Dr Johann Serfontein

By Dr Johann Serfontein

The new year found healthcare
professionals in the usual January scurry to make sense of benefit- and network
changes implemented by the funding industry. One of the latest problems, which
will become more pervasive as managed care measures in the industry increase, is
the quandary of a doctor designated service provider (DSP) admitting to a non-DSP
hospital. The scheme channels the patient to their DSP doctor, but then levies
a co-payment if the patient is not admitted to a scheme DSP hospital, often the
result of impracticality, or doctors not having admission rights at certain DSP
hospitals. The question remains how the patient could be held liable for such a
situation arising and whether it is ethical to levy a co-payment to a patient
who followed the scheme DSP recommendation? Patients see doctors, they do not
consult with hospitals. The 2018 PMB Code of Conduct addresses the issue by not
allowing co-payments in such instances, but the draft document is still
floating around in the echoing corridors of the CMS offices, and abiding by the
content is voluntary.

In the broader environment, the
National Health Insurance (NHI) Bill, Medical Schemes Amendment Bill and Health
Market Inquiry final report remain topical. The 2018 Presidential Health Summit
muddied the waters of access to universal healthcare, by conflating acceptance
of the NHI system as a necessary proviso to fix the ailing public health
system. The poor quality of the public health sector would mean the state
sector does not even qualify to contract with the NHI and introducing it will
therefore not fix the public system. Quality in the public health sector would
need to be improved to acceptable levels before any efforts at implementing NHI
can be made, as failure to do so will render public facilities incapable to
render services in the NHI environment and will leave a major gap in service
provision. The NHI Bill will be presented to cabinet on 30 January for further
discussion. A leaked Treasury letter and a version of the proposed Bill raised
several concerns regarding constitutionality and due process in consideration
of public comments in the contents of the Bill. In an election year, it is to
be expected that there will be increased Legislative activity for appearance’s
sake, as far as the NHI Bill and the political promise of “Free quality
Healthcare for all” is concerned.

The final Health Market Inquiry
report is currently scheduled for release on 29 March, but with additional
stakeholder meetings occurring in February, this may well be postponed again to
ensure that new submissions on industry concentration are appropriately

Industry concerns of failing
regulatory bodies are becoming more prevalent, as the HPCSA is simply not
fulfilling its mandate of protecting the public and guiding professions, while
the Council for Medical Schemes is also apparently struggling to cope with
complexity in the industry. Further to this, the SA Health Products Regulatory
Authority was hamstrung by strikes in the Department of Health for long periods
in 2018. The Prescribed Minimum Benefit (PMB) review process has been ongoing
for 2 years, with limited progress, as the CMS struggles with the ministerial
mandate of changing PMBs into a service based package. The practicality of
changing to such a system has caused major headaches, as treatment protocols
worldwide are diagnosis based, not catering for a service based approach.
Structuring benefit design in line with the NHI service proposal has also
created various practical challenges, which has stalled the process and forced
a reconsideration of the proposed broader benefit framework due to

The year ahead will be fraught
with challenges, as rising costs, the increasing disease burden, and the
economic downturn pressures both patients and the funding industry into finding
ways to ensure continued access to private healthcare, often at the expense of
quality and patient choice. This places healthcare professionals in a
precarious position, as ideal and second line treatments are not always funded,
and yet professionals are ethically compelled to inform patients of appropriate
treatment, whether funding is available or not. Doctors are concerned with the
increasing corporatisation of healthcare and the negative affect that managed
care has on clinical practice. The only solution to this would be open
engagement between funders and healthcare professionals to find an approach
that ensures patient focused, good quality care, which is not simply concerned
with implementing cost cutting measures.