by TSHEGO LEPULE, LETHU NXUMALO, KARABO NGOEPE, ROLAND MPOFU and MANYANE MANYANE
Cape Town - Black medical practitioners have welcomed a high-level report that acknowledges their unfair treatment by top medical aids, and have called for the system – which has made treating patients difficult and forced practices to shut – to be urgently rectified.
Some practitioners – which include doctors, psychologists and optometrists – have shared their harrowing treatment from the medical aid schemes, which blocked payment claims for the services rendered to their patients.
Discovery, Medscheme and the Government Employees Medical Scheme (Gems) were named in the report.
The Council for Medical Schemes' Section 59 Investigation was led by advocate Tembeka Ngcukaitobi, who released his report this week. The investigation looked into allegations of racial profiling and medical unfairness against black medical practitioners.
The report said that African, coloured and Indian healthcare practitioners in private practices had been subjected to racial discrimination between 2012 and 2019.
The panel recommended effective relief, a public and unconditional apology to black health-care workers and that administrators and schemes report to the Council for Medical Schemes within three months their measures to mitigate and remove the unfair discrimination against black providers.
Medical aids are feeling the heat to rectify the serious accusations in the report, but have rejected claims of racial profiling when assessing or auditing health-care claims.
Dr Lungi Nyathi, executive director at Medscheme, said they were disappointed that they had not been afforded an opportunity to review the report prior to it being published.
“The company maintains confidence that Medscheme’s forensic processes are fair, transparent and within the law,” said Nyathi.
Dr Stanley Moloabi, principal officer at Gems, said they would use the afforded six weeks by the investigating panel to study the report and, thereafter provide formal comment.
“Gems has nothing to hide and have throughout the process co-operated with the panel,” said Moloabi.
“Gems has a zero-tolerance to all forms of discrimination and pledges to implement corrective action where such remedial interventions are required and as recommended by the panel for the benefit of our members and health-care providers.”
Discovery’s senior reputation manager, Nthabiseng Chapeshamano, said while the organisation did not accept any racial discrimination in their processes, they accepted and respected the panel’s recommendations and would work hard to ensure that outcomes were more satisfactory, balanced and representative in the future.
The report found that:
- Black general practitioners are 1.5 times more likely to be identified as fraud waste and abuse (FWA) cases than their white counterparts.
- The rate at which black physiotherapists are identified as FWA cases is almost double (1.87) that of their white counterparts.
- Black psychologists are three times more likely to be identified as FWA cases.
- Black registered counsellors and social workers are also three times more likely to be identified as FWA cases.
- More than 50% of black registered counsellors have been identified in FWA cases – this is the highest rate among the disciplines analysed.
- Black dieticians are 2.5 times more likely to be identified as FWA cases compared to their non-black counterparts.
The panel found that some of the current procedures followed by schemes to enforce their rights in terms of the law were unfair.
“These findings are both serious and far-reaching... The evidence shows the unfair discrimination is in the outcomes (of claims),” the report said.
The investigation followed allegations by members of the National Health Care Professionals Association that they were being unfairly treated and their claims were withheld by medical schemes because of the colour of their skin and their ethnicity.
"The complaints of racial discrimination must be taken seriously by the schemes and administrators. In order to understand how a normative system creates unfair consequences, it is necessary to consider the position of the people who are telling you it is not working for them. This is because the power relations operate from the position that is established as the norm and so it operates for the comfort and benefit of the powerful norm,” read the report.
Shortly after the release of the report, Ngukaitobi said individual medical practitioners may approach the Council for Medical Schemes to have an individual dispute adjudicated and also to have redress.
“Where most of the work has to happen is with the schemes themselves, what we hope for is not necessarily redress to individual practitioners but structural systematic changes,” he said.
“Most of the work that our panel does is reconstructive work, it is how we create a new society out of the ashes of a racist one. We should stop race denialism, in other words accepting that race remains a crucial element defining our lives.”
In 2019, the SA Human Rights Commission also launched its own inquiry into allegations of racial profiling by medical schemes.
Spokesperson for the Commission Gushwell Brooks said: "Once we have a final report we will review it and then decide from then what action is required, if any."
Practitioners have shared their experiences in dealing with the medical aid schemes.
Clinical Psychologist Dr Hlengiwe Zwane, who was blacklisted by a medical scheme, said while the news was welcomed more action was needed to remedy the situation.
Zwane, a clinical psychologist, testified at hearings explained how when she refused to produce patient files to prove she had consulted with the patients or started taking cash payments, one of the schemes blacklisted her.
“While this news is welcome we still need action and actual reforms to address this matter effectively. There are people who abuse the system but the way schemes targets and go after those they deem to be in the wrong is problematic,” she said.
“Right now nothing has changed, I still have patients I can’t see because of this. I either have to see patients for free or charge them reduced rates so that they can afford to pay cash or continue with cash patients which excludes a lot of my patients.
“I have had colleagues who have lost their practices because they were blacklisted. Many of us are sitting in a position where we have to balance being caregivers to our patients and human beings who have to eat and provide for their families.”
Zwane said affected practitioners need to seriously consider a class action against schemes.
Optometrist Thabo Matlou told Independent Media that he was forced to stop practising four years ago when the medical aid schemes refused to settle claims.
"Medical aid administrators would audit claims when they see our turnover reaching a certain point. They would then freeze our accounts and not process any more claims," he said.
Instead of paying the black practitioners, Matlou said the medical aids would deposit the money into the accounts of the patients who would not pay them.
Matlou said that he was subject to such allegations by the medical aids’ administrators. At some point, the administrators hired a private investigating team that tried to mussel him and told him he owed the medical aids almost R3 million.
He said he refused to budge and wanted to be shown the proof and how they arrived at this amount.
"They said I must acknowledge that I owed and the figure would be reduced. I refused this and they then dropped to the figure to around R800 000 which I refuted as well. They then came again and said the figure was R100 000which I still refused," he said.
Matlou said he was then summoned to appear before the medical council to explain what he was doing. During that, he claims the administrators could not produce a single piece of evidence or call witnesses to the stand.
"Those administrators could not find witnesses to back up their claims. After appearing, I was told I was wrong for using a mobile unit at a police training facility to which I had sought permission from the senior managers there. I was slapped with a R10 000 fine for that," said Matlou.
Another optometrist Jonathan Tsuene said the report confirmed what has been known for years but was kept a secret. He also accused the medical aid schemes of lying when they said they didn't know the races of practitioners putting in claims.
Dr Mvuyisi Mzukwa, vice-Chairperson of the South African Medical Association (SAMA) said the findings were unacceptable and disturbing, and that they require immediate attention by the implicated schemes.
“We concur with the investigators that these findings are degrading, humiliating and distressing and there can be no justification whatsoever for these actions. It is now incumbent upon the authorities to take these findings further by investigating the regulatory framework which has allowed these practices to not only occur, but to flourish.”
Mzukwa said the report indicates that both the Health Professional's Council of South Africa (HPCSA) and the Colleges of Medicine of SA (CMSA) must reorganise their regulations offering better clarity to avoid abuse.
Neil Nair, chief executive of the National Hospital Network - an association of largely black owned private hospitals, said the finding of the report shows that private healthcare has not been immune to the systemic racism that prevails in the country.
“The independent hospitals can empathise with the Black practitioners affected by the findings of this report - as the private hospital contracting environment (contracts worth many billions of Rands annually) has its own set of transformation challenges and change is urgently needed in this sector too,” he said.
“Black hospital operators face many obstacles, such as challenges to get medical specialists to work in black areas, higher operating costs due to lower economies of scale, expensive financing, contracting challenges with some funders, etc. This is burdened with lower cost for services in medical aid contracting deals. The reality is that the independent hospitals lag the listed groups in volume, tariff, and network participation – this is both unsustainable, iniquitous and sustains our dreadful past.
“We pray that these findings will lead to an eradication of discriminatory practices, the removal of racist individuals from positions of power and usher in a more equitable healthcare dispensation. We need a non-defensive response to these findings from the affected Medical Aid Administrators – in allowing the right to respond by all affected parties.”
Meanwhile the country’s 78 medical schemes have over a nine month period increased their reserves by as much R20 billion. This is largely due to Covid-19 pandemic which saw non-emergency medical procedures postponed.
According to the latest figures released by the Council for Medical Schemes (CMS), reserves stood at R92.8bn as at September 30, which was higher than the R73. bn in December, 2019.
This is despite the fact that the total number of principal members decreased by 31 794 while the number of beneficiaries also dropped by 51 734.