Medical Schemes And The NHI: A Complementary Relationship

While the NHI remains a work in progress in terms of policy and planning, medical aid members and schemes worry about the future. For now, at least not any time soon, nothing will change. As a 2017 NHI White Paper stipulates: until the new system is fully implemented and operational, things will stay business as usual. 

The question is: What will happen to medical aid schemes once the NHI kicks in? According to Gerhard van Emmenis, principal officer of Bonitas Medical Fund, South Africa’s second largest open medical scheme, one of the first changes will be a decline in the number of medical schemes. 

“From what I understand, once the NHI is a fact, there will be three or four medical aids left. These will serve as complementary health product providers and will fill the gaps left by the NHI,” he says. 

While comprehensive in terms of healthcare coverage, the NHI won’t cover everything. “Dentistry and optical care aren’t necessarily high priorities because there are bigger burdens in other areas, particularly lifestyle diseases such as diabetes (blood sugar), high blood pressure and cholesterol,” says Van Emmenis. 

In terms of its own post-NHI future, Bonitas seeks to be one of those complementary healthcare providers. “We also hope to play a role in preventive and managed healthcare coverage, something which has been neglected. There are risks involved when people are only diagnosed once they suffer from a certain preventable condition.”

Diabetes is a good example, he continues. “Many people are pre-diabetic. We try to change their lifestyle and make sure they go to the doctor regularly to prevent them from becoming diabetic. The government has made a pledge to tackle the epidemic of lifestyle conditions and we want to work hand in hand with them on this.”

Besides plugging the gap left by the NHI, Bonitas hopes to play a role in helping government make the new system’s structures as cost-efficient as possible. “Our knowledge and experience enable us to assist the government with the funding aspect, ensuring there is value for money, for instance, by avoiding duplications,” Van Emmenis says, noting that the company has been an active participant in the different NHI discussions between the government and private healthcare providers. “We have quite a lot of experience in making and keeping healthcare systems cost-efficient.”

A greater focus on preventive and primary healthcare at community level is overdue, says physician and industry expert Brian Ruff, the founder of integrated care management company PPO Serve. “South Africa has a very high hospital-centred system as most medical aid benefits apply to hospitalisation,” he says. 

He says high hospitalisation rates for procedures that could be performed at community level, for instance at the GP, are one of the key culprits that have been driving up the prices of medical care. This has resulted in above-inflation premium hikes, benefit cuts and ultimately gaps in care, especially for complex medical problems, he says.

“We need to make healthcare benefits available at a community level,” he says, noting that the NHI intends to do just that. This is good for patients’ well-being and the affordability of care. “Delivering primary preventive healthcare at community level costs much less than in hospital.”