In this AIPA issue:

1. Generic Substitution not Acceptable
   
2. Professional reputation
   
3. ICD10 (International Classification of Diseases and Related Health Problems).
   
4. The Boulder of Sisyphus

Generic Substitution not Acceptable

As anaesthesiologists, various hospital managements persuade us to use generic drugs instead of the ones we are accustomed to using. It is entirely up to the anaesthesiologist concerned if he/she wishes to accept the generic equivalent. If however you are not willing to do so, you are at all times entitled to ask for and insist on the drug of your choice. Generic drugs are in effect EXCLUDED from use in the operating theatre / anaesthetic / ICU environment by the very nature of the patient’s anaesthetised (often-paralysed) condition. This renders him or her by definition an unstable, unconscious patient in whom the drugs we use have a marked and profound effect. Prior drugs and the patient’s unstable condition often influence the bioavailability of drugs used by us. An anaesthetised patient is an unconscious, physiologically unstable patient on life support equipment.

In the Guidelines issued in December 2003 by the Medicines Control Council the following has been stated:

“…The Medicines Control Council... recommends that substitution should not occur when prescribing and dispensing ‘generic’ medicines that:

1. have a narrow therapeutic range;
2. have been known to show erratic intra- and inter-patient responses;
3. are contained in dosage forms that are likely to give rise to clinically significant bioavailability problems, e.g. extended or delayed release preparations, as well as those known to be super bio available; or
4. Are intended for the critically ill and/or geriatric and paediatric patient.”

Since most, if not all, of our patients fall into at least one of the above groups, do not allow yourself to be influenced by any management, pharmacist or clinic. You have the MCC on your side as well as your own clinical judgement. Your paramount responsibility is the safety of the patient and her welfare.

Fees Structure

Because of the Competition Commission promoting more competition, we, as a group, are not permitted to publish recommended fees for our services. It is therefore up to each one of us to determine our level of fees charged taking into consideration the patient’s ability to finance our services. Bear in mind that our “stock in trade” is our expertise (gained at considerable expense) and TIME.

To assist us in arriving at an equitable charge, remember that there are already three published scales of fees:

1. The NHRPL scale.
   This is the lowest scale and is published by the Council of Medical Schemes to be used as a baseline by the healthcare industry.
2. The IOD or WCA scale of fees
   This is a scale of fees published by the workmen’s Compensation Commissioner. This scale is about 55% higher than the NHRPL scale.
3. The HPCSA (Health Professions Council of SA) scale of fees. Also known as the Ethical Tariffs. This scale of fees corresponds almost exactly to the scale as used to be recommended by SAMA and is the highest scale. (This scale can be downloaded from the HPCSA web site via link to HPCSA on the AIPA Home page at: www.aipa.co.za ).

Since it is becoming more common for patients to ask us what our charges will be. Our charges are based on time spent with the patient; it would thus be prudent to calculate a rate per hour or part thereof based on any one of these scales. The maximum hourly fee should be based on the HPCSA scale. In arriving at this charge you should take into account the duration and all the codes that are usually used by yourself in charging for the average particular surgical procedure. Should any patient ask for your fee structure you could then quote an hourly rate (appropriate for that patient) for the procedure...your final cost for the procedure dependent on the time the surgeon takes to complete the operation.

In a continuously evolving fee structure environment, it is advantageous to quote an “all in” hourly fee for any procedure. That is, a global hourly fee and not a ‘global fee’ for a particular procedure, which can often continue for far longer time than that anticipated by the surgeon. Be wary of quoting a ‘global fee’ for a surgical procedure. Remember that it is Time for which we are charging, and our fee must always be time related and not surgical procedure related.

Silvio Breno

PROFESSIONAL REPUTATION

One aspect of private practice that AIPA takes extremely seriously is the reputation of our professionals. We vigorously deal with any organizations that attempt to discredit our members unfairly. Unfortunately, it appears that some medical aids have no problem destroying doctor-patient relationships in order to cover up their non-willingness to pay for services.

Statements like "overcharged" and “doctor not allowed to charge" appear less frequently as AIPA take the medical aids on one by one. In most cases, our phone calls and letters are initially met with non-response, followed by arrogance, bargaining, and finally, an apology.
However, as one battle is won they come up with a new statement and the war continues.
The latest statement, appearing a lot, is "This is an information code only and does not have a value. The member is not responsible for any payment.” This has been applied to the charging of code 0028, which is for low flow anesthesia.

Last year we had numerous successful battles with medical aids about code 0028 as, already then, some of them felt it had no monetary value.
On each occasion, the medical aid had no option but to apologize to both the doctor and the patient for defamatory statements made. This year, things are slightly more complicated as somehow, the SAMA guide to fees has lost the monetary value part of code 0028. This probably was done to save space, as the book had to be made a lot smaller. However, the oversight (I hope) has given some medical aids the impression that they have a right to make these statements.

We supply codes with our bills in order to facilitate payment to patients, by medical aids. If a doctor invoices a patient for services rendered then no medical aid, for any reason, should permit itself to state that the patient is not liable for payment. The issue here is not about whether one should charge 0028 or not but the fact that the medical aid has no right to instruct a patient not to pay a doctor for services rendered. We will continue to pursue this issue with "Funders."

We need your help in collecting as much evidence against Funder institutions and possibly make an example of a few in the courts. Please forward copies you may have of remittances with defamatory statements for Attention Nello

AIPA, P. O Box 2061, Cramerview,2060./FAX: 011 803 6957

Nello Sacca

ICD10

ICD10 (International Classification of Diseases and Related Health Problems).

Coding becomes mandatory from the fist of July. The medical aids have threatened not to pay for claims that do not include ICD10 codes.

What’s expected? We are asked to code to the 5th digit for a specific diagnosis e.g. 'O82.1' for 'emergency caesarian section'. The Council for medical schemes (CMS) says that there should be one code for each line item but other sources suggest that anesthetists will be allowed to use a single ICD10 code per account to indicate the diagnosis and that in most cases this would simply be the same code the surgeon’s uses.

How to get started?
All sorts of resources are available; World Heath Organization (WHO) has an online reference library. Board of Healthcare Funders (BHF) has a program to look up codes and South African Medical Association (SAMA) has a similar program as well as a three-volume set of ICD10 books. BHF is good value for R30.00 vs. R500.00 per annum for the SAMA software. The best value of all is a free 'Prescribed Minimum Benefit ICD10 Coding' PDF document from CMS. This looks very complete and I managed to convert it to Excel.

Practical coding: I think the focus should be on getting your practice management software set up to do the work. You should check out what it can do and plan around that. In the case of Turbomed you need only code account items once. After that, you can reuse that information for all subsequent similar accounts.

The complete ICD10 specification has thousands of codes. If your (PMS) uses a code library, it helps use it to store a smaller list of the codes you need for quick reference. First print a list of all the diagnoses or procedure descriptions that you currently use in your practice, choose the most frequently used ones and add the corresponding ICD10 codes to your library. You can use any of the available resources to build your ICD10 library ('cut and paste' rather than typing will save time and prevent transcription errors).

Confidentiality: This could be an issue. Personal details are provided for a specific purpose and should only be used for that purpose. A patient might provide certain confidential information to a practitioner in order to secure treatment. Until now this did not imply that the confidential information could be passed on to the medical scheme as a matter of course. Do we need to obtain informed consent from the patient to submit ICD10 codes?

Links:
WHO -- http://www.who.int/classifications/en/
BHF -- http://www.bhfglobal.com/
SAMA -- http://www.samedical.org/
CMS -- http://www.medicalschemes.com/

Tony Manicom

The Boulder of Sisyphus

Come sit, we must talk. Nothing is like they tell you it is. When your Son comes to you and says ‘Dad, if I use Axe will I get all the girls?’ you say ‘No son, that’s just and advert.’ Pretty soon the little tyke learns there are all sorts of adverts. Adverts to get you to eat your food keep your room tidy and do well at school.

We adults are subjected to endless adverts as well and though we are skeptical we don’t examine them too closely. In a word; we are credulous. We don’t blink an eye when an insurance company advises us “to spend to save!”

Thus it is with healthcare. As you well remember, the legal advisor to the Minister of Health claimed that the Department of Health ‘owned the Doctor by virtue of the State’s investment in the education of the Doctor.’ Meet the new Slaver; the Department of Health and the new Slave; the Doctor! Was it just an oversight not to mention lawyers engineers and those most delicate of hot house flowers, the BA’s? Does the State not own them? So now we have community service, restriction on private practice and price control although according to the Board of trade and Industries ‘Doctors indulge in collusive practices setting fees and because they are competing business entities, they must cease and desist forthwith!’ The job must go to the Health Professions Council of South Africa (HPCSA) and the Commissioner of Medical Aid Societies (CMAS) – State control by any other name, unless you would like to call it Nationalization of the medical profession. Communism here we are; alive and well but just more subtle in the “New south Africa!” Are you Proudly South African? Proud of the Deputy President?

Then we have a President, who with his then Minister of health was ready to buy a cure-all for HIV/AIDS from Snake oil Salesmen from Tucks, selling a cheap but secret treatment for HIV. This same President, in his advised opinion believes the link between the HIV viruses and AIDS is a plot by Doctors and drug houses to make profits at the expense of the poor. The current Minister of Health is into the African Potato and garlic as a cure for the disease. They are proudly South African.

In May, Elizabeth (a 23 something friend) invited Sisyphus to be her guest at parent’s day at Tucks. Well, he felt honored; after all, why the grouch? This is a young woman who spent some years nursing before she was accepted by a medical school. She lives poor, no bursary, and no support from the State (?????) and ekes out a living working as a mosquito for a path lab. The slave pays to become a slave, the final irony.

What is her motive?’ I want to help people.’
‘That, to Sisyphus is a lame reason for so much hardship for such an improbable reward’ He says. ‘I know’ she replies, ‘it just feels the right thing to do.’

“What if it all ends up as cheap labor,” He asks. “Well then I will get married,” she says fluttering her beautiful brown eyes.

And that my dear colleague. is the crux of the mater. Does medicine attract do-gooders; unworldly people programmed by some life’s experience or inner need to save humanity from itself? People who are naïve and unsmart; who when faced with earning a living are incapable of doing so because they have no street smarts? They believed the advertising in “ER”

The invitation to the old thatch roof Sandown Balalaika Hotel in 1976 is from Ernie Wentzel and his pupil to celebrate another thrashing of MASA by RAMS at the annual fee negotiation week. You will understand if I admit to being vexed by the smirk on the face of the pupil and the Mona Lisa smile worn by Ernie, a stock in trade poker face when he is about to extract the ”Mickey” from a victim as he offers me a glass of Bollinger’s, compliments of the RAMS.

I miss Ernie, a wordsmith of note who had a gentle way of chiding one with a literary reference. Alas, he is no more. That Afrikaner gene for hypercholesterolemia betrayed him. He chose to have a coronary and die before the medical aid gave authorization for his CABG, undone by his finest work, so to speak.

Now Ernie was a young up and coming advocate retained by RAMS for the fee negotiations. A personable man who started humming the tune of the “Walrus and the Carpenter” (From; Trough the Looking Glass and what Alice found there) as I sat down.
You know how it goes:

The sun was shining on the sea,
Shining with all his might:
He did his very best to make
The billows smooth and bright –
And this was odd, because it was
The middle of the night
Tum Te tum Te tum Te tum
And so on.
‘What’ I said ‘are you driving at?’
Tweedledum and Tweedledee
Agreed to have a battle;
For Tweedledum said Tweedledee
Had spoiled his nice new rattle.

Just then flew down a monstrous crow,
As black as a tar-barrel;
Which frightened both the heroes so,
They quite forgot their quarrel.

‘Tweedledum and Tweedledee’ said Ernie, ‘Truth, and Lies’
‘Negotiation’ sang Ernie ‘is all smoke and mirrors with lots of misdirection
Oh how easy it is to send the Doctors in all the wrong directions!
Ask them for a study of costs to find a fairer fee,
Then send them back to do it again,
For an audit validation, of course, you see
Round and round in circles, they never feel the pain!
Up and down and round about they’ll do it over again.’
For negotiation is a poker game with your cards held close to your chest,
Smoke and mirrors with lots of misdirection is always for the best!’

SASA has always been suspicious of AIPA. I do not know why, AIPA does not aspire to anything more than a secure, safe work environment and an acceptable remuneration for specialist Anesthetic services. They have always thought that SASA did the congresses well but were perhaps lacking in ability or enthusiasm for the worldly domain of private practice. Imagine AIPA’s relief to discover that members of the tariff committee were reading business books and that one had actually done an MBA.

Déjà vu!
What do I see in SAMA’S Medigram? And in SASA’s email newsletter? Plain old misdirection. Another survey of costs and go back and do it again with proper control! There they go show the confidential information of what doctors earn for the entire world to see; the medical aids, the receiver and the public. My colleagues tell me the news is going around that Anesthetists are earning R900, 000 PA. – “Sis, skande”

I hear Ernie’s song going round and round my head. Thirty years and it is the same old chain yank, and the same stupid flush.(for the BHF) Ernie liked to quote Warren Buffet; “If you are playing poker and in twenty minutes you don’t know who the Patsy is; then you are the Patsy”
It is the curse of Sisyphus: repetitively trying the same failed remedy for the same old problem on into infinity. The boulder, the mountain and the behavior.

‘Come boys shoulder to the boulder lets role it once again’ describes the carefully thought out strategy of the Profession’s Private Practice think tank. Be reactive forget proactive, be a nice, guy go along to get along. It is only fair to give the opponent the initiative; after all, we chose medicine to help people, so let us be helpful. (We believe mummy’s theory of being a nice well mannered kindly child)Is there any hope of intelligent life in SASA in our lifetime?

Gentlemen, may I present to you the Patsy’s of SAMA and SASA, Patsy One and Patsy Two!

There are other issues besides fees; issues like the quality of anesthetic nurses and recovery staff. One SASA savant can train his domestic servant in a day to be an anesthetic sister. Another savant is sure it is up to every individual anesthetist to ensure standards in theatre. You, dear colleague, up against a multi billion Rand hospital group and the only thing certain is that the SASA guideline is as influential as toilet paper.

I see we have a new crop of Academics at the helm of SASA; savants from down south of the Orange River. They, I am informed know how to work hard; but do they know how to work smart?

I asked Nathan this question over a chop and an acceptable glass of Pinotage.

‘Well’ he said ‘when I was an undergraduate I used feel I was looking at great Luminaries through a telescope. However, after a while in the real world, meeting the same chaps was like looking at a drop of pond water through a microscope. Mind you, I thought that was just personal bias until head office in the States was commissioned to do research on the factors that lead to success. You know; intelligence, drive, creativity, imagination and so on. They studied Entrepreneurs Captains of Industry, movie stars, and Professors in Academic Institutions. They applied conditional probability, (stochastic processes like Bayesian analysis Markov chains and so on.) The surprising thing was that creativity scores in academic institutions were virtually zero. We all thought that was quit contra intuitive. On reflection though, I understand what Kuhn (Thomas S. Kuhn) meant in his book (“The Structure of scientific Revolutions, Second edition, 1962”) by his observation that institutions of learning are inherently conservative and resist change. No imagination you see.”

There you have it, straight from the mouth of Nathan the Actuary. No hope of intelligent life in Academia in our time, so I guess Grumpy is right; evolution will decide: SASA or AIPA for securing the future of Private Practice Specialist Anesthesia.

Do not be surprised if you here nothing about Grand Strategy from AIPA, they know how to play poker. For myself, I am getting up to speed with “Poker for Dummies.”

Come sit closer. It is time to be more serious. The majority of Doctors would rather Doctor than do bookkeeping. This way, no matter what your fees are, you will always be needy because you will never know what you are losing; you will always pay too much vat, too much tax and too much bad debt. You will always be rolling the Boulder of Sisyphus. Repeating old mistakes punishes your family, no one else. There are only two choices; master your practice and master investments or get a competent practice manager, accountant, and investment advisor. Remember an insurance sales representative is not an investor and the stock exchange is a Swiss cheese. Paper money cannot hold its value and your banker is not your friend. You have a major financial conundrum to solve. Seeking help is wise but failure to take responsibility for your financial wellbeing is foolish.
Think about it,

Sisyphus