Further investigation is required to resolve the controversy raging between major medical schemes and the panel of inquiry into racial profiling of black healthcare providers.
If the medical schemes believe the methodology used by the panel of the Section 59 inquiry was flawed, they must take the panel’s report and findings on review. Meanwhile, the findings must stand, casting a stigma on the credibility of the country’s major medical schemes while their existence is threatened by the government’s plan to introduce National Health Insurance (NHI).
Valuable as the panel’s findings are, health minister Aaron Motsoaledi is completely off the mark in painting the entire private sector with the same brush to promote the virtues of NHI. In his budget vote speech this week, he made the wild exaggeration that the findings are “an indictment of our healthcare financing system”.
The report of the panel, chaired by respected senior counsel Tembeka Ngcukaitobi, released this week, found that Discovery, the Government Employees Medical Scheme (Gems) and Medscheme acted unfairly and in a racially discriminatory manner towards black healthcare providers.
The Council for Medical Schemes (CMS) appointed the investigative panel in 2019 in response to allegations from black healthcare providers that they were being treated unfairly by medical schemes based on race.
The panel found that the systems used by SA’s biggest medical schemes to detect and punish fraud were both procedurally unfair and resulted in discriminatory outcomes. It said that statistical analysis of risk ratios over several years showed that black practitioners faced a disproportionately higher likelihood of investigation and sanction compared with their white counterparts.
A risk ratio referred to the likelihood that a black practitioner (coloured, Indian and African) would be subject to an investigation, finding and penalty for fraud, waste and abuse compared with a white practitioner. The risk ratios for the different medical professionals showed they were more than 300% likely to be found guilty, a figure even higher for black anaesthetists (650%).
But the Board of Healthcare Funders (BHF), Health Funders Association and Discovery have slammed the methodology used by the panel as “flawed” and scientifically unsound. The BHF warned that if the findings were allowed to stand it would open the door to “runaway fraud and corruption in the healthcare sector”. It pointed out that if a medical scheme’s membership was overwhelmingly black, there would logically be a higher rate of member interactions with black healthcare providers.
Racial stereotypes, a legacy from SA’s apartheid past, remain deeply embedded in society, and black healthcare providers are justified in having suspicions about unfair treatment. Banks have also been accused of racial profiling in their granting of loans and mortgages, and there are probably other spaces where similar suspicions arise.
One such stereotype is that blacks in general are corrupt, when of course, there are countless examples of this crime knowing no racial boundaries, a glaring example being the huge Steinhoff fraud. These stereotypes need to be comprehensively dismantled if necessary through active lobbying and inquiry, so the probe by the racial profiling panel into medical scheme practices was vital.
Whatever one’s view of the panel’s findings on racial profiling, it made some valuable recommendations that should be implemented forthwith. It recommended amendments to the Medical Schemes Act to include clear procedural safeguards. Also a dedicated mechanism or tribunal should be established to support healthcare providers accused of fraud, ensuring they are not left to defend themselves against the overwhelming power of the schemes.
Schemes must disclose the software and AI programs they rely on to detect suspect claims to assess whether they entrench bias. If this cannot be achieved voluntarily, Ngcukaitobi recommended legislative changes to compel disclosure.
Also, the panel recommended that schemes should conduct yearly assessments of the racial profile of providers investigated for fraud and publish the data broken down by discipline, so discriminatory patterns don’t go undetected for years.
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