Editorial Comment: Societies, doctors must find each other

By IAfrica
In Zimbabwe
Aug 24th, 2014
Dr Parirenyatwa

Dr Parirenyatwa

The dispute between medical aid societies and private doctors is becoming nasty, with the doctors, through their Zimbabwe Medical Association, threatening to sue 31 societies and their umbrella body, the Association of Healthcare Funders of Zimbabwe, unless they pay the full US$35 general practitioner’s fee agreed to by the Minister of Health and Child Care, Dr David Parirenyatwa.
The societies, in turn, are threatening to downgrade those on their general schemes so that consultations with general practitioners are not covered at all, meaning members of these schemes will have to use council clinics and Government hospitals if they do not want to pay or pay the full fee in cash for a visit to a general practitioner.

It is quite unnecessary that the dispute should reach this level. Medical aid societies are insurance schemes and the overwhelming majority, including all the largest schemes, operate on the basis of no profits but no losses. Generally speaking, administrative costs are tightly contained and kept low, the only serious exception in recent years being at PSMAS and there that surge has been reversed. They work on the basis that for all the people they have insured that during a year there will be a known number of doctor visits, a known number of operations of each type, a known amount of dental work and so on.

The costs of these are all added up and that sum divided among the number insured, and that number, plus the small administrative percentage, is what the monthly contribution has to be based on.

The problems arise when medical costs rise. New fees approved recently by Dr Parirenyatwa were not unreasonable and seem to be justified. But if societies are to pay these fees in full then they will have to raise subscriptions, and as consultations by general practitioners form such a large proportion of payments, the jump in GP fees from US$20 to US$35 will, if to be fully covered, mean a significant jump in contributions by members and their employers. Many members and their employers say they cannot afford higher monthly contributions.

There are several solutions. PSMAS some years ago switched to managed health care, whereby medical staff are on salary rather than being paid fee for service. This allowed that giant society to contain costs although members in turn lose a lot of choice over who they wish to consult. The growth in private clinics in recent years suggests that this solution is becoming more acceptable.

A second solution is partial payments. Many doctors have been charging more than what societies will pay or refund. Their patients generally pay the higher fee and claim back what their society will refund. For some services there is agreement that the patient will make a co-payment in cash with the service provider claiming the agreed fee from the societies. This co-payment system works well and with its partial coverage allows a higher fee with a more affordable fraction paid directly by the patient. If we formalise this for present fees and contributions it would mean general practitioners charging US$15 cash and claiming US$20 for a first consultation.

The third solution is to do what motor insurers did in the past, make owners of insured vehicles pay the first US$500 or some other agreed figure and then pay the rest of the bill. This could be adapted to medical aid by saying that contributors must pay for the first consultation but the society would then pay the rest, or use some other viable formula.

The second and third options we have given allow contributions to stay the same but doctors to be paid higher fees. This could be acceptable.
What is not acceptable is for doctors, through ZiMA, to threaten lawsuits to force societies to raise contributions to pay their new fees. Doctors need to understand that medical aid is voluntary, and that if contribution levels rise too high the young and healthy might just pull out and pay cash, bankrupting the societies.

Societies and doctors need to stop making threats and, if necessary, with the ministry refereeing, work out ways doctors can be paid the new fees but where the society members and the patients, and these after all are the ones who count as the people who in the end pay and who need the services, can have a say.

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