If GPs are contracted in to a medical scheme network, they might be pressurised to recommend cheaper treatment options and medications, say SA health bodies.
The Board of Healthcare Funders (BHF) and the IPA Foundation (IPAF) is extremely concerned at the comments made recently by the Health Professions Council of South Africa concerning Designated Service Providers (DSPs).
The HPCSA recently released a statement to the effect that healthcare practitioners should be cautious when concluding designated service provider (DSP) agreements with medical schemes as the medical schemes attempted to reduce costs by applying pressure on practitioners within a DSP network to prescribe medication or recommend treatment options, when other more appropriate, albeit more expensive, options were medically indicated and readily available.
Pushing healthcare costs down
In the current environment where there are no regulated tariffs for healthcare procedures, the ability for medical schemes to contract with DSPs is an important mechanism to moderate the uncertainty relating to cost of healthcare. Without this, medical scheme patients could be faced with unaffordable co-payments which will impact on their access to quality health care. DSP contracted providers agree to service patients within defined parameters and costs.
Medical scheme formularies (the list of medicines covered by schemes) are compiled in consultation with healthcare practitioners in order to manage efficiency and to ensure that the healthcare rand is optimally spent. The formulary does not dictate what a doctor may prescribe but is a guide as to what will be covered by the scheme.
The IPA Foundation supports responsible contracting between doctors in DSPs and schemes, based on widely accepted principles of fair competition, and embracing the “any willing provider” concept. Registered providers voluntarily subject themselves to peer profiling, peer review and mentoring, all of which are based upon the highest quality assurances, combined with reduction of unnecessary, and often wasteful down-stream costs. In return for this behaviour the providers qualify for an enhanced remuneration fee.
The IPA Foundation is attuned to both over-servicing, and under-servicing and is committed to the elimination of both together with the delivery of the highest quality medical services at all times by its GP supporters.
Both parties fully identify with the cautionary offered by Regulation 7(3) of the Ethical Rules of Conduct for practitioners registered under the Health Professions Act of 1974, which states that practitioners “shall not offer or accept any payment, benefit or material consideration which is calculated to induce him or her to act or not to act in a particular way not scientifically, professionally or medically indicated or to under-service, over-service or over-charge patients”.
The BHF and IPAF believe that the HPCSA and the CMS should engage with the Medical scheme industry and organised doctor groupings to find a solution to the HPCSA’s concerns.