1. OTASA Occupational Therapy Association of South Africa HMI 23 rd February 2016 12:10-13:10 Haley Norval Occupational Therapist EXCO: Chairperson Coding & Procedural Committee

2. Main agenda points: What has derailed OT’s in the health industry Lack of faith in HPCSA Coding Employment/Practice management Way forward

3. OTASA Non profit organisation Professional Association for OT’s HPCSA Registered OT’s 2015: 7590 Membership: 2295 Private Practitioners: 1462

4. Areas of speciality Population: Across lifespan Physical: – Orthopedic/Spinal – Neurological – Trauma – Developmental Mental Health: – Psychiatry – Individual & Group – Developmental

5. Clinical locations of interventions Acute: Hospital & clinics Rehabilitation: Hospital, rehab facilities, centres, domiciliary, step down & care facilities, private practices Chronic/Maintenance of long term conditions: Hospital, rehab facilities, centres, domiciliary, care facilities Schools, work place Location of practice/service provision is often determined by field of special interest and geographical location

6. What do we do?

7. Private sector involvement Register with BHF: PCNS number Business models: – Sole practitioner, Partnerships, Associations, Inc. Company, Group practice comprising independent practitioners or practices co-operating Role within Multi-disciplinary team – primary care provider HPCSA rules: cannot be employed by hospital group OT’s not offered shareholding options with hospital/groups

8. Referral sources DoctorsAlliedsFamily OT’s are primary care providers

9. How we work? Once received referral, consent from patient/family: in/out patient Check funding: limited and subject to scheme approval “Pool of funds” shared with other allied professionals Consent obtained – proceed with treatment plan Often influenced by approved length of stay/sessions - approved treatment plan Power imbalance!

10. Why are we here today?

11. Ideal process of OT intervention Referral Contact with patient Consent Treatment plan & goals Outcomes

12. Present process of OT intervention FUNDING REFERRAL CONTACT & CONSENT TREATMENT GOALS & PLAN OUTCOMES

13. Assumptions We assume patients know & understand their rights & benefits with their Funder Do they know what a PMB is? Limitations linked to PMB condition? Do they know they are liable if there are no funds? Do they have in hospital/step down cover for rehab? Do they have sufficient cover for out patient therapy on discharge? Do they have funds for assistive devices?

14. Who’s responsible for telling the patient? Funder Plan Benefits PMB Doctors Diagnosis Medical treatment OT Consent CPA,POPI Understanding diagnosis Treatment Discharge/Quality of life

15. We are not sure this is happening?

16. Breakdown in process Therapists need to intervene & liase with scheme re funds/benefits Support & explain to patient/families Motivate for PMB/Additional funding Reports: Outcome measures – delay in rehab time as therapy is suspended RESULT!!

17. RESULTS OT’s feel forced to adapt/alter/adjust clinical intervention & frequency to what funding will allow Eg. Forensic investigations in 2015 into paediatric OT’s Pts cannot afford additional therapy & private rates Ethical dilemma? Business sense?

18. Power Imbalance FUNDER Patient OT

19. OT / Funder interactions Reimbursement coercion: charge funder rate & get paid directly If NOT - member payment & struggle to recoup from member especially in-hospital payments Code rejections – limited communication Encourage member to interact with Funder Report to CMS: ? Ruling – case only OTASA involvement Delayed recourse/enquiry

20. OT / Funder interactions Global fees Prescribed baskets of care: reduced sessions allocated for conditions esp. PMB Not pay for certain codes i.e. groups, materials: custom made splints Not pay for certain conditions: F82 Effect on prognosis & functional outcomes Do they really understand our profession? Compromising the profession means they are compromising our care of the patient

21. Pt/ OT relationship strained OT gives in & reduces costs/intervention Reduced outcomes/limited progress/affects quality of life Costs exceed income – temptation to manipulate codes

22. Implications Patient’s have to stop therapy prior to achieving goals – increased pressure on families/Care givers Limits access to further rehab/treatment Medical complications OT’s interpretation of codes incorrect – potential for manipulation of codes

23. What to bill? OTASA advises OT’s to cost analysis on practice to determine their OWN RVU rate = Private rate Funder rates: variance NO prescribed rates from OTASA: anti- competitive NO Upper ethical tariff from HPCSA But which will ensure that we get paid and what our patient’s can afford = FUNDER RATES

24. Who is right & who do we listen to? Lack of faith in HPCSA Not supporting our profession Public? No definitive answers: ethics, employment rulings, global fees

25. OT Coding procedures A procedure code is “shorthand” for a professional activity – the profession knows what forms part or not of treating a patient as well as how the various interventions relate to each other. OTASA provides guidelines based on RPL 2009 codes Procedural codes nor RVU’s been updated since then

26. OT Coding procedures OT scope of profession & practice has evolved & grown thus codes need to indicate this No codes added or amended: 2016 rates - 66313 (45min) one/one session:R280.80 - 66315 (60 Min) one/one session: R374.20 (cleaning services that charge around R300 p/h) Limited resources within Association as clinicians

27. Role of OTASA Various standing committees:  Peer mentoring & review related to ethical conduct & coding procedures  Education & research resources on shared data base: focus on outcome measures & Evidence based practice  Review of international guidelines & protocols to work on adapting to SA context  Promotion of CPD

28. OTASA Plan Conduct time studies to determine relevant RVU values Update/add codes & ensure review of coding procedures Support members in providing best & ethical clinical care

29. Why are we here? We are committed as clinicians to provide the best service to our patients from various settings, cultural groups & economic status. We believe all South Africans should have access to various spheres of healthcare including allied healthcare services. We are concerned about the current private healthcare environment in which we are operating affecting our service delivery & future of our profession.

30. Why are we here? We are a valuable member of the Allied profession & we make a difference in quality of life & economic sustainability – save costs in longer term We are here on behalf of our patients. We are a minority/small profession if go up alone against funders. We are asking for help/intervention - recognition of professional activities and its value Permission to explore solutions such as benchmarking system of tariffs associated with procedural codes

31. Thank you for your time & attention. Contact details: Tel: +27 12 362 5457 / Fax: +27 86 651 5438 Email: otoffice@uitweb.co.za Web address: www.otasa.org.za Occupational Therapy Association of South Africa (OTASA) PO Box 11695, Hatfield, Pretoria, 0028