Med scheme support sought for distressed private practitioners

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COVID-19 has slashed patient numbers, leaving many private doctors in financial distress and worsening patient health outcomes, writes MedicalBrief. While private health offers to help the state have “elicited little traction” a novel plan for medical scheme emergency funding for private practices could be the solution, says advocacy group PHF.

SA Medical Association figures show that private practices in Gauteng had a 60% average decline in patient numbers during the hard lockdown whilst some specialists like ophthalmologists, ENTs and dentists effectively shut down. Since the introduction of Level 3, patient numbers have increased, but they are still 40-50% lower than normal.

The Progressive Health Forum (PHF), a national advocacy group, said in a statement that COVID-19 pandemic poses an “existential danger” that necessitates “the mobilisation of all the country’s healthcare resources … to comfort and care for an increasingly anxious populace facing an unprecedented and devastating plague”. All the major representative organisations of the medical profession – the Progressive Health Forum (PHF), the SA 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) – “insist that only an integrated public and private sector approach can provide the best healthcare response to COVID-19”.

The PHF’s Dr Aslam Dasoo said that even though private medical practitioners had made it known, their willingness to demonstrate solidarity in a time of national disaster had elicited little traction with the government. The willingness of private specialists and GPs to join in this effort was also 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,” said Dasoo.

Dr Chris Archer, CEO of SAPPF said that 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.”

Dr Mark Human, chair of Sama in Gauteng, said, “Private practices have seen a 60% average decline in patient numbers during the hard lockdown whilst 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% lower than normal, which is putting tremendous strain on practices’ ability to survive in the short and medium-term.”

Business Day reports that during April, claims for ophthalmology plunged 80%, while those for surgery and physiotherapy dropped 59% and 36%, respectively, according to data from switching houses that process medical scheme claims. At the same time, medical scheme administrators are worried that rising Covid-19 costs and deferred demand will see claims balloon in the coming months, potentially forcing schemes to dig deep into their reserves or increase premiums.

It quotes Dasoo: “It is a proposition to maintain practice solvency, keep them resilient over the next two years and, most importantly, frees them up to help [the state].” The proposal had been submitted to the Council for Medical Schemes (CMS), which regulates the medical scheme industry, to check that it was not at odds with the legal framework governing the sector, he said.

SAPPF’s Archer said 80% of the respondents surveyed by the organisation had indicated they would support such an initiative. Medscheme managing executive for clinical risk and advisory Lungi Nyathi said the proposal could change the way providers and schemes contract and see them move way from the current fee-for-service model.

In another report, Business Day writes that the reduction in regular patient numbers has led some medical practitioners to opt for early retirement, even as fears escalate about South Africa’s lack of medical expertise during a pandemic. Sama’s Dr Mark Human warns that if as few as 10% of doctors – especially the older, experienced specialists who are close to retirement – stop practising, “we’ll be in deep (trouble)”

It’s a precarious economic scenario., according tot he report. Doctors, especially specialists like radiologists and ophthalmologists, have high equipment costs and debt. Yet since April many haven’t been earning enough to cover their expenses.

It quotes Dr Frik Potgieter, speaking on behalf of the Ophthalmology Management Group, which represents most of South Africa’s specialist eye doctors, saying that as COVID-19 cases spike, patients are postponing appointments. But once people become too sick to avoid the doctor, they’ll have to go to the doctor’s rooms or the hospital – and the concern is that there will be fewer specialists to deal with this deluge. If too many doctors have called it quits, waiting lists will be long.

Dr Richard Tuft, head of the Radiology Society of SA, concurs. As it is, he says some medical practices are asking the older radiologists to work from home for their safety. This, he says, has led to some early retirements.

In response to the crisis, writes MedicalBrief, PHF has proposed a solution “which in large measure eliminates this risk and enables an unfettered engagement of over 15,000 medical and other health professionals in the national response.”

Dr Nkateko Munisi, chair of SAMDP, emphasised that family and general practitioners, the bedrock of many communities, face devastating consequences without an intervention of this order.

“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,” said Professor Alex van den Heever of the Wits School of Governance and member of PHF, who helped develop the overarching framework of the PHF proposal.

Key tenets of the PHF proposal include:

Money to be advanced by medical schemes to private practitioners on a non-repayment basis, based on 2019 earnings. This will involve a guaranteed payment to medical practices of up to 70% of historical claims (using 2019 as a base year), and 30% based on activities that exceed the 70%. The guaranteed payment will be offset against actual activities as they normalise over time.

The global cap will be based on both medical savings account and risk benefit claims. In this way medical, dental and allied practices can also be supported with this framework.

Claims activities over the periods 2020 and 2021 will 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 are 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 practices that would have generated incomes during the pandemic, in excess of 100% of their 2019 income.

Discussions have also been held with the banking sector to address short-term needs to access to bridging loans until such time as this framework can be implemented.

“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,” said van den Heever.

Dasoo said that the framework reduces uncertainty for medical practitioners and medical schemes over periods of greatest risk. He said that discussions with major health funders on the proposals have 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 that with the adoption of the proposal, private practices will retain a degree of resilience that will 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.

Professor Glenda Gray, president of the South African Medical Research Council (SAMRC), and PHF member, 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.”

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