Cape Town - In South Africa, the price of medical services in the public sector is predetermined, and/or based on the income of the patient (the Uniform Patient Fee Schedule). Rebates, based on income are determined by this.
Not so in the private healthcare sector, where soaring prices charged for the services of doctors and specialists in and out of hospital have contributed to annual double-digit medical scheme contribution increases for many members over the last few years.
Earlier in 2017 Dr Aaron Motsoaledi, Minister of Health, stated that the price of private healthcare had increased by 300% in the preceding decade.
In all fairness it has to be said that not all private doctors overcharge, and equipment costs and the weak exchange rate can also shoulder a fair share of the blame for the spiraling costs of private healthcare. Let us be clear: doctors are entitled to a reasonable living along with all other professionals. But what is considered reasonable?
Despite efforts to increase membership of medical schemes, membership numbers have remained largely static over the last decade, with just under four million principal members of schemes in SA, and just under nine million lives covered, according to Alexander Forbes Health. That means in a population of close on 55 million people, 84% are dependent on state medical services, unless they are able to pay out of their own pocket for private healthcare.
The rapidly increasing cost of member contributions has been blamed for this state of affairs, putting not only private medical care, but also medical cover beyond the reach of the average South African.
How did we get here?
There is a long history of Price Lists being put together by different players in the field of healthcare. But there has been no set of tariffs to which everyone agrees for many years. These recommended tariffs can differ by as much as 300%, depending on which list you are looking at. Until now there has been nothing, not even market forces of supply and demand, that could put a stop to this.
The high cost of private healthcare in SA
Over the years, Dr Motsoaledi has consistently slammed what he calls “the exorbitant prices in private healthcare” going so far as calling it a “sick situation” and accusing the private sector of over-servicing the rich, while there was general underservicing of the poor in the country as a whole.
He has been quoted as saying at the Competition Commission’s Private Healthcare Market Inquiry that “Nowhere in the world does private healthcare cost as much as it does in South Africa”.
PMBs to be paid ‘in full’
And yet, it is the very wording of Regulation 8 of the Medical Schemes Act of 1998, which requires medical schemes to pay for 270 Prescribed Minimum Benefits in full that is one of the contributory factors to keeping private healthcare costs so high. While there are pricing guidelines, which the medical schemes follow to determine rates they will pay for certain procedures and medication, these are not enforceable when it comes to the treatment of PMBs.
Genesis Medical Scheme launched an application to the High Court to have Regulation 8 struck down, in an effort to curb costs to medical schemes. Their argument was that they were in favour of paying a reasonable fee to a doctor for the treatment of members for a PMB, but they asked the question whether that fee should be without limit?
Genesis recently cited a case of a plastic surgeon who charged in excess of R1 000 per minute for his services in the theatre, which would amount to fees of R60 000 per hour, or R480 000 per day. The procedure was to stitch up the eyebrow of a patient. It was neither an emergency nor life-threatening surgery.
As this fee was for the treatment of a PMB, they are forced to settle the doctor’s fee in full. Genesis also has evidence of doctors seeking to charge the equivalent of R33 000 per hour and R28 000 per hour.
Where does this leave medical schemes?
Medical schemes have two streams of income: member contributions, and income from investing the funds in the reserve. The schemes are not run for profit, and the expenditure of any scheme is basically on two items: paying of members’ claims and the administration of the scheme.
It stands to reason that the higher the medical claims that have to be paid out, the higher the member contributions have to be in order to make this possible in the long run. Even if a doctor discusses his fee with a patient, if he is being treated for a PMB, it is the medical scheme who pays, and not the patient directly.
Not immediately anyway – but ultimately, when contribution increases are announced, it will be. The question arises as to the long-term sustainability of a system where schemes are forced to pay fees to which there is no cap.
Medical inflation is consistently higher than CPI inflation, and over a period of time, this means that the average member’s medical scheme contribution makes up a larger and larger percentage of their disposable income every year.
The result of this is static numbers of medical scheme members, buy-downs to cheaper options, and a reduction in the number of dependents that principal members register on their schemes. Members who are hard-pressed financially can also resign completely from their schemes, placing further pressure on the already overburdened state healthcare services.
The question boils down to the original intention of the legislators in their wording of Regulation 8. Was it put in to protect scheme members by providing them guaranteed access to certain treatments, was it to give the private health sector a blank cheque when it comes to treating scheme members for PMBs. Indeed, can, or should a regulation ever supersede an Act?
The ultimate question that should be asked is what is considered to be a reasonable fee, and who would all parties trust to determine that? Private doctors provide a necessary, if costly, service, their practice costs are often high, their study costs were huge, as are their malpractice insurance costs.
They do not work for the state, and can take their skills and knowledge elsewhere if legislation becomes too prescriptive and restrictive in one country.
Their fees are said to be determined by the normal economic forces of supply and demand. Or are they? If the patients themselves were paying directly, then yes. But the majority of private patients in this country are medical scheme members – and according to the law, the schemes are forced to pay whatever the doctors charge for treating PMBs.
Few private patients could pay any doctor R1 000 per minute, and if it weren’t for scheme members, presumably that specialist would be out of business soon.
But is it not just a matter of time before those same economic forces cripple the medical schemes, which are, after all, just made up from groups of the same patients? In the end, overcharging is counterproductive and leads to nothing but crippling the system that is now keeping the R1 000-a-minute specialist afloat.
And one may ask if the doctor is really that brilliant, or whether they are just doing it because they can?
It’s time to curb excessive costs, before it kills both the private health sector and the country’s medical schemes.
* Susan Erasmus is a freelance writer and regular columnist on Fin24. She first wrote this article for Genesis Medical Scheme.