Back in 2013 the Health Professions Council of South Africa said its Medical and Dental Professions Board had extended the deadline for submissions to determine guideline tariffs for medical and dental services. But then it all went quiet.
We interviewed Heidi Kruger, head of communications for the Board of Healthcare Funders of Southern Africa to find out when the industry will get a new guide soon.
We interviewed Heidi Kruger, head of communications for the Board of Healthcare Funders of Southern Africa to find out when the industry will get a new guide soon.
What has happened since the HPCSA issued a statement that it was looking for submissions from the industry?
Heidi Kruger (HK): After 2013 nothing else has happened. They asked for new submissions because in 2012 they brought out a set of tariffs for a week but these were withdrawn after objections from the medical industry. They then asked for further submissions and that’s as far as they got.
I have a feeling they are waiting for the Competition Commission’s enquiry into the pricing in the private healthcare sector to be completed. The Commissions probe is a long term enquiry which is looking at practices and prices in the private healthcare market and everyone is looking to make submissions for this. They say they will be finished by November 2015.
What if the HPCSA were to issue out a pricing guideline now?
HK: The HPCSA can bring out a reasonable tariff but it doesn’t mean that everyone has to adhere to it. Their tariff is benchmark and doctors are supposed to get consent from patients if they want to charge anything above that.
But this isn’t ideal because often the patient is ill at the point of service or there is only one neurosurgeon in an area, for example. But that is what the HPCSA say under their rules. Over and above that you can complain to them and they will adjudicate over the matter.
But this isn’t ideal because often the patient is ill at the point of service or there is only one neurosurgeon in an area, for example. But that is what the HPCSA say under their rules. Over and above that you can complain to them and they will adjudicate over the matter.
How do we know what is a reasonable fee when there is no tariff around?
HK: We don’t know, which is why it’s so frustrating. Medical schemes have their own tariff that they pay against which is probably based on 2006 National Health Reference Price List (NHRPL).
Currently, the HPCSA doesn’t have an ethical tariff anymore. It used to be roughly three times what the medical schemes’ tariff was. Doctors used to charge within that realm so some of the low-cost options used to charge 100% of tariff whereas some of the higher cost options would then charge 300% per tariff.
As the HPCSA doesn’t have this ethical tariff anymore from what I know most of the medical schemes are basing their prices on the 2006 NHRPL which was issued by the HPCSA, with an inflation indicator added on every year.
Where does that leave the industry?
It leaves the industry in a mess because in some cases doctors are charging 600-700% for prescribed minimum benefits (PMBs) because the Council for Medical Schemes (CMS) has said that PMBs must be paid for in full regardless what the doctors charge.
That means there are a huge number of complaints because schemes cannot afford those kind of prices. Some pay in full and others can’t. The member ultimately pays though because medical schemes raise their prices. The medical schemes find it hard to budget because they never know what could be charged for PMBs because there’s no tariff. So medical scheme premiums end up going up and the member pays at the end of the day.
That means there are a huge number of complaints because schemes cannot afford those kind of prices. Some pay in full and others can’t. The member ultimately pays though because medical schemes raise their prices. The medical schemes find it hard to budget because they never know what could be charged for PMBs because there’s no tariff. So medical scheme premiums end up going up and the member pays at the end of the day.
An added contributing factor to this problem is the way PMBs are structured. They are mostly for specialist and hospital based care. It’s not a structure for primary care interventions. So for example a tetanus shot is not covered under PMBs but you are covered if you have been bitten by a rabid dog and have to go to hospital as that is considered a PMB.
So the PMBs don’t apply to primary and preventative care aspects and I believe that if they did then schemes would save a lot more money down the line.
So the PMBs don’t apply to primary and preventative care aspects and I believe that if they did then schemes would save a lot more money down the line.
While we think that PMBs are great and protect the m embers we believe they are not structured properly.
If you believe you have been charged too much by a health professional, click here to complain to the HPCSA.