Medical aid payment holidays: Are they a good idea?

NOMPU SIZIBA: Medical schemes are now obligated to pay up for Covid-19-related tests and treatments for their members. And, on top of that, the Council for Medical Schemes proposed that medical-aid schemes be prepared to offer premium-instalment holidays where the need arises. Well, to discuss the cost implications and more, I’m joined on the line by Dr Katlego Mothudi, the MD of the Board of Healthcare Funders.

Thanks very much for joining us, Dr Mothudi. You’ve put out a statement saying that medical schemes are paying on average around R150 000 rand for Covid-19 patients. What kind of services does that encompass? And currently, because there’s no cure apart from the use of ventilators, what drugs are used to help treat these patients?

DR KATLEGO MOTHUDI: From the report of our associated schemes, the treatment covers anything from the initial testing, and then once you are in hospital, there is the … and accommodation cost, and then professional services, as well as other treatment.

The high average and maybe another level of the high level of care. So, from the numbers gained from the sentiment survey it shows that about roughly 75% of those who are admitted are either in high care or in ICU. And pertaining to the specific medication – I have not information on that.

NOMPU SIZIBA: Right.

DR KATLEGO MOTHUDI: Because it is under the control of the doctors that care for the patients. I imagine the draft following the general guidelines came from other countries.

NOMPU SIZIBA: So concerns have been raised that, during the lockdown period and because of genuine fears around the virus, fewer people than usual have been seeking medical attention, while some with chronic illnesses have not been keeping up with their appointments and medication. This is a rather worrying development. What have your observations been in this regard?

DR KATLEGO MOTHUDI: Yes. From the data that is coming through, there is for some schemes up to a 60% decline in either authorisations or claims from hospitals. And, while it was expected for the so-called surgical procedures, of which a large proportion is called elective, because it has been like pre-planned and not actual an emergency at that stage.

The surprise is those that are linked to medical conditions. So you’ll find with people with asthma and diabetes, hypertension, there has been a decline. And a worrying one for others is where the reduction of about 50% of mental-health admissions. And that is a worrying thing.

In terms of collection of chronic medicine, there seems to be a stabilisation. There we are relying on two months’ data that show that people have been collecting medicine. And what some scheme did – they were proactive – they arranged or converted most of their chronic beneficiaries to courier services, so that they continued getting their current meds.

But there is a concern that there will be those who either do not follow up and do the necessary pathology tests, for example, those who are HIV-positve, or diabetic –  you might find they won’t do the tests … that find data their stability. And those are the concerning groups, because they might maybe, when this thing blows over, find that other people’s conditions have deteriorated, and they might develop other complications.

NOMPU SIZIBA: Of course, it’s important for individuals to take responsibility for their own health, but what can health providers be doing to give those seeking medical attention more confidence in terms of the safety of visiting facilities, and that feeling of being separated from Covid-19 patients?

DR KATLEGO MOTHUDI: I think there will be … and I think the change in the health-seeking behaviour, although it’s concerning, is not surprising. So it’s important that we have to deal with it differently.

What happened at the beginning of the pandemic’s descent on us, we from a policy perspective discussed with The Health Professional Council of South Africa to allow for what you call … health, and this is virtual consulations and healthcare seeking by beneficiaries. And most schemes have actually communicated that – not just to practitioners, but also to their patients – to say for certain services you are able to call your practitioner and have a virtual consultation.

NOMPU SIZIBA: Yes.

DR KATLEGO MOTHUDI: And, the thing is that, under even the lockdown local regulations, certain areas like some …, for example, have been deemed to be social services. So, under controlled measures, which are also of course governed by the regulations, patients can still seek help in terms of those virtual consultations, maybe also getting their scripts telephonically, and then being able to collect their medicines.

The other thing is to make sure that they do also monitor their conditions. This means from time to time they might be required to go to pathology labs, for example, and make sure that they understand, firstly, what are the rules that are in place. You’ll see when you walk into to ,, some … example. They will guide you. They will say sanitisation, keep your distance and, when you come to the counter, they’ll be screened, and so on, and they will be wearing those masks. I think that will go a long way in firstly allaying the fear, but also making sure that people are aware that certain services cannot be stopped, even during this [harsh time].

NOMPU SIZIBA: So, with the national lockdown, it’s put working people into real difficulties, with some not getting an income during the period, and some jobs obviously hanging in the balance. Have medial aid schemes been amenable to instalment payment holidays, and, if that is the case, what happens when a claimable issue strikes, but you haven’t paid your instalment?

DR KATLEGO MOTHUDI: The approach has not been uniform, because you are aware there are about 78 schemes, and each one has its own different conditions. For example, the majority of these schemes will be employer-base, the size differs, some of the open schemes will be have … 12 groups, some have mainly individual members.

So the interventions have also been varied. What we did from the Board of Healthcare Funders’ side is we approached the Regulator, The Council for Medical Schemes, quite early on in fact. There will be a number of interventions that schemes would look at to seek relief for their beneficiaries, and they should be open too, for the exemptions that might come up.

As you know, the industry has been … created by the Medical Schemes Act, first, and secondly by the scheme rules that are approved by members and overseen by the trustees.

But each scheme, when you … its circumstances, could approach the Council or talk to the trustees to …… several methods. One could be a discussion with their employer groups, because you’d know that those are covered by their employer – those share the portion of the contribution. So some employers are in a position to say, for this time when members are not getting their full salaries, the employer will carry the whole contribution. That has been an option.

Another option is where some schemes have said, “We will offer a payment holiday; however, we will not give you benefits.” What this means is that ordinarily a scheme will not say, … opinions; you are to make critical … and you have to re-apply or maybe catch up with payments later. But the intervention here is, if you are seeking payment, you will not be de-registered. However, your benefits will only be unlocked when you pay. There are some schemes that have done that.

Others have said things like you will get … special grants that are considered, and so on.

So each scheme will have … their own … in fact from the profile of our members they will … what they are able to do, and then they will consult with the Council.

NOMPU SIZIBA: South Africa has been working on flattening the curve during the lockdown. But as we further normalise our lives and lockdown restrictions are eased further, there is a concern of a spike in coronavirus cases. Given this reality, how concerned are medical schemes about this, and the threat to their liquidity levels, because Covid-19 now falls under what is called the “prescribed minimum benefit” tag?

DR KATLEGO MOTHUDI: Yes. I think the … has always been the concern around the heightened experience. This is then around the experience that is to be seen in other countries; we are talking about the US and several countries in Europe. I think the comfort has been because the Medical Schemes Act has made a provision for schemes to put some money aside as reserves to actually cushion the blow. I think that gives people the time when schemes would be moving to funding for Covid and the excessive claims experience from the entire … masks for …

So I think it will be welcome news that the spread hasn’t been as fast as first thought, and at the moment the schemes are actually coping with what has been … in this respect.

NOMPU SIZIBA: Many thanks. That was Dr Katlego Mothudi, the MD of the Board of Healthcare Funders.

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