The impact of proposed Medical Scheme Act changes

There are changes set to ripple across the medical industry as government implements legislation in an attempt to increase access to care.

The South African Medical Schemes Amendment Bill was approved by Cabinet in May and it continues to cause conjecture and concern for medical aid schemes, medical practitioners and patients. The goal of the bill, along with the National Health Insurance (NHI) plan, is to improve the quality of care for patients while reducing the impact on their finances. However, the bill remains contentious as it lacks detail and there are serious questions around funding and feasibility, and how patients with serious conditions, such as cancer, will be assured of ongoing quality care.

“The bill is a bridging attempt to ignite transformation between the healthcare situation we have at the moment and the planned NHI,” says Dr Ernst Marais, COO of Medical Specialist Holdings (MSH); the holding company of the Independent Clinical Oncology Network (ICON). “We have too many medical aid schemes and the Minister is particularly concerned about high costs in the private sector. The Healthcare Inquiry was launched a few years ago and the results are scheduled to be released at the end of June 2018.”

The bill sets out to address medical aid tariffs and apply a standard rate across all schemes. Currently, medical schemes have an individual rate and apply the increase they deem appropriate every year; passing this on to providers. The providers are then dealing with different rates across different schemes which makes the healthcare process both complex and challenging. In addition, the government is concerned about the definition of Prescribed Minimum Benefits (PMBs) – where there is a feeling that these have been exploited by some specialists and that is why these are set to be reviewed.

“Currently, if a patient is diagnosed with a PMB condition, the medical scheme has to pay in full and some have charged much higher fees for PMB conditions and this is one of the reasons for the review,” says Marais. “The bill also proposes to introduce more uniform protocols and pathways of care, removing co-payments or balance billing for patients in the private sector.”

The question is how these amendments are set to impact on patients, especially those who suffer chronic diseases such as cancer. On one hand, the bill is focused on providing for all patients, allowing for more balanced billing and less financial weight placed on those who receive such a complex diagnosis. On the other, there is the risk that the regulation could impact on quality of care.

“Cancer care patients need to ensure that they receive the care and medication that they deserve, and this relies on the choice of provider and that, in turn, relies on the price,” explains Dr Jacques Snyman, CEO of MSH. “The laudable part of the legislation is that it is driving access, but it can potentially impact on quality of care if it takes away the scheme’s ability to negotiate for rates. In South Africa we have limited resources with funding and providers, so we need a corridor where we can negotiate for better prices for schemes and care.”

For patients within the ICON network, however, its likely these broad-brush changes won’t impact them. The implementation of uniform protocols and pathways of care based on easy to understand evidence-based results has been integral to the organisation’s approach for many years. ICON has done significant research to establish these protocols and to ensure they are cost-effective and affordable, again tying in with government goals.

“We have already aligned our organisation with what the government envisions for cancer treatments in the future,” concludes Marais. “We have bundled tariffs that are easy to understand and no co-payments at point of service. There is no need for our member to be concerned about the proposed amendments as ICON oncologists are well prepared for these changes and in a good position to slot in with what lies ahead.”