- The Health Funders Association has questioned the benefit of doctors' request for medical aids and their members.
A proposal by doctors for financial assistance from medical schemes, as they grapple with the impact of Covid-19, appears to have hit a wall after a scheme representative body raised technical and legal questions about it.
The financial challenges the doctors face are a result of patients opting to stay at home rather than going to consult their doctors out of fear of contracting Covid-19.
Specialists have seen up to a 90% decline in patient consultations.
Last month, the doctor representative group made up of the Progressive Health Forum (PHF), South African Private Practitioners Forum, South African Medical and Dental Practitioners as well as the South African Medical Research Council reached out to medical schemes with a proposal.
They suggested they get paid a 70% upfront fee by the schemes and the remaining 30% to be paid as a capped service fee.
In a letter seen by Fin24, the Health Funders Association (HFA), an organisation that represents the interests of medical schemes, raises a number of concerns regarding the proposal.
Addressed to Dr Aslam Dasoo from the PHF, the letter states the groups' request that medical aids provide financial assistance through unclaimed funds is concerning.
"Any funds not paid out due to claims being depressed are in reserves for the benefit of members. It is simply not the case that funds budgeted for claims belong to healthcare providers," said Lerato Mosiah, the CEO of the HFA, in the letter.
Schemes are required by law to keep 25% of annual gross contributions in reserve.
Dasoo previously said doctors were not asking for medical aid reserves to be used but rather schemes should provide, as pre-funding, the funds patients would have otherwise used but have not been able to due to the pandemic.
And schemes have budgeted their claims for 2020 based on historical records, meaning they have received contributions in excess of what they have paid out.
But Mosiah said schemes were facing unbudgeted expenditure for Covid-19 testing and treatment, which was likely to place additional pressure on scheme reserves into 2021.
South Africa now has more than 470 000 Covid-19 cases and the death toll has topped the 7 000 mark.
The increase in cases has led to the government imposing a ban on the sale of alcohol and instituting a curfew over concerns that hospital beds would be taken over by alcohol-related trauma patients leaving those who need Covid-19 care without beds.
Medical schemes and hospitals are bracing themselves for the increase in Covid-19 cases as well as the pent-up demand for medical care patients had put off due to the pandemic.
Mosiah said it was misleading for doctors to say members paid for their medical aid every month and schemes only released their money when they claimed.
"This appears to be an attempt to suggest that there is an insurer profiting from reduced claims experience rather than that scheme reserves are for the sole benefit of the members in terms of funding claims or permitting lower contribution increases," she added.
The HFA also flagged the capped payment the doctors and suggested: "The registrar [of the Council for Medical Schemes] has also been clear that he does not consider the upfront payment of fees for service claims as a capitation agreement. It would be reckless of trustees to ignore this."
The letter stated that HFA could not endorse the proposal without the Council for Medical Schemes' (CMS) support.
It added the proposal needed to be in line with the Medical Schemes Act.
The CMS previously said while it understood the plight of doctors, the proposal did not demonstrate it would benefit medical scheme members.
The doctors' proposal for a savings account for doctors without creating loans needed to be clarified, said Mosiah.
The letter also said the proposal needed to have clarity on how the capped fee arrangement would be implemented and how any funds that were paid out by the schemes would be recovered.
There also needs to be a contracting mechanism that will ensure the seasonal variation in claims over the year are considered in the proposal.
The association will continue with its discussions with the doctors, saying: "The HFA is of the view that a mechanism of this nature requires careful consideration and this needs to be done in the context of addressing a crisis situation which has adverse implications for both health practitioners and medical scheme members."
The HFA would not respond to the letter, saying it was not for "media consumption".
"We will let you know once we are in a position to engage with you regarding articles that we want published," said Mosiah in an email.
Dasoo confirmed he had received the letter on Monday but he could not comment on it since the PHF was still studying its voracity and its "unwarranted" and "unprofessional" attacks against it.