The Council for Medical Schemes, which has been accused of blocking the introduction of low-cost medical aids in an effort to make the NHI seem more appealing and palatable, has been ordered by the High Court to provide reasons for its decisions within 10 days.
The Board of Healthcare Funders won an interim battle in the Gauteng High Court (Pretoria) on Monday as part of a bigger case arguing that the regulator’s decision to block low-income earners from accessing a medical aid was irrational, and has requested the entire record from the CMS for its decision and refusal.
If low-cost medical aids were permitted, it would allow lower-income earners access to some private care, like GP visits and acute medication, reports Business Day.
As medical aids have to provide legislated prescribed minimum benefits, their monthly premiums are not cheaper than R1 000. However, it has been more than seven years since the council began to develop a legal framework to enable medical schemes to offer low-cost benefit options (LCBOs) that would be exempt from providing the full, costly suite of benefits stipulated by the Medical Schemes Act.
But the CMS has not yet decided how to do this. However, it has permitted a select group of health insurers to continue selling primary healthcare cover products that effectively do the same thing with less supervision and lower customer protection.
This led a frustrated BHF, which represents most medical aids in SA as well as Namibia, Zimbabwe, Botswana and Lesotho, to ask the court in August to declare the CMS’ failure to develop and implement an LCBO framework to be irrational, unreasonable and unlawful in terms of the Promotion of Administrative Justice Act and the Constitution.
The Constitution says that administrative action must be lawful, reasonable and procedurally fair.
The medical aid industry has been stagnant with 8m main members for years, and the BHF wants to find a way to increase those numbers, making medical aids more sustainable.
It has asked for a record of how decisions against low-cost options were made, to supplement its legal argument.
While the CMS provided 800 pages of publicly available documents, it is not satisfied, said Charlton Murove, head of research at BHF. From these documents BHF lawyers identified 36 that are likely to exist, based on references to meetings or studies.
Murove said meeting minutes that describe how decisions were taken should exist. “If you are running government and making serious policy decisions, how are you supposed to do that? Aren’t you supposed to record meeting minutes?”
The BHF believes the regulator is blocking low-cost medical aids to make NHI more palatable, Murove said. If medical aids can grow, they can become more affordable for everyone and more sustainable.
“If medical schemes continue being unsustainable, it makes it easier to have an NHI. That is our postulation. But we will look at the record and confirm this.”
The CMS argued the list of 36 documents required is a “horrendous shopping list”. But the court ruled that the fact that the documents “seem to be voluminous and quite extensive is of no concern … the documents are properly identified and described”.
The court agreed with a previous Constitutional Court judgment that “every scrap of paper that can throw light on the state decision-making process is relevant and needs to be produced”.
Meanwhile, the Health Department has assured that private healthcare will be alive and well under the NHI – just severely truncated and limited to reduce costs, Business Tech reports.
“The NHI will not destroy the private sector. The private sector has different role-players, and they are healthcare providers (like GPs, specialists, pharmacies and hospitals); suppliers of goods (health products like medicines, devices and diagnostic devices); funders (medical schemes) and administrators. They have different roles to play in the NHI,” it said.
The department said that private health care providers will continue to operate privately under the NHI dispensation.
“Contrary to some public narrative, the NHI is not going to abolish or do away with private health providers,” it said. However, “NHI will not allow health care providers to set their own fees for NHI funded benefits.”
The NHI Fund will set the fees that it will pay to private doctors, hospitals and others on patients’ behalf.
“Private General Practitioners will be a part of multi-disciplinary networks in their communities and will be paid by the NHI Fund using a capitation model. The private health sector providers will benefit from the opportunity to contract with NHI to provide health services to the broader public, rather than the small proportion for which they currently provide services.
“They will be able to provide services to patients throughout the year not worried about depletion of funds of patients at any stage. Private hospitals will see patients referred by primary health care providers in both public and private sectors and the NHI Fund will settle the bill at the prescribed rates,” it said.
Private healthcare providers won’t be forced to register with the NHI, but the department said it is in their best interestes to do so.
“Contracting with NHI Fund gives the healthcare provider opportunity to offer healthcare services to a designated population – significantly more patients than currently,” it said.
“Patients who consult with providers who are not contracted with NHI will pay cash for the providers’ services. Patients will only be able to use their medical schemes to pay for benefits not covered by the Fund with non-NHI contracted providers.”
The NHI doesn’t see much space for medical aids, but promises they won’t be killed off.
The department made it expressly clear that the NHI Fund will not be taking over the reserves of medical aids.
“The Fund will not take the accumulated reserves of medical schemes since those belong to the members and not the schemes,” it said.
“The business models of private funders and their administrators will change over time. Once the NHI Fund covers a benefit, the medical schemes may not cover the same benefits.
“This means that their membership fees must be reduced, and some will be too small to survive so they will consolidate with others to maintain a viable risk pool for the benefits that they may still cover.”
It said that because administrators of medical schemes will no longer manage over 250 options, the complexity of their services will be greatly reduced.
Once implemented, medical aid schemes won’t be able to offer any health services already offered by the NHI and will only be allowed to offer extra services not covered by the NHI.
Because the NHI will offer comprehensive health care service cover, Medical Aid schemes will remain voluntary arrangements for those who choose to contribute to them – but the services will be very limited.
“The Fund will be implemented over phases and over many years. Regulations will be published to address the phased implementation of the NHI Fund and phased implementation of service benefits as the money is moved to the Fund. Medical schemes will be given notice on the type of services that they will no longer be able to cover,” it said.
Business Day PressReader article – Medical aid regulator told to explain (Open access)
BusinessTech – The-end-of-private-healthcare-and-medical-aids-in-south-africa-government-responds-to-biggest-nhi-worries/
See more from MedicalBrief archives:
Medical schemes appeal CMS scrapping of low-cost benefit packages
Special medicines fund proposal as medical aids under pressure
Business plea to keep medical aids under NHI
Low-cost medical aid guidelines on the horizon