versión On-line ISSN 2078-5135
versión impresa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.98 no.8 Cape Town ago. 2008
Ten of South Africa's 90 neurologists are consuming 40% of all neurology medical aid claims while seeing only a quarter of the disciplines' funded patient pool - and an investigation by the Neurology Association (NASA) points to possible over-servicing by four. Izindaba learnt that the four were charging patients on average double what their colleagues were when procedures and consultations were added together.
According to Neurology Association Chairperson, Professor Girish Modi, the remaining six ran 'highly specialised' practices that, when viewed in context, made apparently excessive charges 'actually very, very acceptable'. The remaining four, 'about whom we are a little bit concerned' would be given every chance to explain their coding usage and, if necessary, mend their ways without being reported to the Health Professions Council of South Africa (HPCSA). If they refused to co-operate, the complaint would be handed over to the HPCSA, 'and then they're on their own,' said Modi.
This is in terms of the arrangement between the Neurology Association and the Board of Healthcare Funders (BHF) after the BHF consulted SpesNet, an umbrella body of specialists, on whether it should hand the matter over to the HPCSA.
BHF spokesperson Heidi Kruger confirmed that 'routine profiling' (GPs and pharmacies are next) across some 11 medical schemes and administrators threw up the neurology 'anomalies' that led to the flurry of consultation.
Softly, softly ...
While the HPCSA has urged the BHF to give it an already prepared formal complaint, the BHF opted for the more conservative, cautious route using the very peers that would have to be consulted anyway to verify whether systemic abuse exists.
Kruger said the discipline of neurology was chosen first for profiling because there were a number of complaints at the BHF's forensic management unit. Profiling will systematically be done on all disciplines and data are currently being collected on GPs who will be profiled next, she said of a practice which Modi expressed grave reservations about.
Of the 10 neurologists whose claims set off flashing lights on the BHF radar, Kruger said: 'This doesn't necessarily mean that they're adding codes willy-nilly, but there was something anomalous about these top 10 that required further investigation'.
The moves comes as traditional wrangling between medical aids, hospitals and health care professionals comes to a head via a controversial government bill proposing a State pricing 'facilitator' tribunal and inspectorate to set and cap pricing.
The South African Medical Association (SAMA) and its specialist doctor groupings claim pricing control will hit the more refined specialties hardest because they have the most expensive overheads. This latest over-servicing probe comes at a critical juncture and may give the central pricing lobbyists, including BHF, political ammunition.
SAMA claims the historical lack of health care professional costing in the National Health Reference Pricing List (NHRPL) will render more than half of disciplines financially unviable. This context has probably led to the BHF's tactical diplomacy ahead of the legislation.
Neurologist 'insider' speaks out
A neurologist who spoke to Izindaba on condition of anonymity, said the neurology coding system was more open to abuse than most disciplines, citing the 'vague' 0717 code for electrical stimulation of muscle, designed originally for laboratory use.
He was 'shocked' to see a colleague bill a patient R5 000 for confirmation of a tentative carpal tunnel syndrome diagnosis by an orthopaedic surgeon. The patient reportedly spent 20 minutes in the neurologist's consulting room where he was extensively tested for trapped nerves in both arms and legs. 'That's a bit steep. You can say you wanted to exclude a generalised nerve problem and get away with it in theory, but one has to use common sense and if there are no symptoms, why do all that?'
While he conceded that carpal tunnel syndrome could come from a variety of sources, the vague coding allowed for all 12 nerves to be tested and charged for. In his experience charging for 'three or four nerves is quite acceptable'.
The neurologist said he knew of two medical aids unquestioningly paying for these claims, 'knowing that this is over-servicing' and claimed they were 'equally to blame'. 'They're not even contacting the guy and saying you are charging too much,' he added.
Modi said his association was initially upset by the manner in which 'this issue was handled', referring to his first reading about it in a news report in the business section of a national newspaper group.
Kruger explained that she had used the 'neurology anomaly' to illustrate a point at a seminar for health journalists in May, without inferring any fraud or dishonesty. The reason they had consulted SpesNet and not the Neurology Association first was that a similar anomaly cropped up in 2000 and 'we were told that the association did not have any teeth'.
Modi said an additional option if the four were found to have abused the system and still refused to co-operate would be to scrap their membership of the NASA. The data provided to them by the BHF were given 'blind' (no means of identifying the actual doctors) in order to ensure impartiality.
Crude BHF instrument leads to 'inadvertent mischief'
Neurology was 'an extremely complex' discipline with no clear guidelines on whether someone was doing too much or too little. To simply take raw data and 'crunch numbers', as the BHF did, could lead to 'inadvertent mischief'.'If you stay below the radar you can get away with everything, but the minute you're picked up you get chopped.'
Kruger acknowledged that neurology was a complex discipline but found it 'difficult to accept' that, given the enormous body of knowledge that existed and the high level of training which neurologists had to undergo, the discipline had not been able to develop guidelines.
Modi bolstered his argument by citing one neurosurgeon conducting 20 back operations a week and another doing five. The one doing 20 would look as if they were overdoing it yet was an expert in the procedure, had taken a second and even a third opinion, and the operation could be fully justified, while the other surgeon could be conducting 'five nonsense operations'.
'Suddenly the guy who shows up on the radar is helluva ethical,' Modi added. To say practitioners above a certain threshold were 'bad' was entering into 'very dangerous territory' and played into the hands of eager legislators. 'There's a lot of art to medicine, it's not just science - the only complaints that should be lodged should be on a case-by-case basis'.
Modi also gave the example of 'guys doing lots of MRIs, charging very high rates and being contracted out of medical aids, they wouldn't even feature in this kind of thing!'
While he conceded that there was potential for systemic abuse and that 'some people are doing it', the result of such crude number crunching was that every discipline would introspect, compare itself with others and 'you end up with a dog fight'.
The principle of over-servicing was industry-wide and not confined to neurology. 'What we have now is a system in which funders have become the controlling body for medical practice and that's wrong. We need to move away from procedure-based medicine to consultation-based medicine, doctors have to be paid for their skills, not procedures they can or cannot do.' He cited South Africa as having an extraordinarily high number of operations for the back and neck in the private sector versus very few in the public sector.
Modi said his association had proposed a stratified system of billing to Health Minister Manto Tshabalala-Msimang so that doctors could get back to a system where 'they regulated themselves and are not regulated by funders'.
Kruger agreed that the current funding structures 'incentivised this kind of behaviour', citing the caesarean section rate of 70% in South Africa versus the international norm of 20% and the local public sector of 21%.
'We need some kind of restructuring of the entire system. Hopefully the new National Health Act, with its bargaining chamber, will begin to address these problems,' she added. She said interrogating codes with the specific disciplines using their expertise was far more helpful in educating funders so they could come up with more appropriate guidelines/Digging down into each record card is costly, unwieldy and ultimately not as productive,' she added.