The Sunday Mail
Veronica Gwaze
THERE is no good time to be sick, but this is certainly the worst!
Apparently, the difference between a patient with or without health insurance has become more or less the same.
At least 1,8 million people are registered medical aid holders under 38 medical aid societies that are affiliated to the Association of Healthcare Funders of Zimbabwe (AHFoZ).
Of the total, slightly over a million pay their subscriptions in local currency.
However, health service providers appear to be colluding to ‘punish’ anyone who produces a medical aid cover at their institutions.
Porous
Ordinarily, health insurance is supposed to cover members on a rainy day, but that is not the prevailing situation.
Policy holders are literally finding themselves between a rock and a hard place as the supposed cover has become porous, exposing patients to paying out hard cash in shortfalls.
Local currency medical aid policy holders are being forced to additionally part with huge sums of United States dollars (USD), or equivalent, for services rendered.
The situation is obtaining at both public and private health institutions.
Shortfalls are not peculiar to Zimbabwe. However, the manner in which medical aid service providers are responding is seemingly spiralling out of control.
While some have resorted to openly turning away patients on medical aid, others are simply charging ridiculous shortfalls, as high as US$125 per session.
“I recently fell ill and required urgent medical attention. I needed a head scan to be precise. I went to Avenues Clinic, produced my valid medical aid card but they could not assist me despite the terrible condition I was in.
“Instead, the clinic demanded a payment of US$250 (cash) or US$120 shortfall on my First Mutual Health medical aid before I could be attended to,” narrated Phillipa Mukome after her traumatising ordeal.
The steep charges left her with no option but to look for an alternative facility.
“I then went to an oncology centre situated a spitting distance from the first clinic I had visited. They accepted my policy but this time around with a US$50 shortfall since I pay my subscriptions in local currency.”
Terrence Zimbeva also faced nasty experiences after he fell sick.
A private health institution that he has consulted over the years with no issues over his medical aid, this time around, only requested a cash payment of US$150.
Unable to fork out that much, Zimbeva went to Parirenyatwa Hospital.
Unfortunately, staff at the main hospital did not attend to him but referred him to their private division.
“I was asked if I am on a USD or local currency medical aid plan. It was my first time coming across this question,” Zimbeva said.
“Upon learning that it was not a USD plan, I was advised to personally visit the medical aid head offices and negotiate with them to give me cash to pay for the service.
“That is impossible and as a result I had a torrid time. I suffered until a relative had to come to my aid with cash payment. The sad thing is I have never skipped my monthly subscriptions yet we are getting a raw deal.”
Stinky
In some instances service, providers charge shortfalls that are way more than the actual price of the product or service.
Nester, who is Zimbeva’s sister, has a typical case.
“I was asked to pay a shortfall of US$40 for prescription drugs. However, I then later discovered that the same medication did not cost more than US$20 when paid for in cash.
“I failed to understand the logic. It did not make sense at all! It seems like they are now penalising patients for using medical aid. I was left with no option but to go for the cash route,” she said.
Government said it is seized with the matter and was meeting with stakeholders for a lasting solution.
“We are handling the issue. We have crucial meetings scheduled in which we are to discuss the key issues and find a way forward. However, I cannot pre-empt much,” said Public Service, Labour and Social Welfare Minister Professor Paul Mavima in an interview late last week.
Resolution on the dispute between the health funders and the health insurance firms is key to ending this shortfalls crisis, or at least improving the situation.
Several policy holders have been questioning whether it is still worth it to be paying their medical aid subscriptions if they end up practically paying cash for health services and medication.
Medical Aid Societies argue that shortfalls and challenges are a result of an unfavourable pricing structure that currently exists on the market. They note that health service providers are pegging their charges to the USD and at parallel market exchange rate, which automatically creates disparity for local currency policy holders.
The black market rate, they add, goes up spontaneously compared to salary adjustments.
Resultantly, some of them are now encouraging the public to migrate to USD policies.
“We also alluded to the fact that medical service providers tend to set their base pricing in USD thus, the review we conduct is meant to try and align ZWL medical benefits we provide to members to what the medical service providers charge when they convert their USD prices to ZWL,” (sic) partly reads a recent communication by First Mutual Health to its clients.
“For those members who generate or have access to USD, we strongly encourage you to convert your medical aid scheme or arrangement to USD.
“Under such an arrangement, the levels of USD medical benefits and USD contributions are stable which makes it simpler from a planning and budgeting perspective. Shortfalls, if any, are predictable and relatively smaller.”
A source from Premier Service Medical Aid Society (Psmas) said challenges in the process of claiming, authorisation and getting payments from medical aid societies were also complicating issues.
“The situation can be made better if the claim process is shortened. As it stands, the service seekers are finding themselves at the receiving end but also note that the medical aid societies and the health service providers are in a fix. This is an unusual business environment.”
Way out
AHFoZ expects service providers to continue accepting both local and USD policies.
The Association’s chief executive officer Shylet Sanyanga said there are uniform standard tariffs (rates) that should be used for medical aid claim purposes.
“Medical aid societies pay the tariff and any excess would usually be shortfall. This therefore means that the patient carries the excess-shortfall. It is in the interests of the affected individuals to seek clarification on the fees raised at the point of service,” said Ms Sanyanga.
She added that cash payment rates are to the discretion of the service providers.
“We also urge clients to compare prices and services, including that of medical aid service providers. Drug and consultation charges differ from one institution to another.”
Steep charges, Sanyanga added, often result in early exhaustion of the individual’s respective annual limit.
This in turn means that policy holders will have to pay non-refundable cash for the rest of the year for the exhausted categories of benefits.
Some argue plans for the Insurance and Pension Commission (IPEC) to have medical aid schemes under its purview may help to ensure that the public is covered for medical treatment hospitalisation.
IPEC is said to have technical capacity in terms of specialist expertise required for managing insurance funds.
“Cabinet made a decision that they want to have a separate regulator for that (medical aid schemes).
“That is all we know. We do not know who the regulator will be and just like everyone else we are waiting for communication,” said IPEC public relations manager Lloyd Gumbo.
Currently, Medical Aid Societies are regulated by the Ministry of Health and Child Care as provided for under the Medical Services Act.
In South Africa, only 16 percent of the population are said to be on private medical aid, with the rest relying on public health.
