With just over two months left in 2024, the Council for Medical Schemes (CMS) finds itself racing against the clock to finalise the Section 59 Inquiry report by the year’s end.
In 2019, the CMS, with the concurrence of the Ministry of Health, launched an investigation into claims by members of Solutionist Thinkers and the National Health Care Professionals Association (NHCPA) that black medical professionals were treated unfairly and schemes withheld their claims because of racial profiling. Allegations included racism, blacklisting, clawbacks, and the targeting of black professionals.
On 25 June 2019, the CMS published a circular outlining the terms of reference for an investigation panel in terms of section 59 of the Medical Schemes Act. The panel released its interim report in January 2021, prompting calls from healthcare practitioners, schemes, and administrators for the final report’s publication.
In March, a leaked letter from the Board of Healthcare Funders (BHF) sought confirmation on the report’s release date. The Office of the Registrar responded to the letter in April, indicating that the final report would be delivered in May. However, a follow-up communication in June from the CMS and the Section 59 Investigation Panel noted that the report was “close to completion” and would be released as soon as possible.
A joint statement at the time indicated that the panel was considering final expert and legal submissions from Discovery Health and Discovery Medical Scheme, received in February and March, in its deliberations.
“The body of evidence and the legal submissions are extensive and require time for proper analysis and consideration. The CMS and the panel request the indulgence of all stakeholders and interested parties and reiterate that the finalisation of the report remains a high priority,” the statement read.
This week, the CMS confirmed to Moonstone that it expects to finalise the report by the end of this year. Although the CMS indicated that the final report was nearing completion, objections from several parties have caused delays. In response to these objections, the investigation panel permitted further submissions from the concerned parties, prolonging the process.
“There were voluminous documents and records submitted. The technical reports also had to be redone. Discovery and Medscheme made further submissions to the Section 59 Panel, and the panel had to collectively analyse the submissions,” the CMS explained.
The CMS clarified that the objections were related to the technical report prepared by Dr Zaid Kimmie.
The interim report published in 2021 noted that the investigation panel had appointed Dr Kimmie – an independent expert in mathematics, statistics, and data analytics – to assess the outcomes of the fraud, waste, and abuse investigation processes conducted by the three main administrators: Discovery, Medscheme, and GEMS. His appointment was done “to progress the panel’s work, particularly in relation to the allegations of unfair discrimination based on race”.
When asked what the objections to Kimmie’s technical report were, the CMS stated: “The parties concerned advanced that Dr Kimmie’s report did not consider all the submissions made by the medical schemes industry.”
Letting bygones be bygones
In a communiqué published in the June online edition of the South African Dental Journal, KC Makhubele, the chief executive of the South African Dental Association, emphasised the critical need to finalise and publish the report.
“The findings are expected to provide crucial insights into whether racial discrimination exists within the investigative practices of medical schemes and to recommend measures to ensure equitable treatment of all healthcare providers moving forward,” he stated.
Providing context and the “current status” of the long-awaited report, Makhubele alleged that its release had been stalled because of an ongoing impasse between the investigation panel and the CMS, “with both parties attributing the delays to each other”.
He outlined several key points of contention throughout the four-year-and-counting wait, starting with “ministerial involvement”. The investigation’s findings were initially scheduled for release on 16 December 2020. However, just before the planned media conference, the release was halted at the request of then Health Minister Dr Zweli Mkhize, who indicated that he had not yet reviewed the report’s findings. Makhubele claimed this intervention significantly contributed to the delay.
He further asserted that the delay had been compounded by “financial constraints”, noting that the CMS reportedly spent R11.3 million in unbudgeted funds on the investigation. Makhubele claimed this expenditure had placed additional pressure on the regulator, to the extent that it considered legal action at one point to compel the panel to complete and release the final report. He argued that these budgetary pressures had added complexity to finalising the report.
Additionally, Makhubele mentioned “allegations of obstruction”. Amid the extended delay in releasing the final report, accusations arose that the CMS was intentionally obstructing its publication. However, Makhubele noted that at the time the CMS maintained it was the panel’s responsibility to finalise the document.
Last, he pointed to the “panel’s stance” as another point of contention. Tracing back to before 2022, the panel, led by Advocate Tembeka Ngcukaitobi, asserted that they had submitted a detailed plan and budget for completing the report, which the CMS did not accept. Makhubele claimed the delay stemmed from a lack of communication and support from the CMS.
The CMS asserts that these issues are a distant memory, noting that the concerns regarding expenditure pressure between the regulator and the panel were resolved as early as 2022/23.
“As per the SLA (service level agreement) with the investigation panel, CMS is still fulfilling its commitments. The project is on track, and there is no need for legal action,” the CMS stated.
The regulator confirmed that the panel and the CMS have a firm working relationship and are currently occupied with the release of the final report.
“The panel and CMS are working very well to ensure that the final report is released without any more delays.”
