Johannesburg - The department of Health is harnessing opportunities to dispense some of its services through the private sector and to fund some benefits for medical scheme members.
Deputy director Anban Pillay, the head of pricing in the department, said the state was looking to offer free health-care services to medical aid members in areas where schemes provided limited benefits.
Medical schemes have limited benefits for vaccinations and family planning, among other things, and members have to fund these through out-of-pocket payments.
Pillay said the department could look at funding these in the private sector so that people without medical aid cover could access them from private service providers.
Pillay said family planning and other primary health-care services could be offered in pharmacies.
“There might be some billing involved but these are the areas that could be negotiated,” he said.
Pillay said there had been challenges to such arrangements in the past as some providers abused the system and this was a problem the department would have to address.
The department wanted the treatment guidelines for disease management and the coding system for claims to medical schemes to be harmonised in both the public and private sectors to prevent potential abuse.
Pillay said the extent to which medical schemes used public sector services was very limited and the department felt that the utilisation of services, especially of public hospitals, by medical scheme members could be improved.
Few medical schemes have low-cost options with state hospital plans.
But, according to medical aid administrator Universal Healthcare, which is contracting with state hospitals as a designated service provider, administrators are often told there are no beds available in public hospitals.
The administrator also said that although the contract with the hospitals would specify fees for using its facilities, in many instances, doctors in state hospitals billed the medical schemes separately and therefore a clearer governance guideline was needed if the department wanted to contract more services from private sector providers.
Pillay said the department would put plans in place to deal with the governance challenges so that medical schemes would be aware of the differences between contracting with the private sector and using public sector services.
“The way that the state contracts with medical schemes should not replicate the problems that schemes currently experience in the private market,” Pillay said.
He said that due to the complexity of the contracting process, there would be a national contracting plan and provinces would not contract directly with the medical schemes or private providers. - Business Report