Updated 17 April
Patient-doctor ‘collusion’ driving up healthcare costs.
Poorly designed and unamended Prescribed Minimum Benefits, PMBs, while well intended, have ballooned out of control, costing funders billions, and ramping up medical inflation as doctors collude with patients to claim in a skewed ‘sick care’ environment.
These assertions came yesterday from Professor Morgan Chetty, Chairman of the Independent Practitioners Association Forum, IPAF and of the KwaZulu Natal Doctors’ Health Coalition.
He was responding to a flurry of recent comments by Board of Healthcare Funders, (BHF), executives, a Discovery Health clinical excellence chief and Dr Unben Pillay, the chief executive officer of the Alliance of South African Private Practitioners Association, ASAIPA.
All agree that the lack of proper government regulation of the private healthcare sector and poor, uncorrected legislation contribute to rampant medical inflation, a hospi-centric/curative approach and the marginalization of family practitioners best placed to co-ordinate care.
Chetty says busy doctors have a duty to educate their patients so they can regain their place as the central role-player in a more holistic and cost-efficient healthcare system.
“For example, you give a diabetic patient a lab form which has ten tick boxes and send him off for bloods. He has no idea what the ticks are for, nor that you may be depleting his medical aid savings or incurring a co-payment. The patient is naïve and passive, the recipient of instructions and healthcare, not an ‘activist,’” he says.
Chetty cites a USA campaign that improved healthcare significantly. Called, “Know your Numbers,” it was aimed at educating patients on the optimum levels for blood pressure, hemoglobin, cholesterol, and body mass index, (for example).
“Now the patient can engage with the doctor and say, for example, “I’m taking all my meds and following your instructions, but my numbers are still high. Suddenly there’s a constructive narrative, instead of a costly demand for services that may not be needed. The moment a patient pays a funder premium, he goes into demand mode – pushing up costs.”
He says primary care family practitioners live in a highly competitive environment, and face an ‘onslaught,’ from hospitals and pharmacies, often prompting them to give in to patient demands on PMB’s and other benefits, resulting in abuse and/or misuse of medical privileges.
“This can result in collusion in order to keep the patient in your practice.”
He gave the example of a psychotherapist “upcoding’ a diagnosis (i.e. claiming for diagnosis more serious than clinically indicated), thus shaking loose 15 sessions a year – which the medical aid must by law pay.
There are over 200 PMB conditions, including a chronic disease list, (CDL).
According to Dr Noluthando Nematswerani, the Chief Clinical Officer at Discovery Health, lifestyle diseases are affecting younger and younger populations and growing at an alarming speed, while the cost of expensive but effective new drugs is adding to the funding burden.
Says Chetty, “it’s a formidable list, the PMB’s. Science is developing very fast. The CDL, while relatively small, has tens of thousands more people on it. There’s been insufficient interrogation of PMB’s. The initial policy needs re-regulation. It’s getting old, tacky, and miserable. The Council for Medical Schemes, CMS, has been remiss. That’s the reason there’s no progress in this country. We’re legislating our way into a crisis and there are too many groups working in silos. PMB’s were well intended, but badly constructed and are not being probed to make them more manageable. They were implemented as a catch-all to help people, but now they’re hurting healthcare. The lawmakers didn’t grasp the complexities of co-morbidities, multiple morbidities and more and more people entering this space,” he adds.
He says the solution is for all role-players to work together – as they did when threatened by Covid – and customize and modify PMB’s, while allowing medical aids to offer low-cost benefit options – ‘or we will have an issue of super (medical) inflation.”
Doctors accused medical aids of being only concerned with a return on investment and having lost the “humanitarian, philanthropic element.”
However doctors had split into a plethora of collectives, each looking after a particular disciplines’ interests and influenced by a dysfunctional system focused on ‘sick care instead of preventative care and wellness’, alongside a rise in short-term health insurance options – often focused on hospitals.
“These funding options preclude them from long term care, so patients get dumped back into the public sector as soon as they need more complex management. Getting more affordable, quality healthcare is the reason why the government pushes the NHI. While I agree with universal healthcare, I don’t think they’re going about it in a workable way.”
He said patients too often saw medical aid and/or insurance in terms of what it cost them and were not educated into making the right decisions. Doctors should complement brokers who too often give insufficient information to enable weighing up the benefits versus the disadvantages of lower-cost options.1
“It’s strange how many patients are forced to change from one plan to another because a broker navigates it for them. Instead, they need to ask this; ‘given my, (and my dependents’) health profile/s, is this the correct scheme for me? We need to turn patients into activists rather than passive recipients of care. Let’s get that ‘Know your Numbers,’ list into every newspaper and waiting room, instead of having a broker sell it to them in the company cafeteria during the lunch break,” he adds.
Council for Medical Schemes Registrar, Sipho Kabane, said the CMS had reviewed PMB’s ‘using the best scientific evidence, cost effectiveness, protecting members and the financial health of schemes, while probing rare, high-cost diseases that threaten to collapse schemes.’
The confidential CMS findings on PMB’s, low-cost benefit options, the lack of consultant tariff ceilings and other recommendations by the Health Market Inquiry are currently with the National Health Minister, Dr Joe Phaahla. Phaahla told the Financial Mail; “they’re tied up in legalities right now – I’ll pronounce within months.”