Roshila Pillay
A stringent set of new measures to clamp down on kickbacks in the health industry has sent shockwaves through the medical community.
The proposals were hatched before the scandal surrounding kickbacks among pathology labs was exposed in May. Some health industry observers have speculated that the recommendations could have been tightened in the wake of the scandal. Members of the health industry have reacted with outrage to the proposed new policy on kickbacks, describing them as “draconian”.
The most recent draft of the proposals, which was circulating in hospitals last week, severely curtails the way in which all health professionals – from traditional healers to masseurs and health hydros – can deal with suppliers of drugs and equipment.
The new rules, if legislated, will compel doctors to disclose, for example, their shares in medical companies or hospitals, in an effort to prevent any conflicts of interest.
The proposed new rules have been drawn up under the auspices of the Forum of Statutory Health Councils, an umbrella body for seven such councils in South Africa.
A committee from the forum, with the task of drawing up the new rules, is due to meet next week to discuss the proposals. The final draft, which was formally circulated to these councils in July, appears to have been compiled on the premise that the proffering of kickbacks is widespread. It even advises councils to use the 1992 Corruption Act to clamp down on errant practice. “The final draft seems more hell-bent on attacking the pharmaceu- tical industry instead of benefiting the public,” says Mirryena Deeb, the CEO of the Pharmaceuticals Manufacturing Association.
The proposed policy narrowly defines acceptable standards of behaviour among all the members of the health industry. “I thought they were quite onerous. Certain aspects are justifiable but they seem to be coming down heavily on the medical profession. Accusations are cheap – we are always the whipping boys,” says Rob Goodall, CEO of Schering, a pharmaceutical company.
Among other guidelines, the draft policy stipulates that a health-care professional may not: l Manufacture medicine, medical devices or health-related products unless it forms part of the normal scope of practice or explicit permission is obtained from the relevant board or council to do so; l Unfairly promote a particular health establishment, medicine, health product or medical device by endorsing or advertising it for financial gain or any other compensation;
l Give preference to any health establishment, medicine, health product or medical device for financial gain or any other valuable consideration, unless it is legally condoned; l Order more tests, procedures or care than is necessary – what the document terms “overservicing”;
l Refer a patient to a health establishment or health-care professional if that constitutes overservicing; l Accept a commission or any financial incentive in return for the purchase, sale or supply of materials used in a practice; l Pay commission to any person for recommending patients; l Share fees with any person or health-care professional who has not helped render the service for which the payment is received. The proposals are equally stringent where the declaration of financial interests is concerned. If, for example, a doctor owns shares in a clinic that he refers his patients to, he must display a notice in his waiting room indicating his interest in the clinic. Dr Aslam Dasoo, the CEO of the Board of Healthcare Funders, the umbrella body for all medical aid schemes, says the pathologists scandal spurred the official bodies to take action.
Although Dasoo believes the policy makes a good start in identifying the problem and areas that have to be investigated, he stresses that to develop a strategy against kickbacks would require creative thinking. He said this would be best achieved by a forum consisting of various members of society, including consumers, doctors, health department officials and health-care professionals.
Deeb says the definitions contained in the policy are based on the 1965 South African Medicines and Medical Devices Regulatory Authority Act – an Act which the Constitutional Court decided should remain enforced only until President Thabo Mbeki determines when to enforce the more recent and updated 1998 Act.
Deeb says this oversight renders the policy technically unsound because the definitions are based on an outdated Act.
Another of the document’s stipu-lations is that all organisations that provide health services, including medical aid schemes, hospitals and pharmaceutical companies, use gene-ric names of products “rather than trade names in the course of continuing professional development activities [activities to further on-the-job knowledge]”.
Deeb believes this could lead to an influx of counterfeit, poor quality medication. “Keeping doctors educated with regard to the latest science is imperative. It is illogical to educate doctors on the latest drug released by your company if you are unable to use the name of the product.” Guidelines are also in place to govern continuing professional development activities – traditionally seen as publicity stunts by health-care organisations to push their products.
The document suggests barring companies from paying for health-care professionals to attend events – either which relate to their profession or, as is sometimes the case, “freebies”, such as international sporting events.
It does make allowances for scholarships or special funding to be provided in the case of “deserving health-care professionals” or students but further elaborates that the principal event should concentrate on “education and not around meals, entertainment or other hospitality”.
Mark Lotter, the CEO of Domestic Operations for Aspen Pharmaceuticals, sees the need for an independent body to govern this aspect of the policy. “It is critical that an independent body is established to judge the content of meetings and accredit them,” says Lotter. He reasons that if an event is education- based then organisations would have no problem having an independent observer to accredit it. Some members of the health industry are dubious about the consultation process followed to draft the proposed policy. One general practitioner went so far as to denounce the process, claiming that doctors from historically disadvantaged communities are often not consulted in important policy formulations such as this. The chair of the committee responsible for the policy, Professor Jan van der Merwe, is adamant that the committee has represented the interests of all concerned. “On two occasions we published previous drafts in the press and invited response. We received a 60% response and considered these comments when drafting the policy.”
Although the committee expects the policy to be implemented at large by the health industry, only the relevant statutory council for each sector of the industry can enforce the policy in their sector.
Deeb reiterates: “They have no right to enforce this. We have our own code of practice to follow.”
The committee also intends helping the Department of Health formulate laws to curb the rampant practice. Until then the health-care industry waits to see the effects of the new airtight restrictions.