Latest news with #medicalschemes
Zawya
30-06-2025
- Health
- Zawya
South Africa: Medshield is committed to building a sustainable healthcare future
Are you curious about what makes businesses stand out in our current environment? It's certainly not about the bottom line and the financials anymore. It's about how they impact the world – the environment, the societies in which they operate, and their governance structures. Environmental, Social, and Governance (ESG) principles have become indispensable in a world grappling with climate change, social inequalities, and corporate accountability. While sectors like mining, energy, and manufacturing have typically been under the ESG spotlight, healthcare is now stepping into focus. Integrating ESG principles is crucial for medical schemes to ensure the future sustainability of healthcare. Factors such as escalating costs, the rise of lifestyle-related diseases, and the environmental impact of medical waste make ESG adoption necessary. Medshield Medical Scheme aligns sustainability with healthcare excellence by developing an ESG roadmap featuring clear corporate sustainability goals. This effort sets the benchmark for responsible healthcare funding in South Africa, paving the way for a more resilient healthcare system. Learning from South African ESG leaders Medshield acknowledges the importance of gaining insights from industry leaders who have effectively integrated ESG principles into their business models. Locally, Life Healthcare is actively driving sustainable healthcare by incorporating energy efficiency and water-saving measures across its hospital network. Aspen Pharmacare, one of South Africa's largest pharmaceutical companies, has embedded ESG principles into its global operations – most notably with sustainable manufacturing practices and community health support initiatives. Sanlam has demonstrated leadership in sustainable investment practices, governance transparency, and transformation targets in the insurance sector, aligning financial strength with social progress. Novartis South Africa also contributes to local ESG progress through public-private partnerships to expand access to healthcare and drive inclusive health equity. By benchmarking against these homegrown leaders and learning from their practical examples, Medshield aims to refine and strengthen its ESG roadmap. Although still in its preliminary stages, Medshield is laying the foundation for meaningful impact. 1. Environmental impact: Pollution and waste management Environmental sustainability is a fundamental ESG pillar, and healthcare providers must tackle pollution and waste management. The healthcare sector produces substantial medical, pharmaceutical, and electronic waste, which can result in severe environmental consequences if not meticulously managed. Life Healthcare has taken a proactive role in managing medical waste and improving energy usage within hospital environments. Aspen Pharmacare has also been recognised for its commitment to reducing environmental impact through improved production technologies and waste reduction systems. Inspired by these local initiatives, Medshield is exploring energy-efficient infrastructure and renewable energy solutions to reduce its environmental footprint and contribute to sustainable healthcare. 2. Social impact: Climate change and human health Climate change poses an escalating threat to public health. Rising temperatures and pollution levels contribute to lifestyle ailments such as hypertension, diabetes, and respiratory conditions. Medshield recognises its responsibility to mitigate these health risks through preventive healthcare programmes, chronic disease management, and promoting wellness benefits to its members. In parallel, Novartis South Africa continues to lead in raising awareness and improving access to treatment for chronic diseases, with a focus on underserved communities. Medshield similarly integrates ESG principles across its internal operations to ensure alignment with corporate sustainability goals and regulatory compliance while supporting climate resilience through health. 3. Corporate responsibility: Social initiatives and member engagement ESG leaders in South Africa prioritise healthcare access and equity. Medshield is committed to extending its corporate responsibility beyond its members. The Scheme supports community health initiatives, wellness programmes, and financial literacy education. Additionally, Medshield embeds ESG principles into its corporate culture – ensuring staff engagement and promoting awareness about lifestyle changes that contribute to improved health outcomes. Aspen Pharmacare, for instance, has significantly contributed to healthcare equity through community-based partnerships and access to essential medicines. Sanlam has also implemented financial literacy initiatives nationwide to drive socioeconomic upliftment. Medshield is actively learning from and contributing to this ecosystem of shared value creation. 4. Governance: The pillar of corporate sustainability Strong governance ensures transparency, accountability, and long-term sustainability. Medshield prides itself on having a robust governance structure and is adopting best practices to strengthen its corporate governance. The Scheme is exploring partnerships with ESG-focused healthcare networks for ongoing improvement and intends to integrate ESG reporting into its annual trustee and Annual General Meeting (AGM) reports to strengthen transparency and accountability. Sanlam's comprehensive sustainability disclosures and Life Healthcare's transparent ESG frameworks offer useful templates for Medshield's ongoing governance enhancement. By drawing from these examples, Medshield aims to ensure that ESG isn't a side initiative but a core part of the Scheme's operation. Medshield is a responsible corporate citizen Medshield's ESG journey signifies its dedication to being a responsible corporate citizen. By embedding ESG principles into its business model, Medshield enhances its reputation and safeguards its operations against emerging global challenges. As one of the pioneers among South African medical schemes in undertaking a structured ESG journey, Medshield is setting a noteworthy precedent. Its approach emphasises long-term resilience, sustainability, and member-centric healthcare solutions. As Medshield refines its ESG initiatives, the greater healthcare sector benefits from a model prioritising people, the planet, and strong governance. ESG is not merely a trend – it is the future of responsible healthcare, and Medshield is at the forefront of this transformation in South Africa. We invite all members, brokers, and stakeholders to join us in shaping a more sustainable and inclusive healthcare future.
News24
14-06-2025
- Health
- News24
SA's medical schemes look to insurance top-ups as membership age increases
Medical schemes are increasingly designing options with gaps in cover that require insurance policies, resulting in consumers increasingly paying for cover in line with their health risks, a leading medical scheme conference heard this week. Hybridising medical scheme membership with insurance policies, such as primary healthcare plans or gap cover, is at odds with the cross-subsidies that medical scheme regulation sought to introduce. However, schemes are increasingly finding they have no choice but to design options in this way to attract younger members, Christoff Raath, the joint CEO of Insight Actuaries and Consultants, told the Board of Healthcare Funders conference held in Cape Town this week. The broken, incomplete and unsustainable medical scheme regulatory system has resulted in schemes becoming increasingly unaffordable and unattractive to younger, healthier people, Raath explained. More than 4.5 million of them have chosen not to join a medical scheme. This anti-selection by younger, healthier members has created a 32% difference between average contributions on open medical schemes and restricted medical schemes, Raath told the conference. Employees are often obliged to be members of restricted schemes, but in open schemes younger members opt out resulting in the average age of the nine million lives covered increasing each year, Raath explained. Every year for the past two decades, the impact of members' aging on contributions is between 1.5% and 2%, Raath said. This issue has now reached a breaking point resulting in structural changes because schemes just cannot continue to deal with the aging of their membership in the absence of risk equalisation and mandatory or compulsory cover, Raath said. Top up with insurance Schemes are designing options that advertently or inadvertently have gaps in their benefits or co-payments, that can be plugged with either primary healthcare plans or gap cover, Raath told the conference. Combining these products provides cheaper cover for younger, healthier lives. Healthcare brokers who sell insurance and medical scheme cover also earn more commission, he noted. Primary healthcare insurance plans were meant to be converted to low-cost medical scheme benefit options and boost cross-subsidisation within schemes. However, this proposed regulation of these options has been under discussion since 2005, and the most recent proposals were only released in February this year after the BHF challenged the Council for Medical Schemes and the Minister of Health over their failure to proceed with this regulation. Siphosakhe Phakathi, a senior associate at Werksmans Attorneys, told the conference that the BHF's court application was for a review of the council's decision not to exempt schemes from providing all the prescribed minimum benefits (PMBs) on their low-cost benefit options Raath said the estimated average cost of providing the PMBs is currently about R1 400 to R1 500 a month, which makes these benefits too costly for low-cost options. Phakathi said the application also sought to review the council and health minister's failure to finalise and implement regulations for low-cost benefit options. Low-cost case The application was dismissed on 1 April this year. The BHF has, however, appealed as it believes the judgement was flawed and the council and minister's decisions frustrate an important constitutional right to improved access to healthcare for millions of South Africans. Phakathi says if primary healthcare plans are converted to medical schemes, members can claim tax credits, there will be improved oversight, risk pooling will improve, and preventative healthcare will reduce healthcare costs. Phakathi said the government's support for NHI was the real reason for failing to implement the low-cost benefit options. It does not suit the government's policy of rolling out NHI to increase medical scheme membership, she said. While medical schemes have been denied the right to offer low-cost benefit options, insurers enjoy an exemption from the Medical Scheme Act allowing them to offer low-cost primary healthcare plans that ordinarily would be regarded as doing the business of a medical scheme. The exemption was first granted in 2017 and was recently extended to 2027. Over this decade, use of these insurance products has grown to cover an estimated 1.5 million lives, despite the Council for Medical Schemes' finding that the cost of these products is high. Slow death for schemes Raath said schemes are being forced to compete for younger members by hybridising membership and insurance products, because of the incomplete regulatory system that has created a slow death spiral for schemes. It is tragic, Raath said. Actuaries warned that schemes would enter a death spiral when the Medical Schemes Act was implemented in 2001 with regulation intended to ensure older, sicker South Africans do not pay more for cover and enjoy minimum benefits, but without key mechanisms to ensure schemes regulated this way were sustainable. The Act obliges schemes to charge all members the same rate to belong to an option, regardless of their state of health or age – a principle known as community rating. Contribution rates can only be based on the number of dependants you register and on your income. Income based contributions ensure that higher earners subsidise lower earners. Open schemes are also obliged to admit anyone who applies to join or, in the case of a restricted scheme, anyone from the employer or industry group for whom the scheme was established. This is known as open enrolment. But Raath says obliging schemes to comply with these principles and provide minimum benefits, without making membership of schemes mandatory, has led to members selecting against schemes – joining only when they are sick and in need of benefits. In addition, it costs schemes with many older sick members more to provide the minimum benefits on average than it costs a scheme with younger, healthier members. The costs of the minimum benefits should have been equalised through a risk equalisation fund. But plans to introduce this fund were scrapped when the government decided to pursue NHI in 2007. NHI's survival In another presentation to the BHF conference, Vishal Brijlal, senior country advisor for the Clinton Health Access Initiative, warned against allowing the status quo to continue. 'Without active reform, the sector may collapse before NHI arrives,' Brijlal said. He said the long timelines for NHI – at least 10 to 15 years — should be recognised and instead of allowing the private health sector to drift, it should be prepared and aligned to be ready for NHI in a way that makes sense. If the private healthcare system is allowed to collapse, nine million members will lose their financial protection and there will be a further burden on the unprepared public healthcare system. Brijlal said the risk of allowing medical schemes to become increasingly unaffordable is that the market for private providers dwindles and is no longer viable. However, a sustainable private healthcare sector is required to serve the NHI, he said. The Competition Commission's Health Market Inquiry's findings were that 'regulatory failure by the government was a central problem' in the private sector. Instead of ignoring reform, governance and oversight should be strengthened, competition improved and the foundation for a more inclusive and sustainable healthcare system, should be built, Brijlal said.
News24
08-06-2025
- Health
- News24
Who pays my medical expenses when I am in a road accident?
The lengthy, ongoing legal battle between Discovery Health and the Road Accident Fund (RAF) may leave you wondering who is liable for your medical costs if you are injured in a motor vehicle accident. The Discovery Health case is confusing and unresolved, but in the meantime, the courts continue to issue judgments ordering the RAF to pay medical scheme members' medical bills. Where does this leave you if you are a medical scheme member injured in a motor vehicle accident? The court cases highlight that the RAF is legally liable for your medical costs, and potentially lost income, when you are injured in a motor vehicle accident and unable to work. However, as a scheme member you are also entitled to claim from your scheme and your scheme is most likely to pay your immediate costs and ensure you are admitted to a private hospital. Schemes pay medical expenses immediately Jaco Rupping, COO of Short-Term Insurance at ASI Insure, says medical schemes are often the first line of financial support for individuals injured in vehicle accidents. 'Your medical scheme will cover immediate and ongoing medical treatment or care, for instance hospitalisation, surgery, and rehabilitation,' he says. The RAF is an after-the-fact insurer, as it takes longer to claim, Rupping says. 'Medical schemes will step in to ensure that treatment is not delayed due to funding concerns,' he says, while cases before the courts prove that RAF claims can take a long time Dr Ron Whelan, chief executive officer of Discovery Health, says that your medical scheme will generally cover the cost of medical care associated with road accidents, particularly where this is an emergency. Schemes are obliged in terms of the Medical Schemes Act to cover all medical emergencies and a number of other listed serious conditions as prescribed minimum benefits (PMBs). Many scheme options also cover you for private hospital admissions. What is the RAF and what does it do? The RAF is a South African state-supported fund that provides compensation to victims of road accidents. It is a form of compulsory social insurance funded by a fuel levy that everyone who puts petrol or diesel into their vehicles pays. The amount of the levy used to fund the RAF is determined annually in the National Budget. In the 2023/24 fiscal year, it was 218c a litre. Last year, almost 80 000 claims were filed and just over 63 000 were finalised. However, the RAF admits that it hasn't resolved all claims dating back several years. It says 90 percent of these have not been paid as a result of inadequate paperwork, which it is attempting to resolve. In addition, the fund has massive liabilities amounting to hundreds of millions of rands and recently lost a court battle with the attorney general to restate its liabilities to a fraction of this amount. In an effort to fix the fund's problems, more proposals have been put forward to limit claims from foreigners and wealthy individuals. What will the RAF pay? The RAF's fact sheet lists the costs for which it will pay, or reimburse, claimants as long as they are not responsible for the accident: Medical expenses, which include emergency and non-emergency medical treatment, only in cases where the expenses have not been paid by your medical scheme; Past and future loss of earnings or income; Future medical expenses; General damages for serious injuries; Direct funeral expenses (excluding aspects such as catering); Past and future loss of support; and, Home modifications and caregivers if needed. Recent court rulings show that if you are in any way to blame for your accident, the RAF will not pay all your costs. Why are Discovery and the RAF arguing over medical costs? In one of the RAF's recent attempts to limit its liabilities, it directed its staff in 2022 not to pay the medical claims of medical scheme members whose schemes had paid their medical bills. Discovery Health succeeded in having this directive declared unlawful in 2023. The RAF then issued a new directive to its employees not to pay medical costs that schemes are obliged to pay as prescribed minimum benefits (PMBs) or emergency medical conditions. Discovery Health challenged this directive as being in contempt of the court order made against the first directive, but two out of three High Court judges ruled against the medical scheme administrator and the challenge was dismissed. Discovery Health has been granted the right to appeal the judgment, and the appeal has yet to be heard. Despite this, in January this year, the RAF was ordered to pay medical costs incurred by Rahldeyah Esack to his estate even though Esack's medical expenses relating to an accident in 2015 were paid by Discovery Health Medical Scheme. Most recently, in March, the RAF was ordered to pay the medical costs of John Moss, a cyclist and medical scheme member who was hit by a vehicle in 2017. The scheme's view Whelan said Discovery Health went to court to stop both the RAF and the Minister of Transport from implementing these directives not only on behalf of the schemes it administers, but also 'in the interests of all medical scheme members in South Africa'. 'Discovery Health's firm contention is that medical scheme members' valid road accident-related medical claims must be processed and paid by the RAF, on the same basis as for any other eligible claimant – as has been the case for the past eighty years,' Whelan says. Whelan said there are two reasons why some medical schemes, such as Discovery Health Medical Scheme, want members to claim medical costs from the RAF and repay the scheme: It ensures that individuals do not benefit from being refunded for medical expenses which they did not actually pay in the first place. The cost of medical schemes is kept as low as possible. Model rules published by the Council for Medical Schemes mean that expenses that can be recovered from other parties are not paid for by the scheme. 'Where these medical claims, which have been paid by the medical scheme, are settled by the RAF, they are refunded to the medical scheme. This protects members from higher medical scheme contribution increases,' Whelan says. Some medical schemes have taken a different approach. The Government Employees Medical Scheme, for example, does not expect members to claim accident-related medical expenses from the RAF. Are scheme members expected to claim from the RAF? Whelan said that, as the process of claiming back from the RAF can take between four and five years on average, Discovery helps members claim these costs back from the RAF. He provided the following bullet-pointed explainer: In terms of the registered rules of the Discovery Health Medical Scheme, members who have lodged a claim against the RAF must: Inform the scheme of such claim; Include the scheme's accident-related medical expenses in the claim against the RAF; Promptly reimburse the scheme with any payment made by the RAF in respect of accident-related medical expenses which were paid by the Scheme; and Inform the scheme of any undertaking made by the RAF in respect of future accident-related medical expenses. KEEP THIS IN MIND Claims against the Road Accident Fund (RAF) can take long and may not cover all your losses, especially income-related losses or non-medical expenses, so it is best to have additional cover to protect yourself, Jaco Rupping, COO of Short-Term Insurance at ASI Insure, says. Also the fund will not pay claims, or not pay them in full, if you were to blame for the accident. Rupping suggests you consider: Disability insurance that pays a lump sum or income if you're permanently disabled; Income protection that covers your loss of earnings if you cannot work either permanently or temporarily; Life insurance that provides for your dependants in the event of death; Severe illness insurance that pays you a lump sum if you are diagnosed with a serious condition; Gap cover insurance that pays shortfalls in medical scheme cover for doctors who treat you in hospital; and, Personal accident cover that pays out a lump sum for injuries, regardless of fault. 'RAF is helpful but not a replacement for these kinds of cover as it is often delayed, partial, and limited,' Rupping says.
The Herald
07-06-2025
- Health
- The Herald
NHI is fiscally impossible, says the Health Funders Association
The Health Funders Association (HFA) has described the National Health Insurance (NHI) Act as fiscally impossible and has tabled a hybrid funding model that will enable private healthcare providers to provide services in tandem with the NHI. The HFA, accounting for 46% of the private healthcare market and representing 21 medical schemes and three administrators, this week became the latest entity to legally challenge the NHI for undermining the right of medical aid members to choose how to access health services. HFA commissioned an independent study released this week which found the NHI required substantial tax far beyond South Africa's fiscal capacity. 'What's more, the proposed model offers no guarantee of improved outcomes, while restricting the mechanisms that currently drive quality and innovation in health care,' said the FHA. Commenting on the report, HFA CEO Thoneshan Naidoo said South Africa needs a healthcare system that delivers equitable, quality care for all. 'However, in its current form, and without private sector collaboration, the NHI Act is fiscally impossible and operationally unworkable, and threatens the stability of the economy and health system affecting everyone in South Africa,' he said. Naidoo said the NHI Act centralises control of all healthcare financing in a single, state-run fund, removing the ability of medical schemes to offer cover for healthcare services reimbursable by the NHI. 'We continue to advocate for a more inclusive, hybrid funding model that incorporates medical schemes in NHI. We believe such a model would expand access to care while protecting the rights of all South Africans,' said Naidoo. The NHI, which introduces universal health coverage, has been challenged in court by Solidarity, the Board of Healthcare Funders, the South African Private Practitioners Forum, the Hospital Association of South Africa and the South African Medical Association. Foster Mohale, the health spokesperson, on Friday confirmed the department had received court papers. 'This is case number six. We have an evolving court process and we'll allow that process to take its course,' said Mohale. FHA commissioned a report by Genesis Analytics, which showed that personal income tax will need to increase from the current average rate of 21% to an average of 46% of income, pushing marginal tax rates in the lowest income bracket from 18% to 41%, and in the highest bracket from 45% to 68%. The Genesis model also considered a scenario of pooling existing healthcare expenditure, citing that personal income tax would need to increase from its average of 21% to 31%. At the same time, medical scheme members would face a 43% reduction in the level of healthcare services relative to what they currently received. 'In simple terms, the equation for medical scheme members therefore becomes 'Pay 1.5 times more tax for 43% less healthcare'. Such tax increases are fiscally impossible, particularly given South Africa's narrow personal income tax base of 7.4-million tax payers,' said the FHA. TimesLIVE
