MEDICAL COVER SPECIAL FEATURE
Covid-19 emphasises the need for affordable health care
COMPLIED BY: LYNETTE DICEY
The growing cost of private medical aid has long been in the spotlight, with medical insurance —or medical scheme contributions —accounting for the single biggest item in the consumer price index, taking up 7.6% of total household spending. As a result of constrained household income in 2020, Deloitte estimated that medical scheme membership in SA would fall by 8.6%. However, this was not the case for the majority of medical schemes, with most reporting significantly lower membership losses than expected as members prioritised their medical scheme membership in the midst of a global health pandemic. Rather than cancelling medical scheme cover many schemes reported that members chose to downgrade to more affordable plans instead.
statutory obligation of the Council for Medical Schemes to protect the interests of medical schemes and their members.
“Ultimately, medical schemes are not-forprofit entities, owned by their members,”says Damian McHugh, executive head of Marketing at Momentum Health Solutions.
“As such, their reserves are owned by members, not the scheme.”
All medical schemes are required to provide certain prescribed minimum benefits (PMBs). In order to cover these PMBs, he explains, the base price of a medical scheme plan is largely fixed, which has made it difficult for the medical funding industry to provide products under the Medical Schemes Act for the low-income market.
In SA around one in six people are covered by medical schemes. The balance of the population relies on the public sector for the provision of health care. The government has been pursuing the idea of national health insurance (NHI) in order to provide universal health cover for all South Africans. In a constrained economy and amid growing unemployment, the biggest challenge is how NHI will be funded.
Ultimately, medical schemes are owned by their members
DAMIAN MCHUGH Momentum Health Solutions
The president of the Health Professions Council of SA(HPCSA), Simon Nemutandani, recently called for the reserves of medical schemes and all other assets under the control of medical schemes to be transferred to the NHI, saying that NHI should replace all funding mechanisms for health. Medical scheme reserves are estimated to be more than R90bn.
Medical schemes have strongly opposed this proposal, pointing out that this move would be illegal and unethical. Not only is the HPCSA’s proposal in direct conflict with the Medical Schemes Act but it is contrary to the
As a result, some administrators, including Momentum Health Solutions, have launched health insurance products that operate outside of the ambit of the Medical Schemes Act and which provide more affordable and accessible cover. Demand for these products, reveals McHugh, exceeds demand for traditional medical scheme cover.
McHugh supports initiatives to improve the standard of care.
“The private health-care sector reduces reliance on the state, which should be considered a positive. The debate should not be NHI or a public and private sector —there is space for both,”he insists.
“The vaccine rollout —while not perfect —has been a good example of the public and private health-care sectors successfully working together for the benefit of the country. The private sector is not making money out of dispensing vaccines but has come together as part of a collective effort to get the country vaccinated as quickly as possible.”
Momentum Metropolitan was the first insurer to open up multiple vaccination sites. At full capacity —and as vaccine stocks allow —the company will be able to administer 20,000 vaccinations a day, reports McHugh.
The Covid-19 pandemic has highlighted inequality in the health-care space and the stark divisions between the country’s public
and private health-care sectors. Not discounting the tremendous toll on human lives, the pandemic has, however, provided some opportunity for a positive change in the health-care funding environment. According to Dr Reinder Nauta, executive chairof National HealthCare Group, a health-care provider in the low-cost and emerging segments of the health-care market, the ground has been prepared for the introduction of several fundamental private sector initiatives aimed at providing costefficient healthcare services to a far larger spectrum of the population.
“The health-care market has never been better placed for the introduction of new health-care models that comprise a blend of firstworld health-care delivery and systems appropriate for SA,”says Nauta, adding that newer entrants to the market are proving themselves to be more agile and innovative and therefore better positioned to harness the many new opportunities that have opened up for well-balanced, more affordable health-care products.
need for more accessible health care.
“More than a year down the line the product has been well received by local companies. One of the first companies to introduce the benefit into its workplace was fast-food chain Hungry Lion, which signed up approximately 3,000 staff members who previously relied solely on government health-care services.”
National HealthCare Group is not the only health-care provider looking to expand access to quality healthcare. Netcare has announced plans to launch additional new cost-effective products under its NetcarePlus brand. Last year the company launched affordable GP consultation vouchers. The product offers a choice between three types of pre-paid vouchers that are redeemable for a consultation with a GP. Vouchers either give access to an in-person consultation (R350), a consultation and prescribed acute medications (R430) or access to a virtual doctor consultation (R250).
This highlights the urgency of closing the affordability gap TESHLIN AKALOO Netcare Innovative Products
In 2020, National HealthCare Group introduced MediClub Connect, an innovative service using mobile communications and chat commerce technology, focused on bringing the benefits of private medical services to the low-cost segment of the health-care market. The product differentiates itself through the delivery of health care using a mobile phone and WhatsApp prompts to pinpoint potential health-care issues.
Patrick Lubbe, CEO of National HealthCare Group, explains that members are provided with online interactive access to doctors and nurses on WhatsApp, physical consultations with doctors on referral and prescribed medication along with other key services for R95 per employee per month. Launched at the height of the Covid-19 pandemic in 2020, Lubbe says the tech-savvy solution fulfils a
This year the company announced the launch of NetcarePlus Accident and Trauma Cover in partnership with Hollard. The product guarantees stabilisation at the scene of the accident or trauma event and Netcare 911 transportation to a contracted private hospital. It also includes access to unlimited in-hospital treatment for up to 90 days for accident- and trauma-related medical care. A Prepaid Procedures product, on the other hand, is an affordable solution for certain medical procedures.
“The Covid-19 pandemic has highlighted the urgency of closing the affordability gap through creative models that work for SA’s economically active population,”explains Teshlin Akaloo, MD of Netcare’s Innovative Products division. “By making new funding mechanisms available to provide financial certainty around private health-care costs it will be possible for more South Africans to benefit from quality health care in the private health-care setting.”
LEADING-EDGE MEDICAL CONSULTATION TECHNOLOGY
According to Dr Johan Pretorius, CEO of Universal Healthcare, the fully integrated system allows patients to connect with general practitioners, no matter whether they have medical aid cover or not,or which medical scheme they belong to. Users connect from their web browsers, so there’s no need to download a restrictive medical schemeprescribed app that is only available to select groups.
Unlike other virtual consultation platforms, uConsult connects patients with health-care providers using safe, scalable microservices technology, making it accessible any time from any device, be it a smartphone, tablet, laptop or desktop. “Real accessibility to quality health care is uConsult’s ultimate objective,”says Pretorius.
The platform enables patients to video-chat and screen-share with their provider, and to receive encrypted prescriptions, pathology forms, radiology forms and specialist referral letters electronically. In many cases the user is able to experience the full journey from consultation to having their medication delivered without ever leaving the comfort and safety of their home or office.
Users are able to search for general practitioners on uConsult by name or geolocation, and virtual consultations can take place no matter where the patient is based —locally or internationally. Providers from other medical disciplines will soon be joining the platform as well.
“Patient and health-care provider
It’s the beginning of a new era for the management of our health
DR JOHAN PRETORIUS CEO OF Universal Healthcare
are also able to connect with other practitioners without having to switch between systems —a revolutionary development,”says Pretorius, adding that the health-care provider does not need to have any specific software installed to enable the uConsult functionality.
“The vision for this leading-edge technology is rooted in the firm belief that anyone, anywhere, should be able to access the best-quality health care available,”he says. The technology was designed and developed at the Universal office in Silicon Valley, California, and was built from the ground up by Universal’s international team.
“The advent of Covid-19 has changed the face of health care and how we communicate. It’s the beginning of a new era for the management of our health and how we interact with our health-care professionals going forward. For us, this comes down to innovating and creating solutions that ultimately hinge on so much more than convenience —it’s about making inroads into inclusivity, sustainability and connectivity for health-care consumers, within and beyond our borders,”says Pretorius.
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“The first step,”says Lee Callakoppen, principal officer at Bonitas Medical Fund, “is to analyse your health-care needs”. No two people or families are alike and each will have their own health-care priorities. Do a quick personal health-care needsanalysis to determine what cover you need. Factor in dependants’needs too. Consider how often you and your family visit a doctor or specialist; over-the-counter medication or chronic medication required; chronic conditions such as high blood pressure or diabetes; specific conditions such as cancer, HIV/Aids or renal failure; and how much you spend on dentistry or optometry.Then consider which of the expenses listed above were one-off and won’t come up again soon (such as childbirth) and which are likely to come up again and again (such as flu). This will help you decide whether you need a comprehensive medical aid or a hospital plan.
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Benefits vary from plan to plan, so establish what is and isn’t covered.
“Ask what additional risk benefits might be available to you that can potentially save significant day-today expenses,”says Callakoppen.
“These could include preventative-care benefits, ranging from basic screenings (such as blood pressure, cholesterol and blood sugar) through to mammograms, pap smears and prostate testing. In some cases, this extends to maternity programmes, dental checkups, flu vaccinations and more. Once you understand what is on offer, you can make an informed comparison and decision.”
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TIPS FOR CHOOSING THE RIGHT MEDICAL AID
It’s a tricky landscape to navigate, so it’s best to compare all the options to find a schemethat works for you and your family —and is within your budget
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“You need to consider the savings and day-to-day benefits offered”, says
Callakoppen. These benefits cover out-ofhospital expenses such as GP consultations and over-the-counter medicines. Some also cover dentistry and optometry.
Establish what managed-care programmes are on offer. Managed-care options help members manage severe chronic conditions such as cancer, diabetes and HIV/Aids.
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Look at what the scheme suggests to make your benefits last, bearing in mind that some plans require you to use a specific GP, hospital network and have a list of designated service providers (DSPs). These keep costs down because the scheme will have negotiated special rates with these
service providers. Check the network in your area before making a final decision. Also bear in mind whether you must be referred to a specialist by your GP, and whether your medical aid offers additional GP consultations, which they will pay for, after you have exhausted your day-to-day benefits.
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Technology and virtual care are being embraced by medical schemes and members. Check what is offered on the plan you’re considering and whether you’re able to access your benefits and medical information 24/7.
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Age will impact on your decision. As parents of young children, ensure the option you select provides sufficient childillness benefits. For young couples looking to start a family, check that your option provides sufficient cover for maternity benefits. If you are slightly older, ensure your option covers chronic conditions and provides sufficient inhospital cover in the event of hospitalisation.
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Consider all the costs involved before you make your final decision, such as monthly contributions —the rule of thumb is that contributions should not exceed 10% of your monthly income at an individual or household level —and the cost of copayments for various benefits claimed. A copayment is a fee that the member is liable for when making use of certain medical services. These co-payments usually apply to specialist or elective medical procedures. This differs from one medical aid scheme to another. It is one of the reasons you should always do thorough research before deciding which medical aid scheme is the best option for you. The ideal option would, of course, be the one that does not require many or any copayments from the member.
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Consider waiting periods and exclusions. The Medical Schemes Act and the specific scheme’s rules determine this. “We recommend that you enquire with the relevant scheme about their exclusion list and waiting periods,”advises Callakoppen.
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Lastly, consider using a broker. “Using a broker does not cost you anything. An independent broker will help you work your way through the different options and help choose the medical aid plan best suited to youand your family’s needs,”Callakoppen says. —Lynette Dicey
RANDOM PRICE INCREASES
MEDICAL SCHEMES MORE NECESSARY THAN EVER
Medical schemes cameunder fire from the Health Professions Council of SA (HPCSA) when its president, professor Simon Nemutandani, told parliament in May that private medical aid schemes should only be allowed to exist in SA if they are funded separately over and above tax paid for the National Health Insurance. He called for the Medical Schemes Act to be amended to ensure it aligns with the NHI.
Principal Officer at Medshield Medical Scheme Thoneshan Naidoo explains that medical schemes are not-for-profit organisations which exist for the benefit of their members. The monthly contributions paid by members are pooled into a trust fund that is used to pay for the health-care claims ofmembers according to the scheme rules and their choice of plan. Any surplus funds are transferred to the scheme’s reserves for “rainy days or health-care pandemics”.
Medical schemes operate in a highly regulated environment, which, he says, is a positive for members as it provides peace of
mind knowing that their funds are safeguarded.
The Covid-19 pandemic, says Naidoo, has been a perfect illustration of just how important membership of a medical scheme is. “In 2020 our top 10 claiming patients collectively cost Medshield R29m in health-care claims. The highest claim was from a 56-year-old member with major complications as a result of Covid-19. As a prescribed minimum benefit (PMB) all costs associated with a Covid-19 diagnosis are covered by the scheme’s plans.”
The member was covered by Medshield’s MediValue plan, which costs just over R2,000 a month, says Naidoo, revealing that the scheme covered the member’s claims, which amounted to R7.4m. “At his current monthly premium it would have taken this member 300 years to pay this amount back. Ultimately, this is the real value of a medical scheme because by pooling all the contributions of members the scheme is able to afford claims of this size. The reality is
that very few people have this much money available to pay for a catastrophic healthcare event.”
In SA medical aid premiums are considered an even bigger grudge expense than car insurance. But as Naidoo points out, if you’re in a car accident you can replace your car. A life is not replaceable, which is why access to quality health care should be a priority.
South Africans have the benefit of a world-class private medical sector. “In my view it is a national treasure and, as such, should be protected and nurtured.”
Public and private health care can successfully co-exist, as they have done in the UK and Australia, he says.
That being said, there is no question that SA should be finding ways to supercharge
NHI given that it will benefit the country as a whole, says Naidoo. “Health care has a close correlation to productivity and a country’s GDP. The entire country will prosper with a healthier population.”
The current Covid-19 vaccine rollout, he says, has been a good example of the public and private sectors successfully working together. “Certainly, we are further ahead in terms of the vaccine rollout than if government had done it alone,”says Naidoo.
Medshield is fully supportive of the vaccine rollout programme, reveals Naidoo. “Covid-19 can be a terrible disease for some and vaccinations are the only way we’re going to curb its spread. The cost of a diagnosis for a Covid-19 test is R850 —for which medical schemes cover the expense. The cost for the double dose of the Pfizer vaccination is R870 including the administration costs. The bottom line is that the financial cost of the vaccine is insignificant when compared to the physical, emotional, social and economic toll of Covid-19, so it’s imperative that we get as many people vaccinated as quickly as possible.”
The rollout of the Covid-19 vaccine is proving the benefit of having a strong and effective private health-care sector alongside the public sector
The entire country will prosper with a healthier population
THONESHAN NAIDOO Medshield Medical Scheme
GOOD UPTAKE OF VACCINES
Every week large pharmacy chains ramp up the number and efficacy of Covid-19 vaccination sites —and they have no trouble finding takers
Phase 2 of SA’s vaccination rollout programme is now well under way.
Though some registered sites reported a slow start in the first few days of the programme in May, there has since been a definite upswing.
Dis-Chem launched and piloted a mass vaccine site at its Midrand head office in mid-May and, based on these learnings, ramped up to five vaccination sites a week later. Three new vaccination sites were opened in June, including two in the Western Cape and one in the Eastern Cape. Another twosites are ready to be opened in KwaZulu-Natal but remain subject to the
availability of vaccine stock.
Dis-Chem’s vaccination sites are not situated in its pharmacies but are in malls with clear posters and signage. The capacity to vaccinate at each site is dependent on the regular supply of vaccines, which is controlled solely by the national department of health.
Ivan Saltzman, CEO of Dis-Chem, says, “We want to get jabs in the arms of as many people as possible. As such, we encourage each and every eligible South African over the age of 60 who has not yet registered on the government’s Electronic Vaccination Data System to do so.”By Friday
May 28, Dis-Chem had administered over 25,224 vaccines across six sites.
Reporting a similarly slow start initially, Clicks says its vaccination sites have since experienced good uptake. “The rollout is going exceptionally well,”reports managing executive at Clicks, Vikash Singh. “We’ve had a phenomenal response from the public with a high attendance and very few no-shows.”
We want to get jabs in the arms of as many people as possible
IVAN SALTZMAN CEO of Dis-Chem
By June 3 Clicks had administered more than 15,000 vaccines at is 60 retail pharmacy registered vaccination sites. Singh says the
target of administering 50 vaccinations a day, per site, is manageable and that an additional 240 vaccination sites will be going live in the next two to three weeks with about 40 to 50 new sites going online each week, depending on demand and vaccine availability. Stores situated in areas which don’t have easy access to other vaccination sites will be prioritised in the rollout. Clicks’ objective is to ultimately have 602 registered vaccination sites, by which stage it will have capacity to vaccinate 30,100 per day, six days a week.
