PPU NEWS

Newsletter to Private Practice Committee Members
Volume 1, Issue 2 August 2005

UPDATES ON ACTIVITIES OF THE PRIVATE PRACTICE UNIT
NATIONAL HEALTH CHARTER

SAMA submitted comment on the draft Charter for the Public and Private Health Sectors on August 15 at two levels. Firstly as part of a consolidated submission by the Private Healthcare Forum and, secondly, as a separate submission in which the issues that are specific to the profession were highlighted. The Department of Health began hearing industry presentations on the draft Health Charter on 25 August and the Association was invited to present on the same day. The SAMA submission was positively received and a further submission was made upon request from the Ministerial Task Team.

The crux of the SAMA submission and presentations was that further engagement on the achievement of the objectives of Access, Equity and Quality is required. In addition to this, the achievement of the BB BEE targets are dependent upon the output of previously disadvantaged medical professionals by the various academic institutions.

The PHF was invited to do its oral presentation on 30 August and presented on the following:

  1. The charter process going forward
  2. Scope and application of the Charter
  3. Alignment with BB BEE Act and DTI Codes
    • Across sectors
    • Scorecard Issues
      • Ownership
      • Procurement
      • Human Resources
  4. Access, Equity and Quality

NATIONAL HEALTH REFERENCE PRICE LIST 2006)

A number of meetings with the CMS have been held during the past few weeks. The purpose of these meetings was largely to discuss the submissions for changes to the Doctor’s Billing Manual for 2006.

The main areas of changes for 2006 are the following:

  1. The restructuring of the structure for consultative services;
  2. The introduction of a new structure for anaesthetics; and
  3. Specific items pertaining to, amongst others ENT, endoscopic procedures and pathology.

Despite the fact that not all items were accepted, it is believed that the process was constructive and that many positive outcomes have been achieved. It is also becoming increasingly clear that the current process is entirely different from the erstwhile BHF process and that a much more factual approach is being adopted. This approach will require an increasing amount of detailed prior research and preparation, which will, in turn, become increasingly resource intensive.

The CMS is demonstrating a clear commitment to the objectives and requirements that were outlined in the by now infamous Circular 8 and it can be expected that those principles will be applied more strictly in the future.

Only two groups, namely the anaesthetists and the psychiatrists, have provided practice cost studies and we are anxiously awaiting the CMS response to those.

COUNCIL FOR MEDICAL SCHEMES (CMS)

The CMS is currently undergoing an operational restructuring and as a result the responsibilities of some of the functionaries are changing.

Regrettably this has led to a placing on hold of the regular meetings of the Technical Committee between SAMA and CMS. It is hoped that these meetings will recommence soon.

MEDICAL ADVISORS GROUP (MAG) ANNUAL CONFERENCE

The Medical Advisors Group annual congress was held on 28-19 July 2005 at Monte Casino, Johannesburg. The purpose of the conference was to discuss “Outreach to the Profession” and a declaration of intent was created by MAG. The following issues were discussed:

  • The differences between the two groups in regard to their frame of reference and the fields in which they have to function.
  • Lack of understanding of Medical disease
  • Peer to peer problems.
  • Dual loyalties within MAG.
  • Availability of Med Advisors.
  • The lack of transparency in decision making.
  • The marketing against the Medical Profession.
  • Ethical dilemmas in the Private Funding Industry are not addressed by Med Adv.
  • A lack of communication between Med Advisors and well informed doctors to advise the funders accordingly. They accept that the Group representatives should be consultants panelists, rather than ad hoc individuals.
  • Evidence based medicine still has unanswered questions.
  • There exists a deep rift between the clinicians and the MAG.
  • Doctors treat individual patients. The MAG evaluates the interests of all patients in the scheme, and thus, the decisions will only take the interests of the larger group into account.
  • Benefit packages were discussed at length. It was agreed that several are inappropriate. The Specialists groups' input is essential into the design of benefit packages.
  • Input from PPC for general advice and Specialist specific advice via the Specialist groups and super specialist groups is needed.
  • Concerns were raised whether Specialist groups EXCO’s do represent specialist groups ,versus the business entities like Spesnet, Surgicom, Healthman and others. There is now a clear understanding of the role of these other entities.
  • Funders use algorithms for Pre-authorisations. There is a huge need for groups to influence the process, by creating their own guidelines and communicating those, after Peer review, for acceptance by Med Schemes.

The end result of the discussion was the creation of a communication channel between the SAMA Private Practice Committee and MAG.

MEDICAL SCHEME FOR LOW INCOME GROUPS (LIMS) PROCESS FOR 2005

This project has the objective of creating a “stepping stone” between the current medical schemes environment and the implementation of Social Health Insurance (SHI). The intention is therefore to investigate the changes, if any, that would be required in order to enable people with an income of between R3 000 and R6 000 to access the existing medical schemes environment.

There are currently three main working groups that are conducting this investigative process, namely:

  2. A “Supply Side” working group that is looking at the various issues pertaining to the delivery of healthcare to this group of patients, including alternative delivery and reimbursement models.
  3. A “Governance and Benefit Design” working group that is looking at a restructuring of the benefits designs, including possible changes to the existing legislation that may be required.
  4. A “Demand Side” working group that is looking at the needs or perceived needs of the target population. To this end a household survey is currently underway.

Although no specific reports or points of view have to date been released, a lot of discussions are taking place.

The profession is for numerous reasons a key stakeholder in this process, which makes it critically important that it is represented at as many as possible of the forums mentioned above.

COID

A meeting has been held between senior officials from the Compensation Commissioner’s office and a SAMA delegation. At this meeting the Commissioner’s office did provide undertakings to establish a regular forum with SAMA and to expedite the payment of outstanding claims.

Regrettably none of these have materialised and a follow-up letter has been sent to the Commissioner in this regard. In addition, this matter will be placed on the agenda for the next SAMA Board of Directors meeting, in order to get a clear mandate on a way forward.



The implementation of the compulsory submission of ICD-10 codes on all accounts for services rendered and procedures performed is continuing, albeit through a phased process.

The various issues that have been raised by SAMA in this regard remain unaddressed and a legal opinion on specifically the issues pertaining to patient confidentiality has been obtained. The crux of this opinion is that confidentiality and privacy is an issue.

A request will now be forwarded to the Medical and Dental Professional Board of the HPCSA for this matter to be placed on their agenda.

CERTIFICATE OF NEED

Chapter 6 of the National health Act of 2003 has still not been promulgated, meaning that the legislation pertaining to the Certificate of Need has not yet been passed.

A process through which a position paper on this matter is being developed is underway within SAMA. The objective of this process is to attempt to pre-empt the promulgation of legislation in this respect.

DEPARTMENT OF HEALTH HUMAN RESOURCES POLICY

The Department of Health has recently launched a draft policy on Human Resources in the South African health sector at large. This draft policy is currently open for comment and the closing date for these comments is September, 15 2005.

The document is currently being studied from a private sector perspective and draft comments will be distributed shortly.

GENERAL

The new Secretary-General of SAMA has taken up office on August, 15 2005 and Ms Maliga Pillay has also returned from maternity leave. It is therefore hoped that the focus on the various matters pertaining to the members of SAMA that are in private practice will be regained swiftly.