In mid May Discovery Health announced that it would pay GPs the higher consultation rate of R90 provided that claims are submitted to it electronically.  In an e-mail sent on 21 May to a large number of GPs (and others) e-mail boxes, the announcement was made: "Excellent News for GPs using Healthbridge".  Since then other carriers for electronic submissions have been included in the jam.  As an aside, The Green Report (TGR) has been idly wondering if the other carriers had cause to complain about Discovery Health driving business to Healthbridge (of which Discovery is a part owner) in this way?

You can imagine TGR's surprise when it received complaints about this arrangement.  Surely everyone benefits from this arrangement?  Initially there were assertions from doctors that this arrangement might constitute a perverse incentive.  That can be quickly put to rest ... it does constitute an incentive to submit claims in a particular way, but does not provide an incentive to pick a particular treatment, service or specialist.  A perverse incentive is one that incentivises the doctor to make a treatment choice that may not be in the best interests of the patient.

"Exactly!", was the response of some our readers (who have asked to remain anonymous leading to the question, does the schemes industry have too much power over providers in this country?).  They contend that submitting claims in this way may not be in the best interests of the patient.  On closer questioning it seems that the problem is not the electronic submission of claims but rather the use of the information picked up off claims.  Medical schemes and their various disease management and managed care arms can make out a lot of information about a patient from the claims that they receive whether or not the claims are submitted electronically.  Indeed, in most cases a diagnosis can be deduced even if a diagnosis code isn't submitted.  Diagnosis coding and electronic submission just makes it a lot easier and quicker to get this information.

TGR received half a dozen or so case reports where medical schemes, or those acting on their behalf, had intervened in a patient's care, directly with the patient concerned and without the treating doctor's knowledge.  In each of these case reports the intervention resulted in a negative clinical outcome for the patient concerned.  The issue here is not electronic submission of claims but privacy, confidentiality and the ethics of intervention in patient care.

Are schemes over-stepping the mark in their quest for cost-cutting when they intervene with patients in this way?  Are their sufficient safeguards of patient confidentiality and privacy in the current systems?  Is the waiver that is generally signed at commencement with a scheme sufficient grounds for the scheme to use patient information in the way that they are?

Bluebird saves Doctors’ time.

Bluebird will be the standard mode of communication between doctors. It transfers confidential clinical information rapidly and then manages that information in your rooms. Sign up now for free software and free support.

-end sponsor's message-