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News Article : Specialist Advocacy Group overview
Category: Healthcare Insurance : Medical Schemes
Author:Edited by ITInews
Email:[email protected]
Posted:22 Aug 2007

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Particularly concerned for the safety of the patient in the current environment

The SAG was formed in response to being approached by Discovery Health, a third party administrator (TPA), (presumably acting on behalf of Discovery Health Medical Scheme) (DHMS) to enter into a service arrangement under which the specialists would treat patients who belong to DHMS

No Contract

It is important at the outset to make the distinction between a rate and service arrangement. A rate put out by a medical scheme means the amount the medical scheme will pay, irrespective of what the caregiver charges the patient.

There is no agreement with the caregiver on fees, or for that matter anything else. However, once a caregiver agrees to a price with the scheme directly or indirectly (via an administrator) the caregiver creates a business relationship with the scheme.

It appears that the majority of specialists and their business advisors have overlooked this very important distinction and the specialists either individually or through their respective societies have unwittingly entered into a service arrangement with a medical scheme covering healthcare services to their patients, without a written contract in place.

This is reckless. Without a written contract covering the full spectrum of the business arrangement between the caregiver and the scheme, clearly laying out each parties’ rights and obligations, including the patient’s, the caregivers are exposing their patients to extreme danger as well as increasing their own exposure to litigation.

What is most surprising and extremely frightening though is that chairman of the board of trustees of DHMS is not only a lawyer, but is also a senior advocate. No one should know better the value and absolute necessity of a comprehensive written contract than this man.

However, under this man’s watch the scheme has entered into a commercial arrangement worth hundreds of millions of Rands with thousands of doctors covering healthcare services for hundreds of thousands of people without a contract and has some explaining to do.

The SAG as the Patients Advocate

Healthcare is a very complex industry primarily made so by the number of stakeholders involved, some of which independently are large industries themselves.

It is very easy to get lost in this maze in which the patient is increasingly becoming cannon fodder, as the more powerful stakeholders battle it out for supremacy and point fingers at one another.

The SAG is particularly concerned for the safety of the patient in the current environment and is committed to making absolutely sure that the patient is getting a fair deal and not being taken advantage of.

The SAG has taken the position that the doctor patient relationship is sacrosanct and should not be interfered with by outsiders.

The fee that the caregiver charges the patient is between the caregiver and the patient, as is the level and quality of services the caregiver directly provides the patient and to which the caregiver refers the patient.

The medical scheme has no business interfering in that relationship and certainly not administrators that are not even involved in the business of providing cover.

Medical Schemes vs Administrators

In the interest of the patient the SAG is not prepared to enter into discussions concerning fees, quality and accessibility of services with administrators, which are not responsible for these areas and indeed have other commercial responsibilities not in alignment with that of the scheme and its members.

The SAG is not prepared to expose patients any longer to this system in which trustees have largely handed over critical areas of health plan business to administrators. The SAG insists on dealing directly with the trustees of schemes.

The SAG insists on a system, which is transparent, and in which there are proper checks and balances, where funders are funders and administrators are administrators and not where administrators pose as funders and make funding decisions that they are not responsible for.

To engage with administrators on matters of price, quality and accessibility would be acting in direct opposition to normal business practice, to which the SAG is not prepared to expose the patient.

There is no reason for specialists to deviate from normal business practice let alone act in direct opposition to it. This would be reckless. Frontliners deal with frontliners and not with back-office service providers that have no business in dealing with frontline matters in the first place.

Authority without responsibility has serious consequences to which the SAG is not prepared to expose the patient.

The argument put forward by some specialists that have negotiated with the administrator and have agreed to go ahead with the service arrangement (with or without a contract) is that they are aware of the difference between scheme and administrator but this is how the system works.

The SAG does not accept this and is not prepared to expose the patient any longer to this one-sided structure, in which funding matters are under the control of administrators. This has led to the exploitation of the private consumer on both cost and quality, with nothing in the way to stop it.

With over 3,000 GPs and the majority of specialists having already agreed to go along with a service arrangement with DH/ DHMS, the SAG is literally the last line of defence the private cover consumer has against an industry that has shown no restraint in the pursuit of profits.

Request to Meet with the Trustees of DHMS

The SAG recognises and is encouraging the need for constructive engagement with trustees of medical schemes, who are directly responsible to the patient with a view to establishing structures through which they can discuss issues of common concern affecting patients / scheme members.

In pursuance thereof the SAG wrote to the trustees of DHMS requesting a meeting, to which the scheme responded by requesting an agenda. Although an agenda was sent a meeting has not taken place.

All that the scheme has said is that is committed to meeting, but has not taken this matter any further nor requested any further information.

Despite the SAG’s request to meet with the trustees of DHMS a communication was sent out by what the SAG assumes was the administrator to brokers attempting to discredit the SAG, calling it a small group of detractors who among other things would have a system where patients would be exposed to uncertainty and gaps in cover.

The communication goes on further to say that this group of detractors do not want to meet at all with Discovery Health. In response, the SAG wrote to the scheme asking it whether it endorses the content of the communication. The scheme did not reply.

Medical vs Non-Medical Management

The SAG is committed to ensuring that there are clear lines between medical and non-medical management of the patient.

This means that the various segments in the industry contain their activities within the boundaries of their respective positions and do not cross them, as trustees have allowed administrators to do. The administrator that has exceeded its boundaries far more than any other is Discovery Health.

Agreeing to a fee to charge patients with a scheme impacts directly and indirectly on the range, quality and level of service the patient will receive, to which the SAG is not prepared to expose the patient.

The SAG also feels that once a fee is agreed to the specialists will be vulnerable to other interventions by the scheme or administrator, which could use the economic dependency created by the fee arrangement previously entered into as a stick.

While the SAG is prepared to discuss fees with the medical scheme and obtain feedback from the scheme, in the interests of the patient it is not prepared to enter into negotiations with a scheme or administrator on what to charge and how to treat the patient.

Resistance by Administrators

In the interests of the patient the SAG does not recognise the standing of administrators beyond their role as administrators, even if trustees of medical schemes do.

The SAG has made its position very clear in this regard in its communications in general, with DHMS and with the BHF.

With regard to the latter the SAG has not received a response from the BHF to its request on the BHF’s position on the exorbitant fees DHMS pays its administrator after targeting the specialists as major cost drivers and for the names of the people that serve on the various committees of the BHF in order to ascertain the extent to which the BHF is influenced by administrators.

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