The SAPPF held its AGM at the end of next last month and passed various resolutions on issues pertaining to issues affecting private practice. At the meeting, Dr Yatish Kara, paediatrician from KwaZulu-Natal was unanimously re-elected as SAPPF Chairperson.

Here are some of the resolutions that were taken:

Appointment of new Minister of Health

The SAPPF has welcomed the appointment of the new Minister of Health, Dr Zweli Mkhize and has written to the Minister to request a meeting to discuss a number of issues; amongst them being the future role of the private sector under NHI, the PMB Review process, and the worsening medico-legal crisis.

Accusation by NHCPA of racial profiling by medical schemes

A recent development has been the accusation by the National Healthcare Professionals Association (NHCPA) of racial bias in its forensic profiling of health professionals. The allegations are currently being investigated by a Commission of Inquiry established by the Council for Medical Schemes (CMS). The SAPPF says while it stands against all forms of discrimination and respects the rights of all South Africans to peacefully protest and air their grievances, the organisation was alarmed by the actions of certain NHCPA members during their recent march to the offices of Discovery Health. SAPPF has responded to the request by CMS for input into its inquiry into this matter.

PCNS contract with BHF

The recent PAIA application by SAPPF for access to the PCNS contract between CMS and BHF has been refused by CMS. This is a concerning development and supports the suspicion held by SAPPF that PCNS funds may not have been ringfenced by BHF and used purely for the purpose of administering the PCNS operation. SAPPF has instructed its legal advisers to escalate the matter and has lodged an appeal against the CMS decision.

SAPPF re-imagined

SAPPF has experienced significant growth in membership recently and this has encouraged the idea that SAPPF could and should play a more pro-active role in reforming the private health sector. In the past, the severe constraints imposed by its deliberate intention to keep the cost of membership as affordable as possible has limited the organisation’s ability to more fully represent its members’ interests. New funding models are currently being investigated that may enable SAPPF to play an increasingly significant role in shaping the future of the private sector and its involvement in a new inclusive

NHI update

The NHI Bill was recently approved by Cabinet but until the new bill is gazetted, it will remain unclear what the perceived role of the private sector will be. This therefore will be one of the main points raised with the minister when SAPPF meets with him. The NHI White Paper will be debated in NEDLAC, where Business Unity South Africa (BUSA) will represent organised Business. SAPPF is a member of BUSA’s NHI Policy Committee, which is supportive of a multi-payer healthcare model. Despite the recent comment by the new minister, there remains hope that common sense will prevail over short sighted ideology during these discussions at NEDLAC.

Medical Schemes Amendment Act

It was announced that the Medical Schemes Amendment (MSA) Bill was shelved in December 2018, with the Department of Health waiting for the final Health Market Inquiry Report before re-publication. It is therefore unlikely that there will be any progress until October 2019 on the MSA Bill. CMS

CMS PMB Review

The PMB Review process gained impetus earlier this year with various stakeholder clinical engagements being scheduled in February and March. These Clinical Sub-Committee meetings, dealing with primary care inclusions, were scheduled at very short notice which made it difficult for the Clinicians involved to avail themselves on such short notice. SAPPF is currently in talks with SAMA, to arrange a joint engagement with the CMS to express concerns at the current process, which is making meaningful clinical inputs very difficult. The process continues to muddle along, and it is frustrating that the real issues around the existing PMBs are not being addressed, with the focus being on developing a primary healthcare package for inclusion in NHI. Several attempts both by SAPPF and SAMA calling for a meeting with the Registrar to have their concerns addressed, have to date fallen on deaf ears

SAPPF appoints Internal coding specialist

SAPPF has appointed Brenda Gous as internal coding consultant. Brenda previously worked at Medihelp Medical Scheme. She has hit the ground running and has already assisted various SAPPF member groupings with revisions of their coding manuals and sections of coding.

SAPPF projects for 2019

SAPPF has identified several key projects for 2019, which is aimed at improving the situation for members of SAPPF and the negotiating position of various groupings during scheme engagements.

Challenging the 2006 RPL

The first project deals with disputing the legal validity of the 2006 Reference Price List (RPL). During the 2010 RPL Court Case, the 2007-2010 RPLs were set aside by the Judge, as not being reflective of Practice Costs. The 2006 RPL is similarly unreflective of the costs of running a practice but was not set aside. Medical Schemes therefore reverted to using the 2006 RPL with inflation related annual increases to determine current tariffs. This situation resulted in scheme tariffs not staying in line with- and reflecting practice costs. The Scheme reliance on the 2006 RPL also creates great difficulty in getting new codes accepted as well as difficulty when outdated coding descriptions are used during scheme forensic processes. If the 2006 RPL can be similarly set aside, it would leave room to establish more practice cost reflective Medical Scheme tariffs and open the door for the introduction of new coding.

Enforcing direct payment by schemes

Many schemes ensure that practitioners sign up to DSP and DPA agreements by threatening to pay patients of providers who do not sign up. The Sechaba High Court Matter pointed out that schemes are compelled to pay providers directly, but the industry and the CMS is loath to accept this finding, on various technicalities surrounding the circumstances of the case. SAPPF is therefore determined to settle this dispute, if necessary, by obtaining a High Court ruling, compelling direct payment of healthcare provider by schemes. Such a ruling would prove invaluable to allow providers more choice in whether to join scheme networks or not.

 Raising awareness

SAPPF is also aiming to launch a campaign to raise awareness amongst SAPPF members and patients regarding various industry issues, such as non-payment of PMBs, Managed Care Initiatives and Clinical Autonomy by organising regular press engagements to enable the general public to be made aware of the positive role that SAPPF is playing on their behalf. SAPPF is also responding to the various industry challenges that arose at the start of 2019, such as the Discovery Health Day surgery network. SAPPF is also busy engaging with SAMA regarding the withdrawal of the SAMA practice costs study results which was endorsed and supported by SAPPF and its various groupings. The withdrawal was the result of a challenge by a provider society who initially insisted on participation in the cost studies and then failed to market the study amongst members.

Source: SAPPF