Dr Tony Behrman

CEO of Qualicare, Dr Tony Behrman, talks
about the financial frustrations South African family practitioners (FPs) are
experiencing due to the 2019 fee increase from funders.

FPs have been recognised as the key to delivery of a
successful National Health Insurance (NHI). Government is now amending its
demand of wanting doctors to see NHI patients only in their clinic settings and
is now open to allowing doctors who are contracted to a future NHI, to see the
patients in their surgeries, provided that sites have been quality assured.

However, NHI is nowhere near being rolled out to FP en
masse; there will still be more pilots and trials.

In the meanwhile, instead of 2019 getting better for the FP,
it looks like we continue to be the whipping boy of the funders who produce
countless new and confusing options with rules, benefits, exclusions and
hospital selections which neither the consumer of health services, their
members, nor the providers of service, our doctors, can be expected to comply
with or master, with or without a tablet or iPad.

Certain schemes and administrators claim that they have not
colluded with regard to the increases for GPs in 2019, but almost everyone has
come out at 5%! How is that possible? Does this even keep pace with practice

Certainly this was merely announced to the IPA Forum as
a “fait accompli” (no negotiation is permitted in terms of competition law).

Our beloved calling needs to wise up, grow up, shape up,
smell the coffee, find your voices and object to this new wave of interference,
price fixing, and total disregard for the real cost of running a practice. It
weakens, not strengthens, the primary healthcare practitioners’ position in
society, and should be rejected out of hand.

Seeing four patients per hour, at some of the current
medical aid offerings, results in an income before tax of between approx. R 1360
and R 1850 per hour, depending on scheme and plan.

You have previously reported in meetings that your expenses
run at approx. 60% of gross turnover after which you pay tax at approx. 30%
leaving you an after-tax income of between R 381 and R500 per hour.

When do you want to retire versus when can you afford to
retire? Do your sums. You may need to work until you are over 90!

That’s why our motto remains “Cash is King!”

Furthermore, FPs across SA are reporting in to the offices
of IPAF, and local offices of their IPAs, that their chronic patients continue
to be disappearing from their practices and popping up in colleagues practices
as that doctor is now part of one or other newly named network.

On closer inspection it appears perfectly well cared for
chronic patients are being moved from unsuspecting practitioners and their
practices and are being redirected to other practices without informed
consent of the patient, warning to the doctor, or reason offered to

Many of these patients and their families have been cared
for, successfully, by the ‘losing’ practices in question for years and there
appears to be no reliable clinical grounds for doing this, let alone any
ethical considerations regarding doctor patient relationships which will be
torn asunder.

The FPs have not managed their chronic patients poorly, nor
have these patients suffered poor outcomes. Patients have not reported these
doctors for poor service, nor have they complained about them to the HPCSA.
They have not objected to their doctors billing practices, facilities, bedside
manners, availability, skills as a diagnostician or their knowledge or
otherwise of gizmos to communicate with them or their insurers.

Patients are left bewildered, unclear why they have been
told that they should leave Dr X and rather see Dr Y. Rumours will inevitably
surface that possibly their original doctors were no good, or behind the curve
with their methodologies, training or IT.

What about these patient’s other comorbidities, their social
and emotional problems and other related diseases, which have also been treated
for years by the ‘losing’ doctor?

What of the perceptions created in their families who may
not be on the same medical aid as the ‘moved’ patient?

What about freedom of patient choice, doctor patient
relationship, confidentiality, fragmentation of care, supersession? Even worse,
no prior agreement from regional or national doctor leaders or doctor groupings
seems to have been sought.

How about transparency to explain why this is being done, or
offering the ‘losing’ doctor a method of retaining his patients?

IPAF has long cautioned doctors about becoming designated
service providers of medical aids; possibly now you can see why!

Almost every funder will have different formularies,
algorithms, benefit structures, exclusions, limitations and varying degrees of
reimbursement strategies and price restrictions, making it increasingly
difficult to run your practice and concentrate on the patient.

Our time is increasingly being absorbed by form filling, pen
pushing and call centres, causing you to end up working more for less. Worse
however, should you step out of line, it’s a question of “fit in or leave –
we’ll send your patients to another doctor who will.”

There is now evidence that old fashioned restrictive models
of healthcare and restrictive narrow network arrangements are again on the rise
with a ‘fit in or leave’ culture where the doctor would enter into a network
arrangement with a funder, and then be at their beck and call to obey their
directives, use their formulary medicines, or follow their algorithms….. or
lose their patients to another doctor.

Should they too move to the great new doctor down the road?

Schemes now report that between 40 and 60% of their costs go
to paying hospitals and 20% to paying specialists. Some years ago, FPs
accounted for 13% of the pie, now we get between 5 and 6% if we are lucky, less
even than the scheme pay on Managed Care initiatives.

A recent letter from a Knysna colleague summarises the level
of frustration evident country wide:

“Dear Doctor Behrman

I represent the
private general practitioners of Knysna. We are extremely unhappy with the fee
increase from funders for the 2019 year. We had to absorb a 1% increase in VAT
last year (we cannot pass that on to the patients and is thus only a straight
cost to company and loss of income). We live in an environment with headline
inflation of about 5-6% and medical inflation of about 15% (staff
increases(7-10%), power(18%), rentals(8-10%), fuel (20%), equipment and

As doctors we are
deemed to absorb these costs and the average 5% increase by the majority of
funders, making medical practice unsustainable. This is a reckless behaviour
and will end tragically in poorer services due to loss of equipment, skills and

I ask that you
urgently discuss this matter and bring sound solutions. I am very happy to be
part of such a discussion/negotiation going forward.

You are most welcome
to share this on any platform you deem helpful.

Dr C M Janse van
Rensburg, Knysna”

If you have pinned your hopes on improved incomes when NHI
arrives, let’s hope that they do not base their offering on some of the current
medical aid offerings to FPs!

Many in the know however doubt that it will be any better
for you financially.

Time will tell.

This opinion piece was
originally published in the Qualicare January 2019 Newsletter