An independent investigation panel asserts that medical aids have been poorly treating healthcare practitioners.
Medical aid schemes have been told to change the way they treat registered practitioners.
A report commissioned by Minister of Health Aaron Motsoaledi found a “power imbalance” that was prejudicing healthcare providers.
Chairperson of the independent investigative panel, Tembeka Ngcukaitobi, presented the report’s key findings to the minister on Monday.
Investigation parameters
The investigation began in 2019 and focused on medical aid scheme procedures between 2012 and 2019 following allegations of improper treatment made to the Council of Medical Schemes (CMS).
Launched by Motsoaledi during his previous term as health minister, the investigation was tasked with scrutinising possible procedural and substantive unfairness.
The version handed to Motsoaledi by Ngcukaitobi was the final version of a provisional report released in 2021.
“What we found is that the fraud, waste and abuse (FWA) procedures for the recovery of moneys allegedly owed is unfair and violates the right to procedural fairness of individual practitioners,” said Ngcukaitobi.
‘Supposedly neutral algorithms’
The report recommends that an early warning system be put in place by schemes to notify practitioners of breaches and irregularities.
Ngcukaitobi also recommended a change to the clawback timeframe and greater protections for practitioners accused of wrongdoing.
“The provider is isolated and has no way of defending themselves and ends up signing acknowledgements of debt in circumstances where they don’t have sufficient representation,” the lawyer explained.
Ngcukaitobi took exception to the technology used by medical aid schemes, saying full transparency on the algorithms and software used was required.
“The CMS itself has no access to the input that goes into this supposedly neutral algorithm, yet the impact it has on individual practitioners is immense,” he said.
Risk ratio racism
The report was also tasked with determining if there were any racial undertones in the medical aid schemes’ treatment of practitioners.
To make this determination, the panel used a risk ratio devised by Dr Zaid Kimmie who holds a PhD in Mathematics from the University of Cape Town, among other credentials.
“The risk ratio is a tool we developed to work out the likelihood that a black practitioner would be subjected to an investigation, a finding and a penalty, versus a white practitioner,” explained Ngcukaitobi.
Ngcukaitobi stressed that this was not a legal proceeding and that the report presented no legal findings.
“What we did have the power to do was make findings of fact, and that finding of fact simply leads to one conclusion: the evidence of risk ratios showed racial discrimination against black service providers by the schemes.”
Disproportionately found guilty
Revealing selected stats from individual years, Ngcukaitobi noted how, in 2017, one private medical aid scheme found black psychiatrists guilty of FWA at more than three times the rate of their white counterparts.
Another private scheme was shown to have found black anaesthetists guilty of FWA over six times more often than other groups in 2018.
In the government employee medical scheme, black dental therapists were generally three times more likely than non-black dental therapists to be found guilty of FWA in 2014.
“We note that all of these risk ratios are probable risk ratios. As I explained above, we do not have to make scientifically certain determinations of the risk ratios,” said Ngcukaitobi.
“Findings based on what is probable is enough for the purposes of this final report,” he added.
Ngcukaitobi said the methodology of the risk ratio tool should be continuously improved, but noted that it was “a useful starting point” and recommended it be used as an annual assessment.
‘Two healthcare systems’
Motsoaledi said the department would review the report before releasing a statement on its findings but did offer an early summation.
“What we have heard is that there is enough to indicate that there is a problem here and that problem is racial discrimination,” said the minister.
He stated that South Africa was operating two healthcare systems that were like “chalk and cheese” serving different economic groups.
Motsoaledi acknowledged calls to improve the quality of government healthcare but said the report highlighted the shortcomings of the private sector.
“We don’t want two healthcare systems in the country. Otherwise, we will keep having this type of problem.
“We are not attacking any one system; we simply don’t want two different systems. We want the population of South Africa to be able to have access to all the healthcare providers,” Motsoaledi said.
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