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, 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.
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.
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),
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.
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.
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.
In the ensuing court battle between Discovery Health and the Road Accident Fund (RAF) over reimbursements to be paid on motor vehicle claims, medical schemes members had always sought clarity or a position from the Council for Medical Schemes regarding this. In normative terms, the CMS is not obliged to release commentary on matters remote to its mandate, however, as a responsible regulator, it became a necessary act to clear any anomality.
Medical scheme members usually do not always have the full understating of the arrangements between RAF and medical schemes. At best, members sometimes have difficulty engaging with their scheme’s rules or RAF due to language barrier or be it of a technical nature of the matter.
In terms of the Medical Schemes Act 131 of 1998 (the “MSA”), Medical Schemes undertake liability in return for a contribution by among others granting assistance in defraying expenditure incurred in connection with the rendering of any relevant health services.
MSA further obliges medical schemes to pay for Prescribed Minimum Benefits (PMB), which include any emergency medical condition, under which motor vehicle claims could fall, in full. Unless a claim is specifically excluded in terms of the schemes’ rules and/or does not meet the criteria in terms of the definition of relevant healthcare, the medical scheme must still pay.
Most medical schemes provide for the handling of motor vehicle claims in their rules, wherein members of medical aid can claim compensation from the Road Accident Fund (the “RAF”) for such claims and any future healthcare services which may arise due to such motor vehicle accident.
It is also common cause that where RAF is responsible for claims, which a medical scheme has paid in terms of its rules and the MSA, that the RAF should refund to such medical scheme the amounts paid. Members of medical schemes who would have claimed directly from the RAF and received compensation for such claims, must also pay such amounts back to the medical scheme. This is commonly known as subrogation.
Should a member not receive any compensation from the RAF even after claiming, the scheme remains liable for the costs of the treatment subject to the registered scheme rules and must not be required to repay/refund such funds to the scheme.
The scheme may, however, attempt to recover such amounts paid from the RAF for the benefit of its members.
Subrogation allows medical schemes to minimise losses as a result of these claims and keep members’ contributions reasonable, by holding responsible parties accountable. It also prevents members from being “overcompensated” or unjustifiably enriched for the loss since they should not receive double compensation from both the medical scheme claim payout and the recovery from the RAF.
It must be emphasized that the financial risk associated with health interventions for which the need is uncertain is equitably shared within the covered population through a risk pool managed by medical schemes under the Medical Schemes Act. Therefore, CMS cannot condone a situation where members of medical schemes are forced to be out of pocket due to the non-payment of medical costs by RAF where these have since been paid out by medical schemes.
In line with our mandate under Section 7 of the Medical Schemes Act, it is not in the members interest if medical schemes are required to claw back payment made on behalf of members due to non-payment of these costs by RAF.
Moreover, the non-recovery of these costs by medical schemes negatively and unfairly withdraws from the entire risk pool that is aimed at benefitting the whole membership.
The World Health Organization (WHO) defines pooling as “…accumulation and management of revenues in such a way as to ensure that the risk of having to pay for healthcare is borne by all members within the pool, not by each contributor individually…” (WHO, 2000).
By implication, the refusal to refund medical schemes by RAF leads to the unfair deterioration of the entire risk pool funds.
Within this background, CMS believes that the refusal to refund medical schemes by RAF is not in line with the provisions of the Medical Schemes Act and it is not in the interest of beneficiaries of medical schemes.
DISCLAIMER: COUNCIL FOR MEDICAL SCHEMES. 2023
This document has been prepared by the author(s) from the Council for Medical Schemes Legal Services Unit and Benefits Management Unit. The views and information expressed in this article are for information purposes only. CMS cannot be held liable for any incorrectness of statements and statistical errors. Recommendations and conclusions are based on the author(s) research outcomes/findings and does not necessarily espouse or state as a CMS policy stance. The information is subject to change without notice. Companies and individuals wishing to use the information must reference the CMS in company reports, news reports, interviews, panel discussions etc.
Various stakeholders within the medical schemes value chain have sharply raised concerns over the unending court challenges brought by the Board of Healthcare Funders (BHF) against CMS. As an agile regulator, the CMS endeavours to clarify any misconception and confusion over BHF’s court challenges.
Chronology of Events
Initially, the main issue brought by BHF in this case was to request the court to grant them a general exemption for medical schemes to offer low-cost benefit options and to declare an alleged moratorium unlawful by the CMS and Ministry of Health in order to prevent medical schemes from offering low-cost benefit options.
In response, the CMS vehemently opposed the application on the basis that there was no moratorium as alleged by BHF and it would be thus unlawful to grant BHF a general exemption for medical schemes to offer low costs benefit options.
“It must be noted that while the main case/dispute was still ongoing (even after CMS submitted an extensive record of documents that were compliant with relevant information and documents having been exchanged between CMS and BHF), surprisingly BHF brought an interlocutory application alleging that CMS and the Minister were hiding certain information.”
Accordingly, the interlocutory application requested CMS and the NDOH to release an exhaustive list of documents which the CMS believed were irrelevant and had no bearing on the main application.
Despite CMS’s vehement contestation to the court on the additional requested documents by BHF, Judge Botha granted the BHF the order they sought, and the CMS, as well as the Minister of Health were ordered to produce the documents listed in Notice in terms of Rule 30A within 10 (ten) days of the Court Order, being 24 July 2023.
Before the expiration of rule 18 of the superior court, CMS filed leave to appeal the court order of Judge Botha as CMS believed that the order was flawed in law and that the judge had no reasons for ordering CMS and the Minister to produce those documents.
While the CMS legal team was studying the order, BHF concurrently lodged a contempt of court on an urgent basis.
CMS, through its attorneys, moved swiftly and wrote to BHF urging them to withdraw the contempt application as the CMS had already lodged its leave to appeal the court order of Judge Botha and this meant that the court order by Judge Botha would been suspended.
BHF refused to withdraw the contempt application and the application was heard on 8th August 2023 and the court dismissed BHF’s application on 10 August 2023 with costs in favour of CMS and Minister.
Citing Judge E van der Schyff who emphasised that “in the Practice Manual of the Gauteng High Court Division that while an application maybe urgent, it may not be sufficiently urgent to be heard at the time selected by an applicant” and also strongly highlighted that it does “not mean that applicants can indiscriminately approach the urgent court on the basis of extreme urgency without having regard to the context and facts of each individual application.”
Based on this order, the contempt application is now in our view moot or rather has been overtaken by the leave to appeal lodged by CMS and the Minister and CMS/NDOH. The leave to appeal will be heard somewhere September 2023.
The main application brought by BHF is likely to be heard in later parts of 2024.
In the recent judgement handed down by the Pretoria High Court in favour of Board of Health Funders (BHF), the Council for Medical Schemes (CMS), Registrar of Medical Schemes and the Minister of Health were ordered to deliver a complete record, which will shed light on the moratorium on granting exemptions to medical schemes to provide LCBO benefits. The order directed the CMS and the Minister of Health to deliver all documents or information requested under Rule 30A within 10 days of the order, but all the respondents failed to meet the deadline.
After the ten-day deadline had passed and noting that the documents were still not produced and there was no appeal to the court order, the BHF was forced to return to court to seek answers. The BHF filed a contempt of court order on an urgent basis. In this application, the BHF highlighted that no complete record had been submitted even though the deadline for the Minister of Health and CMS to do so was on 24 July 2023. In response, the CMS and the Minister of Health opposed the contempt of court action and appealed the rule 30A judgement delivered on 10 July 2023. The Minister of Health, acting through his attorneys, allowed his own team to submit certain documents in terms of rule 30A, and the attorneys have stated that the delivery of the documents demonstrates good faith. This is despite the appealing of the judgement and order delivered in the rule 30A application.
The legal battle against the CMS and Minister of Health not only highlights their failure to comply with the court’s order, but also raises concerns about transparency and accountability within the healthcare system. This delay not only hampers the progress towards implementing affordable healthcare solutions, but also undermines public trust in the decision-making process of these regulatory bodies. This lack of adherence to court orders highlights the urgent need for effective enforcement mechanisms to ensure that court decisions are respected and implemented by the relevant parties.
In a media briefing on Tuesday, 8th August, the Council for Medical Schemes (CMS) sought to clarify its process and recommendations over the approved 5% increase to medical aid scheme contributions, levels above which the medical schemes must motivate for. As for low-cost benefit options (LCBO), the CMS indicated that they would only provide a report to the Health Minister by the end of the month. This could prevent medical schemes from applying for new LCBOs in 2023.
Mr Mondi Govuzela, Senior Manager of Benefits Management, explained that the 5% approved increase is based on the Consumer Price Index (CPI) for 2022, which indicated a 4.9% increase. Schemes therefore may raise contributions by 5%, in line with the Reserve Bank’s inflation prediction for 2024. A prudent percentage markup should be incorporated to take into account cost increases and demographic changes, he advised. Before COVID, contribution increases have typically been 2.4–5% above CPI. The years 2020 to 2022 saw contribution increases dip below CPI.
One of the cost drivers that Mr Govuzela noted in the media briefing was supplier pressure stemming from fewer doctors and specialists, who were pushing for higher remunerations. Increased costs elsewhere in the healthcare industry. On the member side, growing rates of chronic diseases, membership ageing and coverage for medical services also added pressure.
LCBO would appear to be a solution for many individuals to access private healthcare for at least some urgent conditions, but the CMS has yet to comply with a Pretoria High Court ruling ordering that they provide a report on their moratorium on granting exemptions to medical schemes to provide LCBO benefits. The case was brought by the Board of Health Funders (BHF).
As to what the CMS’s response to the LCBO ruling was, CMS Registrar Dr Sipho Kabane said that the CMS was preparing a report that would be delivered to the Health Minister “by the end of the month”, but would not be drawn on what it might say. The deadline for registering new benefit options is September 1.
In their circular explaining the decision increase, the CMS acknowledged the persistent macroeconomic headwinds facing medical schemes and their members, with a meagre 1% increase predicted for SA’s GDP next year. “Against the backdrop of the current adverse macroeconomic conditions characterised by multi-year higher interest rates due to stubbornly higher inflation rate, volatile domestic currency and surging energy prices and overall lacklustre economic growth, it is evident that most household budgets will remain constrained for a foreseeable future, leaving most consumers under a precarious financial position. To cushion members of medical schemes against further financial distress and the probable risk of losing their health insurance cover due to affordability constraints, medical schemes are advised to limit their cost increase assumptions for contribution increases for the 2024 benefit year to 5.0%, in line with CPI.”
