Sama defends specialist pricing

The article “Medical schemes do a deal with specialists to avoid co-payments” (Business Report, January 14, 2013) refers. Accepting that the article was written by a well-known senior journalist who has published extensively on health matters, the SA Medical Association (Sama) is dismayed by the opportunistic and sensationalist manner in which the matter was presented to the public.

In the article, the journalist blames doctors for what she calls “shrinking medical benefits”.

To substantiate her point, she quotes an allegation made at the recent Board of Healthcare Finders conference saying “it emerged that some medical specialists were charging as much as 700 percent above scheme rates” and goes further to assert that Parliament has been asked to intervene in the dispute about Regulation 8 of the Medical Schemes Act.

Sama takes great exception to the kind of reporting and would like to remind the writer of the fact that accepting that some individuals – a minority – might abuse the system, does not mean that all specialists are involved in such activities. Furthermore, the issue of Regulation 8 has been adequately addressed by none other than the Council for Medical schemes (CMS), a statutory body protecting the interests of medical aid members.

The CMS receives quarterly financial statements from all schemes and reports on these annually.

Their assertion, with which we agree, is that while there are outliers in billing practices among specialists the vast majority charge between 100 percent to 110 percent of scheme rates for prescribe minimum benefits (PMBs).

The journalist then refers to obscure billing structures in the private health sector as the reason for patients running out of benefits, but she does not explain what she means by “obscure billing structure”.

So-called payment arrangements are then referred to as if they are an innovation by the two open schemes.

May I remind her that designated service providers are part of managed care and are part of the Medical Schemes Act of 1998 for the schemes to implement a measure that is clearly spelt out in the Medical Schemes Act for funders to limit their exposure.

She goes on to quote a senior executive of one of the major open schemes saying these arrangements “protected the medical scheme from the crazy billing structure when doctors shoot up their rates for PMBs”.

We in Sama are greatly disappointed when journalists who are supposed to inform the public on factual matters choose to sensationalise.

What she fails to inform the public is that the PMBs were introduced to protect medical scheme members from abuse from the schemes from abusing the system.

The aim of PMBs is to protect the members from catastrophic and chronic disease events.

Prior to their introduction, many medical aid members with these conditions ended up with no benefits at mid-year and had to go to the overburdened state sector for further treatment.

We further want to inform the public that a medical scheme benefit is only that – a benefit that a member is entitled to. It does not in any way equate to the cost of services offered by the doctors.

Doctors in this country are hard-working, compassionate individuals who deserve to earn a decent living like all citizens are entitled to.

Doctors cannot be expected to offer services at below what it costs to run the service.

Dr Mzukisi Grootboom

Chairman of the South African Medical Association

Editor’s Response: Business Report welcomes Sama’s feedback on this particular issue. We would take it into consideration as we continue to pursue coverage on this matter and others. I would appreciate if Sama uses the opportunity at hand to constructively engage with us on these and many other pertinent issues instead of mounting a crusade to discredit our reporting. (Ellis Mnyandu)

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