GEMS outlines plans to address discrimination against black healthcare providers

The Government Employees Medical Scheme (GEMS) maintains that, since the release of the Interim Section 59 Panel Investigations Report three years ago, it has taken significant steps to strengthen its Fraud, Waste, and Abuse (FWA) management framework in an effort to “eliminate any potential for disparate outcomes.”

This follows damning findings against the country’s largest medical schemes, which were found to have applied discriminatory risk ratios to Black health professionals. These providers were disproportionately flagged, audited, or penalised through opaque fraud, waste, and abuse (FWA) systems.

The investigation, commissioned in 2019, examined allegations of racial discrimination and procedural unfairness in the application of FWA processes by major schemes and administrators, including Discovery Health, Medscheme and Gems.

Health Minister Aaron Motsoaledi received the final report from the Section 59 Investigation Panel last week. 

“The final Section 59 Panel Investigation Report makes several recommendations, many of which align with reforms Gems has already implemented. These include the revision of FWA policies to prevent bias and improve oversight, along with extensive stakeholder engagement and awareness programmes aimed at preventing rather than remediating FWA.

"Gems has also revised its standard operating procedures to support greater flexibility this includes accommodating reasonable timeframes for information provision, conducting affordability assessments during debt collection processes, and allowing cooling-off periods for Acknowledgement of Debt (AOD) agreements. In addition, the scheme has undertaken independent audits to ensure that race is not a factor in any system parameters.

“It is reassuring that the Panel has found no evidence that GEMS acted with racist intent. This distinction is critical - structural outcomes must not be confused with deliberate discrimination. We are committed to continuous improvement, guided by independent oversight of the Council for Medical Schemes (CMS) and shaped by trust," said Gems Principal Officer, Dr Stanley Moloabi.

Meanwhile, IOL reported that Discovery Health disagreed with the findings.

Discovery Health CEO, Dr Ron Whelan, said the conclusions from the investigation are “based on flawed methodology, unscientific assumptions, and misinterpretation of complex data”.

Healthcare workers union, Health & Other Services Personnel Trade Union of South Africa (Hospersa), condemned the findings, adding that the report had confirmed the suspicions and personal experiences of many black healthcare professionals, IOL reported.

The union called for remuneration and class action litigation against the medical schemes found to have applied such racial profiling, resulting in financial and reputational harm to individuals.

“As a union steadfastly committed to justice, equality, and transformation, Hospersa cannot allow this moment to pass without demanding full accountability, restitution, and long-overdue structural reform.

“To ensure that this injustice is never repeated, Hospersa calls for systemic changes across the private healthcare sector. All race-based profiling algorithms must be immediately discontinued and outlawed,” Hospersa spokesperson, Lindelwa Mdlalose said.

Cape Times