Report on claims that Discovery, GEMS and Medscheme racially profiles health practitioners released

Picture: @CouncilforMedicalSchemes, Facebook

On Tuesday the Council of Medical Schemes (CMS) released the Section 59 Investigation Interim Report into the racial discrimination and unfair procedures by medical aid schemes including Discovery, the Government Employees Medical Scheme (GEMS) and Medscheme. 

This release comes following the Pretoria High Court’s ruling to strike-off GEMS and the Board of Healthcare Funders’ application to interdict the report’s release from the roll due to a lack of urgency.

According to the report, various healthcare providers and members of Solutionist Thinkers and the National Health Care Professionals Association made allegations in early 2019.

CMS launched an investigation into the allegations that that they were being treated unfairly by medical aid schemes, based on race and ethnicity.

Advocate Tembeka Ngcukaitobi, Advocate Kerry Williams and Advocate Adila Hassim were tasked to investigate two issues, namely whether medical aid schemes were racially discriminatory against Black health care providers and whether they were treated procedurally unfairly.

The Inquiry also looked at how fraud, waste and abuse (FWA) systems were implemented at medical aid schemes. An independent expert was appointed to assess the outcomes of the FWA investigation processes by the three main administrators: Discovery, GEMS and Medscheme.

The report states that while there is no evidence of explicit racial bias in the algorithms used by medical schemes, significant differences in the FWA outcomes for Black and non-Black practitioners between January 2012 to June 2019.

Some of the findings reported claims that:

  • Black general practitioners are 1.5 times more likely to be identified as
    FWA cases than their non-Black counterparts
  • The rate at which Black physiotherapists are identified as FWA cases is
    almost double (1.87) that of their non-Black counterparts
  • Black psychologists are three times more likely to be identified as FWA
  •  Black registered counsellors and social workers are also three times
    more likely to be identified as FWA cases. More than 50 percent of
    Black registered counsellors have been identified as FWA cases – this
    is the highest rate among the disciplines analysed
  • Black dieticians are 2.5 times more likely to be identified as FWA cases
    compared to their not Black counterparts

The panel has also found that Black healthcare providers were unfairly discriminated against on the basis of race.

The interim report stated that these findings were both serious and far-reaching. But they believed that it is important to stress that they have not found evidence of deliberate unfair treatment – the evidence shows the unfair discrimination is in the outcomes.

“Our Constitution regards the form of unfairness that we have found to exist as constituting unfair racial discrimination,” the panel says.

The panel says they do not have the power to find anyone guilty and concludes saying, “Our expectation is a constructive engagement with the findings and recommendations
in this report. Rather than conclusive, our findings will hopefully provide a basis for
the necessary reconstructive work which must be undertaken by the role-players in
the medical schemes industry.”

The CMS stated that the issue is not a binary conflict between schemes and providers, but reflective of fissures of the past that remain unresolved.