Council for Medical Schemes: An overview Prof Yosuf Veriava Chairperson: Council for Medical Schemes

Contents 1. Developments of CMS 2. Role of CMS 3. Industry overview Membership trends Benefits paid 4. Competition Commission “Market Inquiry “ 5. Complaints 6. Board of Trustees 7. CMS training 8. CMS indabas and forums 9. Future projects 10. RWOPS 11. Managed care programmes 12. Conclusion

Developments of CMS Promulgation of the National Health Act Regulations amended; require minimum solvency level of 25% Prescribed Minimum Benefits expanded; include 25 chronic conditions Ruling by Competition Commission prohibits any form of tariff setting between schemes and groups of health care providers Single Exit Price (SEP) introduced in an attempt to curb medicine costs The Government Employees Medical Scheme (GEMS) comes into existence.

Developments of CMS CMS publishes National Health Reference Price List (NHRPL) Deductibles and self-payment gaps introduced by industry REF pilot project and shadow return process initiated High Court ruling renders NHRPL invalid High Court dismisses Board of Healthcare Funders (BHF) application re PMB’s at scheme rate Code of conduct published surrounding PMB issues Consumer Protection Act (CPA) is promulgated Green Paper on National Health Insurance (NHI) published and pilot period of 14 years starts Private healthcare pricing investigated by Competition Commission Medical deductions converted into medical tax credits Publication of draft regulations on the demarcation between Health Insurance Policies and Medical Schemes

Roles of CMS Key Roles: Adherence of schemes to the Medical Schemes Act (MSA) Improved management and governance of schemes Advises the Minister of Health on regulatory interventions

Membership trends Reduction of medical schemes is noted in both sectors On average the industry is losing 5 schemes per year This translate to a reduction of up to 32 schemes in 2025

Membership by province – Inequity

Benefits paid **Data to be interpreted with caution due to underreporting by schemes and members Benefits paid for health services by, (%) Medical scheme Member** Private Hospitals Medical specialists Medicines Support and allied professionals General practitioners Other

… the healthcare market does not meet the requirements for normal competition… No barriers to enter or exit the market Perfect information Zero transaction costs Homogenous products Others: Non-increasing returns to scale; infinite buyers and sellers; perfect factor mobility; profit maximisation

…imperfect information in healthcare renders the normal considerations in achieving a balance ineffective… Consumer sovereignty is challenged Ascertaining costs and benefits of treatment is not simple Third party payer

The private hospital market in metropolitan areas (50%+ of medical scheme population) was concentrated by 1999… Only 12.3% of private hospital beds were outside three main hospital groups by 2006…

Non-price competition results in a very high level of high-tech equipment in private hospitals

Terms of reference “Market inquiry” To explore in-depth factors causing escalation of costs. To unpack contractual relationships and interactions between and within the segments of the market To inquire into the nature of price determination

“Market inquiry” on healthcare costs in the private sector Inquiry launch: end September 2013; aim completion June Probe various segments of private healthcare market This is “…a general investigation into the state, nature and form of competition in a market, rather than a narrow investigation of specific conduct by any particular firm”.

Complaints

Complaints categories Technical/clinical complaints: highest of all categories Payment of PMB’s at scheme tariff: highest number of complaints Doctors frequently charge higher rates when providing PMB

Board of Trustees (BOT): Governance issues Distribution of different types of trustees: Governance structure consists of 50% members vs. 50% employer groups

Major role of Trustees Keep records of operations Control systems Communication Payment of premiums Professional Indemnity and Fidelity Guarantee cover Expert Advice Compliance with laws and rules Confidentiality Protect the interests of the members Act with care, diligence, skill and good faith Act impartially

Board of Trustees: compliance Voluntary compliance not yet attained. Schemes place too much reliance on advice from consultants and services providers. Attendance rate of BOT training problematic.

CMS Training Induction: Board of Trustees In-depth: Board of Trustees Broker training Employer groups Various consumer groups

CMS Indabas Indaba means "business" or "matter" Medical schemes industry challenges Various opinions and interpretations of the Medical Schemes Act Engage with stakeholders Find common ground on pertinent issues Optimal benefit for medical scheme members.

CMS Forums Exchange information 3 CMS stakeholder forums - Trustees and Principal Officers - Medical scheme administrators - Regulatory bodies

CMS Indabas and Forums Next Indaba: Johannesburg 23 October 2013 Next forums: Cape Town & Johannesburg end September Regulators Forum: September

Future projects Remunerative Work Outside the Public Sector (RWOPS) National Health Insurance (NHI) Health quality outcomes

RWOPS PCNS: Data Inputs, Information Processing & Reports

Managed care As the medical schemes population continues to grow older, the incidence of chronic disease will likely increase The rising cost of private healthcare necessitate a consideration of the “value” of managed care programmes

Managed care Effective way of controlling health care costs is to: – Manage the scope of benefits provided – The associated costs – Appropriateness of utilisation

Managed care Within this regulatory obligation, CMS is currently finalising the health quality outcomes framework, which will include: – A trend analysis of health quality outcomes – Quantitative and qualitative data analysis of the value of managed care programmes

Conclusion Industry encouraged to work together with CMS in making private healthcare affordable and sustainable. Membership growth is a critical area of concern. Member education about their rights and responsibilities is important. Complying with provisions of Medical Schemes Act is crucial.