Specialist Family Physicians (SFP), short-paid through an unregulated tariff system that treats them as GPs, are victims of a perverse Competition Commission ruling – and legal action by their peers in other specialties, writes Chris Bateman for MedicalBrief.
That’s according to Dr Rajesh Patel, head of health systems strengthening at the Board of Healthcare Funders (BHF) in reaction to complaints by SFPs that they are being financially and professionally discriminated against by medical aids (see story in MedicalBrief).
The BHF has appealed a January 2025 Competition Commission ruling that rejected its application for exemption from some provisions of the Competition Act. The exemption would medical schemes to negotiate tariffs with willing healthcare providers – and make these public. A decision is pending.
Patel told Medical Brief that private SFPs are paid far less than other specialists because of a “regulatory vacuum” around tariffs in the private healthcare sector. In a paradox, SFPs in the public sector earn the same as other specialists, unlike in the private sector where medical aids reimburse them at GP-like rates.
This regulatory vacuum dates to 2003, when the Competition Commission ruled that collective tariff negotiations between medical schemes and practitioners were anti-competitive. The decision barred the BHF from publishing a reference price list for members. Since then, no uniform tariff framework has existed, creating price opacity and uncertainty. The Gap Cover market has flourished as patients claim on the growing difference between what medical aids pay and what specialists charge.
To fill the void, the Department of Health and Council for Medical Schemes (CMS) developed a National Health Reference Price List (NHRPL) – a guideline tariff structure for the private sector. But the Hospital Association of South Africa (HPCSA) and the South African Private Practitioners Forum challenged it in court, and in July 2010, the High Court declared the NHRPL and its regulations invalid.
Since that ruling, no government-mandated standard for private tariffs exists. Schemes and providers now set their own rates, producing large gaps between provider fees and medical scheme reimbursements. Patel said the coding vacuum affects other specialist fields too, including sports medicine and public health.
The Health Market Inquiry Report (2019) acknowledged that the 2003 decision created a regulatory gap. It recommended establishing an independent supply-side regulator to oversee structured, multilateral tariff negotiations, ensuring fair competition and price certainty. Government failed to act on this recommendation, prompting the BHF in 2022 to apply for a Competition Act exemption, which was turned down, hence its 2025 appeal.
Patel said the BHF has engaged both SFP representative groups, but their reimbursement proposals were “unrealistic.” “We’re also aware there are intervention coding gaps, particularly for psycho-social interventions in this specialty,” he added.
“While this regulatory vacuum exists, only the contracted service providers and medical schemes can address reimbursement for SFPs,” Patel said. “Some schemes reimburse SFPs at higher levels, but there’s no standardisation across the sector, which increases billing uncertainty.”
The CMS confirmed receiving an SFP complaint on 6 November and said it would “follow the due processes of CMS adjudication timelines”. “Once finalised, an outcome will be issued and communicated to the complainant as per the Medical Schemes Act,” a CMS spokesperson said.
GEMS, one of the schemes cited by SFPs for underpayment, said it “recognises the critical role that Specialist Family Physicians play in South Africa’s healthcare system”.
In a statement to Medical Brief, Dr Buyo Gqola, GEMS’ chief operating officer, said the scheme recognises SFPs as specialists registered with the HPCSA and reimburses claims “in accordance with the Medical Schemes Act, scheme rules, and applicable tariff and coding structures”.
“In 2020, GEMS implemented enhanced remuneration rates for SFPs, acknowledging their distinction from Family Practitioners,” Gqola said. “Furthermore, in January 2025, we increased reimbursement for in-rooms procedures performed by contracted SFPs. Engagements between GEMS and SFPs on further initiatives are ongoing.”
He added that GEMS placed no restrictions on the clinical decision-making of healthcare professionals practising within their registered scope.
“As South Africa’s largest restricted medical scheme, covering more than 2.4m beneficiaries, GEMS remains committed to fairness, transparency, and ethical governance in all reimbursement practices,” Gqola stressed. “We continue to engage with the South African Academy of Family Physicians, professional associations, and regulators to ensure recognition and remuneration frameworks evolve in a fair, sustainable, and policy-aligned manner.”
Discovery Health, the administrator and managed care provider for Discovery Health Medical Scheme (DHMS), said it recognised the “unique and critical role” that SPFs play in delivering comprehensive, whole-person primary care.
“Following extensive engagement with the SFP society, we co-created a dedicated framework and payment arrangement designed to support their practice.”
This reflected the distinct scope and objectives of SFPs, enabling advanced primary care without requiring transition into organ-based specialties, supports comprehensive, team-based care, integrated mental health, prevention and continuity – key drivers of system sustainability and improved patient outcomes.
The arrangement included enhanced professional fees: approximately 30% above the Discovery Health GP network rates, and access to specialist-level protocols and investigations, including MRI and CT referrals, (subject to clinical criteria.)
“Our approach was shaped by the family medicine leaders, who sought recognition for their specialty and the necessary tools to deliver advanced primary care, without having to transition into organ-based specialist medicine. The arrangement is tailored to the distinct practice patterns and goals of SFPs, supporting comprehensive, team-based care, integrated mental health, prevention, and continuity – all of which are essential for system sustainability and improved patient outcomes.”
Discovery Health remained committed to ongoing engagement with the SFP Society and was open to discussing proposed amendments to the arrangement, it said. “However, any changes must be agreed upon by all relevant governance structures to ensure alignment and sustainability. Our goal is to evolve this framework collaboratively, always prioritising patient outcomes and the long-term sustainability of the healthcare system,” a spokesperson concluded.
Dr Sheena Mathew, chairperson of the Specialist Family Physicians in Private, said the discrimination by DHMS was that SFPs were only given specialist privileges like imaging authorisation if they signed up with the Discovery network. Recognition was not given to the discipline as a whole. Other specialties did not have to be part of the DHMS network in order to get imaging privileges within their scope of practice.
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