SA’s biggest medical scheme for public servants and the two biggest medical scheme administrators are 1.4 times more likely to conclude black health-care practitioners have committed fraud, waste or abuse than their white counterparts, according to the interim findings of an investigation into racial profiling commissioned by the industry regulator.
The interim report was released on Tuesday morning, after the Government Employees Medical Scheme (Gems) and the Board of Healthcare Funders (BHF), an industry association for medical schemes and administrators, failed to block it at the 11th hour with an urgent court application.
They had argued that the affected parties should have been permitted to comment before the document was released, in line with the investigation’s terms of reference.
Judge Colleen Collison ruled that the applicants had failed to convince her why they had not approached the court earlier, since the report’s release had originally been planned for December. She struck the matter from the roll, paving the way for its release.
The investigation was launched in 2019 by the Council for Medical Schemes (CMS) in terms of section 59 of the Medical Schemes Act, after complaints by black medical practitioners that they were being unfairly targeted. At the last count the CMS had spent more than R11m on the probe.
The investigation, chaired by Tembeka Ngcukaitobi, found no evidence of explicit racial bias in the algorithms and methods used by Discovery Health, Medscheme and Gems to identify health-care practitioners who had potentially done wrong, but did find a racial bias in the outcome of their investigations.
"Using the data Discovery, Gems and Medscheme provided the panel ... there is a substantial difference in fraud, waste and abuse outcomes between black and nonblack practitioners over the period January 2012 to June 2019," he said.
The probability that there was no correlation between racial status and the outcome of fraud, waste and abuse proceedings was "for all practical purposes" zero, he said.
Discovery Health said the panel had concluded that there was bias based on the racial distribution in the outcomes of investigations, rather than the underlying processes applied to the investigations.
"It is difficult to rectify processes that were found to be sound, and carry appropriate integrity," it said in a statement.
The panel also concluded that some of the procedures followed by schemes in probing fraud, waste and abuse cases were unfair.
Schemes and administrators were performing a function akin to policing and were given unilateral statutory power to claw back funds from providers.
Ngcukaitobi said part of the investigation panel’s role had been to provide a platform for individuals to express their experience of racial discrimination and unfair treatment.
"We had no power to find anyone guilty. Nor were we appointed to investigate the veracity of each individual claim of unfair treatment and unfair discrimination. But we would be failing in our duty if we ignored degrading, humiliating and distressing impact of racism against the individuals who testified before us," he said.
Medscheme said it "categorically rejected" any claim that it performed racial profiling when assessing or auditing claims.
Unilateral power
"We are extremely disappointed that we were not afforded an opportunity to review the interim report ... before it was published as had been agreed," said executive director Lungi Nyathi.
Gems principal officer Stan Moloabi said the scheme was committed to ensuring there was no unfair racial discrimination, whether intentional or not.
Interested parties have six weeks to comment on the interim report.
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