Medical aid schemes have committed unfair racial discrimination – report

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 the report showed that there were clear differences in the scale of racial discrimination among the schemes. Picture: iStock
the report showed that there were clear differences in the scale of racial discrimination among the schemes. Picture: iStock

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On the basis of providing healthcare – and claiming back for services rendered – what does race have to do with it?

Everything, according to an interim report by a Section 59 investigation panel released on Tuesday.

Two of the country’s largest medical schemes, Discovery and the Government Employees Medical Scheme (GEMS) and Medscheme, one of the largest medical aid scheme administrators in the land were found to have engaged in the unfair racial discrimination against black, Indian and coloured doctors and health practitioners.

The panel’s report, released on Tuesday morning, has damning implications for the three schemes singled out in engaging in unfair racial discrimination and processes when conducting investigations into fraud, waste and abuse cases.

The release of the report came just hours after the Pretoria High Court earlier in the morning threw out the application by the GEMS and the Board of Healthcare Funders to interdict its release.

The panel, chaired by Advocate Thembeka Ngcukaitobi SC and also includes advocates Kerry Williams and Adila Hassim, was mandated in 2019 to investigate two main issues.

For black psychologists, they are three times more likely to be found to be fraud, waste and abuse cases.
Advocate Thembeka Ngcukaitobi

The first was whether there was racial discrimination by schemes against black healthcare providers and secondly if black providers were being treated procedurally unfairly.

“On the first question, after considering all the evidence, we have found that between 2012 and 2019 [the period scoping the investigation), black practitioners [African, Indian and coloured] were more likely to be found to have committed fraud, waste and abuse than their non-black [white] counterparts by Discovery, Medscheme and GEMS,” Ngcukaitobi said.

“This means in summary, they have committed unfair racial discrimination.”

Ngcukaitobi said that while the panel had not found explicit racial bias in the algorithms – in other words an intention to cause discrimination – but using the data provided by the schemes they found “substantial differences” in fraud, waste and abuse outcomes between black and white practitioners between January 2012 and June 2019.

Read: Medical schemes heading for crisis

“Over this period, across all medial disciplines in the aforementioned schemes, black practitioners were 1.4 times more likely to be classified as having committed fraud, waste and abuse than those identified as non-black.

“Secondly, the probability that this distribution happened by chance – in other words it was a mere accident that they were and no correlation between outcomes of fraud, waste and abuse and race – is zero,” he said.

“The starkest differentials are evidenced by the following: black general practitioners are 1.5 times more likely to be identified as fraud, waste and abuse cases than their non-black counterparts. Two, the rate at which a black physiotherapist are identified as fraud, waste and abuse cases is 1.7 times than non-black counterparts. For black psychologists, they are three times more likely to be found to be fraud, waste and abuse cases.”

GEMS is 80% more likely to identify black providers as having committed fraud, waste and abuse cases, while Medscheme is the highest at 330% likelihood.
Advocate Thembeka Ngcukaitobi

And much is the same for black registered counsellors and social workers, who are also three times more likely to be identified as fraud, waste and abuse – with more than 50% of black registered counsellors being identified as fraud, waste and abuse cases.

This was found to be the highest rate analysed.

From the investigation, the report showed that there were clear differences in the scale of racial discrimination among the schemes.

“We found that Discovery was 35% more likely to identify black service providers as having committed fraud, waste and abuse – the lowest rate of the schemes and administrator. GEMS is 80% more likely to identify black providers as having committed fraud, waste and abuse cases, while Medscheme is the highest at 330% likelihood,” Ngcukaitobi said.

The panel emphasised that the report was an interim one, and schemes affected have six weeks to present rebuttals of the report which will inform the final one.


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Vuyo Mkize 

Health Journalist

+27 11 713 9001
vuyo.mkize@citypress.co.za
www.citypress.co.za
69 Kingsway Rd, Auckland Park
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