Medical Schemes Council: briefing

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20 May 2003
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Meeting Summary

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Meeting report

20 May 2003

Mr L Ngculu (ANC)

Documents handed out
Medical Schemes Council Presentation

According to the Chair of the Council for Medical Schemes most of the trustees that head medical schemes were dedicated to high ethical standards and were presently performing a sterling job. The Committee, however, heard that despite stringent regulatory work to guard against malpractice beneficiaries still believed that they were being unfairly treated. This aspect, the Committee heard, stemmed from the large volume of complaints that continued to pass through the Council. The Committee expressed its displeasure at the objectionable practice of contracting schemes to firms where doctors were inaccessible to the general populace. The Council, however assured the Committee that amendments that were promulgated last year fully addressed this issue.

Briefing by Prof. Nicky Padayachee - Chair of the Council for Medical Schemes (CMS)
The chair briefed the committee on the composition and mandate of the Council which he heads. He noted that the Act requires that at least 50% of board of trustees be elected by fellow members at an annual general meeting. Trustees were required to be fit and proper persons and that the Council had to regard a number of factors when assessing the fitness and propriety of those seeking trusteeship. Qualities that were considered included honesty, integrity and the reputation of such a person. He added that competence and the capability of such a candidate was also taken into account. Most of the trustees were a dedicated lot with high ethical standards and that they were presently doing a sterling job.

Briefing by Mr. Steven Anderson - Director of Research CMS
Mr. Anderson informed the Committee that the Council had made significant progress toward ensuring that beneficiaries were treated fairly by their medical schemes. He regretted that judging from the large volume of complaints that continued to pass through the Council many beneficiaries still believed that they were being unfairly treated. He pointed out that whilst some of these allegations were well founded most of them were not. Due to the centrality of the issue of malpractice, the Council had isolated it as its main thematic concern during 2003. He revealed that a project team had been set up to investigate the issue and report back to the Council.

Mr. Anderson further informed the Committee that the Council had received a number of requests for approval of an entity that would allow them to cater for the needs of employees that were in current employment but without medical scheme cover to be insured at least for HIV and AIDS. He pointed out that this issue received added impetus after several employer groups announced that they would start providing HIV cover including anti-retroviral medicines to their employees. He explained that the main impediment to this request was the Medical Scheme Act, which he said does not empower the Council to develop an alternative framework for the regulation of HIV-specific products. He submitted that to the extent that such products emerged within the market, they must function within the ambit of the Medical Scheme Act.

Dr Gous (NNP) noted that medical schemes should be beneficial in terms of savings and quality of care and wondered whether the expanded area of cover would not defeat these objectives.

Mr Patrick Masobe - Registrar -CMS replied that with managed care there had never been a problem with efficacy and stability noting that the concern had always been to ensure that access to care was not compromised.

Dr Gous clarified that he had no problem with issues of efficacy and stability but that his concern revolved around adding the 25 chronic conditions, which he feared, would trigger an escalation of costs.

Mr Anderson explained that the problem did not lie with the addition of chronic conditions but that the issue had always been inadequate coverage by medical schemes noting that it was unlikely this addition would add extra costs.

Mr Masobe pointed out that the Council was concerned about issues raised by Dr Gous explaining that Council made sure that when outlining policy the supporting environment was in place.

Dr Rabinowitz (IFP) expressed concern on the question of social justice that revolved around equity and access to care. How would the Council implement its programs in a manner that would advance these national goals.

Mr Masobe pointed out that the Council was not the driver of these imperatives but that it was not altogether indifferent to them. The Council was keenly monitoring the environment to ensure that changes in national policies whenever they arrive were properly absorbed in and well managed by the medical scheme industry.

Dr. Cachalia (ANC) wondered if increased regulation in fact had the effect of escalating the cost of care.

Prof. Padayachee disagreed with the notion that more regulation led to increased costs noting that there was no evidence to support this claim. Quite to the contrary, the incidence of cost had for the first time in the country stabilised since the introduction of more regulatory framework. He singled out the USA and Canada, which were developed economies with high regulation yet no cost escalation had been reported.

Dr Cachalia asked how the Council dealt with the incidence of market driven costs.

Mr Masobe replied that past experience had shown that the benefits that required protection were those in the vulnerable groups in society where a threshold must be set beyond which one should not go.

Ms Baloyi (ANC) lamented the tendency of contracting schemes to firms where doctors were inaccessible to the general populace. She singled out white doctors for example whose medical facilities were not based in areas populated by the majority of black people.

Mr Masobe acknowledged the point raised by Ms Baloyi and noted that the location of networks was a very important factor in making these schemes accessible to the wider population. He pointed out that this issue was specifically dealt with in the amendments that were promulgated early this year. It was an accepted practice even in the USA that any practitioners should be free to join a network as long basic requirements were met irrespective of where their practice was based.

Ms Baloyi asked if there would be any minimum prescribed benefits for HIV benefits.

Prof. Padayacee clarified that schemes do not ordinarily make provision for minimum benefits save that one's cost of care could be reduced but there was no such thing as an entitlement to a minimum benefit.

Dr Jassat (ANC) lamented the practice by schemes to shuffle patients from one specialist to another merely for check up noting that this practice unnecessarily increased the cost of care.

Prof. Padayachee pointed out that the Council encouraged the board of trustees to seek value for money and guard against situation of either under service or over service. He added that the Council had also strengthened its inspection unit and diversified enforcement measures to deal with any malpractice by schemes.

Dr Rabinowitz urged for more regulation around the area of accountability noting that quite a number of people were ignorant regarding the existence of Medical Schemes and even those who were aware did not know how these facilities function.

Mr Masobe noted that Dr Rabinowitz's suggestion was a valid one especially in so far as it relates to effective communication of products to the beneficiaries. He pointed out that the Council was currently working very hard on this issue and that it was considering putting some of its work in magazine in order to widen its information base. He added that one way of dealing with cases of misconduct was to empower consumers with information on possible areas of abuse.

The Chair noted that there was need for more interaction between Council and the Committee in the near future.

The meeting was adjourned.


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