2017 to R21 000 in 2022. This, spread across the population of South Africa, would require an NHI budget of R1.3 trillion.

Source: CMS Circular 35 of 2024

Breaking down the expenditures, McHugh said that medical schemes spent 37% on hospitals and 28% on specialists, while medicine accounted for 16% and GPs a mere 5%. The CMS also noted that hospitals and specialists had seen greater relative increases than other areas. For the essential coverage of hospitals, medicines, GPs, and dentists, that would amount to R363 billion.

Looking ahead with a little maths

One can take simple compound interest to McHugh’s figures, and even applying the CMS’ best-case “reasonable utilisation estimate” of 3.2%, for say 20 years from will mean that costs rise by 87% in today’s rands. That means the NHI’s ‘basic’ coverage would rise to R682 billion and the full coverage amounting to an incredible R2.4 trillion.

But this nothing special to South Africa. The UK’s NHS costs have similarly grown, at 3.6% per annum in real terms. And that growth has to come out of the GDP: from 3.6% of the GDP in 1949-50 to 8.2% in 2022-23, with a surge to 10.5% in the COVID pandemic.

The UK has now put measures in place to constrain cost growth to 1%, but it remains to be seen whether this will be effective without compromising service delivery. How South Africa can even contemplate an NHI where, 20 years from now, private scheme medical costs run to R39 000 per person in the best case scenario.

While McHugh did not mention the recent High Court blow to the NHI Act that found a key part of it unconstitutional, he described the legal challenge process that would see that part sent back to the National Assembly and the president.

McHugh however struck a note of optimism, noting that the public-private partnerships of the COVID pandemic showed a way forward for NHI and universal healthcare in South Africa. The 2024 elections bring the possibility of the same historic benefits for the population as the 1994 ones.

Categories : Medical IndustryTags :

Opinion Piece: Claims on the Increase

On By ModernMedia

Gap cover providers are seeing more claims of higher values than ever before

Photo by Cottonbro on Pexels

By Brian Harris, General Manager Operations at Turnberry

As medical inflation has continued to rise and the cost of medical procedures has increased, medical aid companies are faced with the juggling act of keeping premiums affordable while still offering adequate cover. In addition, new procedures such as robotic-assisted surgery and new cancer drugs offer better outcomes, but at a greatly increased cost.

As a result, we are seeing increased medical expense shortfalls, particularly when it comes to specialists, as well as increased co-payments and sub-limits. The upshot of this, for the consumer, is vastly increased out-of-pocket expenses, which is why gap cover has become critical. Given the increase in both the frequency and Rand value of claims, having gap cover in place has never been more important.

The state of gap cover

The frequency and value of gap cover claims have increased dramatically over the years as the gap between what medical aid covers and what specialists and providers charge continues to widen.

In 2023, Turnberry paid out R119 968 466 in claims, proportionately this accounted for 56% of the total claims, with medical aid covering the remaining 44%. This figure includes a significant number of high value claims, with many of them exceeding R100 000. Three of the highest claims in 2023 were R129 193.60 for heart disease, R128 485.43 for a nasal polyp, and R125 735.08 for a spinal fusion surgery.

These are figures paid out over the course of a single year and for a single diagnosis. Gap cover policies are subject to an overall annual limit (OAL) per individual covered by the policy, and this limit is increased in April each year, and is currently R198 660.43 per insured person. This limit resets every year, which means that over a lifetime, the amount paid out for individuals and families is far higher. At Turnberry, the top three lifetime claims are figures in the hundreds of thousands of Rands: R502 983, R450 225, and R414 331 respectively.

What does this mean for me?

The most common procedures we see as a gap cover provider are spinal disc problems, cancer, heart disease, cataract surgery and maternity, and these claims can and often do exceed R100 000 per incident. These figures highlight the fact that in South Africa, gap cover is essential for anyone wishing to access private healthcare without potentially incurring significant out of pocket expenses.

The reality is that even young and healthy people could need costly medical procedures, and as your age and life stage changes, your medical needs do too. Accidents can happen to anyone, regardless of age, and injuries related to sports and physical activity are also common in younger age groups. Starting a family inevitably involves increased medical expenses, from pregnancy and childbirth to raising children who frequently need medical attention. Health issues related to stress are also on the rise, including anxiety and depression. In later life stages, chronic diseases like high blood pressure, high cholesterol, and prediabetes become more common. Cancer can strike anyone and is increasingly seen in younger population groups.

The cost of quality medical care continues to increase, and medical expense shortfalls as well as co-payments and sub-limits are becoming more and more common, at higher amounts. This means that any medical treatment, regardless of your age or life stage, can end up costing tens of thousands of Rands out of pocket. Over a lifetime, these sums could potentially add up to millions.

It is important to engage with your broker to make sure you have the right medical aid in place first, and then to supplement this with appropriate gap cover, to ensure that you are able to access the medical care you need without the financial burden of out-of-pocket expenses resulting from medical expense shortfalls, co-payments and sub-limits.

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.

Categories : Expert Opinion Medical IndustryTags :

Building a Culture of Wellness by Fostering a Healthy and Financially Secure Workforce

On By ModernMedia
Photo by RDNE Stock project

By James White, Sales Director at Turnberry Management Risk Solutions

Celebrating Corporate Wellness Awareness Week by highlighting the vital role that companies play in fostering employee health and well-being is not just a matter of timing; it’s a matter of necessity. A healthy workforce is a productive workforce, and a focus on wellness goes beyond just physical health.

This is particularly relevant given that the magnitude of medical expenses has shifted over the years. While common illnesses like influenza pose a threat, the bigger concern lies in hospital stays and unexpected medical procedures. These events can leave employees with significant financial burdens, impacting their well-being and productivity.

The role of employers in mitigating costs

While encouraging healthy lifestyles through fitness programmes and mental health support is vital, ensuring financial security in the face of unforeseen medical expenses is equally important. Employers play a significant role in ensuring their workforce has access to adequate healthcare. Traditionally, medical aid cover has been a common employment benefit, but rising costs have made it less affordable for some employers and their employees. Nevertheless, employers can still help by offering their people assistance through:

  • Understanding medical aid options: A knowledgeable broker can guide employers through the complexities of medical aid options. This includes explaining the benefits, limitations, and potential shortfalls associated with each plan.
  • Considering primary healthcare: For employees who cannot afford comprehensive medical aid, primary healthcare plans are short-term insurance products that offer access to doctors, specialists, and medication, often with capped benefits for private hospital visits.
  • Offering gap cover: Gap cover bridges the gap between medical aid payouts and the actual costs charged by specialists and hospitals, acting as a financial safety net to provide peace of mind for employees facing unforeseen medical expenses.

Common unforeseen medical expenses

  • Hospital stays: These can be particularly expensive, with costs varying depending on the condition and treatment required.
  • Specialist charges: Specialists often charge above the rates covered by medical aid plans, leaving patients with significant bills.
  • Emergency room visits: Even a seemingly minor trip to the ER can result in a hefty bill.

Addressing misconceptions about medical aid

Many employees believe that medical aid offers complete coverage. Brokers can help dispel this myth by explaining the intricacies of the available plan options, such as co-payments, network restrictions, and shortfalls. Some plans limit coverage to specific hospitals or providers, and employees need to be aware of these restrictions to avoid surprise costs, while certain medical aid plans require co-payments for specific procedures or medications, leaving employees with out-of-pocket expenses. Even with medical aid, specialists’ fees often exceed the amount reimbursed and gap cover addresses these shortfalls.

Financial security boosts workplace wellness

By offering (and even subsidising) a combination of medical aid, primary healthcare options, and gap cover, employers can significantly improve the well-being of their people. This is because financial security in the face of medical emergencies will reduce stress and boost morale. Employees with peace of mind regarding healthcare costs are more likely to be happy, productive, and less prone to absenteeism.

However, such assistance is more than simply offering access to such benefits. Employers need to ensure that their workforce can make informed decisions about the healthcare benefits available to them by partnering with a qualified broker. The broker can fulfil a vital educational role by conducting informative workshops to explain medical aid options and limitations and advocate for the value of gap cover.

It makes business sense to invest in a healthy workforce

By prioritising a holistic approach to employee wellness that encompasses both physical and financial health, companies can create a thriving workplace environment. Offering a more comprehensive benefits package that includes access to gap cover demonstrates a commitment to employee well-being, ultimately leading to a happier, healthier, and more productive workforce.

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.

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

Debunking Myths: The Truth About Medical Schemes in South Africa 

On By ModernMedia

Despite the promise of Universal Health Coverage (UHC) for all, the recent signing of the NHI Bill has brought with it several misconceptions around medical schemes that undermine the very foundation of our healthcare system, writes Dr Katlego Mothudi, Managing Director at the Board of Healthcare Funders (BHF).

In a historic move aimed at transforming the South African healthcare landscape, President Cyril Ramaphosa signed the National Health Insurance (NHI) Bill into law. This landmark decision promises to move South Africa towards Universal Health Coverage (UHC) for all citizens, regardless of socio-economic status.

While the goal of UHC is commendable, the rhetoric leading up to the NHI Act’s announcement has created misconceptions about the role of medical schemes. 

With many believing that they should cancel their memberships immediately to enjoy free health services for the foreseeable future. However, Dr Katlego Mothudi clarifies that the implementation of NHI will take several years, dispelling this misconception.

The NHI Act introduces a single-payer system, central to the idea is that healthcare is a ‘public good’, suggesting all healthcare funding should exclude medical schemes, and should be government-funded. Dr Mothudi counters that healthcare is more accurately described as a social good. A public good, like military services, is one that the government must provide and from which no one can be excluded, regardless of payment. While healthcare is essential, it is not feasible to provide it as a public good.

The Board of Healthcare Funders (BHF), concerned about the numerous misconceptions propagated by government representatives since 2009, commissioned Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at Wits Health Consortium, to investigate these claims. Despite their hyperbolic nature and lack of systematic research, these statements have significant weight due to their endorsement by influential individuals. Prof van den Heever’s report identified frequently repeated assertions that he concluded were unsubstantiated and untrue.

Key Findings from the Report:

1. Medical Schemes are Unsustainable – False

In 2009, claims suggested that many medical schemes were headed for collapse due to unsustainable financing models, with 18 schemes reportedly nearing insolvency. Prof van den Heever’s report refutes this, showing stability in medical schemes from 2005 to 2022. The number of beneficiaries increased by over one million from 2009 to 2022, with consolidated reserves of R114 billion in 2022, far exceeding the required 25% reserve ratio. Broker costs have not been a systemic concern, and total non-health costs per average beneficiary per month for all medical schemes decreased by 34.7% in real terms from 2005 to 2020.

2. Health Services are a Public Good – False

   In 2011, Health Minister Aaron Motsoaledi claimed that private healthcare was a “brutal system” due to commercialisation. However, Prof. van den Heever clarified that healthcare is not a public good in the economic sense, as it does not meet the criteria of being jointly consumed without exclusion. Healthcare is a crucial service but providing it as a public good is not feasible.

3. Most Medical Scheme Beneficiaries are White – False

Last year, Prof Olive Shisana, an honorary professor at the University of Cape Town and special advisor to President Ramaphosa, stated that the private sector predominantly serves the privileged white population. However, Statistics South Africa’s 2021 research indicates that of the total population utilising private healthcare services, 50.2% are Black African, 32.3% are White, 9.8% are Coloured, and 7.6% are Indian/Asian.

Need for Balanced Perspectives

While the BHF supports healthcare reform, it raises concerns about the NHI Act’s constitutionality and calls for a factual review of claims about medical schemes. It is crucial to present both sides of the debate to understand the implications fully. Including government perspectives and addressing how the NHI will affect individual citizens would provide a more comprehensive view.

Medical schemes remain a valuable national asset that plays a crucial role in ensuring the long-term viability of South Africa’s healthcare ecosystem. BHF advocates for a balanced approach to healthcare reform that considers both public and private sectors’ strengths and weaknesses.

For a comprehensive look at findings from the report commissioned by BHF, see Prof van den Heever’s presentation at the 2024  Annual BHF Conference here. (Click to download PDF)

Categories : Healthcare Politics and RegulationsTags :

Supreme Court of Appeal Dismisses Council for Medical Schemes’ Reconsideration Application with Costs

On By ModernMedia
Photo by Bill Oxford on Unsplash

In a significant development for the South African healthcare sector, the Supreme Court of Appeal (SCA), has dismissed the Council for Medical Schemes (CMS) and the Registrar for Medical Schemes’ reconsideration application against the Board of Healthcare Funders (BHF) with costs. 

At the signing of the National Health Insurance (NHI) Bill into law, the President asserted that medical schemes were elitist and excluded the majority of the population. However, it is important to note that for many years, medical schemes have actively sought exemptions to provide low-cost benefit options (LCBOs) that would enable more citizens to access medical aid coverage. Despite these efforts, medical schemes face significant regulatory hurdles that prevent them from offering these more inclusive options.

The court’s decision follows the raising of significant concerns by BHF in a letter to the CMS and the registrar, which highlighted key conflicts related to hostility towards medical schemes; unnecessary litigation; delays in developing legal frameworks for low-cost benefit options (LCBOs); ineffective appeal processes; the legality of CMS’s regulatory actions; the influence of the National Health Insurance (NHI) Bill on CMS policies; and the lack of review of Prescribed Minimum Benefits (PMBs) for 24 years. 

Mr Charlton Murove, Head of Research at BHF, said that while the organisation respects the court’s decision, it is unfortunate that a personal cost order against the registrar was not awarded, and that the regulator continues to delay the matter. 

“These delays divert valuable resources, and hinder progress on an issue that is critical to both the South African healthcare industry, and the health of citizens in need of essential services,” added Murove. 

The CMS has since filed the Rule 30A affidavit and the supplementary record. The BHF legal team is currently studying these documents for purposes of moving forward with the main review application, where its members will be updated. 

To this end, BHF remains committed to ensuring a fair and effective regulatory environment for the South African healthcare sector.

“We, as the BHF, will continue to advocate for the interests of our members and the millions of beneficiaries they serve, striving to create a healthcare system that is equitable, transparent, and capable of meeting the needs of all South Africans. 

“This court case is crucial in the context of the National Health Insurance (NHI) as it highlights the necessity of reducing the burden on the state while it prepares for the implementation of NHI, ensuring access to quality healthcare for everyone is essential,” concluded Murove.

Categories : Healthcare Politics and Regulations Medical IndustryTags :

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

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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.

Categories : AntibioticsTags :

Useless Antibiotic Prescriptions are Getting out of Hand

On By ModernMedia
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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