On 24 February 2016 the Health Market Inquiry heard presentations from the South African Medical Association (SAMA), the South African Society of Anaesthesiologists (SASA) and the South African Optometric Association (SAOA).
According to SAMA, one of its main functions is to administer and publish procedural codes which are used throughout the medical field. In a broad-ranging discussion with the Panel, SAMA admitted that its coding system was imperfect in that it is based on the US system which considers incomparable factors. Nonetheless the organisation had encountered regulatory impediments in its objective to develop a South African coding system. SAMA emphasised that there is a regulatory gap in setting prices for medical services and that the regulators had not engaged the organisation effectively in a dialogue about fees.
SAMA reiterated concerns raised by other practitioner organisations that medical schemes are forcing doctors to be ‘price takers’, who charge patients what schemes are willing to pay. This results in co-payments because what schemes are willing to pay does not reflect the value of the service provided. A connected concern for SAMA is the preferred provider network, which restrains the fee practitioners can charge and consequently doctors are providing the health care services as determined by the schemes, and not necessarily the best care for their patients. The Panel suggested that one of the positive factors of the network may be that its members can charge higher rates for their services. However, SAMA disagreed asserting that the fee may sometimes work out to be less.
SAMA argued that a system which requires patients pay to upfront for healthcare and are later refunded by the schemes, creates a barrier to access as some people cannot afford to pay fees upfront.
SAMA submitted that the certificate of need is an insufficient means to address the issue of the concentration of practitioners in urban centres because there is a scarcity of skills. In other words, they cannot ‘move people who do not exist’. The solution should be focused on creating a sustainable and attractive health profession and sector. In response to a question from the Panel on how skills shortages were compounded by the issue of patients seeing specialists for primary health care needs, SAMA recognised that a tariff for primary health conditions, applicable to both GPs and specialists, may be the route to take.
Additionally, SAMA was asked about PMB training for its members. SAMA refuted the claim that doctors were not informing patients of relevant PMB conditions. SAMA stated that the large number of complaints about PMBs lodged with the Council for Medical Schemes was indicative of the fact that problem did not lie solely with the practitioners and that schemes should not be ‘let off the hook’. Even though the issue of PMBs needs to be addressed by both the profession and funders, the population needs to be aware of their entitlements and as such, SAMA offers courses across the country to educate people about their entitlements in the private health system. SAMA said its members participated in continuous professional development focusing on ethical responsibilities, and it frown upon practitioners who do not inform patients about the care that they are receiving, what their options for care are and the cost implications.
The South African Society of Anaesthesiologists (SASA) criticised the HPCSA saying the regulator is ‘at best, dysfunctional’ and that the profession needs a better structure that can provide adequate guidance to the profession. SASA advocated for a benchmark fee, arguing that it would help set a fair tariff because there is too much confusion in the sector about fees.
SASA noted that health services are also regulated by the Consumer Protection Act which provides that practitioners should provide patients with information relating to the procedure and the cost of services. SASA echoed the sentiments of other practitioner groups, saying that the focus of medical services had shifted to non-medical considerations because of the funders. The Panel referred SASA to the OECD study presented last week at the Inquiry, which states that while there is a high admission rate, the length of hospital stay was comparatively short in South Africa. SASA accepted that funding affected the time patients spent in hospital.
SASA also complained that PMB requests for funding of conditions were routinely processed only 120 days later and that this forced patients to pay out of pocket and essentially lose out on a benefit for which they had paid.
The South African Optometric Association (SAOA) suggested that certain DSP arrangements amounted to an abuse of dominance.
SAOA was asked about its view on the employment of specialists by hospitals, which is currently not allowed by the rules of the HPCSA. SAOA was concerned about the employment of doctors specifically because the three large hospital groups in particular are publicly listed companies and have obligations to their shareholders. Whereas doctors have important ethical obligations towards their patients.
IsoLeso Optics Ltd took issue with the multiplicity of coding structures and the limited PMB coverage for optical needs.
On 25 February 2016, the inquiry continues with the HPCSA, regulator of the health profession. There has been much criticism of the HPCSA during the course of the hearings so far and it will be interesting to see how the discussion between the Panel and the regulator unfold. Follow us on twitter @SECTION27news for updates.
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