Governance in medical schemes continues to be a challenge in the regulatory framework.
Moreover, the healthcare system is marred by inequitable access to care and healthcare resources.
And it is against this backdrop that the Council for Medical Schemes (CMS) remains committed to protecting beneficiaries and medical schemes alike.
Offering this assurance Dr Elsahe Conradie, General Manager: Stakeholder Relations, says, “We do so by enforcing the provisions of the Medical Schemes Act and have over the past 16 years built a proud culture of protecting beneficiaries and medical schemes alike.”
She elaborates, “The main pillars of the Act are the requirements for open enrolment community rating and prescribed minimum benefits (PMBs).
“Linked with the governance requirements stipulated in the Act, these provisions protect beneficiaries against discrimination based on health status and other arbitrary grounds.”
The most recent Human Development Report says inequality in access of health services results in lower levels of human development being attained than in countries which spend less on healthcare as a proportion of Gross Domestic Product (GDP).
Close to 23 percent of the Human Development Index globally is lost to inequality South Africa is currently ranked as a middle human development country
This is despite healthcare expenditure as a percentage of GDP being higher than that of the upper middle income countries.
Conradie says, “The problem of access and inequality to healthcare is a source of concern for our Government, which adopted the National Development Plan (NDP), vision 2030 in order to address the problem of inequality and poverty in the country
“Chapter 10 of this policy document deals with matters geared towards promoting health and Government’s strategic goals for 2014 to 2019 respond to the challenges of access and inequality to healthcare.
“The goals being highlighted under the heading of Policy Mandates.”
The CMS discharges its mandate in an increasingly litigious healthcare environment. The 2010 high court judgement, which set aside the Reference Price List regulations, has left a void in the regulation of healthcare prices, and leaves many medical scheme beneficiaries unprotected.
The Council supports the NDoH in the development of an alternative mechanism for the determination of private healthcare prices and comments,
“The newly established Health Market Inquiry by the Competition Commission will also potentially provide insight to some of these structural challenges faced by the industry
“The PMB package was not designed to operate in an environment where there is no price regulation.
“Hence we must work closely with the NDoH, the Health Professions Council of South Africa and other stakeholders to ensure that there is a mechanism in place to determine healthcare prices as soon as possible.”
She concedes that governance in medical schemes continues to be a challenge in the regulatory framework.
“To address this Council frequently appoints curators for medical schemes through court action; manages insolvent schemes and institutes legal proceedings to ensure that beneficiaries are protected.
“These interventions, whilst critical in protecting our mandate, attract high legal costs and increase the cost of regulation.”
In the ensuing period, Council plans to strengthen regulation by way of amending the Act. This process is at an advanced stage as proposed amendments have been submitted to the NDoH
30 September 2016
Business Report – The Star, Pretoria News, The Mercury, Cape Times