Gap-cover health insurance under scrutiny.

THE government is tightening the noose on companies selling “gap-cover” health insurance, hoping it can stabilise the medical schemes market and ensure better consumer protection by scrapping all but a few tightly defined products. Last Friday the Treasury published draft regulations to both the Long-term and Short-term Insurance Acts, which aim to draw a clear distinction between medical schemes and health insurance policies. The draft regulations propose scrapping most gap-cover products, but will allow health insurance for loss of income, travel, emergency travel, HIV/AIDS and frail care. The proposals, which are open for public comment until April 23, are the government’s response to a court case on the legality of gap-cover products which the Council for Medical Schemes lost on appeal in 2008. The council took Alexander Forbes’s short-term insurance subsidiary, Guardrisk, to court, arguing that its gap-cover products were illegal because they were doing the business of a medical scheme but were not registered to do this. The council was denied permission to take the matter to the Constitutional Court, and so turned to the government to amend legislation to deal with the threat it sees in gap-cover products. For several years now, growing numbers of employers and consumers have been buying top-up health insurance to deal with the payment gaps facing medical scheme members. Medical schemes typically set a ceiling on how much they will pay for healthcare providers’ fees, and leave their members to pay the difference if a doctor or dentist charges more. Many medical scheme members face co-payments if they want to use medicines or doctors not on their scheme’s approved lists. They often have to pay a lump sum contribution for medical devices or for certain procedures. Into this breach stepped companies selling health insurance products aimed at two categories of consumers: those who already belong to medical schemes and need extra cover, and those who cannot afford even the most basic medical scheme package but want some protection should they face illness or injury. Whether these gap-cover products are a good or bad thing is open to debate. The Council for Medical Schemes believes gap-cover products destabilise the industry because they encourage younger and healthier people to “buy down” and join less comprehensive medical scheme packages, which they then complement with a health insurance “top-up”. The other problem with health insurance products, it says, is that they are not subject to the close scrutiny faced by medical schemes, which have to comply with the Medical Schemes Act. This leaves consumers in a weak position if they buy health insurance products that turn out not to give them the cover they expect. Wits health economist Prof Alex van den Heever agrees with concern about the lack of protection for consumers, saying the rights of medical scheme members are spelt out in the Medical Schemes Act. Unlike medical schemes, which must charge members the same rate regardless of health or age, health insurance products can “risk rate” and charge more as people grow older. Companies selling insurance products are also under no obligation to take on an individual, whereas medical schemes by law may not exclude anyone. Prof van den Heever says the regulations do not go far enough and should give the Council for Medical Schemes final say over which products are harmful, rather than the registrar of the Financial Services Board.

Jonathan Broomberg, the CEO of SA’s biggest medical scheme administrator, Discovery Health, says the main impact of gap-cover products is to encourage members and employers to buy down to cheaper options that provide less cover than they actually need. He says schemes are being undermined in their ability to provide lifetime cover, which is based on those who are healthy subsidising those who are ill over time. Many smaller schemes, and those with relatively poor risk profiles, are already experiencing these negative impacts, he says. Broomberg says gap-cover products offer poor value for money, as many policyholders fail to claim, adding that typical payout ratios of health insurance products are in the range of 30 percent-50 percent, whereas medical scheme payout ratios for hospitalisation or cancer are typically above 98 percent. He says the low payout ratios of health insurance products make them artificially cheap at present. However, they will become more expensive over time, as policyholders claim more and as they age and experience health events. However, the Board of Healthcare Funders, argues that consumers need the protection offered by gap-cover products. Spokeswoman Heidi Kruger says that without set tariffs for doctors, consumers would be disadvantaged if we were to lose gap-cover products completely. Mike Settas, MD of gap-cover seller Xelus, says the government’s proposals fail to distinguish between products that complement medical schemes and those that compete directly with them.

Tamar Kahn: Business Day, 8 March 2012

Comment from PLWC : Patients must make sure what their medical aid covers and advocate for their rights! Remember – Cancer is a part of  PMB (Prescribed medical benefits)!

Our aim is to ensure that patients get relevant and sound information from their treating oncologist and have access to literature and resources that will assist them in making informed decisions re their treatment and the management of their disease.

We encourage patients to stand on their rights to get a 2nd opinion and to insist in getting information from the medical fraternity that will assist them in coming to an informed decision re their own treatment.

We feel strongly that cancer patients and their caregivers are particularly vulnerable and need to be offered sound scientifically proven information and options.

Our organization’s policy is that it cannot be seen to support any therapeutic invention in the absence of scientifically independently validated clinical trials showing a benefit.

We are not a medical or clinical discussion forum and our services are limited to the psychosocial support of patients and caregivers. We wish to encourage cancer patients and their families to be careful of any treatment modalities that do not adhere to the above criteria.

Directors of PLWC

A presentation by Dr Carl Albrecht on IPT – George South Africa, 16 September 2009.

IPT fact or fiction

MEDICAL AND DENTAL PROFESSIONS BOARD

GUIDELINES FOR GOOD PRACTICE IN MEDICINE, DENTISTRY AND THE MEDICAL SCIENCES

NATIONAL PATIENTS’ RIGHTS CHARTER

BOOKLET 13

PRETORIA JULY 2002

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NATIONAL PATIENTS’ RIGHTS CHARTER

PREAMBLE

The  Department  of  Health,  in  consultation  with  various  other  bodies,  developed  a  National Patients’ Rights Charter.  The Medical and Dental Professions Board at the time also submitted input into the different drafts that were circulated for comments.

The document contained herein was launched by the Minister of Health and agreed to by the Board.  It has since been included in the Board’s Handbook for Interns, Accredited facilities and Health Authorities.

The Board takes this opportunity to make the National Patients’ Rights Charter available to all practitioners provided for by the Board as part of its series of Booklets on Guidelines for Good Practice in Medicine, Dentistry and Medical Sciences.

NATIONAL PATIENTS’ RIGHTS CHARTER

1            INTRODUCTION

1.1         For many decades the vast majority of the South African population has experienced either a denial or violation of fundamental human rights, including rights to health care services.

1.2         To ensure the realisation of the right of access to health care services as guaranteed in the Constitution of the Republic of South Africa, 1996 (Act No. 109 of 1996), the Department of Health is committed to upholding, promoting and protecting this right and, therefore, proclaims this PATIENTS’ RIGHTS CHARTER as a  common standard for achieving the realisation of this right.

2            PATIENTS’ RIGHTS

2.1         HEALTHY AND SAFE ENVIRONMENT

Everyone has the right to a healthy and safe environment that will ensure their physical and mental health or well-being, including adequate water supply, sanitation and waste disposal, as well as protection from all forms of environmental danger, such as pollution, ecological degradation or infection.

2.2         PARTICIPATION IN DECISION-MAKING

Every citizen has the right to participate in the development of health policies, whereas everyone has the right to participate in decision-making on matters affecting one’s own health.

2.3         ACCESS TO HEALTH CARE

Everyone has the right to access to health care services that include -

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a.           receiving  timely  emergency care at  any  health  care  facility  that  is  open, regardless of one’s ability to pay;

b.           treatment and rehabilitation that must be made known to the patient to enable the patient to understand such treatment or rehabilitation and the consequences thereof;

c.           provision for special needs in the case of newborn infants, children, pregnant women, the aged, disabled persons, patients in pain, persons living with HIV or AIDS patients;

d.           counselling without discrimination, coercion or violence on matters such as reproductive health, cancer or HIV/AIDS;

e.           palliative care that is affordable and effective in cases of incurable or terminal illness;

f.            a positive disposition displayed by health care providers that demonstrates courtesy, human dignity, patience, empathy and tolerance;

g.           health information that includes information on the availability of health services and how best to use such services, and such information shall be in the language understood by the patient.

2.4         KNOWLEDGE OF ONE’S HEALTH INSURANCE/MEDICAL AID SCHEME

A member of a health insurance or medical aid scheme is entitled to information about that health insurance or medical aid scheme and to challenge, where necessary, the decision of such health insurance or medical aid scheme relating to the member.

2.5         CHOICE OF HEALTH SERVICES

Everyone has a right to choose a particular health care provider for services or a particular health facility for treatment, provided that such choice shall not be contrary to the ethical standards applicable to such health care provider or facility.

2.6         TREATED BY A NAMED HEALTH CARE PROVIDER

Everyone has a right to know the person that is providing health care and, therefore, must be attended to by only clearly identified health care providers.

2.7         CONFIDENTIALITY AND PRIVACY

Information concerning one’s health, including information concerning treatment may only be disclosed with informed consent, except when required in terms of any law or any order of court.

2.8         INFORMED CONSENT

Everyone has the right to be given full and accurate information about the nature of one’s illnesses, diagnostic procedures, the proposed treatment and the costs involved.

2.9         REFUSAL OF TREATMENT

A person may refuse treatment and such refusal shall be verbal or in writing, provided that such refusal does not endanger the health of others.

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2.10       A SECOND OPINION

Everyone has the right on request to be referred for a second opinion to a health provider of one’s choice.

2.11       CONTINUITY OF CARE

No one shall be abandoned by a health care professional who or a health facility which initially took responsibility for one’s health.

2.12       COMPLAINTS ABOUT HEALTH SERVICES

Everyone has the right to complain about health care services, to have such complaints investigated and to receive a full response on such investigation.

3            RESPONSIBILITIES OF THE PATIENT

Every patient or client has the following responsibilities:

3.1         To take care of his or her own health.

3.2         To care for and protect the environment.

3.3         To respect the rights of other patients and health care providers.

3.4         To utilise the health care system properly and not to abuse it.

3.5         To know his or her local health services and what they offer.

3.6         To provide health care providers with relevant and accurate information for diagnostic, treatment, rehabilitation or counselling purposes.

3.7         To advise health care providers of his or her wishes with regard to his or her death.

3.8         To comply with the prescribed treatment or rehabilitation procedures.

3.9         To enquire about the related costs of treatment and/or rehabilitation and to arrange for payment.

3.10       To take care of the health records in his or her possession.

GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS
GUIDELINES ON THE KEEPING OF PATIENT RECORDS

OWNERSHIP OF RECORDS

10.1       In the case of state institutions, where records e.g radiographs are the property of the institution, original records and images should be retained by the institution. Copies must however, be made available to the patient (or referring practitioner) on request for which a reasonable fee may be charged in terms of the Promotion of Access to Information Act (Act No. 2 of 2000);

10.2       In cases where patients are required to pay for records and images (e.g. private patients or patients in private hospitals) such patients must be allowed to retain such records – unless the health care practitioners deem it necessary to retain such records for purpose of monitoring treatment for a given period. Should the patient however require the records and / or images to further or protect an interest (e.g. such as consulting with another practitioner) he or she must be allowed to obtain the originals for these purposes.

10.3       As the ownership of records in a multi-disciplinary practice depends on the legal structure of the practice, the governing body of such multi-disciplinary practice should ensure that these guidelines and the provisions of the Promotion of the Access to Information Act relating to health records are adhered to. The Act requires public institutions to appoint information officers to administer access to information, and similar provisions apply to private bodies.

10.4       Should a health care practitioner in private practice (both in a single practice and in a partnership) pass away, his or her estate, which includes the records, will be administered by the executor of the estate:

10.4.1    Should a practice be taken over by another health care practitioner, the executor shall carry over the records to the new health care professional.   The new health care practitioner is obliged to take reasonable steps to inform all patients regarding the change in ownership and that the patient could remain with the new health care practitioner or could request that his or her records be transferred to another health care practitioner of his or her choice.

10.4.2    Should the practice not be taken over by another health care practitioner the executor should inform all patients in writing accordingly and transfer those records to other health care practitioners as requested by individual patients.  The remaining files should be kept in safe keeping by the executor for a period of at least twelve (12) months with full authority to further deal with the files as he or she may deem appropriate – provided the provisions of the rules on professional confidentiality are observed.

10.4.3    It should be noted that certain partnership agreements may make specific provision for the management of a deceased partner’s share in the partnership after the death of a partner and such management would include dealing with patient records.

10.5       If health care practitioners in private practice decide to close their practice for whatever reason they shall within three months of closure inform all their patients in writing that:

10.5.1            The practice is being closed as from a specific date;

10.5.2    Requests may be made that records are transferred to other health care practitioners of their choice;

10.5.3    After the date concerned, the records will be kept in safe-keeping for a period of at least twelve (12) months by an identified health care practitioner or health institution with full authority to deal with the files as he or she may deem appropriate, provided the provisions of the rules on professional confidentiality  are observed.

If you would like us to send you the complete guidelines please email us at info@plwc.org.za