Medical schemes under fire for bias against black professionals
Image: File
There must be consequences and punitive measures, which include back payments by medical schemes, that were found to have applied systemic discrimination against black health professionals when they applied risk ratios against them.
This call has come after the findings of a Section 59 investigation report revealed that three medical schemes, namely GEMS, Medscheme, and Discovery, applied discriminatory risk ratios to black health professionals, in disciplines such as physiotherapy, psychology, and social work, who are 'more likely' to be guilty of fraud, waste, and abuse.
It is unclear how many medical professionals were affected by racial profiling and how many lost their business practices.
The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals.
Video Player is loading.
Play Video
Play
Unmute
Current Time
0:00
/
Duration
-:-
Loaded :
0%
Stream Type LIVE
Seek to live, currently behind live
LIVE
Remaining Time
-
0:00
This is a modal window.
Beginning of dialog window. Escape will cancel and close the window.
Text Color White Black Red Green Blue Yellow Magenta Cyan
Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan
Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan
Transparency Transparent Semi-Transparent Opaque
Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps
Reset
restore all settings to the default values Done
Close Modal Dialog
End of dialog window.
Advertisement
Video Player is loading.
Play Video
Play
Unmute
Current Time
0:00
/
Duration
-:-
Loaded :
0%
Stream Type LIVE
Seek to live, currently behind live
LIVE
Remaining Time
-
0:00
This is a modal window.
Beginning of dialog window. Escape will cancel and close the window.
Text Color White Black Red Green Blue Yellow Magenta Cyan
Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan
Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan
Transparency Transparent Semi-Transparent Opaque
Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps
Reset
restore all settings to the default values Done
Close Modal Dialog
End of dialog window.
Next
Stay
Close ✕
However, in the absence of remuneration guidelines by the National Health Act, Health Minister Aaron Motsoaledi, during a portfolio committee meeting on Friday, said they will seek legal advice on the matter.
The findings of the report raised questions during the meeting about equity within the profession, igniting discussions about fairness, accountability, and restitution.
Health Minister Aaron Motsoaledi addressed the Portfolio Committee on Health regarding the Section 59 investigation report, which revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work.
Image: GCIS
Motsoaledi said the Act does not indicate what steps should be taken, and currently, it appears the medical schemes decide their measures.
'This is a statutory matter due to the silence in the Act. It does not indicate the steps that the schemes must take when they investigate such a fraud. That is the weakness picked up by the panel, and the Act itself does not provide guidance on what should be done.
'The medical schemes have decided to divulge their methods, which were unfortunately tampered with by racial bias. Even if the Act does not outline what must be done, whatever is done in a new South Africa governed by democracy cannot be informed by racial profiling. We will have to look into that,' said Motsoaledi.
The minister said the members of Parliament are 'not mere bystanders and observers', and have an onus on them to have the Act amended to speak specifically to such reform.
Motsoaledi said they are still studying the report, and legal advice is being sought after its release on Monday.
Chairperson for the Council for Medical Schemes (CMS), Dr Thandi Mabeba, said the council will have a special sitting next Monday to interrogate the findings, recommendations, and the implications of such recommendations.
Dr Mabeba said they would also hold engagements across the industry, including the steering committee. 'The minister has alluded to the report, which has damning findings, and as such, we need to apply our minds in ensuring that we guide the industry in a manner that is legally and in line with our statutory mandate.'
On Monday, chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, welcomed the findings of the Section 59 investigation panel.
'The report paints a concerning picture of the disproportionate impact that medical schemes' fraud, waste, and abuse systems have had on black healthcare providers…These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste, and abuse systems.
'It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve.
'We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,' said Dr Dhlomo.
Get your news on the go, click here to join the Cape Argus News WhatsApp channel.
Cape Argus
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
IOL News
3 hours ago
- IOL News
GEMS outlines plans to address discrimination against black healthcare providers
Section 59 Report finds black health professionals more likely targeted by medical schemes fraud, waste, and abuse processes. Image: AI / Ron The Government Employees Medical Scheme (GEMS) maintains that, since the release of the Interim Section 59 Panel Investigations Report three years ago, it has taken significant steps to strengthen its Fraud, Waste, and Abuse (FWA) management framework in an effort to 'eliminate any potential for disparate outcomes.' This follows damning findings against the country's largest medical schemes, which were found to have applied discriminatory risk ratios to Black health professionals. These providers were disproportionately flagged, audited, or penalised through opaque fraud, waste, and abuse (FWA) systems. The investigation, commissioned in 2019, examined allegations of racial discrimination and procedural unfairness in the application of FWA processes by major schemes and administrators, including Discovery Health, Medscheme and Gems. Health Minister Aaron Motsoaledi received the final report from the Section 59 Investigation Panel last week. 'The final Section 59 Panel Investigation Report makes several recommendations, many of which align with reforms Gems has already implemented. These include the revision of FWA policies to prevent bias and improve oversight, along with extensive stakeholder engagement and awareness programmes aimed at preventing rather than remediating FWA. "Gems has also revised its standard operating procedures to support greater flexibility this includes accommodating reasonable timeframes for information provision, conducting affordability assessments during debt collection processes, and allowing cooling-off periods for Acknowledgement of Debt (AOD) agreements. In addition, the scheme has undertaken independent audits to ensure that race is not a factor in any system parameters. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Next Stay Close ✕ 'It is reassuring that the Panel has found no evidence that GEMS acted with racist intent. This distinction is critical - structural outcomes must not be confused with deliberate discrimination. We are committed to continuous improvement, guided by independent oversight of the Council for Medical Schemes (CMS) and shaped by trust," said Gems Principal Officer, Dr Stanley Moloabi. Meanwhile, IOL reported that Discovery Health disagreed with the findings. Discovery Health CEO, Dr Ron Whelan, said the conclusions from the investigation are 'based on flawed methodology, unscientific assumptions, and misinterpretation of complex data'. Healthcare workers union, Health & Other Services Personnel Trade Union of South Africa (Hospersa), condemned the findings, adding that the report had confirmed the suspicions and personal experiences of many black healthcare professionals, IOL reported. The union called for remuneration and class action litigation against the medical schemes found to have applied such racial profiling, resulting in financial and reputational harm to individuals. 'As a union steadfastly committed to justice, equality, and transformation, Hospersa cannot allow this moment to pass without demanding full accountability, restitution, and long-overdue structural reform. 'To ensure that this injustice is never repeated, Hospersa calls for systemic changes across the private healthcare sector. All race-based profiling algorithms must be immediately discontinued and outlawed,' Hospersa spokesperson, Lindelwa Mdlalose said. Cape Times
IOL News
2 days ago
- IOL News
Is racial profiling undermining South African healthcare? A call for accountability and reform
The discrimination findings of a Section 59 report affected black healthcare professionals in disciplines such as physiotherapy, psychology, and social work, who are said to be 'more likely' to be guilty of fraud, waste, and abuse. Image: AI / Ron Apologies are necessary, but are not enough; material redress and structural consequences should be the next steps against medical schemes that racially profile black healthcare professionals. Healthcare workers union, Health & Other Services Personnel Trade Union of South Africa (Hospersa), expressed deep concern and condemnation following the announcement of the findings of the Section 59 Investigation Report in which three medical schemes, namely Government Employees Medical Scheme (Gems), Medscheme, and Discovery Health, applied discriminatory risk ratios to black health professionals. The discrimination affected black healthcare professionals in disciplines such as physiotherapy, psychology, and social work, who are said to be 'more likely' to be guilty of fraud, waste, and abuse (FWA). The panel reviewed statistical and testimonial evidence, and found that black providers were disproportionately flagged, audited, or penalised through opaque FWA systems. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Next Stay Close ✕ The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals. Hospersa spokesperson, Lindelwa Mdlalose, stated that the report confirmed the suspicions and personal experiences of many black healthcare professionals. The union called for remuneration and class action litigation against the medical schemes found to have applied such racial profiling, resulting in financial and reputational harm to individuals. Hospersa stated that the medical schemes should be held accountable and issue formal public apologies. It also sought a restitution framework, overseen by the Council for Medical Schemes (CMS), designed to review and remedy individual cases fairly, efficiently, and with a sense of urgency. 'As a union steadfastly committed to justice, equality, and transformation, Hospersa cannot allow this moment to pass without demanding full accountability, restitution, and long-overdue structural reform. 'To ensure that this injustice is never repeated, Hospersa calls for systemic changes across the private healthcare sector. All race-based profiling algorithms must be immediately discontinued and outlawed. Oversight mechanisms must be strengthened to enforce transparency and accountability in audit practices. Affected schemes must implement anti-bias training and submit to regular, independent audits of their fraud detection and disciplinary systems,' said Mdlalose. The union said the issuance of the findings and recommendations of the Section 59 report 'must serve as a turning point'. 'The Section 59 Report is more than an indictment of past practices, it is a call to action. Racial profiling in the healthcare sector is a betrayal of both ethical norms and constitutional values. It undermines professional dignity and perpetuates racial injustice under the excuse of fraud detection.' Meanwhile, Discovery Health strongly disagreed with the findings and called on CMS to carefully review the panel's conclusions to prevent harm to medical scheme members and the long-term viability of medical schemes. Discovery Health CEO, Dr Ron Whelan, said the conclusions from the investigation are 'based on flawed methodology, unscientific assumptions, and misinterpretation of complex data'. Dr Whelan said they are currently reviewing the report in full and considering their options, including a formal review of the findings, which drew numerous conclusions that, according to Dr Whelan, is not supported by credible evidence. Discovery Health said: 'No evidence has been presented to support the allegations that (we have) investigated or sanctioned any healthcare professional in a biased or unjustified manner. In fact, the panel's own interim report in 2021 confirmed that the processes used by medical schemes were legally sound and showed no explicit evidence of racial bias. 'Furthermore, all complaints submitted to the Section 59 Panel by healthcare providers against schemes administered by Discovery Health were shown to have legitimate grounds for investigation, with no evidence of racial profiling.' Gems said over the past three years, since the release of the Interim Section 59 Panel Investigations, they have 'taken comprehensive steps to strengthen its FWA management framework to eliminate any potential for disparate outcomes'. According to the medical scheme, after the interim report made several recommendations, they have already begun to implement policies which 'largely reflect reforms'. Gems principal officer, Dr Stanley Moloabi, said: 'It is reassuring that the panel has found no evidence that GEMS acted with racist intent. This distinction is critical - structural outcomes must not be confused with deliberate discrimination. '(We) will continue to work closely with the CMS, healthcare providers, and members to ensure that our FWA systems are transparent, fair, and compliant to all laws and regulations of the Republic of South Africa.' Enquiries to Medscheme had not been answered by deadline. During a portfolio committee meeting held on Friday, Health Minister Aaron Motsoaledi pointed out the 'silence' in the National Health Act regarding remuneration or corrective measures to be taken in cases where discrimination against health professionals is identified. He also called for algorithm and software transparency in which the department is able to be privy to information regarding risk ratios against black health professionals.
IOL News
2 days ago
- IOL News
Medical schemes under fire for bias against black professionals
A section 59 report revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work. Image: File There must be consequences and punitive measures, which include back payments by medical schemes, that were found to have applied systemic discrimination against black health professionals when they applied risk ratios against them. This call has come after the findings of a Section 59 investigation report revealed that three medical schemes, namely GEMS, Medscheme, and Discovery, applied discriminatory risk ratios to black health professionals, in disciplines such as physiotherapy, psychology, and social work, who are 'more likely' to be guilty of fraud, waste, and abuse. It is unclear how many medical professionals were affected by racial profiling and how many lost their business practices. The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Next Stay Close ✕ However, in the absence of remuneration guidelines by the National Health Act, Health Minister Aaron Motsoaledi, during a portfolio committee meeting on Friday, said they will seek legal advice on the matter. The findings of the report raised questions during the meeting about equity within the profession, igniting discussions about fairness, accountability, and restitution. Health Minister Aaron Motsoaledi addressed the Portfolio Committee on Health regarding the Section 59 investigation report, which revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work. Image: GCIS Motsoaledi said the Act does not indicate what steps should be taken, and currently, it appears the medical schemes decide their measures. 'This is a statutory matter due to the silence in the Act. It does not indicate the steps that the schemes must take when they investigate such a fraud. That is the weakness picked up by the panel, and the Act itself does not provide guidance on what should be done. 'The medical schemes have decided to divulge their methods, which were unfortunately tampered with by racial bias. Even if the Act does not outline what must be done, whatever is done in a new South Africa governed by democracy cannot be informed by racial profiling. We will have to look into that,' said Motsoaledi. The minister said the members of Parliament are 'not mere bystanders and observers', and have an onus on them to have the Act amended to speak specifically to such reform. Motsoaledi said they are still studying the report, and legal advice is being sought after its release on Monday. Chairperson for the Council for Medical Schemes (CMS), Dr Thandi Mabeba, said the council will have a special sitting next Monday to interrogate the findings, recommendations, and the implications of such recommendations. Dr Mabeba said they would also hold engagements across the industry, including the steering committee. 'The minister has alluded to the report, which has damning findings, and as such, we need to apply our minds in ensuring that we guide the industry in a manner that is legally and in line with our statutory mandate.' On Monday, chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, welcomed the findings of the Section 59 investigation panel. 'The report paints a concerning picture of the disproportionate impact that medical schemes' fraud, waste, and abuse systems have had on black healthcare providers…These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste, and abuse systems. 'It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve. 'We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,' said Dr Dhlomo. Get your news on the go, click here to join the Cape Argus News WhatsApp channel. Cape Argus
