FACULTY OF CONSULTING PHYSICIANS OF
SOUTH AFRICA
P.O. Box 2896
Alberton 1450T) 011 907-8827/8
F) 011 907-9429
Dear Colleagues,
It is interesting that after many court cases, meetings, negotiations etc. little has changed in essence. I thought to update you on what has been attempted but which so far has yielded little new!
- CMS / 2005 fees
CMS (as always) has unilaterally developed a schedule of fees and codes for 2005. Very much in line with the NRPL we can prepare ourselves that this will be the benchmark for the medical aids / funders. What’s new? Although the SPPC of SAMA objected very strongly to all aspects of this system, the “negotiations” tend to result in a predictable negative for the doctor / provider:
I include the codes as “proposed” by CMS and I would be pleasantly surprised if they heed any of the objections / suggestions as proposed by the SPPC. The ICD10 coding system is still fraught with problems and although it will again be considered mandatory to include these codes, you can only capture one code, which in the context of time-related tiered consultations does not reflect the complexity nor level of decision-making involved in the average medical patient.
Confidentiality has also not been clarified especially if the diagnosis reflects HIV/AIDS. Again CMS sidestepped these issues although they formed part of the SPPC response.
Funders cannot capture more than one code and one code does not reflect as I said the average medical patient. It would therefore follow that they will probably query every account!
Shortly after the tiered consultation “suggestion” by CMS, it was followed by a letter from Stephen Harrison now with a single consultation fee and I include it for your comment. My comment – you have got to be joking!
- Funder restrictions / PMB’s
I have noticed that groups such as Qualsa has a set protocol for reimbursement in the PMB’s and for example only allow one 0141 visit annually for a diabetic patient, implying a 10 minute consult, no stress ECG, only resting, and limited blood tests. They claim to have developed “Care Plans” for each of the 25 conditions. The same approach is fairly universal across funders.
Some funders are classifying us according to our costs / patient as A, B or C doctors. For example if you prescribe cheaply you are an “A” doctor and all your scripts will pass through without question! If however you dare to use expensive meds you will be a “C” doctor and be penalised by having to motivate for scripts and even investigations or admissions. Again we have no control or influence. The actuaries will dictate our patient care.
I would again ask that you do not enter into contracts with companies as preferred providers. As physicians we are in any case a scarce commodity and it just means you maintain your autonomy and will not be caught in a situation worse than where we are at present. Most of the contracts I have seen offer us very little, no protection and many prescriptions as to how, what and why we can treat patients.
I am slowly meeting with the big funders to see if we can simplify chronic medication forms or avoid them totally if possible. It is a slow process but hopefully we will get somewhere and avoid the immense load of admin we sit with daily. The ideal would be if they accept in principle we have a history with our patient and this determines our prescribing. We make an assessment based on a clinical examination, history and investigations not an actuarial cost model.
To all of you doing a sterling job every day, hang in there. Try to enjoy your medicine as you go and thank you for practicing ethically amidst all the nonsense we face.
Yours sincerely
Dr. Adri Kok
Chairperson FCPSA
MBBCh (Rand) Dip PEC (SA) FCP (SA) MMed (Int. Med)
P.K. No. 1805622