Health tariff guidelines put on hold

Threats of legal action from organisations that represent the country’s doctors and dentists this week resulted in the delay of the publication of a list of guideline tariffs for medical practitioners.

The delay means that medical scheme members will again be in the wilderness when it comes to what their doctors will charge them and what their schemes will pay for medical services.

Earlier this month, the Health Professions Council of South (HPCSA), the body that regulates medical practitioners, published guideline tariffs for practitioners who are obliged to register with the council. The HPCSA said doctors would be able to charge more than the guideline tariffs but would have to obtain your written consent to do so. The HPCSA suggested that you compare your doctors’ charges with the published tariffs.

Medical schemes, which are compiling their benefit schedules for next year, were expected to use the tariffs when setting their benefits, and the Board of Healthcare Funders (BHF), which represents schemes and their administrators, was set to ask the HPCSA to make tariff recommendations for next year so schemes could use them to set their benefits.

However, this week Professor Mochichi Sam Mokgokong, president of the HPCSA, said the HPCSA will not publish the guideline tariffs in the Government Gazette as planned because of:

* The reaction of medical practitioners to the guidelines;

* Accusations that the HPCSA determined the tariffs without considering the input of the affected practitioner organisations;

* Potential legal action by practitioner organisations; and

* The “risk of destabilising healthcare delivery in the country”.

The full council of the HPCSA is now due to meet on September 3 to consider the tariff guidelines and the medical practitioners’ input.

Bertha Peters-Scheepers, senior manager for public relations at the HPCSA, says it is not possible to state when a revised tariff list may be published, although it is unlikely to be in time for medical schemes to incorporate these tariffs in their benefits for 2013.

The HPCSA’s tariffs were based on a 2006 tariff list that had been adjusted for inflation. This has outraged medical practitioners represented by the South African Medical Association (Sama), the South African Private Practitioners Forum (SAPPF) and the South African Dental Association (Sada).

Sama and the SAPPF said in a statement this week that the HPCSA’s guideline tariffs were less than those in the HPCSA’s 2007 list of the highest tariffs that doctors could charge and five percent less than Sama’s tariffs published in 2003.

They said it is highly regressive that the guidelines do not contain tiered consultation tariffs, which would allow medical practitioners to charge according to the time and complexity of a consultation.

Sama and the SAPPF also objected to the omission of 1 000 new procedures from the tariffs.

Dr Chris Archer, chief executive officer of the SAPPF, says his organisation and Sada threatened to take the HPCSA to court if it did not withdraw its guideline tariffs.

Archer says the HPCSA has not applied its mind to the tariffs, has ignored practitioners’ efforts to have the cost of supplying healthcare services reflected in the tariffs and did not consult properly with medical practitioners.

When the Department of Health took over the job of publishing tariffs for practitioners’ services – called the Reference Price List (RPL) – practitioners insisted that the regulations governing the publication of the list gave them the right to provide input on the cost of supplying healthcare services.

The Department of Health published a list of tariffs in 2008 and a draft list in 2009, but practitioners challenged the department over the process it used when considering their submissions on the costs of supplying healthcare services. In 2010, the Gauteng North High Court struck down the 2008 and 2009 RPLs.

The HPCSA decided to publish guideline tariffs this year to fill the gap left after the RPL was struck down. The move was welcomed by the BHF and the Council for Medical Schemes, and this week both described the delay in the list’s publication as “unfortunate”.

Rajesh Patel, head of benefit and risk at the BHF, says the BHF does not believe there is anything near to 1 000 new procedures requiring tariffs, and says the number is more likely to be about 200.

Patel says practitioners have unilaterally introduced new codes and have manipulated codes by, for example, creating separate procedures and codes where previously these had been bundled in a single procedure code.

Practitioners should produce proof that the new codes and tariffs are necessary, he says.

Dr Monwabisi Gantsho, Registrar of Medical Schemes and chief executive of the Council for Medical Schemes, says the Department of Health needs to pursue urgently its intention to set up a negotiating forum at which appropriate tariffs for healthcare services can be determined.