CAPE TOWN - Only an integrated public and private sector approach can provide the best healthcare response to the challenge of the coronavirus (Covid-19) pandemic, the major representative organisations of South Africa's medical profession, together with the Progressive Health Forum (PHF), said on Sunday.
The pandemic posed an existential danger that necessitated mobilisation of all the country’s healthcare resources and health workers, guided by professional ethics and a commitment to comfort and care for an increasingly anxious populace facing an unprecedented and devastating plague, the organisations said in a joint statement.
In March this year, the PHF entered into discussion on strategies required to reduce the looming disaster with the South African Medical Association (Sama), SA Private Practitioners Forum (SAPPF), SA Medical and Dental Practitioners (SAMDP), the Radiological Society of SA (RSSA), and the Independent Practitioner Associations Foundation (IPAF).
Dr Aslam Dasoo of the PHF said although private medical practitioners had expressed their willingness to demonstrate solidarity in a time of national disaster, it had elicited little traction with government. “When it became clear that the private healthcare system, which in several respects exceeds the capacity of the public system, was not being meaningfully engaged by the authorities despite the obvious necessity, PHF initiated a process to forge collaboration among clinicians in both sectors to address the pandemic.”
The willingness of private specialists and GPs to join in this effort was, however, offset by dwindling patient numbers due to their fear of contracting the virus and limitations on hospital admissions and surgical procedures. “This significant decline in income puts the continuing viability of practices in serious doubt. The stark reality that otherwise viable practices will close is of great concern, as it would imperil the Covid-19 response,” Dasoo said.
SAPPF CEO Dr Chris Archer said the private sector was both ready and willing to participate in the required response. “However, the financial pressure on private practices is real and, unlike their public sector counterparts who are salaried, private medical practices face significantly reduced income and require funds to honour staff and overhead commitments.”
SAMPD chairman Dr Nkateko Munisi said family and general practitioners, the bedrock of many communities, faced devastating consequences without intervention.
Sama Gauteng chairman Dr Mark Human said, “Private practices have seen a 60 percent average decline in patient numbers during the hard lockdown while some specialists like ophthalmologists, ENTs, and dentists effectively shut down due to the high risk of infection in these specialties. Although since the introduction of level 3, patient numbers have increased, they are still 40-50 percent lower than normal, which is putting tremendous strain on practices’ ability to survive in the short and medium-term.”
PHF initiated a process to resolve this material problem and a proposal was developed which in large measure eliminated this risk and enabled an unfettered engagement of over 15,000 medical and other health professionals in the national response.
“The proposal envisages private medical scheme funding for practices on a capitation basis that would guarantee sufficient income for practices for the next 18-24 months while capping the risk to medical schemes,” Wits School of Governance and PHF member Professor Alex van den Heever said.
Key tenets of the proposal included:
- Money to be advanced by medical schemes to private practitioners on a non-repayment basis based on 2019 earnings. This would involve a guaranteed payment to medical practices of up to 70 percent of historical claims (using 2019 as a base year), and 30 percent based on activities that exceeded the 70 percent. The guaranteed payment would be offset against actual activities as they normalised over time.
- The global cap would be based on both medical savings account and risk benefit claims. In this way medical, dental, and allied practices could also be supported with this framework.
- Claims activities over the periods 2020 and 2021 would be capped at historical 2019 levels (the global cap), meaning that the risk for medical schemes of a surge in claims either due to Covid-19 patients or deferred treatment would also be capped at 2019 figures. In this way the reserves of medical schemes were also protected.
- The risk of a decline/increase in numbers of medical scheme members would be balanced by a pro-rated adjustment to the global cap.
- The only practices that could be negatively affected by participating in such an arrangement would be those that had generated incomes during the pandemic in excess of 100 percent of their 2019 income.
- Discussions had also been held with the banking sector to address short-term needs to access bridging loans until such time as this framework could be implemented.
"A platform will have been established that will enable productive engagements on the future of the health system and agreements into 2022," Van den Heever said.
"The framework, as proposed, is non-binding on either doctors or medical schemes. Ultimately it will be up to the various associations, the medical practices themselves, and medical schemes to finalise implementation. This framework therefore outlines a feasible point of departure for any final agreements reached between schemes and medical practices,” he said.
Dasoo said the framework reduced uncertainty for medical practitioners and medical schemes over periods of greatest risk. Discussions with major health funders on the proposals had been generally positive and, barring any regulatory impediments, would be supported.
“While we are confident that the proposal falls within the confines of the Medical Schemes Act, we have consulted the Council for Medical Schemes to fully address any potential regulatory concerns. In addition, we have consulted National Treasury in the context of the economic implications of the financial distress of medical practitioners and possible knock-on effects in the wider economy. The issues raised by all parties have been incorporated into the proposed framework," Dasoo said.
With the adoption of the proposal, private practices would retain a degree of resilience that would enable them to support government in addressing the pandemic. “It is vital that we eliminate any impediments to the mobilisation of the country’s health resources in a coherent national response to face down the most devastating global health emergency of 100 years,” he said.
South African Medical Research Council (SAMRC) president Professor Glenda Gray said, “We must be relentless in our pursuit of a response to the pandemic that includes everyone. For health professionals, health workers, and health activists everywhere, Covid-19 represents the greatest challenge of a generation. We must not be found wanting in the ethical expression of the cause to which we as health workers have dedicated our lives.”