Board to fight doctors’ ‘greed’

2013-09-13 00:00

HEALTHCARE pricing had foolishly been opened to ruthless competitive forces because there is no tariff list to determine overcharging.

This challenge from the South African Medical Association (Sama) comes in the wake of the Board of Healthcare Funders (BHF) vowing to take the fight for fair pricing of health services all the way to the Constititional Court if necessary. They claim patients are being forced to cough up for inflated doctors’ bills.

But Sama yesterday hit back at the BHF, which represents most medical schemes. The spat follows the findings of a study by the Health Monitor Company, which revealed that some medical specialists have been overcharging for prescribed minimum benefits (PMBs) in an alleged abuse of the healthcare system.

PMBs are a list of about 300 serious health conditions, including tuberculosis and cancer and chronic conditions that medical schemes have to pay for in full, according to the Medical Schemes Act.

In his study reported in City Press,Health Monitor Company CEO, actuary Christoff Raath, revealed that 40% of the largest anaesthetist practices in South Africa are charging more for their services when surgery is a PMB. He found that general surgeons’ accounts submitted to medical schemes between January 2010 and July 2013 increased dramatically when a procedure related to a PMB.

According to the study, a KwaZulu-Natal psychologist had submitted accounts showing he had worked 56 hours a day, consulting every patient in one hospital. And in another case a dietician had submitted accounts reflecting that she had consulted for 100 minutes with several patients 50 to 70 times a month.

Reacting to the findings, BHF CEO Dr Humphrey Zokufa said it was “no surprise” that specialists were overcharging because the health system “incentivised” doctors to charge exorbitant prices. He said the “greed” was a result of the Council for Medical Schemes’ interpretation of Section 8 of the Medical Schemes Act that schemes must pay in full for PMBs at the price doctors invoice.

“As medical schemes we can’t be in a situation where we pay whatever a provider charges as we would be recklessly using members’ money. The providers are not regulated at all in terms of what they can charge,” Zokufa said.

Zokufa said the BHF would challenge section 8 of the Medical Schemes Act in the Gauteng North High Court, and in the Constitutional Court if necessary, on the grounds that patients’ rights to accessible and affordable healthcare were being infringed.

Zokufa said pricing of PMBs needed to be regulated and capped.

According to the CMS annual report, payments to medical specialists rose 12,9% and accounted for R24 billion or 23,3% of benefits paid in 2012. Expenditure on private hospitals accounted for R37,6 billion, an increase of 11,1% since 2011.

The CMS said in its report that expenditure increases on private hospitals and specialisits “continues to be very high”, indicating an urgency to regulate prices.

However, Sama’s specialist private practice committee chairperson, Dr Meshack Mbko­ta, said doctors were the “scapegoats” as healthcare had been opened to competitive forces after the Competition Commission banned pricing negotiations between doctors and medical schemes, and in 2004 fined Sama R4,5 million for price fixing, prohibiting it from publishing recommended tariffs.

This was followed by the scrapping of the HPCSA’s Ethical Tariffs in 2008 and the removal of the National Health Reference Price List. “The baseline for what an average fee is has disappeared because health was made a commodity subject to competition,” Mbko­ta said.

He added that medical schemes should be investigated for their spending of R10,2 billion in 2012 on brokers and administrative expenses, which siphoned member funds away from health benefits.

Competition Commission deputy commissioner Trudi Makhaya said “matters related to PMBs and the billing practices of specialists and hospitals” would be evaluated during its market inquiry into private healthcare.

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