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DRAFT TERMS OF REFERENCE FOR MARKET INQUIRY: Private Healthcare Sector
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1. Introduction
The Competition Commission (“the Commission”) will conduct a market inquiry into the private
healthcare sector in terms of Chapter 4A of the Competition Act, 89 of 1998 (as amended) (“the Act”)
and in keeping with the purpose and functions of the Commission set out in the Act.1
Section 2 of the Competition Act defines the purpose of the Commission as, inter alia, “to promote the
efficiency, adaptability and development of the economy”;2 and “to provide consumers with
competitive prices and product choices”.3 The functions of the Commission, set out in Section 21 of
the Competition Act, call on the Commission to “implement measures to increase market
transparency”. In order to fulfill the stated purpose and functions of the Commission, Chapter 4A of
the Competition Act enables the Commission to conduct formal market inquiries in respect of the
“general state of competition in a market for particular goods or services without necessarily
identifying conduct or activities by a particular named firm”. A market inquiry is thus a general
investigation into the state, nature and form of competition in a market, rather than a narrow
investigation of specific conduct by any particular firm.
Section 43B sets out the grounds for initiating a market inquiry, stating that the Commission may
initiate an inquiry where it has “reason to believe that any feature or combination of features of a
market for any goods or services prevents, distorts or restricts competition within that market”.4 The
Act further stipulates that the Commission must develop terms of reference for the inquiry that
include, “at a minimum, a statement of the scope of the inquiry and the time within which it is
expected to be completed”. In accordance with these provisions, these terms of reference set out the
scope of the market inquiry, it identifies the factors that give the Commission reason to believe that
there are features of the private healthcare market that may prevent, distort or restrict competition,
and sets out the expected timelines for the inquiry.
The terms of reference start with a broad overview of the peculiarities of competition in healthcare
markets and the historical regulatory and policy changes that affect competition in the South African
1 Chapter 4A of the Act, which introduces the powers to conduct ‘Market Inquiries’, came into effect on 01 April
2013 2 Section 2(a) of the Act
3 Section 2(a) of the Act
4 Section 43B(1)(i)
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private healthcare market. This provides the necessary background to understand which features of
the private healthcare market may restrict, prevent or distort competition. The terms of reference
then sets out the type of information the Commission may seek, or questions it may ask; to evaluate
whether the features identified may have an adverse impact on competition and what form that
adverse impact may take. Procedural and administrative aspects of the inquiry are set out in the final
section of the terms of reference.
While these terms of reference do delimit the scope of the inquiry on the basis of preliminary
research, attendant matters not identified here may arise during the course of the inquiry. If the
Commission believes that the terms of reference should be amended in any way; either through the
addition of new matters or exclusion of matters currently identified herein, the terms of reference may
be amended in terms of section 43B(5) of the Act.
Note: This document is solely intended for the purposes of conducting consultations with
stakeholders.
2. Overview of the private healthcare market
This section provides an overview of the private healthcare sector, identifying the key segments of the
market and mapping the interface between these segments. This is followed by an overview of
regulatory and policy changes that have taken place in the healthcare market since the early 1990s.
These legislative amendments changed bargaining mechanisms and tariff determination in the private
healthcare sector. The impact of these changes on price determination and healthcare expenditure
will be carefully evaluated during the inquiry as part of a broader review of the regulatory framework
wherein private healthcare players operate.
2.1. Structure of the Private Healthcare Market
The private healthcare market refers to that portion of healthcare services that are paid for by private
patients themselves, either through medical scheme (insurance) payments or through out-of-pocket
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payments. Key segments of the private healthcare market include healthcare providers; financing,
administration and managed care services; and consumables (as depicted in the diagram below).
Figure 1: Illustration of the private healthcare market5
2.1.1. Healthcare services
According to a recent survey there are approximately 27 641 doctors practicing in South Africa6. This
includes general practitioners and specialists. It is estimated that 10% of all private healthcare
expenditure goes to General Practitioners (“GPs”) and dentists; and 20% to specialists. 7
5 Hodge, J. Fianderio, F. Lynch, S. Mohammed, R. ‘Genesis Analytics Healthcare Background Paper’ (2012),
pg. 2, Paper commissioned by the Competition Commission of SA 6 “Doctor Shortage to hit NHI”, The Sunday Independent, 25 September 2011
7 Council for Medical Schemes Research Brief No. 2 of 2008, Trends in Medical Schemes Contributions,
Membership and Benefits 2002-2006, page 51.
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Primary care providers (specifically GPs and dentists) are independent agents who work for
themselves. They play a vital role in directing patients along the healthcare “chain of care”. In theory,
primary care providers act as “gatekeepers” responsible for making referrals to the right specialists;
ordering further medical tests, or prescribing consumables. However, it has been observed that, for a
variety of reasons, many patients bypass GPs and obtain direct access to specialists even for minor
ailments. This could place upward pressure on healthcare expenditure.
A further feature that complicates the evaluation of costs and expenditure in healthcare markets is
that healthcare providers’ prices are not regulated and are largely determined on a “fee-for-service”
basis.8 Since the demise of the “National Health Reference Price List” process (more on which later),
industry associations or third parties have tried to compile reference price lists for healthcare
services. Although these reference prices often form the basis of pricing decisions, there is still a
perception that providers differentiate between patients; particularly between patients that have
medical aid and those that do not. Patients with medical aid pay for their doctors’ visits out of their
medical savings accounts and often have to supplement this with an additional amount “out-of-
pocket”9 in cases where doctors charge above predetermined medical aid reimbursement rates. 10
Patients are often unaware of the range and difference in tariffs charged by medical practitioners.
This situation may be compounded by certain rules of the Health Professions Council of SA
(“HPCSA”) that prohibit promotional activities by healthcare providers on the basis that it may mislead
consumers or lead to excessive treatment. These restrictions may exacerbate the pre-existing
information asymmetry between consumers and providers.
2.1.2. Hospitals
It is estimated that hospitals account for over 36% of total private healthcare expenditure. The largest
hospital groups, by number of beds, are Netcare Limited, Life Healthcare Limited and Medi-Clinic
Southern Africa. There is no price regulation for hospitals; tariffs are negotiated between the hospital
groups and medical schemes.
8 In healthcare, ‘fee-for-service’ is a payment model where providers receive a fee for each service they offer
(e.g. a separate fee is levied on a doctor’s visit, for prescription medication, and for tests ordered etc.) 9 The phrase “Out-of-pocket” payment is used to denote cash payments made by patients either in addition to
their medical cover, or in cases where patients have no medical insurance. 10
“Reimbursement rates” are the tariffs that medical aid schemes would pay to providers and are colloquially referred to as “medical aid rates”
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There are instances of joint ownership in smaller independent hospitals. Where there is joint control
of independent hospitals, the corporate group tends to take over the management of the independent
hospitals, including the negotiation of tariffs and other arrangements, resulting in independents
implementing the corporate group’s tariffs.
2.1.3. Financing, administration and managed care services
It is estimated that there are approximately 97 registered medical schemes representing both open
(26) and (71) restricted schemes.11 The Board of Healthcare Funders (“BHF”) is an industry
representative body of more than 85% of the medical schemes in South Africa.12 Medical schemes
and administrators are subject to oversight by the Council for Medical Schemes.
The three largest players in the administration sector; Discovery Health (Pty) Ltd, Metropolitan Health
Corporate (Pty) Ltd, and Medscheme Holdings (Pty) Ltd, account for over 70% of the administrator
market based on number of beneficiaries.13 Medical schemes and administrators act as agents on
behalf of the patient.
Managed care arrangements, which can play a pivotal role in finding innovative ways of reducing
healthcare costs and offering lower prices to the consumers, have not been widely used in South
Africa.14 The inquiry will evaluate the reasons for this and whether managed care arrangements may
be beneficial to competition.
11 Council for Medical Schemes Annual Report 2011 – 2012, Table 11: Number of Schemes by size and type as
at December 2011, page 112. 12
Note that although BHF may represent 85% of schemes, this does not translate to the same proportion of beneficiaries. For example, the largest open medical scheme, Discovery Health Medical Scheme, is not listed as a member of BHF according to the BHF website. Date Accessed: 14 May 2013. 13
Council for Medical Schemes Annual Report 2011 – 2012, Table 11: Number of Schemes by size and type as at December 2011page 152 14
Managed care arrangements refer to a more restrictive type of healthcare plan where medical schemes contract with a select group of healthcare providers and facilities to provide care for patients at reduced cost. The select group of providers and facilities make up the health plan’s network that patients can access for care. Often, there are additional out-of-pocket payments associated with visiting a provider or medical professional who does not form part of the network.
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2.1.4. Consumables
Consumables, mostly pharmaceuticals, operate within a highly regulated sector through the “Single
Exit Pricing”15 regime, as well as efforts that enable effective generic competition. There is some
degree of vertical integration where pharmacies are based at hospitals but there are many
pharmacies not linked to hospitals.
2.2. History of the regulatory and policy changes in the healthcare sector
Before 1993 the private healthcare industry was regulated by government through the National Health
Act (“NHA”) and the Medical Schemes Act of 1967 (now the Medical Schemes Act, 131 of 1998).
The regulations covered many aspects of the private healthcare industry, including tariffs that could
be charged by healthcare providers and reimbursement rates for medical aid schemes.
The regulations allowed and promoted “collective bargaining” and co-operation between the medical
schemes and the healthcare providers through their respective associations. These associations
included the Representative Association of Medical Schemes (“RAMS”) (now called the Board of
Healthcare Funders (“BHF”)), the Medical and Dental Associations (“MDA”) (now called the South
African Medical Association (“SAMA”)), and the Hospital Association of South Africa (“HASA”).
RAMS and the MDA were recognised in the Medical Schemes Act as being bodies with an interest in
determining healthcare tariffs for professional services and reimbursement rates for these services.
These tariffs were then gazetted and were binding on the service providers.
Changes to the Medical Schemes Act in 1993 meant that the tariffs determined by the associations
were no longer binding on service providers – thus effectively removing any explicit regulatory
framework for the determination of tariffs. Despite this, the publication of healthcare tariffs by the
medical schemes and provider associations continued as a standard practice. In particular, the new
Board of Healthcare Funders, South African Medical Association and Hospital Association of South
Africa continued to publish tariffs for healthcare services even after the amendments to the Medical
Schemes Act.
In 2002 this conduct became subject to scrutiny by the Competition Commission. By this time the
determination and publication of tariffs by the various associations had become a well-established
15 The “Single Exit Price” is a regulated, uniform price at which pharmaceutical manufacturers must sell to all
private sector providers, regardless of the volume purchased. Under the single exit pricing regime, the mark-ups added by other players in the value chain are also controlled.
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practice in the industry. Pricing in the insured private healthcare sector had largely stabilised around
the tariffs published by the various professional associations. Specifically, there were generally no
significant discrepancies between the prices charged by providers and the reimbursement rates of
medical schemes. The tariffs were applied nationally across all providers and payers. This conduct
amounted to price fixing, in contravention of Section 4(1)(b)(i) of the Competition Act, as confirmed by
the Competition Tribunal.16 Payers and providers were instructed to cease bargaining collectively
through industry associations. This ushered in an era of bi-lateral negotiation of terms between
individual providers and individual payers.
The new model of independent price determination introduced new challenges. Whereas there was
previously general convergence between the prices charged by providers and the reimbursement
rates of medical schemes, these prices now diverged; sometimes significantly. This resulted in
practices such as “balance billing” where patients became liable for out of pocket co-payments to
cover the cost of treatment that exceeded the medical schemes’ reimbursement rates. This
increased expenditure on private healthcare.
In response to these, and other, challenges; the Council for Medical Schemes, with the blessing of
the Department of Health, developed a National Health Reference Price List (“NHRPL”). The
objective of the NHRPL process was to establish a schedule of prices for healthcare services that
would be based on an independent and objective determination of costs. However, the NHRPL
process was unable to effect a reduction in prices as medical service providers could (and did)
deviate from the NHRPL. Medical schemes were forced to condone balance-billing practices so that
beneficiaries could have adequate cover. The NHRPL process was also successfully challenged in
the High Court by HASA, the South African Private Practitioners Forum and others; and the NHRPL
was set aside.17
Past regulatory and policy changes have clearly impacted the competitive processes and market
outcomes in the private healthcare market. The market inquiry will review the impact of the changes
mentioned here more fully, and will make evidence-based recommendations on regulatory or policy
changes that would encourage a more affordable, accessible and innovate private healthcare sector.
16 BHF Consent Order, case number: 07/CR/Feb05
HASA Consent Order, case number: 24/CR/Apr04 SAMA Consent Order, case number: 23/CR/Apr04 17
Decision of the High Court of South Africa, North Gauteng Division, 28 July 2010, Case Number 37377/09.
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3. The Proposed Market Inquiry
Healthcare markets are complicated; they reflect the intersection of various information and incentive
peculiarities that distinguish them from many other markets. The delivery of healthcare is facilitated
by crucial agency relationships,18 especially those between patient and doctor; and patient and
medical funder.19 The functioning of these relationships, and the nature of the incentives faced by
providers and payers in the medical value chain, will determine the eventual price, quality and
innovation outcomes that patients experience.
Various concerns have been raised about the functioning of private healthcare markets in South
Africa because healthcare expenditure and prices across key segments seem to be rising notably
above headline inflation. Explanations put forward are as varied as the information asymmetries and
distorted incentives inherent in healthcare markets, varying degrees of market power at different
levels of the value chain, and changes in utilisation. Given the large number of possible explanations,
there is a need for a thoroughgoing inquiry into the factors that drive the observed increases in private
healthcare expenditure in South Africa. The market inquiry will help to identify the factors driving
increased expenditure as well as the market dynamics at play.
3.1. Rationale for a Market Inquiry
Access to health care services is enshrined in the Constitution of the Republic of South Africa as a
fundamental human right.20 Further, section 27(2) imposes an obligation on the state to take
reasonable measures to achieve the progressive realisation of this right. Private healthcare provision
takes place within the context of this constitutional commitment to the provision of universal health
care services to all people in South Africa. Though it has been argued that the obligation to provide
universal health care access falls only on the state,21 an affordable, innovative and competitive
18 An “agency relationship” refers to a situation wherein one party (the agent) acts on behalf of another party
(often referred to as the “principal”). In an agency relationship, the principal expects the agent to act in their best interest, but the agent has limited influence and understanding to evaluate whether this is the case. 19
In these examples, the patient is the principal and the medical professional (doctor) and payer (medical scheme) act on his/her behalf as agents of the patient. 20
Section 27(a) of the Constitution states that “everyone has the right to have access to health care services" 21
For this debate, see for example, H Cheadle and D Davis, “The application of the 1996 Constitution in the Private Sphere” (1997) 13 SAJHR 44, 59-60.
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private healthcare system could nonetheless form an important part of the progressive realisation of
universal access to health care services.
The market inquiry will probe various segments of the private healthcare market to determine the
factors that restrict competition and underlie increases in private healthcare expenditure in South
Africa. The segments were selected on the basis of the Commission’s preliminary research, as well
as consideration of areas of inquiry that would make greatest impact within the Commission’s limited
resource constraints. The selected segments thus examine the main features that seem to restrict,
prevent or distort competition in the market.
The objective of the inquiry is to identify the factors that affect competition in the private healthcare
market, and to provide a factual basis upon which relevant recommendations can be made in the
interest of a more affordable, accessible and innovative private healthcare market. If the inquiry
uncovers any concerns, evidence-based recommendations will be developed. The inquiry thus
differs from an investigation in that no specific conduct against any particular firm is under
investigation. Instead, the inquiry asks broader questions about the nature of competition in the
private healthcare sector and, through an inquisitorial process, evaluates the factors that may distort,
prevent or restrict competition. The Commission will then propose recommendations on the basis of
information collected through the overarching inquiry into the sector. Moreover, an inquiry represents
an ideal platform to encourage broad public consultation to ensure that the diverse views of the
relevant stakeholder groupings are taken into account.
3.2. Purpose and Objectives
The purpose of the market inquiry is:
To conduct an analysis into selected segments of the private healthcare market, examining
the contractual relationships and interactions between and within the segments and the
contribution of these dynamics to total private expenditure on healthcare;
An assessment of the impact of Commission’s interventions in the private healthcare market,
through enforcement action and merger regulation; and any impact this has had on bargaining
mechanisms and consolidation in the healthcare market;
To inquire into the nature of price determination in private healthcare market in South Africa;
and
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To establish a factual basis for recommendations that support the achievement of accessible,
affordable and innovative private healthcare
The main objectives of the market inquiry are to:
Evaluate the nature of price determination in the private healthcare market with reference to:
- the extent of competition between different categories of providers and payers;
- the extent of countervailing bargaining power between different categories of providers
and payers; and
- the level and structure of prices of key services, including an assessment of
profitability and costs;
Evaluate and determine what factors have led to observed increases in private healthcare
expenditure in South Africa;
Evaluate how consumers access and assess information about private healthcare providers,
and how they exercise choice,
Make recommendations on appropriate policy and regulatory mechanisms that would support
the goal of achieving accessible, affordable, innovative and quality private healthcare;
Make recommendations on whether price-setting mechanisms may be acceptable within the
competition policy context; and
Make recommendations with regard to the role of competition policy and competition law in
achieving pro-competitive outcomes in healthcare, given the possibly distinctive nature of the
market.
3.3. Subject Matter of the inquiry
The inquiry will examine the topics outlined above, with a focus on the following segments of the
private health care market: healthcare providers, hospitals, medical aid schemes, medical aid
administrators and medical aid brokers. 22 The inquiry will cover, amongst other things, the following
core issues in each sector:
22 The inquiry will not focus on emergency services, consumables and pharmaceuticals.
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3.3.1. Healthcare providers (Primary Care and Specialists)
Tariff Setting Understanding the pricing regime after the Commission’s
decisions in 2003 and the NHRPL process
An assessment of how providers set tariffs and the role of
industry reference price lists
An examination of the extent to which co-payments are
applied in the sector
Referral Process An analysis of the relationships between primary
healthcare providers and specialists
The role of primary care providers as gatekeepers in the
referral process of patients
Relationships with
hospitals
The relationship between hospitals and specialists, how
they operate and access operating rooms and facilities at
hospitals
HPCSA Rules The impact of the HPCSA restrictions, such as the
restrictions on promotional activity and employment of
medical professionals by hospitals
3.3.2. Hospitals
Price setting and cost
analysis
Determine how tariffs are set, i.e. fee-for-service vs.
alternative reimbursement models
The extent of risk sharing between hospitals and funders
in price setting
An analysis of hospital costs
Expenditure on
technology
An analysis of trends in investments and expenditure on
hospital (medical) technology
Review on
concentration and
profitability
An analysis of profitability of hospitals
A review of the trends in consolidation and impact on
profitability
Role of independent
entrants and the
licensing regime
A review of the role of independent entrants
Analysis of the number of hospitals licensed over time
and impact on entry
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3.3.3. Medical Schemes, Administrators, Brokers and Managed Care
Fee and benefit
determination
An assessment of how benefits are determined and the
impact of the Prescribed Minimum Benefit legislation
An assessment of how fees, including contributions and
administration fees, are determined
Relationships between
medical schemes,
brokers, and
administrators
Understanding the nature of incentives in these
relationships and impact on costs i.e. administration cost
Outcomes of Managed
care and cost saving
initiatives such as
Designated Service
Provider arrangement
Evaluating the use and outcomes of managed care and
the overall impact on costs
The extent to which potential efficiencies and savings are
passed on to consumers
3.4. Methodology
The market inquiry will comprise an inquisitorial process of public hearings together with the review of
secondary material. The process of inquiry will be supported by information requests to and
consultations with companies, associations and any other stakeholders that may be required to
provide information on the subject matter of the inquiry.
It is envisaged that a panel of three experts, including an internal chairperson designated by the
Competition Commissioner, will preside over the hearings. The panel will be responsible for presiding
over the hearings, reviewing submissions, examining evidence, and overseeing the drafting of the
inquiry report and recommendations. The panel of experts will be supported by a team of researchers
and analysts who will produce position papers based on their review of secondary materials and
submissions by parties to the inquiry. The support team will also assist the panel with hearings and
the writing of the inquiry report.
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3.5. Stakeholders
Stakeholders in the private healthcare sector include specialists and other practitioners; hospital
groups; independent hospitals, clinics and other private hospitals; medical funder and administrator
groups; government departments; statutory bodies; civil society; contributors to medical schemes and
consumers of healthcare services.23
The main participants in this inquiry will be the providers (hospitals, medical practitioners), third party
payers (medical schemes, administrators and brokers) and their representative industry associations.
These participants will be the primary source of information on the subject matter of the inquiry. It is
also anticipated that the relevant government departments (e.g. Department of Health) and statutory
bodies (e.g. Health Professions Council of SA and the Council for Medical Schemes) will be a useful
source of information. They are important stakeholders as many of the matters arising in the inquiry
may well result in recommendations for their consideration or action. Given the importance of
accessible, affordable and innovative healthcare for the welfare of South Africans the proposed
inquiry will also have significant implications for representatives of civil society and consumers of
healthcare services generally.
3.6. Proposed Market Inquiry Process
The process set out below is merely a high level overview of the phases of the inquiry and is based
on the information currently available to the Commission. It is merely indicative and is likely to go
through a number of iterations of improvement and refinement before being finalised. The
Commission will publish a final administrative calendar and guidelines for the administrative process
to be followed during the inquiry, at least 20 working days prior to the launch of the inquiry.
3.6.1. Launch
It is envisaged that the inquiry will launch in the second quarter of 2013, but before the end of
September 2013. In the run-up to the launch, the terms of reference will be discussed with relevant
stakeholder groupings as identified above.
23 Note that this list may not be exhaustive.
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3.6.2. Public Hearings
The objectives of having public hearings are twofold:
- To allow a wide range of stakeholders the opportunity make submissions and discuss
pertinent issues
- To obtain answers and gain clarity on key issues within a public forum
With the above objectives in mind, it is considered prudent to hold two sets of hearings. The first set
of hearings will be inclusive, allowing a broader group of stakeholders to make public submissions.
The second set of hearings would be more inquisitorial and pointed in nature and would take place
later in the inquiry, when there has been a narrowing of issues to probe by the panel and inquiry
support team. These hearings would be more focused, involving a limited number of identified
stakeholders whose input is required to address the issues identified.
3.6.3. Estimated Timeline of the Market Inquiry
It is estimated that the market will commence in the second quarter of 2013, but by no later than
September 2013 and will issue its draft recommendations in December 2014. Final recommendations
will be issued no later than 30 June 2015.
3.6.4. Human Resources
It is proposed that the inquiry be led by a panel consisting of a chairperson and co-chairs. The
chairperson should be someone within the executive management of the Competition Commission.
The panellists would be experts of high standing. They are likely to be industry experts, such as a
health economist, health policy/health systems expert or a legal expert.
The panel will be supported by an inquiry technical support team led by an inquiry manager reporting
to the Chairperson of the inquiry. The Chairperson of the inquiry reports to the Competition
Commissioner.