More Healthcare Snippets

New Health Minister: Aaron Motsoaledi

ONE of the surprises in President Jacob Zuma' new cabinet was the appointment of Aaron Motsoaledi as Health Minister and the redeployment of Barbara Hogan to the key ministry of public enterprises after just six months at health. The new Health Minister has a Bachelor of Medicine and a Bachelor of Surgery from the University of Natal. He is a former acting premier in Limpopo and was previously MEC for education in the province. His deputy remains Dr Molefi Sefularo, who was health MEC in the North West province and appointed Deputy Health Minister by President Kgalema Motlanthe last year.
SAPA, 10 May 2009

Countries split over steps needed to curb flu's spread

CASES of swine flu have been reported across the northern hemisphere and in the south as authorities remain divided over measures to prevent the outbreak from developing into a global epidemic.

The death toll in Mexico, epicentre of the outbreak, climbed to 152 from 1 995 known cases.
The number of people in the United States known to be infected rose to 68 yesterday, including 28 cases in one New York school alone, while cases were reported in Europe, the Middle East and Asia.

Eleven people were confirmed as New Zealand's first swine flu cases. Australia was investigating 70 possible cases.

The World Health Organisation (WHO) said it was not inevitable that the outbreak would turn into a pandemic, but other scientists said it might be past that point.

In Mexico, the outbreak is affecting the economy, with authorities in Mexico City ordering eateries to halt business until further notice, and tour operators cancelling bookings in favoured destinations.

Governments, meanwhile, appeared divided over how they might contain the outbreak.
Authorities in Asia - where memories of the Severe Acute Respiratory Syndrome outbreak in 2003 remain fresh - are screening air passengers arriving from affected areas and advising against non-essential travel to Mexico.

In the United Arab Emirates, one of the world's premier flight hubs, authorities have arrivals at airports under strict surveillance to spot anyone who might have swine flu.

The WHO said border screenings "don't work", while the European Union's health commissioner said there was no need for travel restrictions. "If a person has been exposed or infected ... the person may not be symptomatic at the airport," WHO spokesman Gregory Hartl said in Geneva.

"We learn as we go on. Severe Acute Respiratory Syndrome was a huge learning experience for all of us."

The WHO raised its alert level from three to four on Monday, signalling a "significant increase in the risk of a pandemic". It conceded that the outbreak was too "widespread to make containment a feasible" strategy.

Androulla Vassiliou, the EU's health commissioner, said that, while precautions were advisable, "at this juncture I don't see any point in restricting travelling".

Reflecting the differences of opinion over measures to curb the spread of the virus, France joined Britain in advising against all but essential travel to Mexico.

The sense of gloom was compounded by predictions from experts that a pandemic was now all but inevitable.

"It is very likely we are at the beginning of a pandemic," Yuen Kwok-yung, head of microbiology at the University of Hong Kong, said.

Dmitry Lvov, head of the Russian Academy of Sciences' Institute of Virology, said: "The risk of a pandemic in the world is high."

No deaths have so far been reported outside Mexico.

Across the border in the US, health authorities reported 68 confirmed cases of swine flu, up from 40 the day before, and said some required hospital treatment.

But the US Centres for Disease Control and Prevention said swine flu had not spread beyond the five states affected. Most of the new cases were in New York, taking the number in that state to 45.

Spain reported a second confirmed easel of swine flu and said 32 other people were thought to have contracted the virus on a visit to Mexico.

In Britain, two people who had been on honeymoon to Mexico were being treated.

The first cases were also reported in the Middle East, with two Israeli men who recently returned from Mexico confirmed as having swine flu.

In Asia, Thai medical authorities placed a woman under quarantine in hospital, while South Korea was investigating a "probable" case.

Mexico said that the number of cases under observation had grown to 1 614.

Faster and more effective laboratory tests for the flu had been introduced, Health Minister Jose Angel Cordova said. "We're in the decisive moment of the crisis. The number (of deaths) will continue rising."

Mexico City remained eerily quiet yesterday, with tour operators such as Britain's Thomas Cook halting holidays to the country.

The impact was being felt on the financial markets as well, with Wall Street skidding at the opening on Tuesday amid investor jitters about the spread of swine flu, mirroring falls in Europe and Asia.

The dreaded flu has not yet hit South Africa but health authorities said they were doing everything they could to prevent an outbreak.

The National Department of Health called on people "not to panic as there were no cases of swine influenza reported in South Africa".

The department's spokesman, Fidel Hadebe, said: "Adequate measures have been taken to ensure the country's preparedness and response, should any cases be identified in the country." Hadebe said these measures include the alerting of outbreak response teams in all provinces, and heightened clinical and laboratory surveillance to identify flu carriers, including at airports.

The Health Department is working closely with the National Institute for Communicable Diseases and WHO, said Hadebe.

Robyn Chalmers, spokeswoman for SA Airways, said: "Cabin crew have been briefed on the origins and symptoms of swine flu and on how to identify suspected cases of the virus among passengers on international flights.

"If a passenger is suspected of having contracted the virus, cabin crew will immediately alert the captain, who will advise air traffic control at the destination that cleaning and disinfection will be required on arrival. Medical ground support will be alerted to help on arrival with the ill passenger."

Airlines are working with the International Air Transport Association, the International Civil Aviation Organisation and WHO on dealing with public health emergencies, Chalmers said.

Sophie Nicholson: SAPA-AFP via The Cape Times, 29 April 2009
Werner Swart & Sally Evans, The Times, 29 April 2009

Government plans to cut the number of medical aids 

GOVERNMENT policy to create fewer, bigger medical aids has resulted in the number of survivors whittled down to 112.

Of these, 70% are "restricted" (industry jargon for in-house medical aids that big corporations offer their employees) and 30% "open", which are those offered to anyone able to pay, by companies like Discovery, Metropolitan, Medscheme and so on.

One way to cut healthcare costs is to join a company offering a restricted scheme. The average monthly contributions for a principal member of these were R1090.50 versus R1189.50 for open schemes, according to data in CMS's annual report published last July.

The minimum monthly contribution for restricted schemes averaged R161 a member, less than half the R330 demanded by open schemes.

Restricted schemes are also less confusing, limiting themselves to two benefit options versus more than five for open schemes.

But the chances of joining a restricted scheme are getting slimmer because the trend is for corporations to sell their in-house medical aids to the administrators of open schemes.

The consolidation of the industry has been driven by the Medical Schemes Act over the past decade. Forcing smaller players into the arms of a few big players will reduce the risks, according the legislation's architects.

"Market consolidation is in many instances desirable, given the bigger size and, consequently, the better stability of risk pools in merged entities," the CMS says in its annual report.

But from a consumer's perspective the result is having to pay more for less. According to research by Discovery, an average family of four could spend the same on medical aid every month as they would on monthly car or bond repayments.

The amount you pay into a medical aid is typically split into two parts: a risk pool aimed at covering hospital bills and a medical savings account for less serious ailments. Not more than a quarter of payments are allowed to be put in the savings account.

The government draws up a prescribed minimum benefit (PMB) list, which is the base line that medical aids are required to cover from their risk pools. The medical emergencies and chronic ailments listed as PMBs changes regularly. The latest draft revision of the PMB list was published last month and the industry has until May 11 to respond.

The discussion document reads: "In the medical schemes environment, PMBs predominantly represent regulatory interventions to address market failure, while a mandated minimum set of benefits in the public sector chiefly represents rationing of scarce resources."

A side-effect of state planners deciding that there has been "market failure" is very expensive healthcare for the one in five South Africans who can afford medical aid.

Making state hospitals a more viable alternative seems to be a strategy government policy makers would rather avoid.

Another three-letter acronym in the medical aid alphabet soup is DSP, which expands into designated service provider. While the law requires medical schemes to cover for PMBs, they are allowed to draw up their own list of DSPs. Some medical aids make state hospitals their DSPs.

The CMS's annual report provides comprehensive data on the financial strength of the various schemes.

A medical aid you join should have a solvency ratio higher than 25%. The country's largest medical aid, Discovery Health, failed this test with only 23% at the end of 2007, the period covered in the most recent CMS report. Discovery's solvency ratio has since improved to above the prescribed level.

Renaissance Health Medical Scheme, which went into liquidation, had a solvency ratio of -22.5%.

While medical aids need to get in more than they pay out to maintain an adequate solvency ratio, they are not permitted to be run for profit, a rule the companies that operate them work around by charging administration fees.

While administration costs should not consume more than 10% of gross income, the CMS's annual report showed this was higher for nearly all the big players.

Government policy makers seem to have thought that consolidating the industry would bring down admin costs.

"Despite their market dominance and the inherent benefits of economies of scale, the larger administrators do not appear to offer any cost advantages over their smaller rivals. Perhaps their size makes them less responsive to clients' needs," the annual report says.

Only covering PMBs with DSPs regime has led to practitioners getting poorer while hospitals get richer. The total paid to GPs fell 8.5% to R4.3-billion in 2007. Dentists similarly saw their payments from medical aids fall 5.3% to R1.8-billion.

Payments to hospitals, meanwhile, grew after inflation by 5.3% to R20-billion. The slice of risk pool payments to private hospitals keeps widening, leading to accusations that a few private sector operators are guilty of profiteering.

The CMS says in its annual report: "Towards the end of December 2007, we received complaints from medical schemes about private hospital tariff increases which appeared unreasonable and, in some respects, potentially unlawful.

"Our lawyers wrote to the private hospital groups warning them that, should they persist with the increases, the Registrar of Medical Schemes would report them to the competition authorities and institute legal action. We also participated in the minister's attempts to engage in discussions with the hospital groups in an attempt to resolve the concerns.

"At its meeting in February 2008 the CMS took note of the Minister's interactions with the hospital groups over tariff increases. In view of these processes, we decided not to proceed with litigation with the hospital groups for now, but instead to continue engaging on the issues and to provide support to ministerial processes where possible."

One problem with the PMB system is that medical aid members have sometimes discovered, after costly diagnostic work and expensive procedures, that their ailment is not on the list.

It has also encouraged "diagnosis creep", whereby doctors sneak through bills for ailments not covered.

According to government policy makers, the cure for unaffordable healthcare is not more competition, but a rethink of PMB rules.

The PMB draft document says: "A systemic outcome of unregulated competition in the private sector is greater exclusivity rather than inclusivity. Unguided commercial imperatives largely contradict the obligation on government to ensure access as it is easier for schemes to compete based on risk selection rather than on price, efficiency, and the quality of coverage.

"The natural consequence of this market conduct is the permanent exclusion of individuals or groups with predictably high healthcare costs. In other forms of insurance, this problem does not arise as the risks of claiming are not known in advance or, where they are, it is appropriate to exclude such individuals. In healthcare, excluding individuals with known health conditions or those known to be at a higher risk of claiming results in a loss of access to health insurance as well as access to healthcare. 
"PMBs structurally reduce discrimination based on health status because if PMBs are broad enough, the ability to separate insurable and uninsurable individuals through benefit design is eliminated."

New legislation is being worked on, the Medical Schemes Amendment Bill, aimed at lowering the PMB bar so that medical aid providers can offer products to low-income families.

New acronyms introduced here are Risk Equalisation Fund (REF to its friends), which seems to be an IT system that doesn't work.

Robert Laing: The Business Times, 19 April 2009

HIV treatment should start earlier

PATIENTS should start taking drugs for the AIDS virus earlier to have the best chance of survival, researchers said on Thursday.

An analysis of more than 45 000 people with HIV in Europe and North America found they were 28 percent more likely to develop full-blown AIDS or die if they deferred treatment until the point currently recommended in many countries.

There is no cure for the human immunodeficiency virus (HIV) that causes AIDS, but combinations of drugs can keep the virus from replicating and damaging the immune system.

Doctors normally don't start treatment until there is some evidence of damage to this system, measured by counting the number of immune cells called CD4 T-cells.

Current guidelines call for treatment only after the CD4 count falls below 350 cells per microlitre of blood.

Jonathan Sterne from Britain's University of Bristol and colleagues found waiting until the CD4 had fallen to 251-350 was associated with a significantly worse outcome than starting therapy in the range 351-450.

The team -- whose findings were published online by the Lancet journal -- concluded that a count of 350 cells should be the minimum threshold for starting treatment.

Deciding when to start taking AIDS drugs has traditionally been seen as a balancing act, since the powerful medicines can have serious side effects and there is also a risk of resistance developing.

Researchers said these problems were now easier to deal with, thanks to the advent of a wider range of drugs, and medics should therefore focus on getting patients onto therapy early.

"It is important that people at possible risk of having HIV get tested regularly so that if found to be infected they can receive the necessary care and treatment," they said.

An estimated 33 million people globally are infected with the AIDS virus, most of them living in Africa and other developing countries.

Ben Hirschler: Reuters, 9 April 2009