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Daily Maverick
16-07-2025
- Health
- Daily Maverick
Beat the mid-year medical blues
There are ways to help manage your costs after your medical savings account is depleted. We're into the second half of the year and you may be one of thousands of medical scheme members now finding your medical savings accounts are depleted, leaving you to pay directly for day-to-day costs. According to the Council for Medical Schemes 2022/23 annual report, South Africans paid close to R40-billion out of pocket for healthcare, with nearly half of this going towards outpatient services, not hospital stays. These costs include essential visits to specialists, radiologists and dentists, which are often not fully covered once medical savings accounts are exhausted. Although there is no magic fix, there are ways to change the way you access healthcare to make it more affordable. For example, Tania Joffe, founder of Unu Health, says that instead of spending R500 or more on a face-to-face GP visit, you could opt to speak to a doctor for a fraction of that cost through a telemedicine app. 'The old model of always visiting your GP or specialist in person for everything just isn't sustainable any more,' says Joffe. 'It's time to embrace the hybrid model that includes telemedicine.' See more: How medical schemes are using AI's predictive power to revolutionise health risk management One of the easiest ways to reduce medical costs is by taking advantage of low-cost or free screening tools offered by your medical scheme. For example, Discovery Health launched a Personal Health Pathways programme earlier this year. Accessible via the Discovery Health app, the platform helps members and their healthcare practitioners to navigate the healthcare system with precise and personalised healthcare recommendations, improving both immediate and long-term health outcomes for each member. Each pathway is tailored to the member's specific health status, risk profile and engagement patterns, dynamically adjusting as new health data becomes available. Dr Ron Whelan, chief executive of Discovery Health, says the AI-powered platform behind Personal Health Pathways processes more than 33 terabytes of data, and an additional 500 gigabytes are ingested daily. To illustrate the platform's scale, there are more than 7 million possible pathways for completing 12 health actions. Examples of personalised pathway prompts include: A healthy 42-year-old woman may be encouraged to schedule a health check, complete a mental wellbeing assessment, go for a dental check-up, get a mammogram or Pap smear, nominate a primary care GP, complete a Vitality Age Assessment or receive a flu vaccine; A 45-year-old man with elevated cholesterol and blood pressure may be guided to visit his GP for a check-up, collect prescribed medicine, monitor blood pressure or cholesterol levels, or go for prostate or colon cancer screening; and A 65-year-old man who has diabetes may be prompted through the app to schedule an HbA1c test, collect medicine, undergo foot and retinal screenings, complete a prostate cancer test or have a mental wellbeing assessment. When you go to your local pharmacy for medication, ask the pharmacist for the cheapest generic option. When you buy milk, you consider different brands and weigh up the costs before you buy – your medication deserves the same consideration. Tax benefits Continue submitting claims to your medical scheme even though your medical savings account is depleted. The scheme will not pay these claims, but it records the amounts as your out-of-pocket expenditure and this information is shared with the South African Revenue Service. In the long run, this means less admin for you when you submit your tax return and a potential tax benefit – the additional medical expenses tax credit. According to TaxTim, out-of-pocket expenditure that could fall under additional medical tax credits includes: A consultation and medicines supplied by a registered medical practitioner, dentist, optometrist, homeopath, naturopath, osteopath, herbalist, physiotherapist, chiropractor or orthopaedist to you or any of your dependants; The costs of a nursing home or hospital, or any duly registered or enrolled nurse, midwife or nursing assistant (or to any nursing agency in respect of the services of such a nurse, midwife or nursing assistant); Medicines prescribed by a registered medical practitioner and acquired from a pharmacist. Note – this will not include over-the-counter medication such as cough syrup and pain relievers; and Medical expenses incurred and paid outside South Africa. DM
Daily Maverick
14-07-2025
- Health
- Daily Maverick
Maladministration, not foreigners, to blame for state of South African healthcare
Although foreign nationals' treatment sparks debate, the key question is: what is a hospital bed's true cost in SA, and what structural weaknesses does this expose? Recent demonstrations against foreign nationals at public healthcare facilities have intensified arguments that taxpayer-funded institutions, already overstretched, are being unfairly used. Though these concerns are not entirely unfounded, as South Africa provides constitutionally protected healthcare to all inside its borders, the demonstrations reveal a deeper systemic issue in our public healthcare system. South Africa's relative stability positions it as a migration destination for the citizens of many neighbouring countries, having a significant impact on border healthcare facilities. Combined with the legacy of apartheid-era health infrastructure, the attention given to foreign nationals often becomes a distraction from deeper systemic issues. The reality is that healthcare infrastructure has persistently lagged behind demand and population growth, irrespective of nationality. Many border-area hospitals face heightened pressure, not primarily from migration, but rather from longstanding underinvestment in capacity and resources. South Africa's healthcare expenditure About 8% of South Africa's GDP is dedicated to healthcare, translating to about R10,000 per person annually. This expenditure includes both public and private healthcare sectors. It's about one-tenth that of Organisation for Economic Co-operation and Development countries, but similar to regional neighbours such as Namibia, which spends about R8,000 per person. However, raw spending figures mean little without outcome comparisons using metrics such as life expectancy, which in South Africa is slightly higher than in Namibia or Botswana. But Professor Alex van den Heever, chair in the field of social security systems administration and management studies at Wits University, says life expectancy is 'too broad as a metric'. 'Look at maternal mortality,' he suggested. Maternal mortality statistics highlight healthcare governance and management shortcomings, suggesting that the primary issue is not hospitals being 'overrun' by foreign nationals. Despite having a substantial public healthcare system, South Africa has one of the highest rates of private medical insurance globally, covering about 16% of the population, according to the Council for Medical Schemes. This starkly underscores disparities in healthcare access and spending in the country. An average patient-day equivalent in a public hospital costs about R3,700 to R4,000, according to the National Treasury's 2023 Budget Review. This figure represents the total cost of providing care for one patient for one full day, encompassing all associated expenses such as staffing, medication and supplies. Notably, 64% of this cost goes to wages. Van den Heever emphasises that despite significant wage increases since 2007, staffing levels have remained largely static, highlighting inefficiencies in resource allocation. Specific treatment costs underline this: a Caesarean section ranges from R18,000 to R22,000; tuberculosis treatment costs between R6,000 and R8,000; and antiretroviral treatment averages between R3,000 and R4,000 annually per patient. The numbers paint a bleak picture of what is being spent per person annually, and they fail to demonstrate the human cost and distress caused to those denied access to care. Janet*, a Zimbabwean who has been living in South Africa for more than a decade with a valid Zimbabwean Exemption Permit, described the challenges she faced. 'They [the hospital staff] said, 'Why are you here? Because you're a foreigner you must pay a certain amount – if you don't pay, they won't treat you'.' The interaction occurred when Janet was seven months' pregnant and went to Rahima Moosa Mother and Child Hospital in Johannesburg for a routine checkup. 'They insulted me. They said I must pay because I'm a foreigner. They didn't want to check my ID or see my papers. They just said if I don't pay, I must go home,' Janet said, noting that many other people in her community – legally in South Africa from Zimbabwe – have faced similar challenges. She stopped going to her appointments in the run-up to giving birth. 'They told me to pay R470 every week. I couldn't afford it, so I just stopped going.' She only returned when it was time to give birth. A 2023 Health Ombud investigative report found that 40% of patients admitted at the Rahima Moosa Mother and Child Hospital were foreign nationals (although the investigation did not stipulate whether they were documented or undocumented). Despite these significant numbers, there remains no mechanism for cross-border billing. The existing Southern African Development Community protocol addresses disease outbreaks, but it excludes routine healthcare services. 'No data system exists to raise an account […] The issue has drifted for 50 years,' Van den Heever confirmed. Fixing the system Despite severe criticism and resistance from some quarters, including over its costs and funding, the government is pressing ahead with the National Health Insurance (NHI) scheme. The Department of Health's spokesperson, Foster Mohale, confirms that NHI implementation is in its initial phase, focused on foundational, institutional and organisational arrangements. 'The NHI implementation is going well with phase 1 (2023–2026) under way, establishing foundational structures including the NHI Fund,' Mohale said. 'Phase 1 provides for ministerial advisory committees focusing on healthcare benefits and health technology assessment, which should be complete by July 2025.' Mohale said the department has also rolled out a supply chain management and payment checklist, pre- and post-audits, and a CFO forum to tighten procurement controls and reduce irregular spending. The NHI alone might not bring the redress needed, but foreign nationals using South Africa's healthcare system is not the core challenge either. Hospital beds were already underfunded and overstretched long before border crossings increased. The Auditor-General flagged about R1.8-billion as fruitless expenditure in the 2022/23 financial year, a sum significantly greater than any healthcare costs directly attributable to foreign nationals. Van den Heever noted: 'It's cyclical – foreign nationals are the bogeyman every election.' Structural inefficiencies mean longer wait times and diminished healthcare quality for the average South African patient. They wait longer for beds, or forever – but it's not because those beds are being occupied by others. The core issues lie in systemic inefficiencies, inadequate infrastructure investment and weak governance. Effectively fixing South Africa's healthcare system means fixing its management and money first. Migration and foreign nationals are an easy target, especially during election season, but they're not the real reason people lie waiting for treatment in hospital corridors. Without real improvements in governance, finance and basic infrastructure, the promise stays a promise. DM * Surname has been withheld.
eNCA
08-07-2025
- Health
- eNCA
Inquiry finds bias in medical schemes
JOHANNESBURG - Medical aid schemes have acted unfairly and in a racially discriminatory manner towards black healthcare providers. That's the finding of a Section 59 Inquiry. READ | HIV/AIDS prevalence | Prevention and treatment not targeting over 50s But the Board of Healthcare funders – representing the medical aids – says it rejects this. According to the managing director of the board of Healthcare Funders, Dr Katlego Mothudi says while they noted from the interim report of racial bias, this does not mean that schemes are deliberately targeting black practitioners. The findings have since prompted urgent calls for transformation within the private healthcare funding sector. Meanwhile CEO and Registrar of the Council for Medical Schemes Dr Musa Gumede welcomed the inquiry.
Daily Maverick
07-07-2025
- Health
- Daily Maverick
Probe finds evidence of racial discrimination against black healthcare providers by medical schemes
The section 59 panel investigating allegations of racial discrimination against black healthcare providers by medical schemes in South Africa issued its final report on Monday, 7 July. The section 59 panel's final report, handed to Minister of Health Aaron Motsoaledi on Monday, found that between 2012 and 2019 there was evidence that the fraud, waste and abuse (FWA) systems used by medical schemes showed racial discrimination against black service providers. The investigative panel, commissioned by the Council for Medical Schemes (CMS) and chaired by advocate Tembeka Ngcukaitobi, began looking into the matter in 2019 after healthcare providers, represented by two associations, made public allegations about their treatment by medical schemes and administrators. 'We were not a court of law… We did not have to make legal findings applying the Promotion of Equality and Prevention of Unfair Discrimination Act or applying section 9 of the Constitution, but what we did have the power to do was to make findings of fact, and that… simply leads to one conclusion. The evidence of the risk ratios before us showed racial discrimination against black service providers by the [medical] schemes,' said Ngcukaitobi at a press briefing marking the handover of the report on Monday. According to the CMS, the inquiry focused on two issues: whether there was racial discrimination by medical schemes against black healthcare providers; and procedural fairness in the treatment of black healthcare service providers. Racial discrimination The panel developed a tool to measure the performance of medical schemes' fraud, waste and abuse systems, looking at discriminatory outcomes or unequal treatment for healthcare providers. 'This risk ratio is basically a tool that we developed to work out the likelihood that a black practitioner would be subjected to an investigation, a finding and a penalty, versus a white practitioner,' said Ngcukaitobi, adding that the panel looked at risk ratios across different medical disciplines and years, between 2012 and 2019. The findings included: In 2014, black dental therapists under the GEMS medical scheme were about three times more likely to be investigated and found guilty of fraud, waste and abuse than white dental therapists; In 2017, black psychiatrists under Discovery were about 3.5 times more likely to be investigated and found guilty of fraud, waste and abuse than white psychiatrists; and In 2018, black anaesthetists under Medscheme were about 6.5 times more likely to be investigated and found guilty of fraud, waste and abuse than white anaesthetists. Ngcukaitobi said there was scope to improve the methodology used by the panel to determine the probable risk ratios for different years and disciplines. 'We have explained that the tool… should be continuously improved, but it is useful as a starting point. We have also recommended an annual assessment of the impact of FWA [systems] on black providers… [and] recommended the splitting of specific disciplines in order to monitor the instances of FWA among the healthcare providers,' he said. Procedural fairness The panel released an interim report in 2021, with findings of unfair discrimination on the basis of race. Subsequent to its release, various stakeholders – including medical schemes – had the opportunity to make further submissions to the panel in 2021 and 2023, according to Dr Thandi Mabeba, chairperson of the CMS. '[In the interim report], what we had found in relation to procedural fairness was that the FWA procedures for the recovery of monies allegedly owed is unfair and it violates the rights to procedural fairness of individual practitioners. We found that the schemes should make changes to the manner in which they claw back monies that they claim practitioners owe to them,' said Ngcukaitobi. 'We've received further submissions, but we remain unpersuaded that our interim findings were incorrect. Accordingly, we confirm the findings and recommendations in the interim report that the procedure that is followed by medical schemes, when they claw back money allegedly owed by practitioners or where they investigate instances of fraud, waste and abuse, are unfair.' Ngcukaitobi noted that part of the problem was that the Medical Schemes Act didn't contain procedures for the administration of fraud, waste and abuse systems, leaving it up to individual medical schemes to make decisions about how to investigate possible infractions and impose penalties. 'The legislation is lacking. It has several gaps. It's not keeping up with technology… We say that the CMS, as the regulator responsible for the implementation of the fraud, waste and abuse systems, is required to ensure that schemes and administrators act procedurally fairly. It is within the CMS's discretion as to how it chooses to progress this object with various stakeholders,' he said. Among the recommendations made by the panel to improve procedural fairness in medical schemes' fraud, waste and abuse systems were: Developing an early warning system that allowed medical schemes to notify service providers as soon as schemes became aware of any circumstances which might lead to the application of section 59, subsection 3 of the Medical Schemes Act; Reviewing the 'audit and clawback time period' for medical aid schemes, as there were instances where healthcare providers were called upon to pay back money to schemes years after alleged infractions; Ensuring a mechanism to assist healthcare providers with representation when accused of fraudulent, wasteful or abusive conduct by medical schemes, to prevent isolation or coercion of accused persons; and Providing complete transparency regarding the software, algorithms and artificial intelligence programmes used by medical schemes to monitor claims made by providers and members alike. 'Most of the evidence we had was that there is a software programme that the schemes use to detect fraud, waste and abuse, but there's no transparency in relation to the input into that software programme… and because it's an invisible programme, it's impossible to work out whether it's discriminatory or not in relation to its outcomes,' said Ngcukaitobi. 'If the schemes persist with the argument that they will not allow this transparency because it will undermine the detection of fraud, waste and abuse, then we say the Council for Medical Schemes must introduce a mechanism where… the council itself has full transparency relating to the software, algorithms and artificial intelligence programmes that the schemes use. The schemes ought to be accountable to a public body for the systems they use, as this in turn ensures accountability to the public, whilst maintaining a form of confidentiality.' Upon receiving the section 59 investigation panel's report, Motsoaledi said that the National Department of Health would study the findings before issuing an official statement. BHF rejects findings The Board of Healthcare Funders (BHF), a nonprofit company representing medical schemes and administrators, released a statement rejecting the panel's findings on Monday. 'We still need to study the final report. However, we are disappointed that the section 59 inquiry panel has confirmed that it has upheld the findings made in the interim report released in 2021. We believe these findings are demonstrably and fundamentally flawed and, if allowed to stand, will open the door for runaway fraud and corruption in the healthcare sector,' it said. The board said fraudulent claims, overservicing, abuse of benefits and improper billing practices cost South Africa's medical schemes about R30-billion each year. 'Based on comments made by the section 59 inquiry panel in today's media briefing, the BHF believes that the final report continues to be underpinned by serious methodological and interpretive flaws, all of which we raised following the release of the interim report in 2021,' it said. The issues the BHF raised with the panel's methodology included: Unscientific methods to assign race, using surnames to categorise providers; Failing to account for exposure bias, which occurs when a group is more likely to be involved in a process or activity simply because of greater contact or interaction; and Confusing correlation with causation, by assuming discrimination without 'rigorously considering other relevant variables such as provider billing patterns, patient load, or socioeconomic contexts'. 'Taken together, these cumulative weaknesses undermine the central finding that black providers were nearly twice as likely to be investigated,' it said. According to the BHF, both the board and its members had undertaken 'significant reforms to strengthen fairness, transparency and accountability', including a comprehensive review of fraud, waste and abuse protocols. 'The BHF remains committed to working collaboratively with the CMS, regulators and the healthcare community to strengthen South Africa's healthcare funding system. While we reject the findings of the section 59 investigation as flawed, we remain steadfast in our pursuit of a healthcare system grounded in integrity, justice and sustainability,' said Dr Katlego Mothudi, managing director of the BHF. DM
eNCA
29-06-2025
- Health
- eNCA
Over 10,000 men in SA commit suicide annually
JOHANNESBURG - Suicide remains a serious public health issue with a lasting impact on families and communities. That's according to the Council for Medical Schemes, which highlights growing concerns around mental health in the country. WATCH | Children's mental health | The effects of screen overexposure In South Africa, men are four times more likely to die by suicide than women, reflecting a deepening crisis in men's mental wellness. Experts say the situation is worsened by a shortage of mental health professionals across many African countries, leaving many without access to adequate support.
