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RAF payment problems hit medical experts, endangering practices

Medical experts have been hard hit by the twin forces of Road Accident Fund (RAF) non-payments and COVID-19, potentially making their practices financially unsustainable.

The survey that examined the Impact of RAF Non-Payment of Medical Experts During COVID-19 Times – mostly, but not only, among occupational therapists (89) and industrial psychologists (21) – found that 98% of respondents indicated they cannot sustain their practices financially under current measures implemented by the RAF.

In addition, 74% indicated that their practice would not remain viable if they do not receive payment in the next 30 days. “Many medical experts are experiencing dire consequences as a result of non-payment by the RAF of outstanding accounts,” says occupational therapist Anne Reynolds on the survey featured on the Legalbrief site.

“This has been compounded by the chaos which was caused by the termination of the RAF's panel of attorneys. Reports and joint minutes have not been finalised as a result; new appointments have not been made; and/or court dates have been delayed. All of these … have a significant impact on the victims of road accidents, as well as the experts (both defendant and plaintiff) whose valuable expertise is required to ensure fair and equitable settlements of the road accident victims’ claims. This scenario is happening against the background of the global novel SARS-2 coronavirus pandemic and significant deterioration in the South African economy,” says Reynolds.

Not a single respondent indicated that their practice was financially sustainable with the current non-payment situation by the RAF.

* 69% of respondents indicated that their practices are not currently financially viable, with 19% of respondents indicating that their practices would only remain viable with adjustments and reduced operations.
* 26% of respondents last received payment in March, 17% in February and 16% of respondents last received payment in November/December 2019. Only 16% had received any payments in July 2020.On the effects of COVID-19, 83% of respondents said they closed their practices under level five; 53% remained closed under level four; 5% of respondents did not close their practices at all; and 12% have not re-opened their practices under the COVID lockdown.

 

STATEMENT BY ANNE REYNOLDS: OCCUPATIONAL THERAPIST
IMPACT OF RAF NON-PAYMENT OF MEDICAL EXPERTS DURING COVID-19 TIMES

INTRODUCTION
Many medical experts are experiencing dire consequences as a result of non-payment by the RAF of outstanding accounts. This has been compounded by the chaos which was caused by the termination of the RAF's panel of attorneys. Reports and joint minutes have not been finalised as a result; new appointments have not been made; and/or court dates have been delayed. All of these sequalae of the recent actions of the RAF have a significant impact on the victims of road accidents, as well as the experts (both defendant and plaintiff) whose valuable expertise is required to ensure fair and equitable settlements of the road accident victims’ claims. This scenario is happening against the background of the global novel SARS-2 coronavirus pandemic and significant
deterioration in the South African economy.

In order to obtain the full impact of the RAF's decisions on expert medical practitioners, as well as the RAF’s inaction in attending to the numerous interactions and requests over the past months, this survey was compiled to gather the facts as to the impact on medical experts and their practices. Alldata was captured anonymously. Personal information (such as first name and HPCSA number)
were requested to prevent duplication of data and have thus been removed for this analysis of the results.

The results were utilised to obtain a factual basis regarding the impact of non-payment by the RAF on medical experts to the Acting CEO and executive management of the RAF, at the forthcoming meeting/s.

Should it become necessary, the results may again be utilised for further activism in the forthcoming months, including being sent to relevant third parties such as the Minister of Transport or the media.

PARTICIPANTS
A total of 122 responses were received, but only 116 were received before the cut-off time. This analysis is thus based on the 116 responses received in time to review and summarise the data prior to the meeting with the RAF on 6 August 2020.

Most of the participants were OTS (89) and industrial psychologists (21). Several clinical psychologists, educational psychologists, physiotherapists and speech therapists also participated.

Only one medical doctor completed the Survey. This raises a question as to whether the Survey did/ did not reach other RAF experts. Alternatively, other medical experts may not be experiencing the same financial pressures as these two fields of expertise and thus felt it less important to express their situation.

KEY FINDINGS
Demographic Information
• Many respondents were members of OTASA (79% of the OTs).
• 43% of all respondents were members of SAMLA and 27.5% were members of other professional bodies. Only 8% were members of APRAV.
• Most respondents are sole practitioners (68%).
• Thirteen percent of respondents worked in group practices, and 11% had multiple practices in different provinces. There may be some duplication in these numbers, as several respondents working in the same group practice may have chosen this option. Hence, it is probably not an accurate reflection of the group practices and multiple location practices.
• Most respondents were based in Gauteng (82%).
• 46% of respondents have other healthcare workers in the same practice. 80% of the practices employ non-healthcare /support staff in their practices.
• 44% have contracts with third party service providers, including bookkeeping services (40%), rental agreements (28%),and cleaning services (17%), as well as practice management software and security services (15.5%).

Practice Income Sources
• 98% of the respondents rely on medico-legal work as the primary form of income to the practices. Of that 98%, 99% of the work is RAF work.
• 86% of the respondents are not involved in any other form of healthcare work, such as lecturing, clinical placements, other training etc.
• Main source of practice income for all respondents was medico-legal work (100%), with insurance work (27.5%) and private patients (11%) contributing a much reduced income source for a limited number of respondents.
• Majority of medico-legal work was RAF work (99.5%), with medical negligence at 47% and personal injury at 46%.
• 81% of respondents gain their income solely from medico-legal work.
• One third of respondents receive instruction from the RAF directly as well as plaintiff and defendant attorneys. Just under one third receive instruction from plaintiff and defendant attorneys (i.e. not from RAF directly). Only 2 of the respondents receive instruction solely from RAF. This implies that the RAF has to address the payment of both defendant and plaintiff attorneys if we are to keep our practices viable.

Financial Impact Findings
• Not a single respondent indicated that their practice is currently financially sustainable with the current non-payment situation by the RAF.
• 69% of respondents indicated that their practices are not currently financially viable, with 19% of respondents indicating that their practices would only remain viable with adjustments and reduced operations.
• 26% of respondents last received payment in March 2020, 17% in February 2020 and horrendously, 16% of respondents last received payment in November/December 2019. Only 16% had received any payments in July 2020 – I think this was been skewed by the one or two invoices that were paid over the weekend when this Survey was open.
• 53% of respondents do not withhold reports / addendums / joint minutes until payment has been received. This means that the attorneys, and ultimately RAF get their services in the majority of cases. The respondents are basically acting as a free banking facility for RAF and the attorneys.
• When considering the number of reports / joint minutes / addendums outstanding at present, the responses ranged from 0, with a number of respondents having stopped taking RAF cases, to exceeding 750 matters that cannot be completed due to the current situation with the RAF.
• With regard to the actual sums outstanding, 25% of respondents have more than R1m which has been outstanding for 12 months or more. I chose not to include an option of more than R5m outstanding in the question, but it was a consideration particularly in light of
practices which have more than one HCW and work over a number of provinces. I think this option would have been valuable to have now when I see the number of respondents who have more than R1m outstanding for more than 12 months.
• With regard to amounts of less than R1m, 13% respondents have up to R 750,000 outstanding, 9% of practices have R 500,000, and 14% have up to R 250 000 outstanding more than 12 months. This means that 61% of respondents each have more than a quarter of a
million rand of accounts outstanding for more than 12 months!
• Against this background, it is not surprising that 98% of respondents indicated that they cannot sustain their practices financially under the current measures implemented by the RAF.
• In addition, 74% of respondents indicated that their practice would not remain viable if they do not receive payment in the next 30 days.
• It is concerning to see the extent to which the current situation with the RAF has affected other employment. 73% of respondents indicated that their administrative and support staff have been negatively affected by the non-payment by the RAF.
• Five respondents are currently under debt counselling at present, which is incredibly sad.

Future Plans of the Respondents
• Twenty seven percent of the HCWs are considering closing their practices if the situation is not resolved.
• With regard to the other future plans, almost one third (29%) of respondents are considering immigration, 27% are considering seeking work outside of the healthcare field, and 33% are considering starting a business outside of the healthcare field. I think that will be a devastating loss to the healthcare service in SA. Unfortunately, this question allowed for the selection of a number of options, so we cannot add the results up, otherwise it would equate to 89% of respondents leaving the medical field.

Impact of COVID-19 on the Practices
With regard to the COVID section of the questionnaire (even though this may not be one of the RAFs
concerns), the following responses were provided:
• Eighty three percent (83%) respondents closed their practices under Level 5.
• Fifty three percent (53%) remained closed under Level 4.
• Five percent (5)% of respondents did not close their practices at all.
• Twelve percent (12%) have not re-opened their practices under the COVID Lockdown.
• Forty three percent (43%) of respondents consider themselves vulnerable to COVID-19 and 14%
are highly vulnerable. Thirty percent (30%) of other HCWs in the practice are vulnerable, and
36% of non-healthcare staff are vulnerable to COVID-19. Sixty eight percent (68%) of
respondents did not know about the vulnerability of other service providers to their practice.
• 89% of respondents have changed their workflow and staffing in the practice as a result of
COVID. This implies all the practices that have opened under COVID lockdown have had to implement changes in their practices.

• Fifty seven percent (57%) of respondents have attended specific COVID-19 training/events to ensure that their practices are safe and compliant.
• Significant costs have been incurred by the respondents in opening their practices under COVID19. The biggest categories was up to R 4 999. I have grouped from R 0 – R 1 000 with up to R 4 999 for ease of report to give the following results:

• Regarding exposure to COVID-19 and its impact on the respondents, the following information was obtained, as a percentage of respondents. Fortunately, only 3% of respondents have tested positive for COVID-19 themselves, but 8% of respondents have had staff have tested positive and 20% of respondents have had to close their practices again due to COVID.
• 36% of respondents indicated that they are currently seeing up to 4 RAF clients a week in their practices at present; with 38% not seeing RAF clients at present.
• The most frequent interventions happening in the practices are Basic Screening, including temperature screening. 
• It is evident from the above responses that there is a significant amount of basic screening and enforcement of non-pharmaceutical measures with those clients attending the practices.

General education re COVID-19, dispelling COVID-19 myths, and encouraging ongoing treatment of chronic conditions is also occurring with clients. 28% of respondents have assisted clients in accessing government support mechanisms and 18% have provided parental support and guidance. Sadly, respondents have also referred claimants for GBV interventions, as well
as referral to other mental health structures.
• It is evident that very few practices have had any form of government based COVID-19 financial support in sustaining their practices, with only 17% of respondents receiving TERS support and 11% receiving SMME Debt Relief from the government. The successful applications for funding experienced by the respondents are in the fields of bank based credit lines (25%) rental relief
from landlords (21%), or financial assistance from family members (33%).

Impact of Non-Payment by RAF combined with COVID-19
• Finally, respondents were asked to rate on a scale of 0 to 5, how well they are coping with the current situation. The results were as follows:
 Physical health – 4.18 / 5 where 5 is excellent health
 Mental health – 3.1 / 5
 Anxiety regarding being infected with COVID-19 – 3.4 / 5, with 5 being very anxious
 Understanding of family and friend – 3.84 / 5 with 5 being very understanding
 Ability to access to support systems – 3 / 5

• I am impressed at the use of all our ‘OT’ and mental health knowledge and skills in accessing tools to support us through this difficult time, with 36% using online exercise forums, 28% using meditation, 22% using a religious leader or counsellor, and 17% accessing their general practitioner. (I know that this may be a bit biased, but 77% of respondents were OTs).
• Some respondents have accessed the SA Healthcare Workers forum, as well as SADAG for support during this time, which is concerning.

Limitations of the Survey and Information Obtained
There are some obvious limitations to this Survey which are evident and need to be borne in mind.
The areas immediately evident are as follows:
1. Choice of Survey Tool:
• Many survey tools limit the number of questions and/or the number of responses possible on their free versions. To obtain more responses, a monthly subscription to the paid versions was required. This was beyond my financial plan at this point in time.
• MS Forms was the best option, as they limit the number of questions to 50, but allow up to 5,000 responses.
• The reporting function was great, but it reports in either a pdf file, or an Excel file. Hence it is time consuming to pull out the most relevant data to report.
• To get the graphs etc, which is valuable, the full Survey Summary pdf would need to be circulated. I am not comfortable doing this as there are still some fields which would allow indirect identification of respondents (e.g. email addresses and HPCSA numbers).
2. Number and Expertise Field of Respondents
• Two main areas of medical experts responded to the survey. Most of the respondents were OTs and Industrial psychologists. It would have been great to be able to increase the number of respondents as well as broaden the fields of practice.
• An additional 6 responses were received following the cut-off time and hence were not included in the data.
3. Data Obtained • I am of the opinion that valuable data has been obtained through this survey. Respondents provided comprehensive input across the issues presented.
• Some questions which allowed for several options made it challenging to obtain meaningful insights. These questions could have been structured more specifically with branching (i.e. sub-questions), but this was not possible in light of the restriction on the number of questions allowed by MS Forms.
• I would expect (but am open to input / suggestions) that there are probably in excess of 500 different medical experts who do medico-legal work across the various professions. Thus, this data is representative of probably in the region of 20% of the medical experts affected.
• There may be an argument for Confirmation Bias in the current group of respondents i.e. only the experts who are experiencing financial difficulties took the time to complete the survey.
• Specific data on the number of staff members retrenched and HCWs not working was not gathered. However, general comments in this regard are included in Appendix 1.
• There was not an option to allow for General Comments under each section and at the end. I think this would have provided some valuable qualitative information.
• I suspect that there was been an under reporting of the impact of non-payment by RAF, when combined with the COVID-19 crisis, on respondents’ mental health, anxiety and general stress levels. This may be due to concerns about the confidentiality of the information obtained and distribution of the survey findings.
4. RAF Response
• At this time, I am unsure if the full Survey Summary was presented to the RAF. It is also unclear as to whether the RAF paid any attention to the findings.
• Hopefully, some feedback on the RAF response to the survey will be obtained in the near
future.

RECOMMENDATIONS AND SOME GENERAL COMMENTS
 It is vital to get feedback on the RAF response to the above data, so that meaningful decisions can be made as to whether any additional steps need to be taken regarding the findings of this survey.
 It may be valuable to figure out how we can get the survey completed by a broader group if it is deemed to add value to the RAF representations (particularly following the webinar this afternoon).
 Distribution of the survey through professional bodies such as OTASA, SAMLA, PsySSA etc should be explored if a wider data base is required.
 Considering the extent of financial and other difficulties, there may need to be more active support/interventions like the recent Webinar hosted by SAMLA ( NRF/SAMLA/Genoa Managing your Mental Health during Trauma, Triage & Tragedy).
 Respondents are strongly encouraged to join the organisations and bodies that can represent them during the current crisis e.g. OTASA, SAMLA, ARPVA etc. I know that times are incredibly difficult at the moment and people do not want to take on more financial obligations. However, some of the organisations are offering payment relief options, or the ability to pay membership fees over a period of time. Without good representative bodies with sufficient numbers, we are never going to win this battle.
 Following on from the webinar later today, I trust that there will be clear steps going forward on how this crisis will be resolved.
 Finally, for the OTs who participated, there is an Employee Wellness survey which has been sent out by OTASA today. I would strongly encourage the OTs to participate in it, and make full use of the support mechanisms that are provided once the survey has been completed. In addition, using mentorship structures as well as other interventions such as the Support Groups that were offered by OTASA early in Lockdown is strongly encouraged.

Finally, a very big thank you to all the respondents who took the time to provide the data. Without you, we would still be fumbling in the dark about the impact of the RAF’s unilateral decisions. If nothing else is achieved through this survey, please take comfort in the fact that no-one is alone in  dealing with the current RAF and COVID-19 challenges.

 

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