Sowetan Medical Cover Options (July 20 2023)

NHI turmoil makes private health schemes' role uncertain

Reports by Lynette Dicey

SA’stwo-tier healthcaresystemcontinuestobechallenged by a highdisease burden and limited resources in the public sector, leadingto significant inequalitiesin care.About16% of the populationcontribute to medicalaid schemes,providingthemwithaccesstoprivate sectorhealthcare.

The high cost of medical aid membership is oneof the biggest challenges facing schemes. Many South Africans in formal employmentarenotmembersofmedical schemes though they do use privateprimary healthcareservices. Tobettermeet theneeds ofthissector ofthe market,a numberofcompanies includingretailers, insurers and even hospital groups have introducedalternative insurance solutions that provide more affordable accessto privatehealthcare.

These insurance products are different fromthe plans offered bymedical aidschemes.

Theirgreater affordabilityis becausetheydon’tneedtocover the prescribed minimum benefits (PMBs)that medical schemes are required to pay for. It is estimated that healthcare insurance products pro-

vide cover to about 1-million South Africans.The healthinsurance market has experiencedgood growthinrecent years, showingthe strongdemand for thesetypes of products.

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The Council for Medical Schemes(CMS) hasbeen working ona framework which would exempt schemes from offering PMBs and allow them to offermore affordable plans, something which medi-

calschemes arguewouldalleviatepressure onthealready over-burdened publichealth sector.

Thebig questionnow,how-

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Public queues at Covid-19 vaccination facilities. / SANDILE NDLOVU

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ever, iswhat rolemedical aid schemes will play if the government pushesahead with the implementationof NationalHealthInsurance(NHI).

Writingin herweekly newsletter recently, Business Leadership SACEO Busi Mavuso said: “The charade continues itsabsurdity. Ican assure youthat it willend up in no improvementsto healthcare qualityin SA, infact the riskispreciselytheopposite.”

If thegovernment isserious about delivering improved health care, shesays, there are “betterways todo it,involving partnershipswith theprivate sector”

Discovery estimatesthat a modestNHI wouldcost R200bn, says Mavuso, “which would requirepersonal taxes to go up by athird or VAT to riseto21.5%,or amixofthe two”

Lee Callakoppen,principal officeratBonitas,saystheNHI and private medical schemes can andshould coexist.

“Curtailing the role of medical aids in SAwill have significant ramifications not only on thechoice ofcitizens regarding management of their healthbut alsotheeconomy. Medical aidsand theirassoci-

atedservices makeanenormous contribution to the annualfiscus, employmentand theeconomy,”hesays.

Critics of theNHI Bill say that it has nottaken into accountthenumerousobjections madebya numberofdifferent stakeholders. It is not clear on whatwilland willnotbeoffered byNHI andthe role if any thatprivate medical aidswillplay.

The governmentenvisages that NHIwill bephased in over several years,offering an expandingbundle ofservices astime goeson. Theofficial planisfor twophases.The first, due to start this year and rununtil2026, issupposedto prepare the groundand start deliveringfor onlyselected groups: children,women, the elderlyand peoplewithdisabilities. Forthem, healthcare services are supposed to be boughtfromtheprivatesector.

Phase 2, dueto run until 2028, is supposedto broaden the contracting of health servicesfrom privateproviders beyond these groups and set up the “mandatory prepayment”system thetaxeveryonewillhavetopaytofundthe NHI.

“In its currentform the bill limitsthe roleofmedical schemes. In fact,medical aids

asweknow themwillbe scrapped because theywill not beallowed tocover thehealth servicestheNHIpaysfor.This meansmedical aidmembers will beforced to relyon the NHI once it kicks in,” says Callakoppen.

Thereisno questionthatthe collective strengtheningof

funds belong to the members ofthoseschemes.

DamianMcHugh,executive headofmarketingatMomentumHealthSolutions,hasa similartake,explainingthat whiletakingstepstouniversal healthcoverageistheright thingtodotoprovidemore healthformorepeoplefor

the government,” says McHugh. He saysthe introduction of low-costbenefits is an immediatefirst stepthat will improve accessto health care,while incrementalsteps towards theimprovement of public healthservices mustbe takentoimproveaccesstocare forallpeople.

A number ofprivate healthcarecompanieshaveofferedto collaborate with the government to ensurehealthcare excellenceand toretainexpertisein thehealthsystem tothe advantageof allSouth Africans.

AsCallakoppen pointsout, NHIis afundingmechanism ratherthan universalhealth coverage. “A multitudeofinterventions need tobe consideredtosupporttheprogresstowardsuniversal healthcoverage including strengthening existing healthsystems, quality standards,governance and management capacity, all of which requireequal attention and willcontribute independentlyto advancinguniversal healthcoverage,”hesays.

The funding industry, he says,has extensiveexperience andexpertiseinfinancing,value-based care,management and administration,which willbevaluabletoreformsthat lieahead.

Prevention saves lives

Business Leadership South Africa CEO, Busisiwe Mavuso. / MASI LOSI

Guiding members on their wellness journey

Medical aids need to be innovative and nimble with their healthcare offerings

Even before theCovid-19 pandemic, South Africans were strugglingwith risingunemployment anddeclining incomes. Addto thatspiralling utilitycosts,load-sheddingand fuelincreases andthingsare eventighter,financially,foreveryone.

When income is stretched, the decisions on where to spend and savebecome critical, includingwhether to spend hard-earned income on privatehealthcare.

Thisissomethingthatmedical schemes havelong been grapplingwith.

It means,says LeeCallakoppen,principal officeratBonitasMedical Fund,beinginnovativeand nimblewithhealthcareofferings.

“Wehavetriedtokeepthings simpleandeasytounderstand, with plans structuredto meet a diverse rangeof quality healthcare optionsthat are easier onthe pocket,” he says. Bonitas hasa strongpresence inall sectorsof thehealthcare market,witha widerangeof plans that appeal across all demographicsand incomecategories. This allowsfor greater freedomof choiceformembersandpotentialmembers.

Callakoppen saysthe roleof private medical aidshas neededtochange.Inadditiontocollecting member contributions

and paying claims, schemes areincreasinglyinvolvedinassistingmembers ontheirwellnessjourney.

“Our core focus is to ensure thatwe actin ourmembers bestinterestsatalltimes it’s multifacetedand coversvarious aspects, including creating valuevia anoutcome-based healthcaremodel aswellas partnering withhealthcare providers to improve clinical outcomes.We thereforeplaya more critical role as a healthcare partner to our members ontheirjourneytowellness.”

Bonitas, hesays, isa medical aidforall SouthAfricans notjustcertainsegmentsorincomegroups.

“We havea responsibilityto be proactivein termsof guiding memberstowards livinga healthier lifestyle. And, to do this, we needto take cognisanceof allsocioeconomicfactors affectingSouth Africans. Issuessuch aspoverty,unemployment, mentalhealth and gender-based violenceare affectedbyhealth careandmust thereforebeconsideredwithin thebroadervaluechain.”

It is for this reason, he says, thattheschemeintroducedEfficiency DiscountedOptions (EDOs).

These plans use network healthcare providersand members payabout 15%less for thesame benefits.EDOs currently covermore than 70,000lives.

“Our model is clear: Ensuring members can find a network GP closeto either their homeorplaceofworkthrough anenhanced providerlocator. The network GP then pre-

Cancer cases on the rise in SA

Actuaries predict they will almost double by 2030

The WorldHealth Organisation says canceraccounted for nearly10-million deathsin 2020 globally. SA has not been immune from thistrend, with the incidencesof cancerrising considerablysince thebeginningof thepandemic,making it a major and growing public healthconcern.

Cancer diagnosis claims increasedby631% in2021and 2022, compared with 2019 and 2020 figures, saysSirago UnderwritingManagers.

Dr Dion Kapp, executive managerfor managedhealth care and providers at Bestmed MedicalScheme, saysthe numberof newcancerdiagnosesarealarming.

He saysthat understanding therealitiesofthediseaseisan importantstep towardsencouraging consumers to take

preventiveaction.

“Frequent cancer screening and prevention remains the mosteffective methodofcurbing the economic, financial, physical and mental toll the disease takes onpeople of all ages, ethnicities and circumstances, includingthe high costs of treatmentthat become necessary whencancer isonly diagnosedat alate stage,” he says.

Like Sirago,Bestmed also recorded asteep increasein cancer incidences in recent years. Kappsays thereason for this is not an increase in screening or anyknown direct correlationbetweentheCovid19virusandcancer.

Rather, it’s aknock-on effect of Covid-19, especially during thehard lockdownwhenpeople avoidedvisiting hospitals or pathologists forfear of contractingthevirus.

Actuaries predict that cancerincidenceswillalmostdoubleinSAby2030,from62,000 cancer-related deathsin 2019

Lee Callakoppen, principal officer at Bonitas Medical Fund

scribes medication, aligned to themembers optionandformulary and, if areferral to a specialistis required,the member is referred to a networkspecialist. Wehavenegotiated rateson behalfof our memberswith networkspecialiststo avoidco-payments. Should themember require hospitaladmission, ourspecialists will admit them to a networkhospital toavoidfurther co-payments,” says Callakoppen.

Rapid urbanisationas peoplemovecloser tojobopportunitiesmeans that63% ofSouth Africans already live in urban areas.Thedownsideofurbanisation, says Callakoppen, is a negativeimpact onpeople’s health,themostsignificantbeingan increaseinnon-communicableorlifestylediseases.

cancers in SA.Though this is nothing new, we are seeing comparatively higher numbers for this period, indicating that many ofthese incidences could havebeen detectedtwo yearsago,”hesays.

“More frequentscreening testsgive peopleabetter chanceofbeingdiagnosedearlier,thus makingtreatment moreeffective.

Thetotal benefitspaidby Bestmed towards oncology treatmentincreased by47%in 2022.

The biggest contributor of this escalation, saysKapp, was biological medicationand immunotherapy. The cost increasefor thesetwotherapies alonewas31%.

In response,Bonitas introducedEdge plans,which Callakoppenbelieves arethe mostinnovativeinthecountry, while remaining affordable. Edgeplans,he says,areaimed atnewentrants totheworkplace, economically active singles or couples, living in the largermetros,agedbetween18 and 35.They aredriven by technology and easeof access through virtual integration anddigitalintervention.

Two Edgeplans areavailable BonStart and BonStart Plus bothdistinct intheir scope andpopular, withmore than10,000livescovered.Both planshave monthlycontributions, for theprincipal member,ofunderR1,350.Contributions decreasedin 2022while nocontribution increasewas implementedin2023.

to121,000 insevenyears, based on existing mortality trends with thenumbers impacted by anageing and growingpopulation.

These predictions align with data collected by Bestmed which show steep increases across allpredominant types of cancerbetween 2020and 2022, with breastcancer increasing by 35%and prostate cancerby45%.

“Breastand prostatecancer remainthe dominanttypesof

Radiology-related claims also increased, with advanced radiology such asMRI, CAT scans andnuclear medicine used to monitorand diagnose cancer increasing by 19% in 2022,compared topre-pandemiclevels.

Kapp attributesthe biggest driver ofincreased cancer treatmentcosts toadvancedstagecancerdiagnoses.

“Latediagnoses oftenresult inthe prescriptionofmore novelmedicines totreatcan-

cers more aggressively, which are more expensive. This is why it’sso importantthatindividuals reach outto their medical aidscheme tofind out which preventive screenings suchas mammograms,pap smearsandprostateexamsare availabletothem.”

Bestmed like most medicalschemes offers anumber of preventivehealth benefits that memberscan access, along withvarious oncology care benefits depending on theirselectedplan.

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More frequent screening tests give people a better chance of being diagnosed earlier

Bonitas says they have a responsibility to be proactive in terms of guiding members towards living a healthier lifestyle / SUPPLIED

‘‘ We need to take cognisance of all socioeconomic factors affecting South Africans

Dr Dion Kapp, executive manager for managed health care and providers at Bestmed Medical Scheme. /SUPPLIED

Flexicare is a health insurance product for South Africans that provides reasonably priced private day-to-day healthcare cover distributed through the Clicks retail network. It is not a medical scheme, nor is it intended to be a substitute for medical scheme membership. Flexicare has been available to Clicks employees since 2018, and for the first time ever, it is now available to our Clicks customers.

“We are pleased to partner with Discovery Health and Auto & General Insurance to make private healthcare cover easily available and affordable for everyone, with the added benefit of cashback in your pocket,” says Vikash Singh, Clicks Managing Executive. “This forms part of our continued commitment to providing great value, convenience and rewards for our customers.”

Flexicare is available to all our Clicks customers, but our ClubCard members earn the right to a unique loyalty benefit. When they choose Flexicare using a simple four-step digital purchasing process, they can earn 10% ClubCard cashback on their premium. For an average family of four, this amounts to R129.30 in monthly ClubCard cashback that can be used at any Clicks or The Body Shop nationwide.

Why Flexicare for our ClubCard members?

Discovery Health’s research demonstrates that there are five to eight million South African residents in formal employment who do not have medical aid. Yet, they already utilise the private healthcare sector for their primary healthcare needs and are paying out of pocket for each consultation and prescribed medication, for each point of entry.

Flexicare is a product of Auto & General Insurance Company Limited, administered by Discovery Health, and designed to provide access to private healthcare services from only R435 per month. The benefits include unlimited GP consultations, medicine, dentistry, eye care, x-rays, flu vaccines, maternity, health checks, blood tests, procedures in GP rooms, HIV care and private ambulance service, with an optional add-on of trauma cover at a private hospital (for an additional fee from R174). Trauma cover, underwritten by Discovery Insure, provides additional private emergency healthcare services for the individual and all registered beneficiaries for a range of serious events including burns, car accidents, and serious head or chest injuries to name a few.

“This partnership brings a truly innovative, integrated healthcare product to the public, and most importantly broadens availability and affordability of private healthcare to more South Africans,” says Ricardo Coetzee, Head of Auto & General.

“Our research and experience have proven the importance of creating easy-to-understand healthcare products. Having affordable cover also means ensuring that people never have to pay out of pocket or face hidden costs. Flexicare is provided through a suite of world-class digital tools so that people can manage their membership and retrieve their benefits on the go,” says Nonku Pitje, Chief Growth Officer at Discovery Health.

“Flexicare reflects our commitment to expand cover to millions more South Africans, and it’s made possible by the strengths of excellent partners who share this vision. We can’t wait to make a significant impact on people’s lives through Flexicare and through our network of dedicated healthcare providers,” she added.