The long-standing issue of medical aids not fully acknowledging the difference between a specialist family physician (SFP) and a general practitioner is hobbling patient diagnosis, care and treatment, and conversely, likely to place an even greater burden on the state, ultimately, in the context of the National Health Insurance plan, writes SFP Sheena Mathew for Bhekisisa.
SFPs are primary care specialists. Like all other medical specialists in South Africa, they have four years of postgraduate training and a compulsory fellowship examination through the Colleges of Medicine of South Africa, following the same path as paediatricians, anaesthetists, psychiatrists, surgeons and gynaecologists.
But despite being registered with the Health Professions Council of South Africa as specialists, medical aids often consider them as general practitioners – reimbursing them as such and limiting specialist privileges like ordering CT scans for patients.
In her op-ed for Bhekisisa, Mathew argues that this limits their ability to fully practice their speciality, with patients paying the ultimate price.
She writes:
What I love about being a specialist family physician is getting to play Sherlock Holmes every day. The mystery is always a mind or body symptom, but the culprit could be any organ, and the breadcrumb clues could be any symptom, any bodily sign.
Like all other medical specialists in South Africa, SFPs studied for four years of postgraduate training, along with a compulsory fellowship examination through the Colleges of Medicine of South Africa, after we obtained our MBChB (Bachelor of Medicine and Surgery degree).
Just like paediatricians, anaesthetists, psychiatrists, surgeons and gynaecologists, we are registered with the Health Professions Council of South Africa as specialists. We differ from a GP, or general practitioner, who is a doctor who finished medical school and then practices without postgraduate training.
Although SFPs and GPs both treat everyday health problems, SFPs do this with a significantly higher level of training and are qualified to handle more complex care.
Our speciality is the ability to manage patients with multiple diseases in one consultation. A typical patient at my practice will be seen for 45 minutes to an hour, where I might treat everything from depression, gynae issues, allergies and diabetes, all in one consultation at a specialist level of care.
Take, for example, my middle-aged patient who came in with his wife for a second opinion. He had already visited a few doctors before landing at my doorstep.
One of the doctors detected prediabetes and high cholesterol, prescribed medication and said he’d see him again in three months. But his wife was still concerned. What about his new onset of forgetfulness? And his difficulty articulating sentences – a big concern for a pastor who delivers weekly sermons – and mistaking his rosemary bush for thyme when collecting leaves for his daily tea?
The detailed history taken during my consultation and his additional bloods showing the highest Vitamin D level I’d ever seen in my career, which can be indicators of diseases such as TB or lymphoma, were deeply concerning. I ordered an urgent CT brain scan, where I’d be able to see detailed images of the brain, skull, and blood vessels.
But his medical aid initially denied coverage. The reason: his medical aid doesn’t allow SFPs specialist privileges such as CT scan authorisation.
This routine is all too familiar to my colleagues. We are often forced to ask another physician or surgical specialist to write a request for imaging or certain prescriptions. Or the patient is forced to go to another specialist, something that can take weeks or months.
It was only because I had one of the top managers at my patient’s medical aid on speed dial – because of ongoing discussions with private sector medical aids about problems like these in my work as vice-president of the South African Academy of Family Physicians (SAAFP) – that I was able to bypass the system.
When the scan was done the next morning, it found lung cancer with brain metastasis (cancers that have spread to the brain from another part of the body) and impending herniation, meaning his brain was swelling and causing intense pressure, which would’ve stopped his breathing and other vital organ functioning. He was immediately admitted for emergency treatment.
It’s been nine months, and he’s back to his baseline levels of functioning.
That authorisation saved my patient’s life. But there was no reason for the behind-the-scenes manoeuvring required to get him care.
Specialist training, generalist pay
In the public sector, SFPs earn the same as all other specialists, working in primary care clinics in district and rural hospitals. That’s because it is more cost-effective than having a multitude of hospital specialists to cover every discipline, a model that would fit well in the National Health Insurance Act.
In the private sector, that’s not the case. Most medical aids categorise SFPs as GPs. That means we are not only denied specialist privileges, limiting our ability to fully use our specialist training, but we are also not being paid as specialists. We are often reimbursed the same, or at a similar rate, as GPs, forced to have volume-based practices with short consultations to remain financially viable.
Medical aids apply an inconsistent and inequitable standard when it comes to recognising SFPs. For example, groups like Discovery Health Medical Scheme accept us as specialists through initiatives like its Hospital at Home programme, but deny us basic specialist privileges on their other programmes unless we sign their network contracts: all other specialists are automatically granted specialist rates and privileges.
(Discovery Health responded: Not all specialists are automatically granted the same privileges or reimbursement rates because each discipline differs in scope of practice and new disciplines are not automatically assigned codes and rates when they enter the system. Read Discovery’s response.)
Meanwhile, a comparative tariff list published by healthcare consultancy HealthMan suggests that very few of the 14 medical aids managed by the medical scheme administrator, Medscheme, make a distinction between GP and SFP rates.
The SAAF has had multiple meetings with Medscheme and has asked the administrator to facilitate meet-ups with the individual medical aids, including, among others, the open schemes Bonitas, Fedhealth, Medshield, and the closed schemes like the SABC Medical Scheme, South African Police Service Medical Scheme (Polmed) and South African Municipal Workers Union Medical Scheme (Samwumed) it administers, but only one of our requests have materialised, and only with the additional help of an outside organisation.
We’ve been able to meet with the Government Employees Medical Scheme (GEMS), and those discussions are still ongoing. We are hopeful that these talks will result in changes to the scheme’s SFP policies in 2026.
We haven’t been able to make contact with any of the other Medscheme-administered medical aids. Instead, we’ve been told that all discussions, including the proposals, submissions and presentations we’ve submitted, have to go through the administrator.
(Medscheme responded: Medscheme’s healthcare professional support unit committed during its most recent engagement with SFPP in 2025 to assist in positioning SFPP’s case to Medscheme-administered schemes. This commitment forms part of an ongoing engagement process, and correspondence in March 2026 confirmed that work had been completed and was continuing, with further feedback scheduled in Q2 2026. It is also important to note that healthcare provider organisations are able to engage directly with medical schemes. Read Medscheme’s response.)
Our specialist work in the primary care setting, which can actually help reduce the over-consumption of expensive hospital care and hospital-based specialists, is being ignored. In addition to saving patients and medical aids the cost of seeing multiple specialists, it also avoids the long waiting periods for appointments while conditions deteriorate, which can lead to an increased need for hospital care.
Private medical schemes have shifted to what is known as “value-based care”, a move away from the number-of-services-charged-for model and toward results-based care, which pays the practitioner depending on how well the patient is doing. (For example, a doctor managing a diabetic patient works on a package of care services, and their reimbursement is dependent on the improvement of the patient’s chronic condition.)
Yet they fail to include the SFP as the primary care specialist that embodies the epitome of this value-based care – a preventative focus and acute care management.
Since 2023, the SAAFP has spent hours in meetings with Discovery Health Medical Scheme, GEMS, Medscheme, Bestmed and others to explain our scope of practice. We’ve been constantly assured that schemes acknowledge our training. But that acknowledgement has not translated into fair billing codes or privileges.
Simple solutions for complex problems
When a private SFP closes their doors because they cannot cover overheads, the medical scheme doesn’t save money. Those patients simply arrive in emergency rooms and get referred to high-cost subject specialists where the billing is significantly higher.
I know more than one colleague who’s been driven out of private practice or has gone overseas where their skills are respected and properly remunerated. Still others have no choice but to remain in the public sector, where they are able to do their work as specialists and be compensated as specialists.
Medical aids need to stop seeing SFPs as “expensive GPs” but as primary care specialists who can stabilise and strengthen a fractured primary health system, provided we are granted access to the specialist tools required for us to practice at our full potential.
Without it, it is our patients who pay the highest price.
See more from MedicalBrief archives:
Specialist family physicians take on big funders
Bigger role ahead for family physicians in SA, at last
SA’s family physicians make significant contribution to district health system