Threat of Tariff cuts, coding issues, clinical notes, VBC

Dear Members of the CPF,

2020 has been an extraordinary year in many respects and exceptional challenges have presented themselves especially in the professional spaces in which we work, as well as deeply personal adjustments being demanded from many of us.

With the advent of the lockdown after our president declared a national state of disaster on 15th March of this year due to the spread of CoVid 19, professionals have faced numerous shifts in the healthcare industries. In particular psychologists in all categories have been met with unexpected new regulations, restrictions, and requirements from the medical funders even as we were attempting to navigate the HPCSA ethical issues confronting us in managing our vulnerable patients.

Initial threat of tariff cuts

Most if not all of these new requirements have been unilaterally formulated prior to any consultation with the professional bodies. Many psychologists, probably out of fear of not being funded, rushed to comply, or so the funders continue to lead us to believe.

The initial attempts at restrictions for online practice was to slash the tariffs by 60%. The news of this intention was stumbled on by members of our forum, not communicated by the funders themselves. It was left to the CPF to approach the funders ourselves to request meetings and discussions. We found that the funders were surprised that psychotherapy could be conducted online at all. In fact it seemed that funders took a shotgun approach to restrict practices and payments possibly as a precaution to a feared draining of funds in the wake of the pandemic. Agreement was reached all round that the tariffs would remain unchanged as the work of psychologists is time based.

Coding issues for online sessions

This was swiftly followed by demands to use complex codes for online sessions, codes which would have differed for each scheme. In addition some schemes required the completion of additional paperwork and demanded “high level clinical notes”. After much negotiation the changed codes were dropped, and it was agreed that clinical notes could be optional – for now.

Demand for clinical notes

Concerns around the submission of clinical notes are numerous but hinge mainly around ethical issues of breached confidentiality, a lack of clarity of understanding of informed consent by both patients and practitioners, and uncertain reasons for data collection by the funders. It remains a concern that many practitioners may actually be providing data to the funders when the responsibility to maintain confidentiality lies firmly between the patient and the practitioner yet some funders are sending the consent form to the patients.

Information provided to the funders on online platforms is potentially available to all other practitioners who also use the platform for the same patient.

Psychologists now face a new plan of payment designed again without consultation with the professional bodies. Bodies have been informed but not consulted or collaborated with on these new developments. Most of you will have received communication that a certain scheme will pay directly for services on condition that practitioners sign up to the new payment plan. The payment plan will require practitioners to submit – wait for it – high level clinical data! Should practitioners choose not to sign up they may be subject to a penalty in terms of payment. Why this is considered a new “direct payment” plan is not yet clear despite repeated requests for explanations. As far as the CPF is aware practitioners already get paid directly when they claim for services rendered according to medical aid rates.

The CPF have been supported in the above matters by the psychiatrists in PSYCH MG and the counselling psychologists in CPSA.

Disregard of skills and expertise

Other issues which have developed during these past few months include medical schemes insisting that PMB conditions must have the diagnosis confirmed by a psychiatrist, GP, or in one case, a social worker before referral to a clinical psychologist for psychotherapy.

Besides the fact that this disregards the expertise of the clinical psychologist in matters of psychiatric diagnosis, it potentially adds cost to the patient’s treatment plan.

During last month, in October, the CMS produced three documents of guidelines for mental health treatment in the instances of PMB conditions. These focussed separately on acute mental health conditions, bipolar mood disorders, and schizophrenia. In not one of the guides is a clinical psychologist recognised as being able to diagnose.

In the above matters the CPF is actively challenging these decisions which seem to have been made on poor information.

Most recently a medical scheme has informed its members that if they wish to claim for a PMB they may do so and be treated by any practitioner of their choice from the list of psychologist, psychiatrist, registered counsellor, or social worker. Again the CPF have questioned this but await a response. They neglect to stipulate what category of psychologist (research?), and ignore the fact that two of the service providers are not qualified to treat PMB conditions.

Way Forward

Value based care matters

Worldwide there is a movement towards operating healthcare within a value based care framework. Earlier this year we ran a webinar on VBC lead by Dr Eugene Allers of the Psych MG. This informed us of the purposes of such a process and what the implications may or may not be for practitioners. We are very aware that the concept may carry a sense of loss of independent decisions in practice choices. Thus we are again inviting Dr Allers to speak at our AGM on how VBC relates to a future envisioned mental healthcare landscape as we move towards a possible NHI initiative.

The concept of VBC was introduced in 2006 in a book by Michael Porter and Elizabeth Olmsted Teisberg (Porter, M., 2006. Redefining health care. Harvard Business School Publishing).
The book is available from Amazon, Loot, Takealot, Exclusive Books.

The fundamental notion on which VBC rests is a collaborative professional team approach. This is distinct from managed health care which is cost driven. VBC on the other hand encompasses philosophical, intellectual, pragmatic, relational and technical challenges. The process matters as much as the end-point, and engages the practitioner in a process of willingness to learn and re-create. The philosophical backbone of value-based approaches is that the purpose of the healthcare system is not to minimise costs but to deliver value to patients, and value to patients is determined by outcomes that matter to patients.

According to Porter and Teisberg, improving the value of health care is something only medical teams can do. This implies that a true VBC process should lie in the hands of the professional practitioners and not be dictated by the funders. It allows for a full engagement of professionals with other team members treating patients in collaboration with each other. Whether this would mean that all role-players need to be involved in cases and interventions is not determined by the fact that there is a VBC approach, but by the needs of the case as it presents.

Medical schemes in South Africa are pushing aggressively for this approach and it is one that worldwide, healthcare systems are engaging in. The CPF believe that it would be naïve to ignore this development, but through proactive engagement we can direct it for our profession to move towards better outcomes for our patients in the way that we see best in the light of our own practice approaches.

Phi: A proposed collaborative initiative to own the VBC process

As said above, certain medical schemes, major role-players in the field, are pushing the VBC approach. However, as the discussion above suggests the approach should be driven by the professional practitioners and not the funders.

One of the major concerns is that in allowing the funders to drive the process they will end up owning it and effectively “employing” the practitioners and dictating the process. They will also own the data harvested from the patients.

A group of practitioners involving psychiatrists, clinical and counselling psychologists, OTs, dieticians, and physiotherapists, have discussed taking the process back. The idea is for the professional practitioners to design a VBC process and to own the data on their own terms and as determined appropriate, to collect from patients.

In order to be able to do this a new organisational structure is being discussed collaboratively, and this is currently known as Phi.

Dr Eugene Allers is leading this process and this is why we have invited him to talk at our up-coming AGM on these matters. The AGM details will be forwarded shortly. We believe that it is critical that our members are informed about these developments in the field so that informed choices can be made. We hope that concerns can be raised and perceived obstacles debated in depth.

On behalf of the CPF Exco:

Dr L.M.E. Blokland
MA Clin Psych (SA), PhD (UP)

Chairperson: CPF