The fact that the views of the medical schemes presenting to the parliamentary health portfolio committee on the NHI Draft Bill and the views of the healthcare professionals were largely aligned bodes well for the possibilities of co-operation between the two healthcare funding and delivery entities as the country moves towards NHI.
“Perhaps the collaborative type of models is the way one needs to go,” industry legal expert, Elsabe Klinck (pictured), suggested when addressing these possibilities during an Institute of Health Risk Managers (IHRM)-hosted webinar late last week.
Examples of models that have already been used, “that we’ve seen”, and, combined, already have some of the elements required. These, Klinck noted, included: in return for a higher/fixed fee, adhere to an agreed protocol; measure and reward good health outcomes; and patient entry programmes, according to an agreed protocol.
Key contributing considerations in the collaborative processes, she pointed out, were the roles of the professional societies as the clients of the medical schemes, and peer guidance as opposed to peer review programmes.
“One of the interesting things is what I always thought was peer review is being substituted with something that seems softer, namely peer guidance, but that seems to be quite effective.”
An issue with peer review, Klinck observed, was that, being a review means reviewing a procedural matter. In simple terms, however, it means “I’m checking up on you. Did you do the right thing” – someone in authority checking up on someone else.
“This is why peer guidance is a better concept. It can guide somebody from where they are to where they should be.”
Professional societies, she suggested – with the proviso that their constitution allows them to negotiate on fees or peer guidance – should in fact make peer guidance a formal policy linked to the body’s constitution; setting guiding principles such as evidence based medicine and clinical appropriateness linked to the objectives of the association, and linked to the power to enter into agreements with funders in the specific field, or fields in which the grouping operates.
Alternatively it could be a complaints receiving body – “stipulate who can complain and on what e.g. coding” – and could also be a query, or advisory body.
In terms of a provider not being a member of a society raises several issues, not least when the main agreement between the scheme and the society stipulates that the provider subjects themselves to the society. But if not a member they obviously can’t, Klinck noted, presenting problems which have resulted “in heaps of case law” as well as competition law issues.
“They could sign up to the peer guidance process as a non-member. That is possible.
“Don’t think that the overarching agreement that makes this a condition to contract with the scheme as an individual you must subject yourself to a society that you’re not a member of, that is usually problematic in constitutional and competition law.
“But the voluntary option is an option.”