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Edition Two :: May 2019
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Industry Update

Fraud, malpractice, burnout and divisions rise to the fore.

The election being top of mind, little appears to have been said about healthcare prospects in the run-up other than the usual and not unexpected ruling party pronouncements that National Health Insurance (NHI) is the only way to go and it will definitely happen despite its detractors.

But will it?

The now almost concretised question “where will the money come from” took on a new dimension during a mid-March seminar when noted medico-legal expert, Donald Dinnie, predicted that NHI would be “stillborn” due to the amount of medico-legal claims faced by the Department of Health.

What had to be avoided, he said, was a situation where billions of rands were taken from the health budget annually to resolve the medico-legal claim debt - an eventuality which would mean that money would not be spent on delivering and improving healthcare quality and facilities thereby creating a spiral of ongoing claims “which the public sector will have difficulty in escaping”.

Legal issues were also very much to the fore a fortnight earlier when a Council for Medical Schemes (CMS) Fraud, Waste and Abuse Summit culminated in the launch of an Industry Charter, key objective being a national commitment to reduce fraud, waste and abuse “to improve efficiencies while ensuring transparency across the healthcare system”.

The enormity of the problem was reflected in a plethora of incidents and statistics reported on and reflected during the event, not least the opening address revelation that the funding industry was losing more than R25bn, or approximately 15% of all claims annually due to fraud, waste and abuse.

Interestingly, the Department of Health was among the first stakeholder signatories to the charter, followed by Council for Medical Schemes (CMS), Healthcare Professions Council of SA, Pharmacy Council of SA, Board of Healthcare Funders, and Healthcare Funders Association, among others.

Still debating on whether to sign or not (at the time of writing) was the SA Private Practitioners Forum (SAPPF) which has publicly expressed its concern about the “unilateral” nature of the charter. In a late March notice to members the SAPPF explained that concerns remained around the charter focusing on provider fraud, waste and abuse, “but does not acknowledge that there is also waste and abuse in the administration of medical schemes and in managed care processes.”  This still needed to be discussed by the forum leadership to determine whether the body will support the initiative.

A “side-attraction” of the CMS Fraud, Waste and Abuse Summit, certainly from a media viewpoint, was the “irony” of the council holding a fraud summit when the organisation itself was being investigated following fraud and corruption allegations facing its own Manager of Compliance and Investigations, Stephen Mmatli.

The CMS handed the case over to the Special Investigations Unit (SIU) whose head, Adv Andy Mothibi, told media representatives at the Summit press conference at which the CMS was asked to comment on the irony, that the SIU was encouraged by the action taken by the CMS and “must be seen as a commitment on the part of the CMS, something we would expect from other state institutions as well”.

The CMS Summit, no doubt, enjoyed the stakeholder fall-out benefit of industry focus with the postponement of the three Health Market Inquiry (HMI) preliminary report/recommendations-based seminars on market concentration and supply-induced demand for stakeholders, scheduled for the same week.

They eventually took place during the second week of April, giving the likes of Discovery, Medscheme, Mediclinic and the SA Medical Association (SAMA) the opportunity to have their say on some the HMI recommendations in question.

While the HMI responses should be released soon in light of its 30 September final report deadline, specific stakeholder comments of note will have included Discovery’s contention that the “HMI has overstated supply induced demand and understated demand side effects”.

The company’s CEO, Dr Jonny Broomberg, broached the subject briefly at a medical specialists’ seminar in March when discussing the HMI panel’s proposal of a bargaining chamber to settle funder/provider tariff negotiation issues. This, he warned, was potentially risky as problems would arise when there was no agreement and a maximum rate set by the proposed bargaining chamber would be enforced. He added that such a process would have to be watched carefully as “we can’t control what’s going on in the bargaining chamber”.

What was really needed for the effective control of tariff negotiations, he concluded, was a whole new bureaucracy: But would that ever see the light of day, he asked…

Bearing the brunt of tariff control shortcomings for decades now have been the GPs - still wallowing around 6% of the provider income pie. By their own admission, GPs, or family practitioners as they are now designated, have failed to counter these largely due to divisions within their own ranks.

Led by SAMA’s Private Practice department and chaired by none other than former SAMA chair and Northern Province MEC for Health, Kagiso GP Dr Norman Mabasa, a new body with a “just one voice” objective, the Family Practice Unity Forum (FPUF), is reaching the final stages of formalisation to remedy the fragmentation problem.

One of the GP bugbears the FPUF plans to tackle head-on is medical scheme contracts, to reverse the roles of doctors and medical schemes in the drawing up of contracts by enabling the doctors to draw up the contracts with the schemes themselves.

To conclude on a more personal issue facing the country’s medical practitioners: the growing incidence of burnout and its consequences raising concerns throughout the medical world. Doctors, past president of the South African Society of Psychiatrists (SASOP), Prof Bernard Janse van Rensburg, said in an early April statement, are 2.5 times more likely to commit suicide than the general population, while physician burnout is a leading cause of medical error.

Encouraging to note, therefore, that SAMA and SASOP have joined forces to assist healthcare professionals in dealing with mental illness and occupational, professional and personal difficulties, to create an environment conducive to professional exchange and debate, networking and support, and importantly, to develop strategies to de-stigmatise mental illness in the healthcare profession.

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