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June 2015 Newsletter

Qualicare hosts our members to meet Discovery and GEMS

The meeting between 50 concerned Family Practitioners, GEMs and Discovery couldn’t have happened on a colder night.
It signalled the start of winter, and the first ever FRIDAY NIGHT DEBATE between the doctors of CPC/Qualicare, and the funder industry. The first 2 delegations were those from GEMS and Discovery represented by Dr Stan Moloabe for GEMS and Mr I Rasool, for Discovery Health.

Discovery showed us their vision for 2016 in terms of their Premier Practice, sketching how doctors could be paid R600.00 per chronic case in their practices which are registered with Premier Practice per year as well as R50 for submitting this information on the Ipad, and a further R50 for managing the patient monthly and monitoring his chronic medication.
A new concept in antibiotic stewardship Smart Health Choices, which concentrated on the wise choice of appropriate medication and limiting the use of antibiotics to only when fully appropriate, was widely appreciated and embraced by the doctor audience. Special banners will be made available for the doctors to display in their waiting rooms, giving the strong message of appropriate use of antibiotics.

Doctors present were critical of Keycare's low fees  paid to them for consultations, as well as  the methods of marketing by brokers for Keycare, and alleged that patients are told that they have unlimited consultations with their GP. This caused lively debate with some doctors suggesting that all doctors walk away from the concept, whilst other pointed out that this would be anticompetitive.

Some of the doctors in the audience enquired of DH what they felt a doctor should be paid for a consultation, but answers were not forthcoming.

Balance billing came under the spotlight.  Doctors felt that Discovery permitted certain specialists to balance bill and still paid them the insured portion, whilst they do not do this for Family Practitioners, and rather paid the patient.
GEMS then presented their vision for 2016 and  explained that they would again introduce the GP/FP nomination and denial of direct access to specialists, by the patients, who would have to proceed via GP for their referral to a specialist, failing which, they would be liable for a significant co payment.

As expected this met with wide approval from the mainly FP audience, however FP nomination was in need of extensive refinement, as the concept was good, but the previous attempt at implementation was unacceptable.
Wide spread dissatisfaction was voiced regarding the clearing house, Mycare and its late payements of the GP’s /FP’s, ranging from non payment, to paying Chronic medication from the Acute medication allowance, paying Chronic medication from the Consultation allowance, and in general waiting for up to 4 month before paying the doctors at all, followed by a myriad of payment errors, claw backs, and delays.

Qualicare had run an email campaign to ask doctors for their age analysis, and have passed these on to GEMS for their urgent attention. GEMS was also placed under significant pressure to address these non payments and get urgent monies out to the profession, which had in effect, bankrolled GEMS for 4 months at no charge!
2 major payments, one on the 16th March and one on the 31 March, resulted in some  doctors getting paid significant outstanding amounts, whilst others were again by passed for payment.
Apparently clawbacks are now in the pipeline against some of these amounts which were overpaid.  However, many doctors are still significantly out of pocket.

We are determined to look into whether there was a penalty clause in the contract between GEMS and Mycare, and shall insist that this penalty be partially applied to the doctors who financed the system with their own money.
Still other audience members commented on the impossibility of referring patients into the State Hospital sector, and the length of time spent on call centres to GEMS as well as trying to make appointments at the Govt Hospitals, which time was not paid for by GEMS.

All in all a highly successful,  and thought provoking evening which left most present with the clear feeling that doctors were not impressed with moving into new plans and processes for 2016 until they were correctly, fairly and timeously paid for their 2015 efforts.

Tony Behrman

Last modified on Thursday, 02 July 2015 12:55