The’a’im of this ex­er­cise is to make pri­vate healthcare af­ford­able for all those who want it

Health pro­fes­sion­als and as­so­ci­a­tions threaten court ac­tion over health min­is­ter’s ‘price-fix­ing’

CityPress - - News - ZINHLE MAPUMULO zinhle.mapumulo@city­press.co.za see graphic).

Doc­tors across the coun­try ac­cused Health Min­is­ter Aaron Mot­soaledi of price-fix­ing this week. Doc­tors and their pro­fes­sional as­so­ci­a­tions have threat­ened to go to court to chal­lenge the pro­posed amend­ments to reg­u­la­tion 8 of the Med­i­cal Schemes Act, which Mot­soaledi gazetted last Fri­day and which will see med­i­cal aid schemes pay­ing doc­tors far less than they earn at present.

Reg­u­la­tion 8 com­pels med­i­cal schemes to pay in full what­ever the doc­tor charges for di­ag­nos­ing and treat­ing 300 com­mon med­i­cal con­di­tions on the list of pre­scribed min­i­mum ben­e­fits (

But Mot­soaledi wants this reg­u­la­tion to be amended to re­quire med­i­cal schemes to pay up to a cer­tain amount that will be based on the 2006 price list, which has been ad­justed for in­fla­tion.

What this means is that med­i­cal schemes will pay doc­tors ac­cord­ing to a price list for­mu­lated about 10 years ago – which doc­tors say has no re­gard for their in­creased over­heads, which have es­ca­lated as a re­sult of ad­vances in med­i­cal tech­nol­ogy – and if there is a short­fall, pa­tients will have to dig deep into their pock­ets.

Natalie Zim­mel­man, CEO of the SA So­ci­ety of Anaes­the­si­ol­o­gists (Sasa), said: “Re­quir­ing med­i­cal prac­ti­tion­ers to charge a set rate would be in vi­o­la­tion of the reg­u­la­tions of the Health Pro­fes­sions Coun­cil of SA and the Con­sti­tu­tion, and would amount to price-fix­ing by the gov­ern­ment.

“While Sasa does not op­pose price bench­mark­ing ex­er­cises, such prices must be based on fact and re­late to the ac­tual cost of the ser­vice.

“If this reg­u­la­tion is passed as is, we are likely to ap­proach the courts be­cause the North Gaut­eng High Court de­clared the Na­tional Ref­er­ence Price List [which was based on the 2006 price list] null and void in 2010,” she said.

The SA Med­i­cal As­so­ci­a­tion (Sama) also didn’t rule out the pos­si­bil­ity of tak­ing the mat­ter to court.

Dr Mark Son­derup, spokesper­son for doc­tors in pri­vate prac­tice at Sama, said they were not at all happy with the pro­posed changes.

“It is too early for us to say that we will take the mat­ter to court. We will re-eval­u­ate our po­si­tion when the time comes, but we hope that san­ity will pre­vail,” he said.

Among Mot­soaledi’s amend­ments to the Med­i­cal Schemes Act is one that en­ti­tles med­i­cal schemes to choose to ne­go­ti­ate higher tar­iffs with healthcare prac­ti­tion­ers to pro­tect their mem­bers from co­pay­ments.

How­ever, Zim­mel­man said this im­plied that pa­tients would po­ten­tially be li­able for higher co­pay­ments.

But Dr An­ban Pil­lay, head of reg­u­la­tion and com­pli­ance at the na­tional health depart­ment, told City Press that doc­tors have mis­in­ter­preted the pro­posed amend­ments.

“Many say that the amend­ment will have neg­a­tive im­pli­ca­tions on pa­tients, but that is not true,” Pil­lay said.

“The aim of this ex­er­cise is to make pri­vate healthcare af­ford­able for all those who want it. Cur­rently, med­i­cal aid premi­ums are very high be­cause schemes op­er­ate on an ope­nended li­a­bil­ity when it comes to pre­scribed min­i­mum ben­e­fit claims.”

Pil­lay said that un­til now, reg­u­la­tion 8 has given doc­tors carte blanche to charge what­ever they like.

“This has re­sulted in some doc­tors abus­ing the sys­tem, forc­ing med­i­cal schemes to in­crease premi­ums to be able to meet es­ca­lat­ing pre­scribed min­i­mum ben­e­fit claims,” he said.

Zim­mel­man dis­agreed, though, say­ing: “While it’s true that some prac­ti­tion­ers abuse the sys­tem, most doc­tors do things by the book and charge rea­son­able rates based on the scope of work they have done.”

Son­derup agreed, say­ing: “The min­is­ter seems to have been ill-ad­vised in this mat­ter. The pa­tients who he says he is pro­tect­ing will be the worst af­fected by this. Un­der the pro­posed amend­ments, med­i­cal schemes will pay out less than their own ben­e­fit sched­ules and the pa­tient will have to cover the short­fall.”

How­ever, Pil­lay dis­missed these claims, say­ing: “Med­i­cal schemes al­ready have set des­ig­nated ser­vice providers, and if a mem­ber uses these providers for any pre­scribed min­i­mum ben­e­fit con­di­tion, there will be no need for ad­di­tional pay­ments.”

Des­ig­nated ser­vice providers are net­works of doc­tors who have con­trac­tual agree­ments with med­i­cal schemes to charge a cer­tain rate. This means that if a pa­tient goes to a pre­ferred provider net­work, the scheme will pay for the treat­ment in full.

“But if a pa­tient chooses not to use a scheme’s net­work, they will have to in­cur the ex­penses of ad­di­tional pay­ments. What the public must un­der­stand is that if doc­tors con­tinue to charge what­ever they want, schemes will be forced to in­crease premi­ums to such a point that many would not be able to af­ford it,” Pil­lay said.

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