The SA Private Practitioners Forum (SAPPF) has given notice that it is still considering whether to support the Fraud, Waste and Abuse Charter (FWA Charter) launched at the recent Council for Medical Schemes (CMS) FWA Summit in Sandton, given the “unilateral nature” of its content.
“Concerns remain on the unilateral nature of the Charter, which focuses 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,” the SAPPF has noted. To this end it adds that the final Charter still needs to be discussed by the SAPPF leadership to consider whether the body is willing to support the initiative.
In a notice to members to this effect, the forum explains that prior to the summit a draft FWA Charter was circulated for comment, with a very tight schedule provided for input. The SAPPF responded and has since indicated that three major changes to the original draft appear to have been affected in the final version based on the SAPPF submission. Two of these appear under Principles as follows:
1. “A recognition that healthcare cannot be subject solely to normal free market principles and the current inadequacies in pricing regulations and guidelines need to be addressed;”
Was amended to:
“A recognition that healthcare cannot be subject solely to normal free market principles and, in certain instances, the progressively increasing gap between the actual Cost of healthcare versus the current Price of healthcare needs to be addressed”; SAPPF raised that current pricing does not reflect costs of healthcare.
2. “A commitment to develop clear and binding best practice policies on the ethical and moral obligations of a healthcare practitioner, pharmaceutical company, pharmacy or health facility when it comes to servicing a patient and billing for such service;”
Was amended to:
“A commitment to develop clear and binding best practice policies on the ethical and moral obligations of a healthcare practitioner, pharmaceutical company, pharmacy or health facility when it comes to servicing a patient and billing for such service; through industry wide collaboration” in response to SAPPF querying the CMS mandate on regulating service providers
The third was the inclusion of the paragraph: “16.2.7 Medical Schemes, MCOs and Administrators undertake that their engagements with recognised representative health professional societies on managed care interventions, including clinical funding protocols and value-based reimbursement models, will be guided by the principles of clinical soundness, cost-effectiveness and affordability; in the interest of sustainable patient care.” Both SAPPF and other specialist groupings proposed this inclusion.
* Stakeholders invited to pledge their commitment to reaching the Charter Objectives included the National Department of Health, Council for Medical Schemes (CMS), Healthcare Professions Council of SA, Pharmacy Council of SA, Board of Healthcare Funders, Healthcare Funders Association, schemes registered with the CMS, brokers, managed care organisations and administrators registered with the CMS, law enforcement agencies, and professional societies associations within the sector on behalf of their members.