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’
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.