'National Health Insurance wants cheap labour'
By introducing low guideline tariffs, they were trying to force down fees to a level that the government's planned National Health Insurance (NHI) scheme could afford, according to Chris Archer, chief executive of the Private Practitioners' Forum.
"Without the private health sector, the government won't be able to provide universal healthcare for all South Africans. But it can't afford realistic private practice rates. This is clearly why the HPCSA is apparently so determined to press ahead with its plan, despite the widespread resistance to it that has developed across the professions," Archer said.
Doctors said Health Minister Aaron Motsoaledi was putting pressure on the council, which regulates health practitioners, to implement the tariffs before the NHI is rolled out countrywide within the next five years. But Motsoaledi said it was "nonsense" and the council was merely attempting to protect patients from exorbitant rates in "the law of the jungle where there are no guidelines on doctors' fees".
According to Usuf Chikte, from the council's medical and dental board, most of the complaints the HPCSA received from patients related to overcharging. "In some cases, certain practitioners charge more than four to five times the medical aid rates and they feel it is their right to do so in terms of the law," he said.
In August last year, the HPCSA backtracked on its decision to gazette standard tariffs for doctors and dentists after medical associations threatened them with legal action because of a lack of consultation. According to the South African Dental Association (Sada), dentists' tariffs were on average between 30% to 40% lower than the professional fees published by the council seven years ago. In 2006, the HPCSA's professional tariff for a comprehensive oral examination was R705 but, in the 2012 list, an amount of R245.21 was recommended. The same was true for a porcelain crown: R2690 was allocated for it in 2006, but only R1064.87 in 2012.
"At such unrealistic rates, doctors won't be able to afford to practise. They will close down their practices and go elsewhere … The NHI will be a dead dodo, because there will be very few private practitioners left to contract for services, which the state won't be able to provide on its own," Archer said.
By the end of last year, South Africa had only 38652 registered doctors and 5652 dentists for a population of 51-million.
Professional tariff rates
The HPCSA used an inflation-adjusted version of the 2006 national health reference price list, a guide that was used by the medical schemes industry to determine reimbursement rates, which the HPCSA had adopted as an ethical, or maximum, tariff. The 2012 tariffs are in effect the 2006 reference list rates plus 46.66%. But the 2006 reference list tariffs were significantly lower than professional tariff rates, calculated by the South African Medical Association (Sama) and Sada, which the HPCSA published in 2006. Doctors argue this should have been used as the basis from which to work because these tariffs were aligned to inflation or the consumer price index.
Although the new tariffs won't be binding, doctors argue that patients and medical aids will gravitate towards them. "The concern with a published guideline that is unreasonably low is that it will guide public expectation in respect of what should ethically be charged," said Maretha Smit from Sada. "It is simply unfair to expect from a highly qualified professional to go through the humiliation of patients continuously calling him or her unethical as a result of an unreasonable guideline in the public domain."
After withdrawing the publication of its guideline tariffs last year, the HPCSA opened up the process for public participation until February 21, but doctors and dentists are not convinced that the process of determining new tariffs will be fair.
"We are watching the process with a hawk's eye and are highly suspicious of it. We strongly suspect there is an already written document with tariffs lying on someone's desk that will be accepted, regardless of our input," Smit said. "If that happens, we will go to court to get an interdict against the result of the consultation process, as our Constitution requires proper consultation in such cases."
However, Chikte said: "The HPCSA has no hidden agenda. We have not received a mandate from government to get private tariffs down. We are willing to obtain, waiting to receive and wanting the broadest range of comments from the widest possible cross-section of society to assist us in the determination of guideline tariffs."
According to Motsoaledi, the NHI white paper will be released later this month. "The NHI will be there within the next five years. Doctors who outprice themselves won't be part of the NHI; I don't know what they will be part of. I, as the health minister, need to make sure healthcare is affordable to all South Africans and I can't be expected to be neutral in the matter."
A decade of blips on the tariffs radar
2004: The Competition Commission rules that doctors are not allowed to sit around a table to discuss fees as it amounts to price fixing.
2006: The Council for Medical Schemes develops a national health reference price list (NHRPL) and the Health Professions Council of South Africa (HPCSA) adopts it as its ethical, or ceiling, tariff. This was, in essence, a list that medical schemes would use to determine reimbursement tariffs. The country’s medical and dental associations calculate professional rates that the HPCSA publishes. These rates are significantly higher than the NHRPL tariffs.
2008: The HPCSA scraps its ethical tariff list as the health department decides to publish its own reference price list that will be used instead.
2010: The North Gauteng High Court declares the health department’s price list invalid owing to a lack of consultation with stakeholders about determining prices.
August 2012: The HPCSA announces it will publish new guideline tariffs for doctors and dentists. Doctors consider the rates unreasonable and claim they were not consulted. The council withdraws the tariffs and opens the process for public participation.
January 2013: Health Minister Aaron Motsoaledi says he is in discussions with the Competition Commission to overturn its 2004 ruling and start a collective bargaining process to allow doctors, medical schemes and government to discuss fair prices.