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SOLUTIONISTS THINKERS GROUP

Discover the complex dynamics of the medical aid industry in South Africa, understand how monopoly practices impact access to healthcare, and delve into issues of benefit allocation, indirect payments, and ethical dilemmas within the system.

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SOLUTIONISTS THINKERS GROUP

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  1. SOLUTIONISTS THINKERS GROUP SEC 59 DR T MMETHI

  2. HISTORY • A central element of the apartheid legacy for the country is extreme inequality and human development disparities • The health system was seen as one mechanism through which to maintain difference in the quality of life enjoyed by different population groups, and so ensure support for the ruling party (Price, 1986).

  3. History • By 2002 the value of the tax subsidy per medical scheme beneficiary was estimated to be greater than the amount spent from government funds per public sector beneficiary

  4. Oligopoly/Monopoly • Discovery (DH and DMS) • Gems (Denis and Medscheme) • Medscheme – 09 medical Aid Schemes • Platinum Health • Difficult/ impossible market entry requirements • Predominantly white owned • Few Small black owned

  5. Medscheme • Hosmed • Sizwe • Bonitas • Medshield • Hosmed • Medipos • Keyhealth • Thebemed • Transmed

  6. Monopoly • Highly Anticompetitive • Destroys market entrants • Does not last forever • Maximise Profits

  7. Government Subsidy • Only Private business subsidised • SA Spends 8,6 % of its GDP on health • Majority on private health care sector • Only accessible to 14% of the population • Health expenditure per capita highest in GP and WC

  8. Market entry • 6000 Members • 5 Mil Capital • Compliance audits by CMS

  9. Monopoly • Cooptition • Once one investigates, the others follow • Meschem-9 medical aids

  10. Collusion with Employers • Agreement with big cooporates • All employees coerced to the medical as employment package • Market growtn strategy

  11. Forward Integration Strategy • Medical Aids want to own the whole supply Chain in the health care industry

  12. Supply Chain • Money Collected from Patients  • Money received by Medical aids • Money managed by Medical Aid administrators • Brokers  • Payment to Private Hospitals  • Payment to Health Care providers

  13. Payments to healthcare Practitioners • Only part where Medical Aids do not benefit

  14. Benefit Allocation • Low cost model • Growth strategy of Medical aids • Keeping premiums low • Economies of Scale • Hospitalisation well covered • HCP do not benefit • Benefits exhausted early in the year

  15. Code of good Ethics • We are not supporting fraud • The system disadvantages ethical practices

  16. Closing down of Entrepreneurial Activities • Black owned Medical Aids • DSP • Audits • Indirect payments • Blocked Drs • AOD and Repayment formula • Spy Camera • Undermining HPCSA • Depression and Suicide

  17. 1. Black owned Medical Aids • COMMED • Members were moved to Bonitas / Mescheme • Racism? • Ms P Ramosolo vs Medscheme

  18. 2. DSP • Beneficiaries promised low cost from practitioners • If you don’t join, competitors will do • We are coerced to join

  19. 3. AUDITS • Profmed audit within 30 days • Discovery and Medscheme (3-5 years or more) • Files and proof of purchase • Clinical notes • Starts with one then other Med Aids follow

  20. Most Common • Request for Clinical Notes • Illegal Audits • AOD • Indirect Payments

  21. Case study • DR. SP Diale • Dr. P Maebane • DrSeeco • Mr. Sibusiso Sithole • Dr. T. Mmethi (low Cost Model)

  22. DR STP Maebana • Bought practice 1and half yrs ago • Improsoned by Discovery and medscheme • Blacklisted by banks…Car taken • 18 yrs old daughter will not attend her matric dance. • 14 yrs old presently told my wife is sneaking to class as she has been told to stay away till payment. • I have tried to kill my self twise

  23. DR Seeco • Medscheme • Failure to honour cms ruling • Continuing violating their funduisary responsibilities to pay for services that are not related to the invetigations • 7years without Payments • Failure of cms to hold them accountable

  24. Drseecoe • Fines 1,5 Mil Medscheme • Servicing members for 7 yrs without payments • Complained to cms, unsuccessfully • Currently being assisted bt attorneys • 3 years anomalies found by cms with the scheme and nothing done

  25. 4.Indirect Payments • Sechaba and Ngoepe Judgements • Practitioner Renders Services • Medical Aid Pays patients • Patients don’t pay Professionals • 10-20 yrs on indirect payments • Business shuts down

  26. 5. Spy Camera • Dr Patient confidentiality • Patient never charged – Membership Protected • When funds are exhausted-Pro Bono

  27. 6. AOD and Repayment Formula • Medical Aids decide what you have to pay back • They backdate to since you started practicing • Instrumental Compliance • Reward Power • If you sign they continue to pay

  28. 7. Undermining CMS • Medical Aids undermine CMS recommendations

  29. 8. Depression and Suicide • Health care Professionals • Doctors • Psycho-social effects

  30. 9. Opening Clinics • Platinum Health • All Patients only seen by their HCP • DSP

  31. 10. Stakeholder Management 1. Patients 2. Doctors 3. Medical Aids • Medical aid given utmost power • No stakeholder engagements-workshops

  32. 11. Benefit Allocation • Most money allocated to Hospitalisation • Oligopoly • Big three (Life, Netcare, Medicross) • Difficult for African doctors to be allocated suites • More benefits allocation to the big three (R20 000/nite) • No one questions this, including patients • Medical aids do not have issues with high hospital bills • Collusion?? • Independent HCP have the least benefits more audits • Benefits keep decreasing each year against inflation

  33. EX-Gratia • Never explained explicitly to HCP • Never concerned about the patient • Unconscious Capitalism • Focus on fraud

  34. RWOPS • WHO recommends 2,28:1000 (HCW: Population) • SA 1N 2010: 0,29 Drs:1000 and • HCP try government and private • Medical Aids (Medscheme)refuse to pay due to RWOPS

  35. Conclusion • Medical aids register as NPO • Through their collusion with Administrators huge profits are realized • PHC Often Pay more dividends than mining sector • More reserves than prescribed • Forward integration strategy-Slowly reducing the number of private HCP and controlling through DSPs • At the expense of HCP • Accountability on Money recouped by AODs

  36. Recommendation • All extorted money be refunded with interest • Racial Profiling should be severely punished • Dignity of HCP should be restored • Never again • Benefits should be structured to favour patients and suffient for the year

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