Johannesburg - New price guidelines for medical practitioners, intended to protect patients, could unintentionally force them to pay higher co-payments on health bills and could see nearly 1 000 procedures not being covered by medical aids.
The Health Professions Council of SA (HPCSA) has released the guideline tariffs to provide a benchmark from which medical professionals can charge their patients.
Council ombudsman Dr Abdul Barday said they were brought about by the high number of complaints of overcharging against professionals in the absence of guidelines.
According to Barday, the guidelines serve only as a yardstick, and practitioners may charge more than is stipulated – provided there is consent from the patient or a next-of-kin.
“The doctor or his staff should explain to the patient what they are in for, if they go through with the [treatment] procedure. The process of informing should be in lay, simple language.
“The practitioner must tell the patient what is the HPCSA charge and what she/he is going to charge. Patients should be informed upfront of the fees for the services,” he said.
On Tuesday, Barday admitted that the controversial guidelines had not been entirely scientifically calculated and would need adjustments as they lack 200 to 300 procedures.
Meanwhile, practitioners could proceed with treatment only after getting “informed consent”, which would be in the form of a written document from the client or a next-of-kin.
The SA Medical Association (Sama) and the SA Private Practitioners Forum have labelled the tariffs “ill-conceived” and warned they could be detrimental for patients as they vastly underestimate the cost of procedures.
They estimated that the tariff list had excluded 1 000 procedures.
“Since 1 000 new procedures are excluded from the current HPCSA guidelines, having been based on the 2006 lists, medical schemes are not obliged to pay for these procedures. Patients will therefore have to pay out-of-pocket,” the organisations said in a statement.
However, the guidelines could see the costs of consultations and other procedures dropping.
For example, if the guideline is implemented, a consultation with a gynaecologist could drop to R271 a visit. Currently a visit to gynaecologist could cost a woman R1 000.
But Sama believes the guidelines vastly underestimate the costs for practitioners. “The 2012 HPCSA tariff is not only 53 percent less than the 2007 HPCSA tariff, it is also 5 percent less than Sama’s own 2003 tariff,” it said.
Heidi Kruger, spokeswoman for the Board of Healthcare Funders, which represents medical aids, welcomed the new guidelines.
“They provide certainty for the medical schemes to pay on… Medical scheme members are at the mercy of doctors who charge opportunistically, which causes a huge cost spiral at the moment, and it’s making medical aid unaffordable. One of the reasons for this is that there has been no costing,” she said.
“There have been a lot of coding manipulations since 2006… for example a knee replacement… some medical practitioners have unbundled those codes to be separate codes and therefore the knee replacement ends up costing more.”
Kruger admitted, however, that theoretically medical aids could refuse to pay for procedures not on the new guideline lists.
She said medical aids would be adjusting the amounts they paid for procedures to suit the new guidelines to take effect in the new year.
The Star