Cough up more: Medical fund contributions rise, benefits decline

In the first quarter of 2025 alone, medical aid funds reported a combined surplus of N$229.7 million – all while patients bear higher out-of-pocket expenses and doctors struggle to keep their practices sustainable.The CEO of the Namibian Private Practitioners Forum (NPPF), Dr Jürgen Hoffmann, says members are paying more but receiving less.“The public needs to understand that fund contributions increase every year, but benefits either decline or remain static,” he said.As examples, Hoffmann referred to the Namibian Association of Medical Aid Funds (Namaf), which between 2022 and 2025 reduced the so-called ‘additional hospital benefit’ by 33%, cut rates for daily hospital management by doctors by 30%, emergency and 24-hour services by 30%, and anaesthesia by 27%. “In 2025, the Namaf fee for a medical emergency call (for transport and consultation) is N$741.60 – less than a plumber's call-out fee, and that’s before any service is rendered.”In practice, Hoffmann says, this system shifts the cost burden to fund members while the funds accumulate surpluses.He pointed to benchmark tariffs, which he argues justify lower reimbursements even when the actual costs are higher.Namaf – with whom the NPPF has been embroiled in a dispute for years regarding its role in setting tariffs – earlier referenced the High Court case of Namaf and Others vs the Namibian Competition Commission (2017) in a full-page advert. The court confirmed the purpose of the tariffs is to serve as a guide to the reasonable cost of healthcare. According to Namaf, the tariffs are not prescribed and may be used by a fund to determine reimbursement levels for claims. Namaf states the tariffs are determined through a systemic approach focusing on relative value units (RVUs) and monetary conversion factors.Lack of transparencyHoffmann, however, says the reality is quite different. The last independently verified cost model dates back to 2003.“Since then, no transparent methodology has been made public. Inflation, medical technology, and practice costs have risen drastically, yet tariff adjustments remain opaque and inconsistent, based on internal calculations without public input.”Namaf, however, refers to the tariffs as a “flexible system” that adapts to changes in healthcare practices and costs. In a media release earlier this year, Namaf said the system is updated at least once annually through a process that includes submissions from, among others, service providers.“Namaf reviews and adjusts standard tariffs annually to reflect changes in healthcare costs and procedures,” their statement, published as a full-page advertisement, said.The updates are also informed by public data such as inflation rates and provider input. Namaf further stated that service providers may request further changes if they can prove their costs have risen significantly beyond standard factors, ensuring that tariffs remain aligned with evolving market costs.However, Namaf cannot negotiate tariffs collectively with providers, as this would amount to price-fixing by service providers.Hoffmann says the claim that providers are free to set their own rates is misleading.“If the standard tariff does not cover the actual cost, the patient must cover the difference. Practitioners are then falsely accused of being ‘greedy’, while the system itself fails to fulfil its obligations,” Hoffmann said.Regarding co-payments, Namaf says that although tariffs offer a point of reference, the actual cost to members depends on both the benefit structure of their medical fund and the provider’s fees.According to Hoffmann, the true aim of the tariffs is to limit fund costs, to the detriment of doctors and patients.“By tying payouts to low tariffs, funds limit the compensation for medical services. Practitioners, who face rising costs and under-compensation, are forced to charge above these tariffs. The result is a gap between what the fund pays and what the provider charges – with the difference, the so-called ‘co-payment’, coming directly from the patient’s pocket.”No statutory mandateHoffmann also claims that Namaf has no statutory mandate to determine the tariffs, arguing that the outdated tariff model undermines access to private care, reduces the value of coverage, and threatens the sustainability of private practices in Namibia.According to him, Namaf is a legal entity created under the Medical Aid Funds Act to monitor medical funds and is funded and influenced by the same funds it supposedly advises.As an institution, Namaf maintains that the constitutionality of its authority to regulate medical aid funds by setting benchmarks that serve a legitimate public interest is found in sections 10(3) and 12 of the Medical Aid Funds Act, read in conjunction with regulations 5 and 6.

Cough up more: Medical fund contributions rise, benefits decline

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Namibian Sun 2025-11-03

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Cough up more: Medical fund contributions rise, benefits decline

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Namibian Sun 2025-11-03

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