February 2016 groundup; “The best way to get your prescribed minimum benefits (PMBs) paid is to complain on the HelloPeter website,” consumer rights activist Angela Drescher said at the public hearings of the Health Market Inquiry, which got underway in Pretoria on 16 February.
The inquiry is being run by a high level expert panel appointed by the Competition Commission and chaired by former Chief Justice Sandile Ngcobo.
Drescher said “It feels like PMBs are randomly rejected [by medical schemes] in hope that we will give up”. She relayed to the panel a story of a three-year-old child bitten by a cobra. The child belonged to a medical scheme but the family was forced by the medical scheme to make copayments for treatment.
Drescher emphasised that patients are often left demoralised because “there is nothing more soul-destroying than being abandoned by your medical scheme” in a time of need.
A key purpose of the inquiry is to investigate the causes of high and increasing costs in the private healthcare market in South Africa. The Terms of Reference for the Inquiry acknowledge that “prices in the private healthcare sector are at levels at which only a minority of South Africans can afford” and that there are regular “above-inflation” increases in prices.
Approximately 9 million people access health services through the private sector in South Africa, predominantly through medical schemes, commonly also called medical aids.
Though a large portion of medical aid members are wealthy, many others are working class or lower middle class union members and public servants. And many people who cannot afford medical aids pay “out of pocket” to doctors, hospitals and pharmacies for their daily healthcare services.
In his opening address at the first set of public hearings in Pretoria last week Justice Ngcobo urged players in the private healthcare sector to cooperate with the inquiry process emphasising that it should not be treated in an adversarial manner as if it were litigation. Ngcobo also emphasised that the government was required to facilitate affordable access to healthcare in terms of section 27 of the Constitution which provides a right to access to healthcare services.
The first week of hearings saw the Health Inquiry Panel hear submissions from users of the private healthcare system, patient groups and organisations acting for the public interest. Submissions were made by SECTION27, the Congress of South African Trade Unions, the Southern African HIV Clinicians Society, the Rural Health Advocacy Project, and patient groups such as the South African Depression and Anxiety Group (SADAG), the Cancer Association of South Africa, the South African Federation for Mental Health (SAFMH), the Treatment Action Campaign.
Mark Heywood, executive director of SECTION27, warned that “The Health Inquiry is a matter of life and death” for many people in South Africa.
Umunyana Rugege, an attorney at SECTION27 noted that the High Court has already recognised that the Inquiry as a whole is a “constitutional measure to realise the right to health”.
Patrick Mdletshe, deputy chairperson of the Treatment Action Campaign brought this point home by emphasising that the prices of medicines should not be “excessive” and that “unethical excessive profits” bought at the expense of patient rights should not be tolerated. He asked the Panel to consider price regulation in the private health sector.
A problem which came up again and again in the submissions of patient groups is the non-payment or partial payment of PMBs by medical aids. PMBs are a list of 270 conditions and 25 chronic diseases. The Department of Health has published regulations which require medical aids to “pay in full” for the “diagnosis, treatment and care” of these listed conditions without any copayments in cash or from medical savings accounts.
Justice Ngcobo questioned patient groups about whether the review of PMBs required by the PMB regulations every two years has ever been completed. Patients groups responded that they had not.
There were not only complaints about failing to cover PMBs, but also their breadth. In its submission, the SADAG, for example, questioned the coverage for mental health services provided by the PMBs saying “mental illness needs to be taken seriously. The PMBs need to be updated to reflect this.” SADAG bemoaned the fact that presently only bipolar and schizophrenia are covered as chronic conditions by the PMBs. This despite the fact that “the are 23 … suicides in SA per day. Depression is the leading cause”. The private health system is not “patient centered” SADAG concluded.
The SAFMH added in this regard that “medical aids cover physical but not psychosocial rehabilitation” which constitutes discrimination because patients who are admitted to healthcare institutions often need support in readjusting to ordinary daily activity and interaction.
SAFMH also decried the fact that the 21 days for which mental health patients may be admitted in terms of the PMBs is often insufficient. “When it is exhausted sometimes patients must take out loans for mental health treatment”.
But the problem is not only isolated to medical aids.
COSATU criticised the fact that “overall the reforms in private health have been patchwork and piecemeal.”
The World Health Organisation and the Organisation for Economic Co-operation and Development (OECD) presented a study which received significant interest from the Panel. The study concludes that price levels in South African hospital services are the least affordable in the OECD countries [South Africa is not an OECD member, but a partner] and are higher even when compared with high income countries like France, the United Kingdom and Germany.
“High hospital prices are passed on as a burden to users of the system through medical aid premiums” the study notes.
Umunyana Rugege also called into question the efficacy of key regulators in the sector such as the Council for Medical Schemes and the Health Professions Council of South Africa (HPCSA). She said both had failed to fulfill key duties that protect patients rights.
A Department of Health investigation concluded in 2015 into the HPCSA reveals “irregularities” and “maladministration” within the HPCSA. The HPCSA, Rugege noted, has failed to regulate overcharging by healthcare professionals.
The Health Market Inquiry presents a crucial opportunity for patients to have their voices and rights protected. The hearings continue this week in Pretoria and then move to Cape Town from 1 to 3, and 8 to 10 March.