KZN doctors angered by 0% increase from municipal workers med scheme

Members of the South African Municipal Workers Union Medical Scheme (Samwumed) in KwaZulu-Natal may have to pay cash to see a doctor after the scheme failed to give general practitioners an annual increase for services.

In a letter to members, the KwaZulu-Natal Doctors Healthcare Coalition (KZNDHC) told doctors, it had written to the chief medical officer of Samwumed expressing its dissatisfaction. 

The organisation said the union had arranged a meeting on February 23 to discuss the 0% increase. 

It said it was alarmed to find out that while member fees went up by 10%, all other providers including specialists, pathology, radiology, hospital groups received an increase. Only general practitioners were exempt.

“Samwumed wanted us to explore options to help reduce their costs further. This was despite GPs being the lowest-cost drivers, and specialists and hospital groups being the higher costs drivers. Their “reason” (excuse) behind their 0% increase was that they had felt GPs were paid a far higher rate historically by the scheme. 

“We have pointed out that schemes such as LA Health, which also serves municipal workers, had tariff fees in line with inflation, with a consult fee of R544 (versus R475 as Samwumed network provider, or R429 as non-network provider),” reads the letter from KZNDHC CEO, Dr Neven Govender. 

Govender said they alerted the scheme that their costs have increased disproportionately to their tariff rates and that they have been at the mercy of looting and floods, to no avail. 

As it stands, he said, the scheme maintains that GPs do not deserve an increase from the 2022 tariff, which remains at R475 (or R429), while it continues to reward its specialists and hospital groups which have driven costs. 

As a “network doctor” to Samwumed, he said, you will be peer-reviewed, restricted to billing the network rates, “audited” for being expensive, and expected to manage the costs of the scheme by changing your referral patterns, hospitalisation usage and so on. 

“Doctors deciding to exit their network agreement, are not bound by this and can charge co-payments to their Samwumed patients in keeping with what they consider fair remuneration. You will not be reviewed for being “expensive”, referring to specialists or admitting a patient to the hospital,” said Govender. 

One of the doctors who spoke to TimesLIVE and asked not to be named, said they were shocked by the refusal, especially because all the other medical aid schemes announced their increase. 

The doctor said what was also puzzling was that they increased fees for others, but not GPs.

“The doctors have now resolved that we will see Samwumed members but we will ask them to pay us cash, give me a receipt and then they can claim from the medical aid. Most of the doctors who have agreed on this are from KZNDHC — which is about 1,500 doctors. Members must take the fight to the board of directors of the medical aid. 

“The 0% increase is a shame considering that the cost of living has gone up, and the cost to run a practice is up. All 209 medical aids in the country gave us an increase except for them,” said a doctor. 

The scheme said it was aware of the matter and would be tabling KZNDHC’s request to revisit the decision at the next board meeting later this month. 

“On an annual basis, the scheme undertakes a benefit review process via its benefits committee. This benefit review process draws on expert input from the scheme’s executive, managed care partners and actuarial consultants. The recommendation, tabled on the 2023 GP rate by a scheme partner, was discussed extensively at the benefit committee,” said the scheme’s clinical executive, Dr Andrew Good. 

Good said the scheme was reassured that even if it did not increase the GP rate, the scheme GP rates would remain competitive in relation to other schemes in the industry.  

He said the scheme funds GP benefits from risk benefits and has traditionally been a generous funder of GP benefits.  

“GP benefit funding from risk benefits at Samwumed is over 9.5%. This compares favourably with the GP funding from risk benefits of 5.71 % for restricted schemes and 3.11% for open schemes, as reported in the last Council for Medical Schemes (CMS) report,” he said. 

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