SOME medical aid members will have to make
fewer co-payments to specialists or for hospital admissions as the country`s
two biggest open schemes seek to maximise direct payment arrangements with
doctors. The absence of guideline tariffs for medical specialists has
prompted Bonitas to establish a specialists` network and Discovery Health
Medical Scheme is looking to make payment arrangements with more specialists.
Much finger pointing has taken place in the private health sector about who
is to blame for shrinking medical aid benefits. At the last health funders`
gathering, it emerged that some medical specialists were charging as much as
700 percent above what medical schemes covered, while most charged two to
three times more than medical schemes` tariffs. Even Parliament was asked to
intervene in the interpretation of regulation 8 of the Medical Schemes Act,
which deals with prescribed minimum benefits (PMBs), as medical schemes
alleged that the cost of treating these conditions had shot up.
billing structure experienced in the private health industry has more often
than not left members footing the bill where their medical schemes could not.
Bonitas announced the creation of a medical specialists` network towards the
end of last year and Discovery said it had made payment arrangements with 89
percent of the country`s medical specialists to date. Both schemes have
undertaken to pay a tariff that is higher than their normal rates to
specialists with an agreement that no co-payments will be levied on their
members when they use these designated service providers. Alain Peddle,
Discovery Health`s head of research and development, said the scheme had
initiated these payment arrangements in 2007 and now, about 88 percent of its
members were seen by specialists participating in these agreements.
with this arrangement in place, Discovery Health had experienced fewer
billing problems and the debate about the guideline tariffs for specialists
was less of a concern to it. Peddle said that, in the past, the scheme had
experienced huge amounts of in-hospital billing by specialists and this had
driven the decision to contract with doctors. He said the arrangement had
protected the medical scheme from the crazy billing structure when doctors
shot up their rates for PMBs. Discovery Health Medical Scheme paid
specialists between 140 percent and 216 percent of its tariff, he said.
However, a small percentage of doctors were still not willing to contract
with the schemes even if they paid more than twice the usual medical aid
tariffs. Bonitas`s principal executive officer, Bobby Ramasia, said the
scheme started contracting with specialists in mid-2012 even though the
specialist network went live in September. The scheme now had more than 1 800
specialists contracted onto its network and it was expecting to increase this
number to about 2 300 by the end of March.
Ramasia said because of the
open-ended financial liability that the absence of guideline tariffs and PMBs
created, medical schemes and their members became the price takers in an
environment where clinical outcomes measures were not easily available. The
cost was passed on to members in the form of high contributions. Now that
Bonitas had contracted with specialists, the scheme would realise significant
savings which would ultimately translate into more favourable contribution
increases for Bonitas members.