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Roselyn Sachiti Features Editor
Government has been making consultations for the Medical Aid Societies Bill that is expected to address multiple challenges in the health insurance sector. The reactions have been different depending on who is affected or who gains from certain proposals in the Bill. At the Association of Healthcare Funders of Zimbabwe all-stakeholders conference which was held in Victoria Falls between September 6 and 9, AHFoZ made its views, misgivings and what they like about the Bill known.

The Herald’s Features editor Roselyne Sachiti (RS) spoke to AHFoZ chief executive officer Ms Shylet Sanyanga (SS) on this and other issues in the health insurance industry.

RS: How will the anticipated Bill for the setting up of the regulatory authority for medical aid change the landscape of health care in Zimbabwe?
SS: For us as AHFoZ and as the medical aid industry, we are not quite clear of the advantages and disadvantages. What difference will it bring? We are made to understand that it is supposed to strengthen the regulation of the industry.

RS: Why do you say you are not clear, what is not clear about the Bill?
SS: Going through the Bill, it is similar to the existing Act. That part is not clear as to what difference it will make. We are saying if it is going to strengthen the regulation of the medical aid industry, we are happy with it because we believe medical aid societies are running legal businesses professionally. Our focus is more on what it is going to do, what is the approach? We expect that it will promote the growth of the medical aid industry, the membership figures which have remained static for a long time. Promote the sustainability of the medical aid industry as a whole.

RS: In terms of compliance, how does the regulatory framework deal with offenders who fail to comply with regulatory system?
SS: The proposed Bill criminalises non-compliance and we think this is not the way to go. We think we should have constructive remedies as opposed to criminalising all compliance issues. If it criminalises, the risk is that it may disrupt the sustainability of the industry, especially given the contribution that the industry is making, and when you compare with the allocated budget figure from Treasury.

RS: There are instances where employers have deducted money and failed to remit subscriptions to medical aid societies. In your presentation you called for the cancellation of medical aid membership cards for patients whose money has not been remitted. How fair is this given that an employee would have paid but the employer fails to remit the money to the medical aid society?
SS: In fact, that is one of the suggestions we are making and this Bill should provide a solution to that. If an employer has not remitted subscriptions to a medical aid society, medical aid societies will not be able to pay. There is need for a holistic approach whereby employers also come in and become part of this system which is supposed to be seamless.

There is need for a clear understanding as to the reasonable turnaround time for payment of claims, what is the realistic period for employers to remit subscriptions, and what should happen to employers if they fail to remit subscriptions to medical aid societies.

The regulatory authority should also offer a solution to the anomaly that is created when employers fail to remit contributions to medical aid societies by due date.

RS: Last year you made a number of resolutions during your annual all-stakeholders’ conference. From your wish list, what have you managed to achieve so far, what is currently being worked on?
SS: What we have managed to achieve though still work in progress is the scientific tariff. Last year we discussed the need to conduct a scientific study on tariffs that is underway. It was commenced on July 4 and we expect that it will be completed on October 4 this year.

RS: For the benefit of our readers who are, maybe learning about the scientific tariff for the first time, kindly outline what this entails.
SS: What has happened over the years is that certain tariffs or fees were charged by health service providers (be it a general practitioner, specialist, a hospital). Any health care service provider would charge a certain fee for services they render. Initially all those fees were pegged at certain levels based on scientific research conducted years back and there was a formula which was used to adjust fees according to inflationary changes or any adjustment that may be necessary.

That formula was very consistent but because of economic decline at some point, service providers started charging what they wanted. We now had a distortion of the fees in the market and so much acrimony whereby some service providers felt they were paid too little. Medical aid societies felt the fees that the service providers were asking for were not affordable especially given the economy we are working in. The purpose of a tariff is to come up with fee structures that are relevant to the economy. It will look at the cost of running a practice for the different various service provider groups, what a member can afford in terms of subscriptions and then what will be sustainable going forward.

RS: As AHFoZ you seem not at ease in having medical doctors as part of the regulatory board. Where is the discomfort coming from? What is your idea of a regulatory board?
SS: Introducing doctors as part of the board that will regulate medical aid societies will bring in an element of conflict because they are interested parties. If this regulatory authority is supposed to be independent and to adjudicate any conflict or to preside over any challenges that would have arisen, doctors will not be impartial. They are conflicted and interested parties. Doctors have their own regulatory bodies which comprise doctors. This is a regulatory authority for medical aid societies therefore doctors should not be involved.

RS: Most medical aid subscribers have been complaining over cash upfront payments when they visit doctors and specialists. As a result some patients are losing confidence in medical aid societies. How can you regain their confidence in health insurance?
SS: The issue of cash upfront differs. There are many reasons why service providers would ask for cash. Some service providers operate on cash and that is their business model, their choice. Other service providers will say I am no longer accepting this medical aid, again it is a business decision the service provider would have made. Going forward, this is one of the issues that the regulatory authority should investigate to find out the reasons. Do the doctors just not want to be on direct payment, nor do they go on cash payments because they are owed? Some doctors do not accept certain medical aid societies because they are owed. It’s a business decision, if a medical aid society has not received subscriptions and is not able to pay a service provider, it does not make business sense for a service provider to continue incurring a huge debt from a debtor who may never pay.

RS: One of the issues you have raised is that of annual registration of medical aid societies, why is AHFoZ not really excited about this?
SS: The requirement that medical aid societies should be licensed annually should be reviewed under the new dispensation. The uncertainty created by annual licensing inhibits business continuity and investment in medical aid societies. Funders approach may be restricted to short-term goals both in financial and health terms. Funders may focus on acute care rather than chronic care in their benefit design. Because of uncertainty, members may decide they would be better off using up as much of the benefits as they can before the end of year.

RS: What do you expect from the regulatory authority?
SS: Part of the regulatory authority’s role should be to enforce observance of the agreed ethical practices by medical aid societies, their members and health service providers and to ensure robust measures are in place to deal with non-compliance by any of the parties.

Robust supervisory structures should be put in place to ensure that all stakeholders are protected and that the Authority can identify signs of distress at an early stage.

If the proposed regulatory changes embrace constructive provisions, the sector would operate in an environment that is fair to all parties, protecting the interests of medical aid society members/patients healthcare providers and medical aid societies. The result would be the country would benefit.

RS: This year’s conference theme was “The Health Care Ecosystem and Quality of Life.” Why such focus? Who are the stakeholders in the health care ecosystem?
SS: The architecture of the healthcare ecosystem begins with the patient — the first “P” in what has been called the five Ps of the healthcare ecosystem. These are the patients, policy makers, providers, pharmacies and payers. The quality of health ultimately depends upon ecosystem products and services which are a prerequisite for good human health and productive livelihoods. As we go through the 2017 conference, we seek to work on capitalising on this new appetite for information and to harness the self-interest and autonomy of informed consumers towards becoming more aligned with the integrated and healthcare ecosystem.

In this new ecosystem, everyone involved will have to rethink financing, technology sharing and use analytics and collaborative measures to understand and improve the healthcare experience. These collaborations will become the heart of the healthcare ecosystem. Through it, we can establish accountable and trustworthy care for generations, which enhances the quality of life.