Toward the end of 2006 Discovery Health announced changes to their tariff structure for specialist doctors. The result was the introduction of a premier rate for specialist services. To date, an estimated 65% of the countrys specialists have consented to
Nearly eight months since the new structure was announced there are still a number of vocal detractors.
FAnews Online spoke to Discovery Health CEO Neville Koopowitz to find out more about some of the issues negativity surrounding the premier rate.
Three major intentions
Koopowitz says the three main intentions with the Discovery Premier Rate were to pay doctors more, to pay doctors directly and to ensure that members have more certainty about their benefits. Implementing the new reimbursement arrangement would also increase administrative efficiencies.
To achieve this goal "we increased the Discovery Health tariffs by an average of 35%," says Koopowitz. Specialist doctors who agreed to the reimbursement arrangement had to apply this rate to all Discovery Health members regardless of their plan option.
Koopowitz believes that both specialists and patients benefit from the premier rate. Specialists receive an average of 35% above the NHRPL rate and medical scheme members receive specialist services without having to make further co-payments. Koopowitz also stressed that specialists were not being forced to sign up for the Premier Rate and were free to continue pricing for their services as they felt appropriate
Addressing the major concerns
There is a small group of specialists who remain opposed to the Premier Rate. Prof Chris Joseph, ENT representative on SAMA's Specialist Private Practice Committee believes that Discovery is "attempting to take control of the profession." He feels that Discovery "wants to control fees and control what codes [specialists] eventually charge against." We put this to Koopowitz who stated categorically that there is no clinical interference from Discovery's side.
Specialists raised more concerns when Discovery launched a search facility to assist its members in locating specialist doctors who charged the Premier Rate. Some specialists believed that this was an attempt by Discovery to channel patients to specialists who had signed on for the service. The suggestion was that specialists who were not on the list would lose business as a result.
Koopowitz said that Discovery had noted these concerns, and after discussions with various interested parties had agreed to remove the search facility from September of this year. Discovery will encourage specialists to disclose their fee practices when consulting with patients.
To relate quality of care to the reimbursement rate is completely insulting
Another fear doing the rounds recently is that patients on certain medical schemes will receive inferior treatment from specialists because these specialists were aware that they would receive lesser remuneration for their services. Koopowitz dismissed this assertion as extremely insulting to the medical profession as a whole.
This aside, specialists have received varying remuneration from different medical schemes for many years.
Making it work in the future
At this stage there is little that Discovery can do to bring the dissenting voices into the specialist reimbursement arrangement. Perhaps over time those who are unhappy with the proposal will come to accept it. Koopowitz mentions that the total of approximately 100 dissenting doctors is relatively small when considering the 4,500 to 5,000 specialists active in the country at this time.
Koopowitz believes that the premier rate is here to stay and will feature in the medical schemes environment in the coming years. He says that while the system might become more complex to include additional derivatives it will remain simple for medical scheme members. He also expects that subject to approval by the Board of Trustees of the Medical Scheme the Premier Rate will increase over a period of time.
To sum up, Koopowitz believes that medical schemes have an important role to play in controlling price inflation in the healthcare environment. He says that medical schemes remain important for the preservation of private healthcare in South Africa and should strive to create a legacy for future generations to receive excellent private healthcare.
Editor's thoughts:
Discovery states that the premier rate specialist reimbursement arrangement leaves both specialists and patients in a better position. They do not force specialists to join the network, nor do they force customers to use specialists from the network. Do the specialists opposed to Discovery's premier rate policy have a case? Send your comments to gareth@fanews.co.za
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