HPCSA warns against global fee arrangements with medical schemes

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The Health Professions Council of SA (HPCSA) has urged healthcare professionals not to sign agreements with medical schemes that bundle the money available for procedures such as hip replacements into a global fee, citing concerns over patient safety and doctors’ autonomy.

Business Day reports that if the HPCSA’s call is heeded by its members, it would throw a further spanner in the works for medical schemes that want to introduce global fee arrangements to contain costs. South Africa’s biggest open medical scheme, Discovery Health Medical Scheme (DHMS), already had to delay its plans to introduce global fees for hip and knee replacements in a network of arthroplasty centres on 1 April over concerns expressed by the South African Society of Anaesthesiologists (SASA) and other specialists.

Global fee reimbursement models provide a single payment to a healthcare team to cover all the tests, procedures, drugs, devices and rehabilitation needed for a patient’s condition – a vastly different approach to the current fee-for-service model which has medical schemes reimbursing each healthcare provider individually.

"We are not trying to obstruct them [DHMS], but we want them to get the mechanism right," said SASA CEO, Natalie Zimmelman. "It’s not easy to put a proper reimbursement model in place. We are willing to work with any of the funders. Discovery is working with us to try and find a way forward: some other schemes are less amenable."

DHMS principal officer Nozipho Sangweni said the scheme was engaging with professional associations and hoped to achieve global fees that are acceptable to healthcare professionals and the HPCSA. "We believe firmly that global fees pose no substantive ethical concerns and can be structured to ensure ethical practice," she said. "This approach is consistent with global best practice, and is certainly the most effective way to ensure optimal health outcomes and efficiency."

The report said the HPCSA issued its warning after SASA and the South African Arthroplasty Society raised the alarm over the potential risks they believe global fee arrangements pose for patients, as they create incentives for under-servicing, said HPCSA chair, Kgosi Letlape. Global fee arrangements limit patient choice, as schemes "impose penalties for patients who use healthcare professionals that are not participating in these arrangements, and raises questions about who is ultimately responsible for a patient’s care", he said.

"There are a whole host of concerns. If you are acting as part of a group, who does the patient belong to? Who does the patient hold liable? We are mindful of the high cost of healthcare, [but] this approach is medical schemes flexing their muscle," Letlape said, confirming that the HPCSA plans to canvass experiences and views from healthcare professionals, and engage with the health department and the Council for Medical Schemes to clarify the risks and benefits associated with global fee arrangements and chart a way forward.

The report says DHMS is not the first scheme to see merit in reimbursing healthcare professionals with global fees: three restricted schemes administered by Discovery Health already do so for knee and hip replacements. Global fees are also used by Profmed medical scheme, and the Improved Clinical Pathway Services joint-replacement network.

Business Day report

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