Last updated on 1 July 2023
Mokgadi Mogy Mashako
With the imminent release of the final Section 59 Investigation report, health practitioners eagerly await for a breakthrough that could reshape the health system and ensure equal treatment for all.
After years of raising concerns about racial profiling, healthcare providers have faced dreadful repercussions, including depression, heightened stress, tragic suicides, and the potential closure of their private practices.
The evidence presented indicates that this report has the potential to serve as a significant milestone in confronting the systemic discrimination deeply embedded within the South African health sector.
The prominent advocate for the cause, Dr Donald Gumede, has sounded the alarm on the detrimental impact suffered by healthcare providers as a result of mistreatment by medical schemes.
Former Chief Executive of the National Health Care Professionals Association, Gumede, has urged the independent investigation panel, led by advocate Tembeka Ngcukaitobi, to promptly release the final report.
The Section 59 Investigation Interim report didn’t find any explicit racial profiling in the systems used by the schemes but found strong evidence of racial bias in the outcomes of fraud, waste and abuse (FWA) processes implemented by Discovery Health, GEMS, and Medscheme.
“In all this drama that is happening, it is not about the doctor and it is not about the medical aid. It is about the health of the patient that is at stake,” Gumede said.
His concerns shed light on the urgent need for comprehensive changes to address the detrimental effects of unfair treatment within the health sector.
Gumede has appealed to all medical aids, urging them to refrain from employing outdated acts that pose harm to healthcare practitioners.
“These draconian laws and acts that they [medical schemes] have- don’t actually exist, because it has been proven that they are applying Section 59 Act wrongly.
In health care practice we both need the medical aid and the health care providers. We can’t have a one-sided situation whereby one institution is in charge of the whole system,” Gumede said.
To oversee the investigations, regulatory body, Council for Medical Schemes appointed Advocate Thembeka Ngcukaitobi, Advocate Adila Hassim, and Advocate Kerry Williams.
The Panel was mandated to investigate whether there is racial discrimination by schemes against black health care providers and whether black providers were being treated procedurally unfairly.
It found that between 2012 and 2019 black (African, Indian, Coloured) practitioners were more likely to be found to be guilty of fraud, waste and abuse than their white counterparts by the three medical aid schemes.
The report revealed that Discovery was 35% more likely to identify Black providers as guilty of FWA, GEMS was 80% more likely, and Medscheme was 330% more likely, indicating a significant racial bias.
All implicated schemes and administrators denied allegations of unfair racial discrimination in their investigation process regarding FWA complaints.
“In the main the denial was based on the fact that the FWA investigations are triggered by either: an automated system, underpinned by an algorithm, that flags outlier practices for investigation; or tip-offs and whistle-blowers.”
Statistician, Dr Zaid Kimmie, formed part of the experts appointed by the panel to inspect and analyse all data relevant to the investigation.
“There may, as I stated in the original report, be external factors that may help to explain this disparity, but given the existence of centuries of systemic racial discrimination we cannot blithely dismiss the notion that racial prejudice has played some part,” said Dr Kimmie.
Kimmie also noted “the base facts remain – there is firm evidence that there is a racial bias in FWA outcomes, in the sense that Black practitioners are more likely to be found guilty of FWA than their non-Black counterparts.”
The schemes and administrators were also accused of not following fair procedures when implementing their powers under section 59(2) and (3) of the Act. This section enables a scheme to claw back amounts from future benefits that are due to be paid.
GEMS said it uses “approximately one year’s historic claims data to estimate claw back amounts,” Discovery can use “up to three years of historic claims data” to estimate claw back amounts, and Medscheme appears not to have an explicit methodology and rather adopts a case-by-case approach to how it calculates claw backs.
Healthcare providers have noted changes in treatment by medical schemes over the past two years, where Medscheme’s approach worsened, Gems improved, while Discovery showed inconsistencies.
During this week’s Section 59 virtual public hearing, Nomaefese Gatsheni, Chairperson for Solutionist Thinkers, said profiling by schemes was meant to hinder the expansion of black healthcare practices.
“The interim report expresses disappointment that these issues have not been addressed as they are crucial steps in rectifying the definition of fraud waste and abuse.
Solutionist Thinkers still believes that the starting point to address racial discrimination will begin when CMS, the schemes and administrators put into consideration the promotion of equality and prevention of unfair discrimination act,” Gatsheni said.
In preparation for the final report’s release, the panel has asked all parties to provide written submissions regarding the actions they have taken to comply with the interim report over the past two years. – news@mukurukuru.co.za
Be First to Comment