1. BHF response to Medical/Dental Practitioners submission to Parliament Dr. Rajesh Patel BHF August 2012

2. Outline Coding issues Cost studies to determine fee level Quality of care Concluding remarks

3. Abbreviations HPCSAHealth Professional Council of SA DBM Doctor's Billing Manual. SAMA coding and fee publication SAMASouth African Medical Association NHRPLNational Health Reference Price List BHFBoard of Healthcare Funders of Southern Africa CPTClinical Procedure terminology NDoHNational department of health FBCFull Blood count. Commonest pathology test. FFSFee for Service

4. Coding Issues Coding structure published by HPCSA is based on “Scale of benefits” and NHRPL, rather than DBM as claimed by SAMA. 2012 DBM Problems –“Intellectual property” poses copyright risk –Coding manipulation aligned to CPT (US coding). Risk of copyright cost. NDoH,HPCSA and BHF: public domain coding structure –Full of coding manipulation over many years

5. Coding Manipulation & Scope of practice “Guide to Billing” not linked to coding structure –Provides room to unilaterally change interpretation. Abused over last decade E.g. Hip replacement billing –Hip replacement + debridement + partial Synovectomy + tendon separation. This is charged as routine. What does Hip replacement code represent? –Current coding therefore does not reflect scope of practice an must be fixed. 2006 structure least abused.

6. Coding Manipulation & Scope of practice Oncology coding change in 2005 was in response to dispensing fee regulation and single exit price for medicine. Coding change intention is to retain levels of oncologist income. New codes not consistent to scope of practice: –E.g. non-infusional facility fee R500 for dispensing tablets/injection Pathology fees in HPCSA publication represents over-remuneration –FBC (commonest test) cost is <R25. tariff price <R160 –Numerous duplicate code that must be fixed. Billing abuse to maximise revenue. –Uncontrolled, unregulated introduction of new technology

7. Coding Manipulation & Scope of practice Coding changes in DBM2012 (SAMA) compared to 2006 published codes by CMS –Unilateral changes, no consultation with stakeholders Mostly change in existing codes rather new codes for new scope of practice –No transparency –Existence of coding abuses and duplicate codes suggests SAMA review process is flawed

8. Current SA pricing abuses being exported to other SADC countries.

9. HPCSA must be allowed to publish! Scope of practice determination and its aligned coding structure development should be function of Regulator not representative body like SAMA that changes coding unilaterally. Healthcare access is a public good. Need for price regulation! –To assure access to care without risk of co-pay. –To address arbitrary price setting by providers

10. “Cost studies” Method suggested by Competition Commissioner (2004) Excellent example of badly conducted research –Output therefore is flawed –Cannot be used for policy making Must consider willingness to purchase/Affordability as well…this is ignored!

11. Quality of Care Latest and greatest type care: good quality Outpatient care: significant room for improvement

12. Diabetes (2007): FFS vs Center of Excellence Benchmark for primary care services

13. Concluding remarks Biased coding structure must be fixed Public must be protected from arbitrary determined provider pricing Need to fix pricing in private sector through regulated pricing mechanism HPCSA must public fee: – for protection of public –Allow coding and pricing to be fixed. Providers must be made accountable for quality of care delivered