Report finds medical aid schemes guilty of discrimination against black health practitioners

By: Health Reporter

High Court Judge Colleen Collis passed a ruling on Tuesday (19^th January 2021) morning that the Section 59 investigation which found medical aid schemes guilty of discrimination against black, Indian and coloured doctors be publicly released.

Two of the country’s top-tiered medical aid schemes, Discovery and the Government Employees Medical Scheme (GEMS), as well as Medscheme, one of the largest medical aid scheme administrators were, implicated in the damning report.

Numerous allegations from black doctors led to an independent investigation launched in 2019 by the Council for Medical Schemes (CMS). The findings from the investigation formed the basis of the report that alleges black doctors were required to hand over patient files, when submitting a claim to medical aids schemes. This is a violation of Section 59 of the Medical Schemes Act.

Chairing the inquiry, Advocate Tembeka Ngcukaitobi wants medical aid schemes to pay back the money if it is proven they deducted money unfairly from health professionals.

Unfair racial discrimination

The schemes and administrators argued that the automated system used for the FWA investigations only picks up practice numbers and does not assign identification or race to the various cases.

However, the panel found that between 2012 and 2019 black practitioners were more likely to be found to have committed FWA (Fraud, Waste and Abuse systems, worked in practice) than their non-black counterparts. This was true of Discovery, Medscheme and GEMS, providing a strong argument in the interim report outlining unfair racial discrimination.

The differences in the scale of racial discrimination between Discovery, GEMS and Medscheme were as follows:

Discovery was 35% more likely to identify black providers as having committed FWA.
GEMS was 80% more likely to identify black providers.
Medscheme was 330% more likely to identify black providers as guilty of FWA.

A further disproportionate impact on black providers, which amounts to unfair racial discrimination remains as below:

Medscheme assumes the correctness of their expert’s methodology, is 35% more likely to find black providers guilty of FWA.
GEMS is 47% more likely to find black providers guilty of FWA.
On Discovery’s own version, it is 36% more likely to find black providers guilty of FWA. However, Discovery reduces the risk ratio further to 1.09 on the basis of what it describes as confounding factors.

The panel requested that this be directly discussed with panel investigator,

Dr Zaid Kimmie. “We find that Discovery’s theory that there are confounding factors that affect the risk ratio is not credible,” the report says.

Privacy concerns

South Africans who make use of the above- mentioned medical aid schemes took to social media to vent their frustrations about the Section 59 investigation. Many have expressed their concerns around privacy violations and unfair medical practices that are unconstitutional if proven to be true.

The implicated schemes have six weeks to respond which will inform an outcome of the claims and allegations.