Business Day

Four issues to get right for universal healthcare

• Medshield’s principal officer spells out the conditions that would allow the scheme to work


As a medical doctor and principal officer of a leading medical scheme, access to healthcare is an issue that Dr Stanley Moloabi cares about deeply.

At the recent Board of Healthcare Funders conference he spoke about four issues affecting the medical schemes industry that he believes keeps leaders awake, namely governance, sustainabi­lity, value for money for members, and policy uncertaint­y.

Moloabi, principal officer at Medshield Medical Scheme, says: “Firstly, the fact that curatorshi­ps have been a regular feature of the medical schemes industry is evidence that governance failures are a problem that need to be resolved.”

Moloabi says possible solutions to the problem of governance failures include: ensuring proper governance structures; clear role definition that differenti­ates between the governing body oversight and executive management role; the need for proper delegation­s of authority; strict contractua­l relationsh­ips with third-party providers; ensuring accountabi­lity and inculcatin­g an ethical culture.

He says the industry should be guided by the corporate governance advice laid out in King IV principles which clarify the governing body governance responsibi­lities.

“The concept of proportion­ality, which means that there is no ‘one-size that fits all’, is also important. Each and every medical scheme has to have a governance structure that is uniquely appropriat­e to it, but guided by the general authoritat­ive principles of King IV.”

A second issue that Moloabi regards as very important is sustainabi­lity, which to a large degree boils down to factors that are putting pressure on schemes’ claims ratios.

These include but are not limited to:

•An aging medical scheme population – leading to a worsening clinical risk profile;

•Increased utilisatio­n of benefits, which could be due to consumer awareness of prescribed minimum benefits (PMBs);

•The requiremen­t for options to be self-sustaining. This could defeat the basic tenet on which medical schemes are based, namely cross-subsidisat­ion;

•The fact that members are able to buy down on options;

•New health technology — inclusive of new drugs like biological­s; and •Fraudulent claims. Moloabi says another important factor affecting sustainabi­lity is that members’ contributi­on increases are consistent­ly higher than CPI.

“This has put pressure on members’ ability to afford medical schemes. The current contributi­on increases are, therefore, not sustainabl­e in the medium to long term.

“The third issue of concern is whether members believe they are getting value for money from medical schemes.

Moloabi says the question of value is complicate­d as there are many players with conflictin­g interests involved in the healthcare funding industry.

However, in his view, the most important stakeholde­r is the member, who is often faced with complex scheme rules.

“The public perception­s revealed in the Health Market Inquiry health consumer survey of November 2016, showed that many people perceive medical schemes to be expensive with members always having to pay excess fees and clearly this is of concern says Moloabi.

The fourth issue that Moloabi spoke about is the question of what role medical schemes will have when National Health Insurance is fully implemente­d.

He says the perception that NHI threatens to decimate the medical schemes industry persists and the question is whether such perception­s are unfounded or not.

“Commentary on medical schemes in the NHI policy document is largely non-complement­ary and the document doesn’t provide clarity on what the exact role of medical schemes will be in future.

“However, paragraph 309 of the NHI policy states that government recognises that there is existing expertise residing in the medical schemes industry and where necessary and relevant, this expertise may be drawn upon to support the implementa­tion activities for the establishm­ent of Universal Healthcare Coverage.”

Moloabi said there is a need for a “toenaderin­g” between the government and the medical schemes to find a unique South African working solution that will ensure universal healthcare is implemente­d successful­ly, preserving all that is good.

 ?? /SUPPLIED ?? Solutions Dr Stanley Moloabi says government needs to meet with medical aid providers to resolve the issues.
/SUPPLIED Solutions Dr Stanley Moloabi says government needs to meet with medical aid providers to resolve the issues.

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