Beware dodgy Aids insurance products
By Pat Sidley who can be contacted at the council for medical schemes
It took last year's international Aids conference in Barcelona for several of the world's larger transnational corporations to feel that public pressure might dent the bottom line, and that they had better find ways of treating workers for HIV/Aids.
The pressure was on - not just to prevent the disease, provide home-based care, or supply African potatoes and garlic, but for anti-retroviral drug treatment.
A sudden flurry of activity appeared among South Africa's product designers, who are always ready to plug a gap, sometimes with corks of dubious quality.
Anti-retrovirals used to cost much more than they do now. Vast populations of people with Aids are effectively part of an elaborate real-life drug trial - but the demand comes from infected people who risk death, not the odd side effect.
Some companies simply pay for treatment. These are very large concerns, like Anglo American, with the resources to cover drug bills and the attendant laboratory testing.
Others may look for different vehicles. South Africa has spawned a new industry of insurance products to finance the provision of expensive treatment for HIV/Aids. This, in turn, has spawned allied industries. Unfortunately, many of the new enterprises and products are the work of charlatans and can do more harm than good.
Conducive circumstances in South Africa include the existence of a large, well-developed industrial sector with hundreds of thousands of workers, many of whom are not covered by medical schemes.
The available mix includes schemes that provide anti-retroviral treatment for people with Aids. At present about 30 000 people receive such treatment through their medical aids, meaning that employees themselves pay a large portion of the costs.
2. Payment options
Ideally, workers unable to join medical schemes should receive adequate treatment at public health facilities and, if rumour is anything to go by, this may happen in due course. In the meantime, something has to be done to help HIV-infected employees who are not covered by schemes and whose employers are unable, or unwilling, to fork out the entire cost.
Enter the new HIV insurance products, and with them problems for regulators, beneficiaries and their partners. At best, these products are honest attempts to address a serious health problem for a reasonable return. At worst, they can bring increased resistance to anti-retroviral treatment or even cause death, while bringing unseemly profits to their originators.
The Council for Medical Schemes has had many approaches on these products. In some cases, employers who would like to form a separate HIV fund to cater for the needs of all employees who lack insurance.
Insured employees get their HIV benefits through their medical schemes, and in some instances, such as at DaimlerChrysler, a fund has been created to pay bills in excess of medical scheme benefits.
In another model, an independent party starts an HIV fund catering for a group of companies, again for employees without medical scheme cover. The service is rendered through a "managed-care" company or by the company itself with defined methods of financing and delivery.
In a third model, an independent party starts a fund for all employees, regardless of whether they belong to medical schemes. The service is delivered to those who need it through a managed care company.
The glitch with all of this - and several other models for delivery - is that in terms of the Medical Schemes Act they are illegal. The Act states that a medical scheme undertakes a liability in return for a contribution or a premium, so that the health-care service can be paid for.
Once an insurance set-up looks like a medical scheme, it has to comply with the Act - meaning that it must meet a range of conditions, many of them designed to protect the consumer.
Other medical conditions also have to be attended to - certainly those listed as compulsory minimum benefits. Dependants have to be eligible to join, as well as other workers.
If the service is not adequately delivered, or the law is broken in another way, employees and their dependants have recourse to the council.
With HIV/Aids these are particularly important considerations. Other conditions develop; partners should also be treated; and children may need help.
Numerous managed-care organisations have sprung up to diagnose and deliver treatment, often at a fixed cost per patient. However, their profit margins frequently depend on under-servicing, or servicing that meets the needs of the bottom line rather than those of patients.
Unfortunately, some product designers react to a council rejection by devising ways of "getting around" the obstacle.
Employers should be wary of these products, which often involve pitfalls for employees that may end up hitting the company's bottom line.
Aids is a bottom-line problem - nobody knows this better than the life assurers and others that are dreaming up products. But it involves human concerns, too. Eventually, these can also affect profitability.