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SA Orthopaedic Journal

versión On-line ISSN 2309-8309
versión impresa ISSN 1681-150X

SA orthop. j. vol.20 no.1 Centurion feb./mar. 2021




2020, a year of challenges and achievements on our path together into the future



Phillip Webster

Past President (2020): South African Orthopaedic Association





Every year, the SAOA is presented with hurdles to overcome, and 2020 certainly lived up to this. We have all been significantly affected by the Covid-19 pandemic, but we have survived the onslaught and we live to fight another day. I commend all of you who were directly involved in treating patients during this period for the manner in which you buckled down to often menial tasks and working outside of your comfort zone. I congratulate all academic departments and the College of Orthopaedic Surgeons for your ability to adapt to the new virtual environment and continue with teaching our students and registrars. It was a remarkable achievement to have been able to host a virtual exit exam. No other English-speaking association was able to achieve this. The Covid-19 pandemic has hit us hard, but as a nation, we appear to have come through the first surge without exceeding capacities, and the very low death rate as well as protection of valued healthcare practitioners has been a great success. During this time, the SAOA has worked hard behind the scenes together with Business for SA (B4SA), the South African Medical Association (SAMA), the South African Private Practitioners Forum (SAPPF), hospital groups and the Department of Health (DOH) to try to smooth the path through the pandemic as much as possible. We have managed to get indemnity for work outside scope of practice with insurers, and through the DOH contract, we negotiated relief of premiums with malpractice and have played a role in securing PPE through a weekly meeting with B4SA.

In a meeting held with Dr Nokutho Bhengu, an independent economist, and subsequently the Minister of Health, Honourable Dr Zweli Mkhize, the following key points were stressed for all medical disciplines:

1. We must implement alternate reimbursement models (ARMs) for the future.

2. Outcomes reporting is essential for any future negotiation with the government.

a. Practitioners must own the data.

b. It will be impossible to negotiate tariffs without outcomes.

c. Independent outcomes are necessary to defend against claims of negligence, particularly in public practice.

d. Capture of clinical data, particularly patient-reported outcome measures (PROMs) must be done.

3. Government has identified a problem with provider networks with regard to price in that there is no reference to quality of treatment provided.

The SAOA is way ahead of any other society in terms of meeting these goals because we have already set up a pathway for ARMs through the SAOA event-based contract (EBC) and are producing valid independent outcomes from the South African Orthopaedic Registry (SAOR).

Many projects have been implemented through the year and I thank all the members of the EXCO who have worked tirelessly under difficult circumstances to achieve our goals of making the SAOA more relevant and of greater benefit to you, our members. It is our aim to provide you with more and more benefits over the next few years and would value your feedback as to what you feel could benefit you the most. We are proud to report that our finances are sound, membership is finally up to date, the registry has absorbed all historical data from the South African National Joint Registry (SANJR) and the business core is up and running. The clinical practice committee has worked hard to negotiate better fees, and the path to alternate reimbursement models is well under way. The South African Orthopaedic Journal gets better and better and is, in my view, a world-class journal.


South African Orthopaedic Registry (SAOR)

The SAOA has worked hard to introduce the SAOR and, although there are some teething problems, the implementation has gone well. All data from the SANJR has been cross-walked and surgeons who were inputting their results to the SANJR can continue on the SAOR. The registry is not limited to arthroplasty and there are currently 29 pathways spread throughout all fields of orthopaedic surgery. The registry belongs to us and therefore the outcomes generated are completely independent of any other parties. This is of key importance in the future in that it provides us with great leverage in negotiation with other parties, but will also provide an alternate income stream in the future. We acknowledge that the initial input of data is tedious, but the system is intelligent and with time the data input will be much easier. We all need to persevere and generate our own outcomes in the future; if we don't do this, then funders will use their own data, often inaccurate, and use this to control us. Participation in the SAOR is not a choice, it is essential for our future clinical autonomy and financial security.


Peer mentoring

One of the key issues that the SAOA has dealt with over the last few years has been registrar support and this accounts for the bulk of our net expenditure annually. We host the registrar congress, sponsor many registrars in full to attend the annual congress and arrange fellowships. In keeping with our support of members in full-time public service, we offer significant discounts on subscriptions, congress attendance and levies for these members. We have realised that there is a need for support of junior surgeons, both in public and private practice, and the peer mentoring programme, which will be introduced in 2021, will address these issues. With the development of super-specialisation and separate meetings of specialty groups, we have abandoned support of general orthopaedic surgery. The combined congress addresses this problem by providing access to specialist education in one venue. I understand that it is 'nicer' for specialty groups to meet in smaller groups, but the reality is that it makes it impossible for registrars to attend all of these meetings and, given recent events, is unaffordable for our sponsors.

The peer mentoring programme will be rolled out in 2021. It will require input by all parties involved in the provision of orthopaedic surgery, the SAOA, funders, hospital groups and our trade partners. The aim of the programme is to bridge the gap between registrar and private practice and will involve fellowships, visitation, clinical teaching via cadaver courses and personal mentorship. The programme is not limited to junior surgeons and will be available to all members of the SAOA.


Coding and fees

Another key issue that needs urgent attention is that of billing of fees. In recent times, this has escalated and there is an increasing prevalence of auditing by funders, sometimes clawing back three years. We have drawn your attention to double billing of fractures, and it is imperative that all codes billed for are reflected in your clinical notes. We have obtained legal advice as to the requirement of funders to notify surgeons of outlying codes and have had success in reducing the obligation of the quantum of claw-back demanded. It is very important to consult us before signing any obligation of debt or repayment agreements. The only way to resolve this impasse is to shift from fee-for-service to alternate reimbursement models of payment. We have been in negotiation with funders and hospital groups to provide a model that is fair, ethically compliant and supports experience and efficiency. These models are available for nearly all procedures and require only adherence to SAOA clinical guidelines and compliance with the SAOR. The SAOA will negotiate the quantum of the global fee on your behalf.

The ARM initiative is well under way and roll out will start from now. The model involves a global fee for the surgeon, anaesthetist, physiotherapist and hospital/prosthesis. The SAOA will negotiate a global fee per procedure in conjunction with specialty groups with funders and hospital groups using the AE-EBC contract (administrative entity event-based contract). The surgeon joins the programme by signing the SAOA event-based contract or EBC, which will be amalgamated with most existing contracts. There are two reimbursement options. The first is a fixed-fee model and the second a sliding scale model in which each surgeon negotiates a fee with their hospital manager based on experience and efficiency. The anaesthetist and physiotherapist portions remain fixed. The EBC requires that we practise according to SAOA clinical guidelines (provided by specialty groups) and enter results in the SAOR.


Financial position

Despite the severe financial crisis caused by the extended lock-down and curtailment of surgery, I am pleased that the SAOA remains financially sound and in a good position for the future.

Decreased revenue has been offset against a smaller congress and significant decrease in presidential travel.

Our profession is facing huge challenges in the near future. We have to contend with the financial devastation of the Covid-19 pandemic and the requirement for reconstructive procedures as a result of delayed surgery, implant companies in dire straits and the real threat of implants not being available, vexatious and spurious litigation, and the threat of NHI. All of these factors will result in a higher demand for treatment at a lower cost and introduction of value-based care for our patients. In the past we have been fragmented by hospital groups and funders to their advantage, but we, as surgeons, are the gatekeepers of our profession and we have the ability to take care of our own destiny. We have been at these crossroads many times in the past and each time we have allowed third parties to dominate our clinical autonomy and reimbursement. I say enough! We are once again facing a precipice in our long-term financial sustainability and again we have the ability to control our destiny. You may well ask, what is different now? The answer to this is the SA Orthopaedic Registry. The leverage provided by robust outcomes is immense and with these, and alternate reimbursement models, it will be possible to once again take control of our profession. It is vital that we overcome the inconvenience of input of data to protect our future. Please support the registry, it belongs to you. The second way to ensure financial sustainability is through group practices. These allow for sharing of costs, purchasing parity and transfer of knowledge to junior colleagues. The Mayo Clinic started as a small group practice. An efficient group practice will allow you to free up 30% of your time for billable procedures in addition to reducing the cost of maintaining your practice.

In summary, through the extraordinary effort of my predecessors and a shared strategy over the last Ave years, together with the support of orthopaedic surgeons in South Africa, the 2020 presidential line and executive committee have tried to introduce many programmes to support you through troubled times and we promise to continue to roll out more benefits in 2021. I believe that the SAOA has become a representative and relevant body for all orthopaedic surgeons in public and private practice, and with your involvement will continue to add support to you in the practice of orthopaedic surgery.



Phillip Webster

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