The South African Medical Association (SAMA) has raised
concerns about certain aspects of the provisional report of the Health Market
Inquiry (HMI) into the private health sector in South Africa, released by the
Competition Commission last week. The report took almost four years to complete
and given the amount of time, at first review, is somewhat disappointing in its
overall analysis, SAMA says in a statement.

The main report is several hundred pages long and will be
reviewed thoroughly in due course by the Association. However, SAMA
chairperson, Dr Mzukisi Grootboom, says that of the recommendations published
by the HMI, the association is particularly concerned about the allegations
that doctors increase demand of unnecessary services, including increased
admissions to hospitals.

“The HMI reached this conclusion after analysing claims
data. We are of the considered view that the methods used by the HMI were not
robust enough to conclude that many admissions are unexplained and thus
constitute a doctor-induced moral hazard,” Dr Grootboom says.

He says in 2017, the Medical Research Council presented to
Parliament the top ten diseases that kill South Africans. These included HIV
and AIDS, cerebrovascular disease, lower respiratory tract infections,
ischaemic heart disease, tuberculosis, diabetes mellitus, hypertension,
interpersonal violence, other trauma related injuries, liver disease and
diarrhoeal illnesses. In 2015, Statistics South Africa reported cancer to be
the fifth cause of death in the country.

“Typically the private sector uses the Prescribed Minimum
Benefit Chronic Conditions List (PMB CDL list) to define chronic conditions.
The PMB CDL list only includes three conditions which kill South Africans. The
HMI can therefore not conclude that there are unexplained admission after
adjusting only for chronic diseases and age. SAMA believes the increase in
admission can be explained by high prevalence of injuries, acute infections,
cerebrovascular accidents, cancer, tuberculosis, and substance abuse, amongst
other factors,” says Dr Grootboom.

Dr Grootboom says SAMA also finds it concerning that the HMI
assumed all psychiatry and paediatric admissions are discretionary. This is
patently wrong.

“This cannot be true given the recent developments in mental
health. If psychiatry admissions are really discretionary, we would not have
witnessed the development of the Life Esidimeni crisis. No doctor will choose
to admit a mental health patient if an option for community-based care exists.
In a country where high causes of mortality rates in children include lower
respiratory tract infection and diarrhoea, assuming that all paediatric
admissions are discretionary is quite flawed,” Dr Grootboom notes.

According to Dr Grootboom, the HMI analysed the proportion
of discretionary admissions in ten specialities. He says it is astounding that
all cardiology and cardiothoracic admissions appear to have been considered
discretionary against the backdrop of ischemic heart disease being responsible
for a significant proportion of deaths in the country.

He notes that almost all of urology and orthopaedics
admissions were also considered discretionary. 
“Treatment of hip fracture with arthroplasty or early prostate cancer is not
discretionary; these are the standards of care,” he says.

In addition Dr Grootboom notes that black men in South
Africa are more likely to suffer aggressive forms of malignancies or cancer and
that a watch and wait strategy is therefore clinically not appropriate in the
South African setting. 
Further to the report’s findings that unpaid claims should be construed as
unnecessary care, Dr Grootboom says schemes typically do not fund clinically
appropriate care if they judge it is not a prescribed minimum benefit and not
covered by plan type.

“Unfortunately, the allegations of doctor-induced demand can
erode the patient-doctor trust. As a profession we will continue doing our
level best to care for and save the lives of all South Africans. We will also
further engage with the HMI after a complete analysis of this lengthy
document,” concludes Dr Grootboom.