Medical schemes face scrutiny over racial discrimination against black health professionals

There must be consequences and punitive measures, which include back payments by medical schemes, that were found to have applied systemic discrimination against black health professionals when they applied risk ratios against them. 

This call has come after the findings of a Section 59 investigation report revealed that three medical schemes, namely GEMS, Medscheme, and Discovery, applied discriminatory risk ratios to black health professionals, in disciplines such as physiotherapy, psychology, and social work, who are ‘more likely’ to be guilty of fraud, waste, and abuse.

It is unclear how many medical professionals were affected by racial profiling and how many lost their business practices.

The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals.

However, in the absence of remuneration guidelines by the National Health Act, Health Minister Aaron Motsoaledi, during a portfolio committee meeting on Friday, said they will seek legal advice on the matter. 

The findings of the report raised questions during the meeting about equity within the profession, igniting discussions about fairness, accountability, and restitution.

Motsoaledi said the Act does not indicate what steps should be taken, and currently, it appears the medical schemes decide their measures. 

“This is a statutory matter due to the silence in the Act. It does not indicate the steps that the schemes must take when they investigate such a fraud. That is the weakness picked up by the panel, and the Act itself does not provide guidance on what should be done.  

“The medical schemes have decided to divulge their methods, which were unfortunately tampered with by racial bias. Even if the Act does not outline what must be done, whatever is done in a new South Africa governed by democracy cannot be informed by racial profiling. We will have to look into that,” said Motsoaledi.

The minister said the members of Parliament are “not mere bystanders and observers”, and have an onus on them to have the Act amended to speak specifically to such reform. 

Motsoaledi said they are still studying the report, and legal advice is being sought after its release on Monday. 

Chairperson for the Council for Medical Schemes (CMS), Dr Thandi Mabeba, said the council will have a special sitting next Monday to interrogate the findings, recommendations, and the implications of such recommendations.

Dr Mabeba said they would also hold engagements across the industry, including the steering committee. “The minister has alluded to the report, which has damning findings, and as such, we need to apply our minds in ensuring that we guide the industry in a manner that is legally and in line with our statutory mandate.”

On Monday, chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, welcomed the findings of the Section 59 investigation panel. 

“The report paints a concerning picture of the disproportionate impact that medical schemes’ fraud, waste, and abuse systems have had on black healthcare providers…These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste, and abuse systems.

“It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve. 

“We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,” said Dr Dhlomo. 

chevon.booysen@inl.co.za