The accusations levelled at the private healthcare industry recently are not unfounded when one considers that we spent 8.7% of GDP on healthcare in 2005 when the international standard is around 5% of GDP. If we break this number down further, public healthcare accounts for 42% of this expenditure, which seems a fair number if one does not consider the fact that the public sector serves 80% of the population and simple math proves that 20% of the population is therefore responsible for 58% of our healthcare spending. The only reason that such a disparity could exist would be that costs in the private healthcare sector are much higher than costs in the public sector. I do suspect however that the Minister and researchers discount a very important structural difference between the public and private sectors of our healthcare industry when doing their comparisons.
The major difference I have found is that doctors working in the public sector work for a fixed salary regardless of the amount of patients they treat or the services they render, whereas the private sector doctors write up the full professional fee every time and it would be interesting to see what the comparison would look like if it were done on a full professional fee basis. As has become the rule with our Government, they are basing their argument on skewed facts, but this does not mean that private sector providers are not making themselves guilty of artificially inflating costs in a few ways. I promised you before that none will be spared.
A new ethical question
A lot of us have been to a large private hospital recently, where we found the specialist doctors and hospital not only sharing the same piece of real estate, but it is my understanding that the doctors we find here are also shareholders at the hospital. While this shared scheme makes sense from a logistical standpoint, it does create somewhat of an ethical question. If a doctor can profit financially from admitting a patient to the hospital he holds shares in, is the decision to have the patient admitted still solely based on the circumstances surrounding the patients illness?
You may have noticed by now that I do hold the medical industry and medical professionals in the highest regard, but I also know for a fact that there are some unscrupulous sharks out there trying to make a few quick bucks and what easier way than to admit a patient to hospital when it is not really necessary or keeping a patient in hospital for longer than is medically required?
Mothers, especially new ones, are the common target
It is a sad but undeniable truth of our country that women are perhaps the subgroup of our society most targeted by all sorts of unsavoury characters and it is equally sad that the private medical industry has been cashing in on mothers for years, if not decades. We are talking about the C-section.
When it was first devised, the C-section was an alternative procedure to be performed when vaginal childbirth would put the health of either the mother or baby at risk and this was the norm for many years. The World Health Organisation (WHO) recommends that C-sections should ideally not comprise more than 15% of all childbirths in a country over a given time period, but for the 2010 calendar year the C-section rate in our private healthcare industry was around 70% (30% for public healthcare). The primary reason for this should be that the HPCSA declared that the delivery method must be the choice of the patient, but the truth is that doctors are actively promoting C-sections as the safest method of childbirth. If one considers the WHO research findings that C-sections are ten times more life threatening than vaginal births, one cannot help but declare that doctors are duping women into taking a more dangerous birthing option for the sake of convenience alone as they are scheduled ahead of time and less disruptive to the doctor’s private practice.
Medical reasons aside, the simple fact of the matter is that C-sections are far more expensive than vaginal births since they require an operating room, operating staff and a three day hospital stay, when compared to the delivery room, doctor and next-day discharge with vaginal births. The average vaginal childbirth costs around R25000.00 in the private sector, but C-sections start at around R30000.00 and while one or two would not make a big difference, the fact of the matter is that it cost a certain medical aid an additional one million rand in 2009 alone.
It is not surprising then that the Department of Health is currently working on regulations and perhaps even legislation to curb the excessive amount of C-sections currently being done by private healthcare providers.
Doctors are losing their touch
While nobody can deny that technology has improved our lives in indescribable ways, this is not always a good thing and one has to question not only the medical necessity of the use of technology in the private healthcare industry, but also the costs involved.
Many of the older doctors complain that the young ones are losing their clinical skills by relying too heavily on the use of imaging equipment like X-rays, sonars and CT or MRI scanners. Not too long ago, these machines were exclusively used to confirm a difficult clinical diagnosis, but today they are too often being used to make the primary diagnosis and this fact is nowhere better illustrated than in your medical aid benefits. When you closely examine your benefits, you’ll find that you need to obtain authorisation from your medical aid for specialised radiology services and more often than not, you also need a motivation from the treating physician. This requirement exists for a reason and that reason is that these services are not only expensive, but are often abused by doctors who are unable/unwilling to make a clinical diagnosis or seeking an added financial benefit. When compared to public healthcare, we again find a much lower instance of this technology being used and one cannot ascribe it to the poor state of the public sector alone.
Fraudulent billing
As is the case with all other businesses, the private medical industry has been faced with rapidly rising cost pressures over the last few years and this has prompted a lot of services providers to not only charge patients for items they never used to charge for before (syringes and swabs for example), but also “dress” their income in some ways.
The most common way to do this is to use a cheaper generic product, but then charge the patient or their medical aid for the full price of the “original” medication, thereby taking a bigger profit on the generic product than they would be able to under Single Exit Pricing legislation. The medical aids have tried to counter this practice by only paying the price of the generic medication, but the truth is that these doctors then either co-bill the patient or charge them an additional “administration fee” to make up the difference.
I suspect that there might be more ways for private sector doctors to line their pockets and artificially inflate the cost of healthcare, but they fall outside my knowledge. What is clear though is that the private healthcare industry is currently filled with many loopholes that provide these opportunities for those that would take them and I am all for any attempt at closing them. What we also cannot discount though is the effect that patients currently have on our healthcare system, but more on that next time.
The Needle's Point 