Market Inquiry into the Private Healthcare Sector
Public Hearing 6
Day 2
held at
Olive Convention Centre, Durban
KwaZulu Natal
on
18th May 2016
Panel:
 Chairperson: Chief Justice Sandile Ngcobo
 Professor Sharon Fonn
 Dr Lungiswa Nkonki
 Dr Ntuthuko Bhengu
 Drs Cees van Gent
Stakeholders/ Presenters:
 Department of health Free State.
 Department of health Limpopo.
 National pathology group.
Ground Level Enterprises (Pty) Ltd
www.groundlevel.co.za
Pg. 3 – 129.
Pg. 130 – 185.
Pg.186 – 428.
Transcriber’s Certificate
I, the undersigned, hereby declare that this document is a true and
just transcription, in as far as it is audible, of the mechanically
recorded proceedings in the matter of:
Health Market Inquiry Public Hearings
18th May 2016
....................................................
Transcriptionist:
Date: 18th May 2016
Editor’s Certificate
I, the undersigned, hereby declare that this document is a true
reflection, in as far as it is audible, of the mechanically recorded
proceedings in the matter of:
Health Market Inquiry Public Hearings
....................................................
Editor: Godfrey Malgas
Date: 18th May 2016
Health Market Inquiry
18th May 2016
Page 3
___________________________________________________________________
SESSION 1: PRESENTATION BY DEPARTMENT OF HEALTH
FREESTATE.
CHAIRPERSON
Everyone is here, we can begin.
Good morning
everyone and welcome to the second day of the series of public
hearings.
Today we are going to listen to three presentations, the
first one will be off ered by the Free State Provincial Government
10
and
the
second
will
be
offered
by
the
Limpopo
Provincial
government, and the third presentation will be made by the
National Pathology Group. Is the Free State ready? Good, do you
want to come forward?
Once again good morning, I apologise for you know starting this
20
late.
If there is anyone to blame you must blame the National
Pathology Group, they prevented me from coming here on time
because they insisted they wanted to see me before we start. It is a
Health Market Inquiry
Page 4
18th May 2016
___________________________________________________________________
pity I did not see you before we started, but anyway you are here
now.
I wonder would you want to place yourself on record and
indicate to us who is with you and who is going to make the
presentation?
MARCUS MOLOKOMME
Good morning chairperson and panel
10
members. My name is Dr Marcus Molokomme, I will be presenting
on behalf of the provincial Department of Health, Free State. With
me today to my left is Advocate Justice Finger who is head of legal
services in the Department of Health Free State.
Immediately to
my right, the fair lady is Mrs Pinky Berlot, she is head of the
licensing unit in the Free State Department of Health, the private
20
facilities side and the far right is Mr Reuben Ruiters who is head of
emergency medical services in the Free State. I wil l be making the
presentation.
facilities side and the far right is Mr Reuben Ruiters
Health Market Inquiry
Page 5
18th May 2016
___________________________________________________________________
who is head of emergency medical services in the Free State. I will
be making the presentation.
CHAIRPERSON What language are you going to speak? SeSotho?
MARCUS MOLOKOMME
I would have loved to use my mother
10
tongue which is Sepedi, I am a traveller, I am originally from
Limpopo so and with me here I have Reuben Ruiters, hy praat die
taal, and then two of us are just around here.
So we will use
English Chairperson , if you allow.
CHAIRPERSON
Because you come from Limpopo you cannot
20
speak what they speak in Free State, you have to speak in Limpopo,
but they speak in Limpopo.
Okay, very well.
Again just place
yourself on record and then if you are ready to start t hen we can go
Health Market Inquiry
Page 6
18th May 2016
___________________________________________________________________
ahead.
First of all let us make sure that we have all the
documentation that you sent to us. Okay, you can go ahead.
MARCUS MOLOKOMME Thank you very much to the panel for
the opportunity.
Health.
I am representing the Free State Department of
Our approach with the documents which we have already
10
delivered are going to focus on the summarised version of our
PowerPoint presentation so I will be talking to the slides as we go
along.
I will make the presentation to the end.
The colleagues
around me as introduced will then be of assistance i f there are any
questions or clarity or discussions at the end of the presentation.
Our intention as the Free State is to stick within the hour or even
20
less if you allow Judge or chairperson.
Health Market Inquiry
18th May 2016
Page 7
___________________________________________________________________
CHAIRPERSON Can we do this? Ja, sure. I think what would be
very helpful to us would be if you can just summarise your
presentation
so
that
at
least
we
have
sufficient
time
for
engagement, okay. But of course I cannot stop you from you know
reading your presenta tion. Thank you.
10
MARCUS MOLOKOMME Thank you very much chairperson. We
were
here
yesterday
for,
we
just
missed
the
Medscheme
presentation at the end, just to get the sense of our approach so that
we can save you time, so we are committed to that. It wi ll not be
10pm again.
Thank you, we will basically almost stay on these
content slides because we want to just give a narration of the
20
summary that you already have and in that way I am sure we will be
able to save time. We will not go verbatim what is o n the slides.
Health Market Inquiry
Page 8
18th May 2016
___________________________________________________________________
The Free State in a nutshell as being in the middle of the country
faces different complications or implications in terms of its
geography.
It is a primarily rural province, divided into five
Municipal districts; Xhariep district which is more towards the
south close to the Orange river, close to the Vaal is Fezile Dabi, to
the north west we have Lejweleputswa, to the east is Thabo
10
Mofutsanyana close to where we are now and central is the
Mangaung Metro which covers area from Thano, Botshub elo and
Bloemfontein city.
So that is the only metro we have.
Our
population size is according to Statistics SA around 2, 6 million for
the entire province.
20
In your presentations you will look at the distributions of the
private sector beds, with all t heir differentials but what is of note
when you look at them you will see that MediClinic Group in the
Health Market Inquiry
18th May 2016
Page 9
___________________________________________________________________
Free State dominates
the number
of
beds
in their
different
configurations, albeit acute, sub -acute and even some of the day
beds or mental health beds th at they have.
Another thing that is
clear it is how Bloemfontein is dominating the number of beds in
the Free State. The Health System Trust in 2010 had a little study
and per capita we are showing that we are really competing with
10
Gauteng in terms of pr ivate beds against the population, but the
issue in the Free State is the distribution of those beds and what we
are trying to show there is that we are having the rural areas like
Xhariep district where there is not even a single private sector bed,
Thabo Mofutsanyana is the biggest district, but it is the poorest of
all the districts.
It is only now that they are starting to have a
20
second private hospital being built in that district.
So as the
committee, as a private facility licensing committee th ese are some
of the mandates in our regulations; this is one of the areas that we
Health Market Inquiry
Page 10
18th May 2016
___________________________________________________________________
are looking at – the distribution of the beds.
It is an area that
became highly contested two years ago in 2014 when we Gazetted
the Free State Private Facilities licensing beca use there were
groups, especially Hospital Association of South Africa, which the
document we have included that were challenging us that we are
instituting section 36, certificate of need indirectly by declaring
10
that this committee or the committee should be looking at where
these beds should be placed in terms of need.
And it is at this point that I want to touch on a point that briefly
was touched yesterday, that the complication of the health sector is
when need and demand are mixed together, or the two terms are
20
used interchangeably because demand can be created and I can give
you examples. Many of us we are parents here or grandparents for
some chairperson you would find that many of our children are
Health Market Inquiry
Page 11
18th May 2016
___________________________________________________________________
exposed to psychometric tests ; we have now psych ologists who are
education specialists.
In my case my own daughter is going
through occupational therapy just because of the way she holds the
pen and because she writes 8 not flowing, she writes two zeroes put
together. So that is demand, the demand is created and we can go
on and on about the attention deficit diseases that all our kids are
10
on now.
That is demand to us, it is an economical concept which
can be created, it is linked to want which can be religious, political
and so forth.
We are talki ng need and to us need means we look at burden of
disease, we look at what do we need to do to get people healthy and
20
what is available to get them to that.
The difficulty with that
approach that we have found in the Free State which was maybe
touched even yesterday, was that because we do not measure and
Health Market Inquiry
18th May 2016
Page 12
___________________________________________________________________
some of these things do not have signal s, we end up having a
problem of what is healthy – how do we define a healthy society?
What is this outcome we are talking about? Is it based on usage?
Is it based on headcount?
services?
How many people contact or use our
Or is there a more community based measurement in
terms of what is healthy?
10
So the need in itself sometimes is not an exact science.
So when
we talk about the need for beds, in the Free Sta te if you look at the
statistics that we have given you in terms of the numbers, you will
see that in Bloemfontein because it is urban in relation to the rest
of the districts as a metro, you will find that the demand is higher
20
than
the
need.
So
invariabl y
you
are
continuously
having
oversupply of services because it is informed by the economy of the
area, but if you go to districts like Xhariep, Thabo Mofutsanyana
Health Market Inquiry
18th May 2016
Page 13
___________________________________________________________________
you will find that those are the poorly serviced areas in terms of
private healthcare becaus e the demand is lower than the need. You
have this juncture between urban and rural areas and applications
for private facilities follow the markets.
So you end up having
everybody applying for Bloemfontein which is what the slides will
show you that you have in terms of the numbers we have shown.
10
Now what we have done in 2014 was to try and reverse that by
looking at what joint ventures are possible with the private sector
to make sure that we service the population not based on demand,
based on need. The examples for demand and need can go on and
on.
I sometimes watch TV and I listen to somebody called the
Wallet Doctor where you can get doctor for being admitted, so that
20
in itself creates a demand for a bed in private sector because I can
get money whilst I am lying there .
So demand can be tampered
with and we should then focus on need and in the Free Stat we
Health Market Inquiry
Page 14
18th May 2016
___________________________________________________________________
maintain that that is where we should be going with our regulation
in terms of the private facilities.
I am going to skip the other areas, I t hink they are quite
straightforward in terms of what we regulate. It is not too different
from other provinces, but what we did add given that all the
10
information was telling us was inclusion of a need for a business
plan by the applicant to be included.
What we had realised in the
past without having business plans people were just supplying
based on demand or need, we have gone past that, but then what we
ended up having at the end was that people were getting approvals,
not necessarily licenses.
The w ay it works in the Free State we
20
give an approval, you get a license when you have finished building
and we have inspected. So you have an approval to build and then
Health Market Inquiry
Page 15
18th May 2016
___________________________________________________________________
you get a license at the end of the time, which is according to our
regulations, in three years.
Now, what used to happen is that people would get this approval
but never got things off the ground because they then had financial
difficulties because the planning was not what it was supposed to
10
be. So what we had said we now include a request for a business
plan, but what we are struggling with to be upfront with the panel
and the commission is that chairperson we do not have stringent
financial instruments that we can use to measure this business
plans.
As you know business plans now can be produced by the
internet, you Google it, you get a template, you populate it, it looks
20
good on paper but sometimes it is never practical and this is why
you will find in many of the slides people who got approval in
Health Market Inquiry
Page 16
18th May 2016
___________________________________________________________________
2012, 2013 many of them are still in pro cess and many of them are
struggling partly because of the finances.
In another scenario that really woke us up as a province was that
we will sometimes then approve sub -acute bits for a particular area
based on need.
That supplier would go and turn th e soil, make
10
foundations pay about R7 – 8 million, when they go to Standard
Bank for example in this case for more funding, Standard Bank says
we have done our own study, there is no way you can have sub acute bits in that area, they should be acute bits, that is the only
time we are going to give you the money.
Then the supplier then
re-applies for amendments of the application, so it becomes a
20
vicious cycle where now the need is tampered with, informed by the
finances.
So we are maintaining that we need a proper business
Health Market Inquiry
Page 17
18th May 2016
___________________________________________________________________
plan from day 1 that we can adhere to as something that is
sustainable.
Secondly what we introduced is this community involvement, social
responsibility. It used to be quite loose in terms of the way it was
penned in the regulations an d many of these hospital groups would
10
just provide CPD training for doctors and say that is our community
involvement. What we have done since 2014 was that we want an
annual plan, that annual plan must include things that we can
measure because if you ca nnot measure it it is not going to be done
and the community involvement should be clearly defined and also
the social responsibility.
Not in general terms, but it should be
20
drilled down and customised to the communities that these hospital
groups find themselves in. It needs to go beyond just CPD training,
or continued professional development.
I apologise for the
Health Market Inquiry
Page 18
18th May 2016
___________________________________________________________________
abbreviation.
It needs to be proper social development linked to
the needs in that area.
We even are asking for them to set
milestones so t hat these things are time bound in terms of the social
responsibility.
So the way we are interrogating applications now
going forward will be that and we want to make a humble request
chairperson that municipalities maybe through SALGA should be
10
engage maybe in this process because many of the delays in the
Free State are caused at that level, in terms of private facilities.
We give approval, part of the process is that you must submit your
plans to the Department, or to the municipality.
The municipalit y
must then okay the plans and give an approval. Secondly the
purchasing of the sites or the land becomes a huge delay for many
20
of the applications – so many of them give up at that level and
when they give up, the panel should appreciate that we give this
based on need so when things do not happen it means we are
Health Market Inquiry
18th May 2016
Page 19
___________________________________________________________________
denying people services in that area because then for three years
nothing happens and then after three years only then do we realise
okay this is not going to happen, then we restart the process. So it
means it is three years of people not getting a particular services, it
be
sub-acute,
acute
or
mental
health,
and
for
a
province
disadvantaged like the Free State with its own geographic that we
10
are sharing soft borders with everybody, except Limpop o it
becomes quite difficult. So we propose humbly that municipalities
maybe if there is time can be engaged, maybe broadly through
SALGA just to check what issues are in terms of allowing people to
get land, what are the issues, is it contested lands, is it farms that
are green land and not brown, all those kind of issues, or in terms
20
of special planning.
Sometimes the two departments, because we
do not have those interactions will approve and find that there is
another plan from the municipality to do s omething else in that
Health Market Inquiry
18th May 2016
Page 20
___________________________________________________________________
area.
So I think it will be another area to complete that loop in
terms of...
CHAIRPERSON
Has the provincial government engaged the
municipalities on the issue of the delays?
10
MARCUS
question.
MOLOKOMME
Thank
you
Chairperson
for
the
Not at the moment, I think we are engaging them on
other matters but when it comes to this facility licensing since 2014
when we came on and changed the regulations we still have not.
The other area that we know we are struggling and we as a province
have not moved forward is the quality assurance wing in terms of
20
assessing these facilities. You will see in the documents there are
different kinds of assessments and the first assessment is that we
said we will only inspect at completion of the constru ction and we
Health Market Inquiry
Page 21
18th May 2016
___________________________________________________________________
found problems with that approach because then if some people
build an infection or what do you call a sluice room, a dirty room,
and you find that dirty room is built without an exit so the dirty
things are going to walk through the clean are as and the reception.
It is difficult when you come and you discover that opening, that no
you need to open this door, there must be a door here and
10
sometimes that is on the third floor, there is no way they are going
to break that wall and create a stair case for them to be compliant.
So what we are opting for going forward in reviewing our
regulations is to make sure that we identify key levels in those
building where we coming to inspect. Currently our regulations are
saying those kind of inspections a re done by invitation, meaning
20
the group must then invite us to inspect.
So we want to stop
making it voluntary, it must be mandatory visits by our units,
maybe a foundation level, window level and so forth, depending on
Health Market Inquiry
Page 22
18th May 2016
___________________________________________________________________
how infrastructure engineers will advise us. To make sure that we
correct things because variation orders at the end are quite
expensive to get people to be compliant.
information with the public.
Also it is sharing the
We do share the office of Health
Standards Compliance or National C ore Standards what used to be
through our governance bodies for public sector facilities.
So we
10
have clean committees, hospital boards, we have provincial and
district health councils – that is where all these CEO’s and district
managers are held to accou nt to the public in terms of our
compliance. But with private facilities we still have not shared our
findings, for example MediClinic Group would score 72%, that
information invariably had always remained in the department, we
20
would not go out and publis h that MediClinic compared to Life,
Rosepark compared to Netcare, this is their scoring; compared to
Ernst Oppenheimer this is their scoring – that we have not done and
Health Market Inquiry
Page 23
18th May 2016
___________________________________________________________________
I want to declare that upfront. That is an area that we are willing
to go and look at.
We also need to review the penalties.
CHAIRPERSON That has not been done?
10
MARCUS MOLOKOMME
No particular reason chairperson.
I
think there has been an oversight and it is informed by I think in
the past where we approached private and public sector it is only
now I think in the past five years that even the department itself is
starting to call itself Free State Health, not Free State Department
20
of Health because once you do that you are already suggesting that
demarcation between private sector and the public sector. Whereas
the Minister always says he is not the Minister of Public Health, he
Health Market Inquiry
Page 24
18th May 2016
___________________________________________________________________
is the Minister of Health in the country and even our MEC should
start approaching as we are doing in the Free State Health to
approach that we are responsible for the entire system of health,
not public and private.
So we have been rigorous in assessing,
even if you look at our outcomes in terms of mortality rates, you
will find that we are willing to publish number of maternal deaths
10
that happens in a particu lar facility in Bloemfontein, but you will
not find us doing the same about MediClinic down the road in
Bloemfontein. So it is only now that we are starting to engage them
– our legal department actually next week has a meeting where we
are starting that p latform so that we are able to report to the public.
20
CHAIRPERSON Is that required by the regulations?
MARCUS MOLOKOMME No.
Health Market Inquiry
Page 25
18th May 2016
___________________________________________________________________
CHAIRPERSON
That would require public institutions to report
on these matters but does not deal with the private sector?
MARCUS MOLOKOMME
Yes, our regulation and our Act is
focussed primarily on public sector. We are mandated, but what we
have done as districts you will find in Lejweleputswa you will find
10
when we report mortality rates, we report maternal deaths for
example from all facilities including our private sector.
So it has
been sporadic, it is not something that had been structured and that
is what we are saying as the unit that leads for licensing we need to
start on that platform to make sure there is that collaborat ion, but
there is nothing stopping us, it is just something that was not done
20
in reporting in the public sector and the data.
Health Market Inquiry
Page 26
18th May 2016
___________________________________________________________________
I will just give a quick example – when we had that campaign by
the Minister in the country for HIV counselling and testing, HC T,
that was the first time since I have been in the system that we have
had interaction in sharing data with the private sector proper
because when we did the mop -up we went to the National Health
Laboratory Services, NHLS, to get their data. We physicall y went
10
to every practitioner to get their data on HIV counselling and
testing, including Male Medical Circumcisions.
We went to all
private hospital groups to get their data as part of the mop -up
process so that is why maybe the end people claim we perfor med
well as a country because we for once had an eagle view of what
the system is doing in terms of strategies for HIV and AIDS and
20
those are the initiatives that I am talking about, but we have not
built on them going forward. Up to now, but going forwar d that is
what we intend doing.
Health Market Inquiry
Page 27
18th May 2016
___________________________________________________________________
Chairperson, should we continue?
CHAIRPERSON Yes, please by all means.
MARCUS MOLOKOMME Let me get Adv Finger to just make one
point, if you allow chairperson?
10
ADV FINGER
I just wanted to bring to the panels attentio n that
the new regulations it is compulsory for private sector to provide us
with data, so we have made it compulsory.
If you look at
regulation 31 in the new regulations. Thanks.
20
CHAIRPERSON
Previously it was not, was it?
So you had to
focus on publi c institutions, and who was responsible for gathering
Health Market Inquiry
18th May 2016
Page 28
___________________________________________________________________
this information, was it the district council or was it the provincial
government?
MARCUS MOLOKOMME Provincial government, yes thank you.
Lastly we want to now in terms of our assessment, I have spo ken
about
penalties,
penalties
are
R100 000,00
or
five
years
10
imprisonment for non -compliance.
We think that is too light.
I
think going forward in the way we want to take quality assurance
seriously we need to review those penalties. It is quite easy I am
sure for some of these hospital groups to budget R100 000,00 just
for compliance, it would be quite easy to budget for that. So we
need to look at how we are going to enforce and make that heavier.
20
Lastly we want to look at our assessment tools.
Health Market Inquiry
18th May 2016
Page 29
___________________________________________________________________
I think our assessment tools are designed based on national core
standards and national core standards for their purposes are quite
brilliant, but they measure the basic, they look at the floor, they
look at how clean things are, we want to upgrade that to st art
looking
at
governance
governance issues.
issues,
to
start
looking
at
clinical
As you would have heard yesterday that
10
sometimes even clinical notes are not what they are supposed to
me.
We need to start measuring those and lastly we need to start
measuring outcomes – it be patient satisfaction and so forth. So the
tool needs to be redeveloped to move beyond just the core basics.
CHAIRPERSON
20
previously?
Is there any reason why this was not done
Health Market Inquiry
18th May 2016
Page 30
___________________________________________________________________
MARCUS MOLOKOMME
I think the reason is that our syst em is
still growing, I will not say it is still you know immaturity, it is
still growing because even in the public sector itself we are still
using
national
core
standards
to
assess
ourselves
and
those
standards are quite basic. So if you were to just dep ose our tools
against other developed countries or even some other countries in
10
the continent, their measurements are more advanced than what we
are measuring. For example we would come to a facility and just
measure if there is a policy, so we have not tr anspollated that or
moved that into the private sector. So what we actually even did,
we did not even have a tool – you will find many provinces have
developed their tools based on the national core standards that we
20
use to assess our clinics or hospitals in the public sector. It is only
now that we are starting to now come up with better tools for
emergency medical services, mental health institutions because we
Health Market Inquiry
Page 31
18th May 2016
___________________________________________________________________
were using just generic terms to measure as you will have seen in
our submission to you.
So i t was not happening because even
ourselves we are still learning from these tools within the public
sector.
The ways of standard compliance itself has now as
independent group, as I will say upped the game in a way in terms
of what they are measuring with their triangulation approach, not
10
only where there is a policy, they will then go and check if the
policy is applied at the production side.
I want to move to the second section that we have – I think just
finally because we have not been approving fac ilities, almost all
our facilities that we have standing were regulated with regulation
20
158 so you will find that going forward we will then have some
legal battles with some of the groups in terms of applying our
Health Market Inquiry
Page 32
18th May 2016
___________________________________________________________________
current regulations. Like we have submitte d the HASA document
indicating areas of concern that we are raising.
I am moving chairperson if you allow to the second section that
[inaudible].
CHAIRPERSON
Is someone going to speak to those issues – the
10
litigation – at some point? Yes, thank you.
MARCUS MOLOKOMME Adv Finger will talk to that ones, I just
finish the summary then we will just touch on those areas. Thank
you.
20
The Free State in its uniqueness back in 2000 to 2002 entered into
PPP, a public private partnership, with the hospital group Netcare.
The contract is included in one of your folders there.
Now the
Health Market Inquiry
Page 33
18th May 2016
___________________________________________________________________
intention of this firstly was to look at, we define the concession
period to be 16 years which would have meant 2018 will have been
the last year of this PPP, but right from its ince ption it took longer
than anticipated to finish the bricks and mortar building of the
private wings, so there was a concession between the department
and Netcare groups through CHM to move that concession period
10
by an extra four years so now it will end in 2022, not 2018.
I
wanted to just clarify the way that concession came from, but the
principles that were on the table from the beginning were we need
to have a shares services model with Netcare and this was at two
facilities – [inaudible] tertiary hospi tal and Universitas Academic
Hospital, with different bits. There will be facility fees, we needed
20
to look at the model of improved revenue collection from both sides
but primarily we needed to redirect that revenue to improve the
patient experience of ca re in the public sector.
So we needed to
Health Market Inquiry
Page 34
18th May 2016
___________________________________________________________________
improve revenue collection, but that revenue collection must be
translated into patient experience in the public sector. We needed
to also look at efficiencies in terms of management and clinical
care, but the mos t important one was the risk bearing – the risk
needed to be transferred to the Netcare group.
So those were the
principles.
10
In 2010 as shown in the document we realised an Exco took a
resolution, provincial executive committee took a resolution that
we need to interrogate this contract because we are not realising
any of those principles and this was eight, nine years into it.
We
then engaged KPMG to come and be the arbitrator and also
20
continue with their audit and interrogation of this contract.
The
document is included in the Word document that we sent as a
narrative to our presentation – what we have done there in detail
Health Market Inquiry
Page 35
18th May 2016
___________________________________________________________________
chairperson, we have included the milestones right from day one,
month by month in the Word document what has been happening to
date. What we had found was that this partnership, the risk burden
rested with the Department, there were disagreements with almost
all the fees, we could not see how revenue streams were re -directed
to the public sector for patients to benefit and there a re many of us
10
who were of the opinion, even though we have not provided the
evidence, that Netcare was in this partnership primarily as a
comfort zone to get a license because primarily it means they have
a license until 2022, in essence.
It is a partners hip that we have
and if we want to exit the partnership there are legal fees and we
could be sued.
So basically Netcare is in this space, they are
20
guaranteed a license until the concession period ends.
So we are
all agreed that could not be, we needed to go back to the principles
of the PPP, but the most important part to raise here is that this was
Health Market Inquiry
Page 36
18th May 2016
___________________________________________________________________
before regulation 16.
So this was happening without any legal
framework in the country, so the country was not ready for any
partnership of any sort, especia lly of this kind, but it happened. So
what we are trying to do because we cannot apply the law
retrospectively and I am in your hands here Judge, I am not a legal
eagle but that is my understanding of the law. Now the issue then
10
that we have is that we n eeded to then interrogate and go through
arbitration as in our contract, have some agreements, have some
concessions and at the moment as we speak one of the biggest
problems that we realised was firstly we needed to make sure we
have what we call a manage ment unit for this PPP because of the
nature of the PPP and the amount of capital or investment that we
20
are talking about, but also we looked at the revenue streams and we
looked at the problems. Because even data collection was not what
it was supposed t o be, we could not measure things in terms of this
Health Market Inquiry
Page 37
18th May 2016
___________________________________________________________________
contract and there are those who are of the opinion that this
contract really has introduced other complications.
And one
complication I want to touch on is the Radiology Building or
radiology revenue str eam that also became as part of this contract.
I know the RSSA, the Radiology Society of South Africa has
already presented in Pretoria and I know they also use that popular
10
term price takers, but in the Free State we have a different notion
or concept an d experience from radiologists. Radiologists formed a
group and through that group they entered this PPP space to bill for
radiology services on behalf of the Department. So there is a
contract that we have included in the pile there, in the folder, but
the funny thing about this contract is that it entitled the department
20
right from the beginning to only 33,3% of the net collections and
when we did this assessment we all felt that this could not be and I
do not want to make this a legacy issue and blame p eople in the
Health Market Inquiry
Page 38
18th May 2016
___________________________________________________________________
past, it is a matter that we needed to deal with. Because firstly it
meant all the risks rests with the Department of Health – we own
the equipment, we maintain the equipment, we have the personnel,
this is all the administrative people and th e radiologists and the
radiographers, people who are all in the company are actually our
employees, but they are making 76% for just providing a practice
10
number and claiming on our behalf – that is exactly what that
contract entails and we needed to put a stop to that.
So what we
did, actually then issued which is included in your archives there to
terminate and then go properly on to tender if there is a need for
billing for radiology services. So I just wanted to touch on that in
terms of part of the PP P – it is not in essence legally part of the
20
PPP, but the PPP platform created an environment where such
practice could happen.
Health Market Inquiry
Page 39
18th May 2016
___________________________________________________________________
CHAIRPERSON Just tell me, you know, is there a policy now that
governs these PPP’s?
MARCUS MOLOKOMME
Yes, there is now, re gulation 16 I am
referring to in the Treasury and also the PFMA, but back in 2000,
1999 when this was contemplated there was none, it was just an
10
open land where innovative people could enter the space and I must
say there are a lot of lessons that we lear ned from this PPP and I
am sure other provinces will give their experience and so forth, but
ours is quite unique and I will touch on the second section. I am
coming back to this point, on other complications that this PPP
brought.
20
Health Market Inquiry
Page 40
18th May 2016
___________________________________________________________________
PROF FONN Can I just understand, so the nature of the issue with
the radiology group is that they did the billing service for the
province?
MARCUS MOLOKOMME
Yes, there was a notion that somehow
our department and Netcare were made to believe that they will not
10
be able to char ge total fees in terms of the uniform fee structure,
the UFS, so they needed a practice number from specialists to be
able to bill for 100% of the fees, so that is the arrangement. So
what they are providing as a group like you heard yesterday that it
is better to pay into groups, they made that kind of a group as
radiologists.
Once they made the group they came out with an
20
association which had a practice number, that practice number is
the practice number that claims for all medical aid patients and
private patients that comes to the facility.
So they are basically
Health Market Inquiry
Page 41
18th May 2016
___________________________________________________________________
claiming for all the services of imaging and treatment, radiological
treatments in our facilities. So that money gets into their account
as people who have carried out the service, but that s ervice is not
only them, they report on the images, the service is done by
radiographers who are employees of the state. This people in this
group also are professors and Head of Departments who are
10
radiologists within the Department so that is the arrang ement – just
to paint the picture, but once those monies are there they will pay
all their costs and then 33% is due to the person or the Department
that owns the equipment, that pays salaries and maintains the
equipment.
20
PROF FONN So the costs that are covered by the income does not
include the Departmental costs?
Health Market Inquiry
Page 42
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
Not at all, it is just what you pay the
people who do the electronic data interaction, the EDI, who send
the batches, their claims.
Some monies was paid as bonuses to
radiographers I think they were paying them like stipend on top of
the salaries we pay.
So those are the costs and maybe other
company costs that they might experience. So it is not the cost of
10
the State, that is why I am saying all the risks, 100% rested on th e
State, they just provided an administration and a practice number.
PROF FONN And was this contract signed between the Free State
Department of Health, Treasury was not involved at all?
20
MARCUS MOLOKOMME Not at that point.
CHAIRPERSON Treasury?
Health Market Inquiry
Page 43
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME Not at all.
CHAIRPERSON And how much are we talking about here?
MARCUS MOLOKOMME I will share the figures because we had
asked for confidentiality because we wanted to be open with the
10
panel as much as possible because our idea is tha t we need to
correct things, we are not here to defend or hide anything because
we want things to be done in a correct framework.
They were
talking turnover of up to R80, 90 million a year, that is the
turnover so we will be entitled to around 33% of that . Let me just
add chairperson that this month of May, oh sorry.
20
CHAIRPERSON Are you going to come back to this point at some
time, are you going to come back to this issue?
Now precisely
Health Market Inquiry
18th May 2016
Page 44
___________________________________________________________________
what is it that these radiologists did apart from supplying the
practice number?
MARCUS MOLOKOMME
In terms of service these are our
employees, so basically in the daily process of giving our service
those patients that are fee paying then get billed through that
10
vehicle. So all your patients that are on medical aid wh en they
interact with our service, will be billed. Let me just add where this
other
stream
of
patients
came
from.
In
our
Netcare
PPP
arrangement, Netcare does not own any radiology capacity so all
the patients that are in Netcare at both Universitas Acad emic
Hospital and [inaudible] tertiary hospital are then transferred to the
20
public side to come and have the tests and the imaging done.
So
basically all the patients that ever had an x -ray, an MRI scan, a CT scan or any contrast medium treatments from Ne tcare Group as part
Health Market Inquiry
Page 45
18th May 2016
___________________________________________________________________
of the PPP were seen in the public side at Universitas and
[inaudible], but will have been billed by this group. Now Netcare
at some point also had some, I do not remember the percentages,
also had some money that was paid from the gro up to Netcare as
part of their revenue because of that arrangement, but Netcare will
tell you this arrangement was not part of them, they are pointing
10
the finger towards the provincial government because that is where
the contract is held. But in terms of benefits, those benefits went
both ways, we can call them benefits – I am just saying the
payments and we even had a concession chairperson, that patients
that came from Netcare would not wait when they came to the
public side. So if you find 100 poor pat ients queuing up in
20
radiology for a particular x -ray modality and three Netcare patients
arrived, those will be the first to be seen. And these are just some
of the things that we have been challenging because we did not
Health Market Inquiry
Page 46
18th May 2016
___________________________________________________________________
want, and in one of our discussion s it is just you know things
sometimes do not get returned, people were saying people who do
not pay do not mind waiting sometimes. And these are some of the
notions that we want addressed, that is why we are saying we are
here to open up in terms of our e xperience with our PPP so that we
once and for all correct what has been going on. So to answer your
10
question they did nothing else, they just provided practice numbers
but continued to work as they would anyway for a salary because
they would report on e very image – that they would have been
doing anyway. But the issue was that the hospital on its own could
not be able to, I think we allowed thirty to thirty five percent, but
do not quote me on that, we need to cross reference, as a hospital
20
who could only bill for a section of the fee, but them as
radiologists could get 100%, but from that 100% we still get 30%
anyway.
Health Market Inquiry
18th May 2016
Page 47
___________________________________________________________________
CHAIRPERSON Help me understand this – these radiologists were
employees of the provincial government and they were getting paid
a salary by the provincial government?
MARCUS MOLOKOMME
Yes, they were.
The second section I
am not going to come back to this, the technical part, but there is
10
another element that I want to touch on that informs how employees
of the State end up doing busin ess in this manner with the
Department.
CHAIRPERSON
Now in addition to the salary that they will
receive monthly, then they have a share of about 63%?
20
MARCUS MOLOKOMME Yes chairperson. So as the RSSA would
have
presented,
the
Radiology
Society,
the
ra diologists
are
Health Market Inquiry
Page 48
18th May 2016
___________________________________________________________________
basically hospital based so there is always an argument that I am a
radiologist in the State, there is no way I can go do any other work
outside.
So my work needs to be done where I am at, so that is
another argument that has always been fl ighted in terms of
justifying this practice. That I am here 24/7, I am not like another
private sector radiologist who is in another hospital and getting all
10
this money on their own, so that is another element to this angle
which I will touch on just now.
The next concept that I want to touch on, thank you Chairperson, is
this whole concept of remunerative work outside the public service.
I am not too sure if other provinces have touched on it yet, but we
20
want to go deep into it because to us this is t he biggest problem we
face. And part of it is that the Free State with its PPP arrangement
has created an enabling environment, the fertile ground for this
Health Market Inquiry
Page 49
18th May 2016
___________________________________________________________________
practice to happen.
Basically as we said Chairperson now, these
are employees of the State that ar e now given approval to now go
do remunerative work, work where they are paid outside the public
service and outside in this case does not mean outside of his hours,
it means outside the premises.
I want to be clear on that because
sometimes people think we are saying out means it is after work so
10
it does not matter – in this case we are talking work that is done
just outside any of our premises.
This is section 30 in the DPSA
you will find that it is by policy allowed to happen, but many
provinces have t heir own interpretation of how to apply this
concept of RWOP’s or remunerative work outside the public
service.
Other provinces, especially in this case where we are
20
sitting Kwa Zulu Natal has put an end to it in 2010 and many other
provinces we are still struggling with this beast.
In terms of our
arrangement Netcare is attached to our facilities, we can be sitting
Health Market Inquiry
Page 50
18th May 2016
___________________________________________________________________
here if you go to the loo here you are already in Netcare that is
about three or four steps. Now if you have an arrangement with a
specialist who works for Netcare and works for you, you never
know where they are at. So invariably during office hours they are
able to see their own private patients and see public sector patients
and we all know Chairperson that if somebody is called by Netcare
10
and they are still seeing ten poor people we know where they are
going to go. I think we can argue about the ethics and the behaviour
the whole day, but the issue is we know that sometimes this market
is driven by income or money or revenues. Now it is a gainst that
that we then in 2013 started the process of reviewing the policy and
what we had done was that we are not going to approve any
20
remunerative work outside the public service where people apply to
do it during office hours or during when they are on call, that is
Health Market Inquiry
Page 51
18th May 2016
___________________________________________________________________
overtime. This applies to all public officials in the Free State, but
we were focussing specially on clinicians.
The biggest problems that we are facing, I will tabulate them now.
Number one was service delivery – we realised that peo ple were
leaving the public sector to go and work in their private rooms in
10
the hospital groups or their own private practices during peak
hours, by this we mean 10 and 2 o’clock.
This is when you find
many patients in our out -patient departments, patient s in the wards,
ward rounds were not done the way they should be, meaning we are
not discharging patients as we should and so forth in terms of
service delivery.
The second part was supervision – we felt that
20
this practice was encouraging what we call thi s “juniorisation”, if
there is such a word, of the doctors sector where you find there is
no hierarchy anymore.
We knew many of us when we trained we
Health Market Inquiry
18th May 2016
Page 52
___________________________________________________________________
knew it was almost like military – there was a Head of Department,
there were consultants, there were sen ior registrars, there were
junior registrars, there were medical officers, seniors and junior
medical officers, there were comp -serv doctors and then there were
interns in that order.
So that was the pecking order, but now all
that has gone murky because people are just haphazardly leaving at
10
any given time, not in a structured manner.
So you will find
sometimes in the services, the front line person is not the most
senior.
You will find a new registrar who is basically a medical
officer
being
the
one
ru nning
the
services
because
the
top
[inaudible] has left the service to go do their remunerative work.
So it “juniorise” the front line of medical care and this has led to
20
many litigations, especially when you find junior doctors having
mishaps because the y were not supervised and we could test in
some of the cases that if the senior person was there the decisions
Health Market Inquiry
18th May 2016
Page 53
___________________________________________________________________
taken, or the problem list that would have been drawn or the
interaction with the family or the intervention would have been
more robust in ident ifying what is wrong and doing something
about it. So this practice is now coming and showing its ugly head
in litigations because the senior was not on site.
We know the
problem with this chairperson is that you will not get many
10
witnesses to this becau se as junior doctors we all want to be
promoted and qualify as specialists.
We would hardly report our
seniors as they were not on site and that is the biggest problem
RWOP’s brings.
But to me the biggest one is the next one – training and teaching.
20
Yesterday you were told here that some of the doctors do not write
the quotes and it is our submission here that that problem starts at
the production line.
The doctors we are producing now and we
Health Market Inquiry
Page 54
18th May 2016
___________________________________________________________________
have all been saying it in corners, we are saying it here – the
doctors we are producing now in terms of quality are a far cry from
what we used to produce. The specialists we produce now are a far
cry from what we used to produce. Let me just give an example –
if you get a good intern who is produced from a par ticular
University, the first day they arrive you give them an A4 paper to
10
write clinical notes, they will complain, they will want three more
pages to write clinical notes but you meet that same intern when
they are a medical officer, they need half of th at page to write the
notes.
So they will be so domesticated because the hierarchy has
lost its shape to a point that people get domesticated with the bad
cultures within the medical sector and RWOP’s is the cause of all
20
this in terms of training and super vision.
Health Market Inquiry
Page 55
18th May 2016
___________________________________________________________________
Research is suffering because the Heads sometimes are not on site,
teaching is suffering because people are chasing RWOP’s and this
is in 2013 is what informed our position on RWOP’s.
We got
challenged , taken to court, we were interdicted for technical bits in
terms of creating expectation because this is a privilege, it is not a
right, it is something that is applied for annually and we can say
10
yes or no, but later on Adv Finger can maybe touch on the legal,
technical bits if you so wish chair person. Now...
CHAIRPERSON
Okay, these doctors who are supposed to train
these young, these trainee doctors if that is their proper term, are
they attached to tertiary institutions as well where they teach?
20
MARCUS MOLOKOMME
Yes, the biggest problem w e face with
these RWOP’s is basically the academic facilities because this is
Health Market Inquiry
Page 56
18th May 2016
___________________________________________________________________
where you find all the super -specialists and many of our specialists.
In the Free State like in many other provinces you will not find this
as a big problem in district hospital s, clinics, community health
clinics or centres or regional hospitals – that is where it starts. In
regional hospitals yes you will find it; your [Bongani?] regional
hospital, your [inaudible] in Betlehem, but [inaudible] tertiary
10
hospital and Universitas – that is where you find the biggest
problem because most of all applicants are from those facilities and
we are focussing on this because the biggest problem we were
concerned about teaching and we had contacted the dean because
we feel in terms of what I am going to present now later, we feel
that the Universities have a key role to play because we cannot
20
allow teaching and research and learning to suffer whilst we are
allowing people to go and do RWOP’s. And then in between that it
is service delivery. So that was our position. It was not to tamper
Health Market Inquiry
Page 57
18th May 2016
___________________________________________________________________
with any autonomy of any nature, all those things that we were
accused of, but the issue we are not here to defend our position, we
just presenting the problems we experienced.
Okay, fifty specialist to d ate since 2013 left the services because of
this matter.
10
CHAIRPERSON Can I ask you this question – these professors, I
assume they are professors because they are attached to tertiary
institutions, would they go and do RWOP’s during teaching hours?
In other words absent themselves from lectures because they want
to go and do RWOP’s?
20
MARCUS MOLOKOMME I would not say yes, but it is something
we could not measure because our Human Resources measurements
are not that advanced because people will always giv e you a work
Health Market Inquiry
Page 58
18th May 2016
___________________________________________________________________
plan, but whether they adhere to that work plan in terms of
measurements it becomes difficult which is why we then need the
Dean of the Medical Schools to be assessing that on their side
because we have this space called joint appointments. S o these are
people who are employed by the State, we pay 70% of their salaries
and 30% comes from higher education because they are linked to
10
the facilities, to the medical schools.
So half the time when they
claim I am in an academic meeting, as CEO I am not too sure if I
do not collaborate with the Dean if that is so because on my
worksheet it will say 2 till 4 academic commitments.
If I am a
CEO I will just assume at the University, but if I do not follow up
to say where is Professor Molokomme at this time and be told no he
20
is busy in lectures or sometimes you are told he is busy in his
rooms, please phone his rooms. So those kind of... Our HR has not
entered that space rigorously to do those measurements.
Health Market Inquiry
Page 59
18th May 2016
___________________________________________________________________
CHAIRPERSON Are you suggesting that one of t he problems with
RWOP’s is that it is difficult to monitor?
Please say that on
record.
MARCUS MOLOKOMME Yes, there is a notion that RWOP’s as a
policy if not a problem, the problem is its monitoring because we
10
do not have the necessary tools to do that.
PROF FONN
Can I just clarify with regard to the teaching
commitments – there are two kinds of teaching as I understand it
that happens.
The one kind of teaching is lectures and the other
kind of teaching is service learning. Service learning takes pla ce in
20
the hospitals around the beside so is it the case that if doctors are
not in the hospitals running their ward rounds, they are not doing
their teaching?
Health Market Inquiry
18th May 2016
Page 60
___________________________________________________________________
MARCUS MOLOKOMME
Yes, you are absolutely correct and to
us that is the most important teaching i n a medical school – the
academic ward round.
Now many of those ward rounds will have
been given by senior registrars because the consultants invariably
would have been doing RWOP’s.
That is the point that I was
making that we have “juniorised” all front s so an academic ward
10
round where as a junior doctor you panicked and never slept the
whole night to knowing that tomorrow is an academic ward round,
it is going to take an hour of rigorous learning with patients, now it
is done by junior officials because the seniors might have been out
doing those RWOP’s.
So there are two components I agree; it is
the physical traditional lectures, standing in front of the students in
20
the medical school or research supervision and there is also the
most important – the textbook is the patient.
Health Market Inquiry
Page 61
18th May 2016
___________________________________________________________________
PROF FONN Can you give us a bit more detail please on the court
case? So you were taken to court over RWOP’s and what was the
outcome?
MARCUS MOLOKOMME Okay, can I allow Justice Finger to give
that detail?
10
ADV FINGER
The outcome was that well it was really a
procedural issue because I think they raised the issue that there was
not enough consultation.
We had issued an instruction that
RWOP’s would not be allowed between 07h30 and 16h00 and you
know they went to court and bro ught the whole history as to where
20
RWOP’s came from and that you know, it is something that they are
used to and we should have allowed more time to consult with them
Health Market Inquiry
18th May 2016
Page 62
___________________________________________________________________
and also not just stop it immediately – give them some time to
adjust and the Judge agree d with them at the time.
CHAIRPERSON
So it really was that you should have consulted,
given them more time, it really was a procedural matter, the court
did not get into the merits or the demerits of the whole exercise – is
10
that right?
ADV FINGER That is correct.
MARCUS MOLOKOMME
Thank you.
Now taking it further, we
always said who are the actors in this space, obviously it is the
20
clinicians themselves, but hospital managers in what chairperson
has raised in terms of managing and monitoring, clini cal managers
and Heads of Clinical Departments and Clinical Units but the
Health Market Inquiry
Page 63
18th May 2016
___________________________________________________________________
problem is that many of them are involved in the scheme so it
becomes an agency issue in terms of how it should be managed.
We also need to highlight that you know, as Adv Finger ha s
touched on, the issue of RWOP’s was really as a policy like I said
it is not a bad thing, it was to mitigate the disjuncture or the
disparity between what private sector doctors were earning and
10
what public sector doctors were earning.
So it was the bal ancing
act to allow and also to allow some skills, sometimes there is some
equipment that we do not have in the public sector, but it is
available out there. So it exposes our clinicians to both worlds if
you like, and were supposed to benefits patients – who were
supposed to benefit from that practice, but we know it has not
20
happened.
But in terms of monies, the specific dispensation
occupational, OSD when it came it basically closed that bridge, but
then we just continued with RWOP’s as if it was a righ t and not a
Health Market Inquiry
Page 64
18th May 2016
___________________________________________________________________
privilege. We never assessed whether we have reached Utopia, we
reached a point where we have equalised what private sector
doctors are earning and those doctors with us in the public sector
and there are many people who would argue that we ar e paying,
even though the salaries are not what they are supposed to be in
terms of being risk based and so forth for doctors, but by far we
10
have bridged that gap.
Because also now I will give you an
example – an obstetrician for example for indemnity wil l pay up to
R300 000,00 in private practice. The same obstetrician working at
[inaudible] institution pays nothing because we carry his liability.
So basically we, in terms of costs and benefits we have equalised
what people earn.
So meaning the need for RWOP’s must be
20
reviewed and it is behind that background that we are going to give
a resolution.
Health Market Inquiry
Page 65
18th May 2016
___________________________________________________________________
Deans of medical schools are the biggest player, oh...
CHAIRPERSON I have this question, but there is another problem
though isn’t there because you must be able to attract and retain the
specialists and for you to do that you need to offer them conditions
of service with which they will be comfortable and wasn’t RWOP’s
supposed to address that problem partly?
10
MARCUS MOLOKOMME
Yes, partly but in the main it was to
equalise like I said that gap that existed.
In terms of the our
services competing with the private sector, that is something we
need to as a province to work on, to make sure that the goods and
services are in order, the equipment is up to scratc h so that
20
specialists are seeing they are doing what they are trained to do.
We do not want them to venture into private sector to go experience
things.
When they are sitting for tea they should be able to
Health Market Inquiry
Page 66
18th May 2016
___________________________________________________________________
compare notes in terms of what they are treating with their
counterparts in the private sector and to many of the people even
though they are complaining about RWOP’s, the biggest thing that
we have not maybe addressed is to address the environment that we
work in to make sure that it attracts people on its own without
having them do RWOP’s.
Sometimes we do not want to paint
10
everybody the same batch – there are many clinicians that are
committed in the public sector, have stayed in the sector and there
are many medical officers who we even call career m edical officers
for you know maybe wrong reasons, who are those traditional
doctors who just stay there and render a service, even in this milieu
of RWOP’s and so they are not participating in that. So there are a
20
few people that we are focussing on who a re the ones that really are
abusing the system, but there are many committed doctors. I do not
want to leave the panel with the impression that in the Free State it
Health Market Inquiry
18th May 2016
Page 67
___________________________________________________________________
is ‘hallo-ballo’, people are just doing RWOP’s, it is a few people
that we are dealing wit h but it creates a problem.
The second point that I wanted to make in terms of access is the
hospital groups themselves, after the Deans of medical schools.
Because when many of these people leave to do RWOP’s, they are
10
doing them in the private hospit als so it is for the benefit of the
hospitals that we allow these people to go out. For example if I am
an anaesthesiast like for theatre you will find that my theatre lists
are booked between ten and one o’clock, then the question should
be asked should y ou not be in the public sector hospital right now
while you are running theatres here?
So in the Free State we
20
started with Netcare now to partner because they have biometric
systems to start monitoring movement of our doctors.
So for
cardiology departme nt I know I did not give in time, which
Health Market Inquiry
18th May 2016
Page 68
___________________________________________________________________
cardiologists is in there at what time, which is necessary to support
are in there at what time. So there is an area there to be looked at
in partnership in controlling the movement of our clinicians.
Lastly is the medical aids, we know Gems started in 2013/2014 to
produce lists based on Persol numbers and ID numbers, lists of
10
clinicians that are being paid by Gems medical aid, whereas being
employed by the State.
It is a little measurement, even if it can
create other problems, it is at least a beginning of knowing who is
earning money from medical aids whereas in the State because we
then start, it is a proxy measurement because we can then even
measure if there are specialists what time those patients were seen.
20
Now the hurdle that we could not jump when Gems provided the
lists was that many people were threatening to take us to court
because
they
were
claiming
this
is
an
employer -employee
Health Market Inquiry
Page 69
18th May 2016
___________________________________________________________________
relationship, it cannot be entered by a third party, in this case
Gems. So I am just putting that as one of their terms that were out
there to try and curb this abuse of RWOP’s.
Lastly in our proposal we are saying we need to standardise this
practice.
Many provinces have different approaches, some have
10
actually outright ba nned
RWOP’s, some of us tried other means
and we struggled and we are calling that we need to standardise it
in the short term, but in the long term we need to call for a repeal
of section 30 and come up with an innovative and more inclusive
method of ins tituting another kind of RWOP’s in a way, or another
retention strategy.
I have given one instance about magnet
20
facilities where we make sure that every specialist have got
everything they desire to treat patients in the public sector and we
pay them well because at the end this is what this is about.
Health Market Inquiry
Page 70
18th May 2016
___________________________________________________________________
The last point that I wanted to make Chairperson then if there are
any other issues then my colleagues can come in, is...
CHAIRPERSON Go ahead, yes thank you.
MARCUS MOLOKOMME The last point, sorry le t me start again,
10
the last point I wanted to raise representing the Free State is one of
the experiences we have as a public sector divided from the private
sector is that we invariably get calls to receive patients from the
private hospital groups based o n that the medical aid is exhausted
and we have had a few meetings locally to try and address this with
the hospital groups, but we are putting it here because the practice
20
has not stopped and we have put in confidence two cases; one from
I think last year one that was quite recent as well about a practice
where you will find a private hospital will meet a pregnant mother,
Health Market Inquiry
Page 71
18th May 2016
___________________________________________________________________
that mother gives birth to a baby with maybe a little abnormality
needing a neo-natal ICU.
Depending on the scheme, what they
cover and what they are willing to cover or how much savings they
have you will find the mother is admitted in that hospital, but the
baby is ferried to a public sector hospital, separating mother and
child right from day one based on money. And in the case that w e
10
are putting forward unfortunately the baby demised and we are
saying that cannot be – going forward this is the space we need to
look at. We expect our private hospital groups to nurse patients to
wellness and this is the point that was made yesterday, we are not
measuring outcomes – we are measuring price and affordability.
Whereas in the midst of all the presentations we even heard
20
yesterday, this point was not addressed in terms of what happens
when a patient lying in ICU runs out of funds, what is t he
obligation of the medical aid – is it a pro rata determination, do
Health Market Inquiry
18th May 2016
Page 72
___________________________________________________________________
they have to apply for motivation or do you ship out this patient
expecting government to now take over because now there is no
money.
There are many cases like this, the most other rec ent one
that we did not include was a case from a patient from Lesotho and
this is one of the challenges that we face in the Free State with the
proximities,
that
patient
came
admitted
in
MediClinic
10
Bloemfontein, got a drug reaction, a condition she did no t come
with initially, got a drug reaction, ended up in ICU, three weeks
later money runs out and the family is called from Lesotho to come
and collect.
Now the family ends up at my office saying please
help, there is nowhere else to go, we feel this is a practice that
must be brought to an end.
20
The other part that we want to raise is the issue of protocols – the
clinical protocols that we have are not standardised so private
Health Market Inquiry
Page 73
18th May 2016
___________________________________________________________________
sector sometimes driven by the bottom line will do renal dialysis on
a patient because the medical aid for that pensioner would allow,
but they do not plan that what happens when that money runs out
because when that same patient comes to a public sector facility,
our protocols will now dialyse the pensioner, just putting it brutall y
as it is.
So you will find somebody comes with all the tubes
10
hanging expecting to be dialysed, and we tell them we are not going
to do it and their argument is woah is it because I am poor, but the
medical aid has been dried out elsewhere and those peop le will not
touch that patient because that patient now has no money. And we
have a lot of patients that are falling through the cracks because of
the protocols but also because of the approach from the other side.
20
Lastly we want to just touch we know EMS regulations are being
finalised, we are also going to form a committee to regulate our
private ambulances.
The issue that we are raising it here with
Health Market Inquiry
Page 74
18th May 2016
___________________________________________________________________
private ambulances is that we are finding and Mr Ruiters is here to
just confirm, we are finding that at
an accident scene you
sometimes find that the private ambulance groups would not touch
some of our patients or our victims because they ask the question
from the side, whether you are able to pay and that is the difficulty.
We have attached a case that w e have handed over to the police
10
where there was an accident in an area called [Poliroo] in Thabo
Mofutsanyana, next to Bethlehem and three of the victims were
speedily taken to Hoogland MediClinic because they were on
medical aid and the rest of the victi ms were left there for him and
his crew in public sector to arrive and we are saying these are some
of the areas that we need to look at in terms of experience of care,
20
right from the streets. Not only focus on the bigger facilities and
that is the case t hat we want to...
Health Market Inquiry
Page 75
18th May 2016
___________________________________________________________________
And lastly when these patients run out of medical aid even the
ambulances in those hospital groups will not carry these patients,
we get phoned to come and pick up.
So that practice must be
looked at and I know people are calling for reg ulations.
Some of
these things need regulation, some of them just needs us to be more
human.
10
Lastly, the public EMS, maybe out of trauma from the past, if you
were to be picked up on the N1 around the Free State, before you
get to [inaudible] tertiary hospital trauma unit, you will have
driven past three private sector hospitals and our ambulances do not
even bother, they just past those with red lights wailing, high speed
20
to [inaudible] because they know those patients are not going to be
accepted. We do not have the evidence of how many were rejected,
because like I am saying it has become a culture of some sort that
Health Market Inquiry
18th May 2016
Page 76
___________________________________________________________________
if those people are poor, stabbed chest around next door to
MediClinic, you drive to [inaudible], you stand more chance of
saving that life than going next door.
And these are some of the
practices unfortunately that come and we cannot just stand here and
prove that this is what is happening, here is the evidence because
will say we have never rejected a patient but in our call centre we
10
do record all these calls that we get and some of the calls are such
calls where we are requested to come and pick up and people are
declaring, please come pick up because the patient has run out of
money.
Chairperson, that is almost 90% of our presentati on linking as an
20
oral submission and I will just check if...
submission, but the panel is available to answer.
That is our oral
Health Market Inquiry
18th May 2016
Page 77
___________________________________________________________________
CHAIRPERSON Yes, on this last issue may I ask you this question
– does the provincial government have a policy on emergency
medical care?
MARCUS MOLOKOMME
Emergency
Medical
Yes, we do Chairperson.
Services
Unit
which
covers
We have an
pre -hospital
10
transport, we have high trauma or high life support vehicles, we
have disaster vehicles and then we have the planned patient
transport – these are the ones that are used for referral of patients.
So these are the big bakkies or big Iveco busses that you will see
transporting patients within between levels of care. We also have
maternity
ambulances,
we
are
one
of
the
provinces
that
in
20
2010/2011 financially reduced maternal mortalities by 50% so we
were the icon of Africa at the point by just instituting skilled
attendants speedily by putting maternity ambulances where we
Health Market Inquiry
Page 78
18th May 2016
___________________________________________________________________
should.
So we have different policies for different vehicles.
We
also have ICU vehicles and mental health ambulances because we
always have the opinion that mentally challenges people we usually
call the police, in our case we call an ambulance because that
person is ill, not a criminal. So we have those policies in terms of
medical care. We also have airborne medicine, so we have now in
10
the new contract; in the past we experienced biggest problems
because people could not fly at night because of the nature of the
configuration of our service; so we have not introdu ced 24/7
service so we can fly to clinicians, to patients at once at night with
our airborne medicine.
Interaction with the private sector – we
have a contract with Buthilezi EMS for inter -facility transfers that
20
we have gone out on tender on people compe ted and the preferred
bidder was awarded the contract. So we have a policy on all those
Health Market Inquiry
Page 79
18th May 2016
___________________________________________________________________
areas.
All of them are underpinned by our referral policy and the
aversion policy.
CHAIRPERSON
What is the attitude of the private sector to
individuals who are in need of emergency medical treatment such
as those who get involved in serious car accidents, who might
10
require immediate medical attention?
MARCUS MOLOKOMME What we have seen is that on arrival at
the accident scene or a call, if it is a call people will always check
before they come out if there is a method of payment.
On an
accident scene when they arrive there is that triage and that triage
20
is no more only clinical, it is also based on their ability to pay and
the cases we are reporting here for [Poli roo] indicates just that.
But also when they pick up patients who are unable to pay, the
Health Market Inquiry
Page 80
18th May 2016
___________________________________________________________________
same private facility ambulances that are linked to hospitals would
not go to their own facilities, they will drive to public sector
hospitals to go and deliver. So you invariably find private, and it
is not unique for Free State, you will find private ambulances
entering public facilities to drop off and this is because they get
paid from Road Accident Fund, nothing else. I might not be able to
10
prove it here, but we know the driver there is because they are able
to claim for the trip to go drop off, but they will not drop off that
patient in a private sector for them to be stabilised. They will drop
that patient destination is the public sector hospital, but they ar e
able to claim for that transport. So you will find many times
accident scenes have all these cars and they are willing to
20
transport, but they will check if you can afford the destination – so
the destination is determined by your ability to pay because t he
kilometres will already be claimed from Road Accident Fund.
Health Market Inquiry
Page 81
18th May 2016
___________________________________________________________________
CHAIRPERSON
Has the provincial government engaged the
private sector on the rendering of emergency medical care?
MARCUS MOLOKOMME Yes chairperson, can I allow Mr Reuben
to give you...
10
REUBEN RUITERS I thank you Chair. I think how operationally
it happens is the private facilities being your Netcare, your ER24,
they also have their own control centres of which they advertise
their call centre number to be called and so forth.
So the call
centre or call management process is not yet in a state where we
centralise it where we have only one entity. So currently each
20
provider receive their own calls and they dispatch their resources
as basically how they receive the calls and based on that we do not
have control of us knowing at the go that there is an accident
Health Market Inquiry
Page 82
18th May 2016
___________________________________________________________________
outside on the N1, we will always we informed by their call centre
talking to our call centre that we need additional resources or send
more vehicle support, but only when we arrive in s uch incidences
then we will experience that they did have capacity at the moment,
but they chose not to render services to other victims.
10
CHAIRPERSON Yes, thank you. Okay.
DR VAN GENT Thank you Judge. I received and read with a lot
of interest... I heard with a lot of interest your presentation and I
read thank you very much. I think I have two areas where I would
like a bit of clarification.
I think I understood what you said the
20
difference between demand and need which is very interesting
statement you made, it is easy to make the statement to find a
solution to find out what really need is and also part of our job is
Health Market Inquiry
Page 83
18th May 2016
___________________________________________________________________
finding out whether demand is really demand isn’t it – it is part of
what we do and we both struggle in doing that.
But in the
application, I am obviously talking about the licensing process, in
the application there is a number of forms and requirements and
one of them is a business plan, and I do think that is the document
in which you would like to find information on the need to
10
establish a hospital in a particular area or district whatever.
And
then I see that you have a committee, I think you are chairing the
committee from the licensing committee that meets every month
and discussed the application and amongst them also the bu siness
plan and it is quite hard to really interrogate a business plan and
find out what the reality on the ground is of these behind these
20
sector – so do you issue requirements, your own requirements, of
this business plan.
So I read that you have five d ifferent sort of
criteria by which the committee makes its call on the business plan
Health Market Inquiry
Page 84
18th May 2016
___________________________________________________________________
and ultimately advises the Head of Department whether or not to
give the license, do you require these applicants themselves to
make a self-assessment of all these criteri a that your committee are
going to judge this on?
PINKY BERLOT Okay, thank you chair. What is required is for
the applicant to submit all the information and what we do as the
10
committee, we verify that information because already we would
have that infor mation at our disposal in terms of the information
that we would be having on data, but now like the presenter said on
the issue of the business plan, they do submit but we do not have
the skill to can say is it good enough or what.
20
DR VAN GENT I sympathise, I myself have in my long life have
tried to find the truth behind business plans and it is not easy, but
what I was asking is have you considered they themselves to ask
Health Market Inquiry
Page 85
18th May 2016
___________________________________________________________________
for a self-assessment on equity for example, you know on the
equitable distribut ion between districts of beds in the Free State or
by demographics or one of the other criteria, BEE of course that is
easy for them to assess it themselves, you just find out who owns
the thing.
But actually what I am coming at is to do a real need
assessment themselves and put that position to you instead of you
10
yourselves having to do the analysis.
PINKY BERLOT No, we have not considered that.
DR VAN GENT It would make life much easier I think.
20
MARCUS MOLOKOMME
Yes, thank you panel.
What I was
presenting was that this is our biggest problem in terms of business
plan and we are looking for instruments so that we can assess, but I
Health Market Inquiry
Page 86
18th May 2016
___________________________________________________________________
hear what you are saying that we should also create a criterion that
people can self -assess so that we can then interro gate their own
assessments. We appreciate the point.
DR VAN GENT Yes, it is, of course I should not mingle into your
affairs, but on one hand it makes life easier, but it is also more
10
predictable I think for parties that apply for a license to know
precisely on what criteria they will be judged upon and they can do
a self-assessment and try to... It would also make life for us a bit
easier because we would understand precisely what the criteria are
and how they are going to be applied, in what ways mo re and in
what ways less in this situation.
20
Can I go on to the second subject and that is also that the panel is
looking into the matter of quality and quality and information on
Health Market Inquiry
Page 87
18th May 2016
___________________________________________________________________
quality provided by hospitals and then primarily of course our
mandate is to look into the private sector, but the same probably
will apply to the public sector. So your new regulation 2014 I see
under section 31 point 3 that the Head of Department may request
routine statistics and in fact the Head of Department has quite
recently in 2016 I think issued a list of statistics that he or she
10
requires, it is a list of about eight pages with data points that these
hospitals have to provide to you on a regular basis, on a monthly
basis even I think it is. My first question – this applies to both the
public sector and the private sector?
MARCUS MOLOKOMME
Thank you.
Yes, it does.
Like we
20
discussed with the chairperson, in the public sector almost all those
are mandatory.
There are regulations set already in terms of the
clinical data sets and all the other national data sets or provincial
Health Market Inquiry
Page 88
18th May 2016
___________________________________________________________________
data sets that must be reported on, so in the public sector we are
quite rigorous on that.
We are now trying to transfer that
mandatory obligation or expectation to the private sector with that
section 31 of our regulation.
DR VAN GENT Thank you. When reading through the list of data,
10
for example the maternity data is about twenty items referred to
maternity data and other data, but I had the impression that these
are statistics, these are not d ata points that one can use to come up
with meaningful quality or outcome measures or indicators – it is
pure statistics.
How many women come in and this and this
condition and that.
So a list of statistics, but you cannot derive
20
from that meaningful out come measures, am I correct?
Health Market Inquiry
Page 89
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME Yes, you are correct. Like I mentioned
we are having a meeting next week led by our legal department to
develop that section 31 further.
We were meeting all the hospital
groups.
DR VAN GENT
This has been postponed because I saw it was
10
intended to take place today, maybe it takes place today somewhere
else.
I will be happy to be part of that as well, it is very
interesting.
What I am getting at is this – again maybe the same
sort of basic comment or quest ion that I had before, did you ever
consider asking, and I am referring to the public and the private
hospitals – to they themselves do an assessment of their clinical
20
quality in the sense that you hand them let’s say fifty clinical
quality indicators whic h can be taken off the internet for free plus a
description how to measure them easily, you just hand them over ; it
Health Market Inquiry
Page 90
18th May 2016
___________________________________________________________________
is a bit more complex than what I said now, but just ask them to do
a self-assessment on a number of pre -described standardised quality
indicators and do that on a continued basis.
Maybe not every
month, but every half year and do that in a standardised way. First
off for all private hospitals, probably starting with new licenses as
a requirement for the license, but you would probably also be able
10
to extend that to already existing hospitals because you refresh
your requirements every year, don’t you.
PINKY BERLOT Not really, the only self -assessment that they do
is after we train them on the National Question then we require
them to conduct the self-assessment and we verify that, but not as a
20
continuous basis we do not, it is not the expectation currently from
the Department.
Health Market Inquiry
Page 91
18th May 2016
___________________________________________________________________
DR VAN GENT It would be such a good thing to start with I think
to get the hospitals to first of all self -assess on a standardised
format and you could do that I think as a provincial authority.
Secondly to ask them to publish this information on their site
because it is very important for the public to learn of course what
the quality is that is being provided at all these private hospital and
10
it is a completely compliant with the National Health Act.
And
thirdly to use this information as input for sort of a risk assessed
inspection.
I see that you inspect these hospitals every year or
every two years, but I rea d a couple of these inspection reports and
they are find, but they are not risk orientated. It is not you know,
they are not... People do not go and the team does not go in with
20
prior knowledge about what the outcomes of this particular hospital
are, where the problems probably are and sort of focus in on these
problem areas. I am actually talking like a consultant to you now,
Health Market Inquiry
18th May 2016
Page 92
___________________________________________________________________
not as a panellist asking you questions. Can I have your comments
on this?
PINKY BERLOT
I think what we are saying is we have not yet
engaged into that, that is the way to after I think this consultation.
Thank you.
10
DR VAN GENT Thank you very much, I have no further questions,
thank you very much.
DR
NKONKI
presentation.
Thank
you
very
much
for
your
interesting
My first que stion is around your description of I
20
would say mis -alignment between what you have licensed and what
sometimes financial institutions, a bank in this instance, would say
they would lend money on. So what I would like to know is what
Health Market Inquiry
Page 93
18th May 2016
___________________________________________________________________
would be the rational e for the bank to say you have issued a license
for an acute hospital and they would say we would rather fund a
different type of hospital - what rationale would they put forward
for that?
MARCUS MOLOKOMME
Thank you.
The discussion it is never
10
between us as a Department with the banks. The banks will discuss
with the applicant, but through suspicion when we interrogate these
applications because then we treat them as almost new applications,
when we interrogate the reasons we are finding is that they w ill just
oppose performance in that area from other institutions against the
applicants.
So if the applicant has applied for day beds, I am
20
giving an example, and they feel there is no sustainable business
that they can fund on that model as compared to a cute for example,
I would not say they have looked at MediClinic or Netcare, but
Health Market Inquiry
Page 94
18th May 2016
___________________________________________________________________
invariably I am sure they would compare apples with apples.
So
they look at performance in Bloemfontein for acute bits against
performance maybe in other areas or even provin ces for sub-acute
beds. In this case it was approval for sub -acute beds based on our
need, but when the banks entered the frame they felt there is no
business for sub -acute beds. But I might add that in this example
10
that we are giving there was also anot her element – there was a lot
of delay in finalising from the municipalities in terms of the plans
so what was needed as sub -acute beds five years prior, now when
you wanted to build and get funding six years later might have
fallen off as a business model .
So that was just another element.
So what we are saying is that our business plan should be so solid
20
as we have been advised now that whether it is tested today or in
ten years, it will still make sense because invariably if we would
build those sub -acute beds in three years it means the business
Health Market Inquiry
Page 95
18th May 2016
___________________________________________________________________
could have collapsed two years later according to the banks.
So
that lack of alignment I think we can mitigate against if we have
sound business plan interrogation; either self -assessment by the
applicants and also as a committee when we assess the business
plan.
10
CHAIRPERSON
The problem though that you know, as a
provincial administration one assumes that your primary focus is
the provision of healthcare services, you identify that in this
particular area t here is a need for healthcare services and therefore
it is appropriate to issue or to grant a license, but the bank have got
different considerations.
They look at whether it is economically
20
viable to have a hospital there. So you have two opposing inter ests
which might not coincide and that is what they would look at.
Health Market Inquiry
Page 96
18th May 2016
___________________________________________________________________
MARCUS
MOLOKOMME
Correct
chairperson,
that
is
the
dilemma. Like I am saying the only way to mitigate that is to make
sure as we assess the business plan we also have that view because
at some point nobody had R300 – R400 million lying around, they
are going to need institutions at some point. So our business plan
interrogation must reach that level so that when we approve at least
10
we have that strong suspicion that this is sustainable.
CHAIRPERSON
But you should have different considerations
because for you it is not a question of whether or not the provision
of healthcare services in a particular area is economically viable,
for you the question is whether there is a need there because you
20
have a constitutional responsibility to provide those services.
If
they cannot go to Xhariep for example you have to go there
yourself.
Health Market Inquiry
Page 97
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
Yes chairperson that is the point, but
the point we are making is that we equally cannot be obl ivious to
those requirements by financiers, even though it is not our focus
which is why we included the business plan so that we can look at
the sustainability of what people are saying, but not use it as a
criterion because that will then create other di fficulties.
10
CHAIRPERSON
That is going to land you into some problems.
There will be areas where you would never be able to issue a
license whereas there is a need for it simply because it is not
economically viable.
And the question really is – what are the
alternatives?
20
MARCUS MOLOKOMME
Yes, that is the experience in Thabo
Mofutsanyana and in Xhariep which is why maybe we did not cover
Health Market Inquiry
Page 98
18th May 2016
___________________________________________________________________
it here. We talk about joint ventures, like you correctly have said
chairperson if we do not open the private fac ility we are going to
have to go there because the need exists in those areas.
So we
mentioned joint ventures in that vein, that is not the PPP in its
current form, no way, but what we are talking about is joint
ventures going forward to ensure that we ad dress the need in those
10
areas.
So joint ventures in terms of a business plan and we
currently even have new applications now, people innovators who
go, people who apply now are actually even now starting to
mentioned joint ventures, they are not applying just a single
entities, they are proposing that they are willing to partner with
government in those peripheral areas based on preventative models.
20
So we are starting to see new applicants now coming because
everybody now sees that the financial instituti ons would not fund
the demand anymore in Bloemfontein so we are now forced into an
Health Market Inquiry
Page 99
18th May 2016
___________________________________________________________________
innovative space where we need to now find those joint ventures
between the private sector and the provincial Department as well.
DR NKONKI Thank you. My second questio n is around your PPP
experience and I think it is widely acknowledged that public
facilities do struggle with billing and so I think that your
10
experience is useful in terms of how you tried to improve your
billing through your interaction with radiologists . So what I would
like to know, you have gone through all these different steps and
you have outlined your milestones here, but what have you learned
specifically to billing?
Would you say that your capacity to bill
has improved now through this PPP expe rience and if yes, in what
20
ways had it improved?
Health Market Inquiry
Page 100
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME Thank you for the question. I think our
capacity as a provincial department increased in other instances. I
will start with the latent phase – I think we have proper policies
now in terms of revenue collection. We appreciate that yes, we are
not for profit but we equally are not for losses. Now, the PFMA is
quite clear in terms of the responsibility of the accounting officers,
10
CEO’s and district managers in terms of revenue collection – so
that is quite clear on the latent softer side of things.
In terms of
the practicalities we have now appointed case managers to be able
to, and it is a practice that we learned from our PPP experiences
and we have last year reviewed even their job desc riptions to focus
on revenue.
Treasury gave us money in the past two years in a
20
revenue enhancement programme, so what we have learned in terms
of capacity is that we need to create an ambiance to pay. I think if
I go to Pick n Pay and there are no tills I would leave my wallet in
Health Market Inquiry
Page 101
18th May 2016
___________________________________________________________________
the car, I am just going to collect and leave, but the presence of a
till suggests and creates that expectation to pay. So if you go to
many of our facilities, there is not even a SpeedPoint, nobody
carries cash, we expect peopl e to pay, but we are saying they must
give us R50,00.
Nobody walks around with that kind of money
anymore, so what we have done as the Free State we are even
10
engaging service providers to come and supply us with this
[inaudible] where you can swipe a Jet Card, a Sales House card,
there is no Sales House you are right any more, okay, but you
understand chairperson, Edgars and all those Truworths cards as
methods of payments. So we are creating expectation that even
though the service is for public we still need to pay our R20,00, we
20
still need to pay our R10,00.
There is actually in the province a
move now even to take the model, the Cuban model where we even
though the service is free we put how much it costs so that people
Health Market Inquiry
Page 102
18th May 2016
___________________________________________________________________
can appreciate it is free, but i t has cost the State R20,00 for me to
be here today. So sometimes when you come next time you wonder,
hey I have cost the State R100,00 already, I am not going to go. So
we are creating those expectations in terms of the practicalities of
revenue.
10
We are now in the process of advertising a new tender for this new
revenue services based on our experiences so the contract will be
very different from where we are at.
So we are terminating the
current Radiology’s contract, it is its last month, in June we are
running the bidding processes, in July we will start with a new
service provider based on all regulations currently because now we
20
are in a very nice regulatory space than where we were years ago.
In terms of the PPP, in 2022 there are two options – it is either
we...
There are three options actually.
The immediate option is
Health Market Inquiry
18th May 2016
Page 103
___________________________________________________________________
that we pay the exit as you will have seen in that R206 million I
think and then we will be sued, litigation costs maybe another R200
million so we can pay around R400 million and e nd up with
immediately tomorrow a hospital with equipment with 210 beds. It
costs up to R2/R3 million to build each bed in a hospital so
meaning
if
we
wanted
to
build
an
equivalent
hospital
in
10
Bloemfontein it will cost us R2 billion. So some people argue pay
the R400 million, get out of this PPP, count your losses, you have
the equipment, you have the new hospital at half the price, that is
the one approach. There are some who are saying let us sit out the
concession to 2022, benefit without paying the R 400 million and do
not get a service provider, absorb those beds into the system and
20
move on.
There are those who are saying the third option is to
clean up our act, get the regulatory framework, bid, get people to
Health Market Inquiry
Page 104
18th May 2016
___________________________________________________________________
tender for those beds and move forward.
So the Department still
has those decisions to make in terms of lessons learned.
In terms of the PPP beyond radiology services with revenue
streams, yes there are lessons to be learned on how we channel now
that money towards the benefit of the public wh ich is the principle
10
that underpinned this PPP arrangement. So we do not have capacity
for radiology yet, that is why we are going out on tender, but based
on new regulations, new set up, new contract, new monitoring and
evaluation, new data sets and so fo rth.
CHAIRPERSON
As a government these are the sort of services
20
that you will be providing for the rest of your existence.
Now it
does seem to everyone that perhaps it is high time that the
government should reconsider outsourcing these things and devel op
Health Market Inquiry
18th May 2016
Page 105
___________________________________________________________________
the capacity to do these things itself.
You have been with this
process for a sufficient time to have had a transference of skills so
that you train your own people to be able to do these things .
I
mean these are not people from Mars who are doing thi s, these are
ordinary human beings and you can train them and make sure that
they perform this task rather than relying always on service
10
providers to come and do the job that civil servants are supposed to
be doing. Isn’t that, shouldn’t that be the long term plan?
MARCUS MOLOKOMME
Thanks Chairperson.
In principle yes,
but in these highly specialised areas unfortunately the principle
does not hold. What we are outsourcing is this arrangement where
20
we will be able to claim 100% of the radiology fees, it is just
maybe unfortunate that when the Society delivered their submission
in Pretoria maybe this point was not highlighted.
We were told
Health Market Inquiry
Page 106
18th May 2016
___________________________________________________________________
when we engaged this group that actually there are now a set of
rules that came from the Society that Adv Finger is here to
elaborate on that, which protected radiologists in terms of this kind
of claims and profit sharing mechanisms. So even when people say
they are price takers there are many other arrangements that are not
being declared in essence and in the Fre e State that is what we are
10
experiencing.
So what we are outsourcing is not the revenue
collection, it is the mechanism to collect that money because that
capacity we will never have until we change our regulations in
terms of our Medical Aid Scheme Rules , in terms of who can claim
what and who can claim 100% and if we allow our public hospitals
for example in this strata of patients from age zero to age four to be
20
able to claim 100% from our fee structures then we would not need
to outsource anything beca use the capacity exists, but the challenge
becomes in the specialised areas.
Health Market Inquiry
Page 107
18th May 2016
___________________________________________________________________
CHAIRPERSON
What prevents you from doing that?
It is the
rules and you made the rules?
MARCUS MOLOKOMME As government yes we make the rules.
CHAIRPERSON Then you cannot blame anyone else because you
10
make the rules and you change the rules if the rules do not work
out.
MARCUS MOLOKOMME I agree to the principle, the practicality
is the difficulty.
20
DR NKONKI So finally on this revenue, you mentioned Gems and
when Gems came to present to us on many of their options, the
State is their designated service provider for their PMB’s.
So I
Health Market Inquiry
Page 108
18th May 2016
___________________________________________________________________
would like to know if your capacity to build, how is your capacity
to build in that area?
MARCUS MOLOKOMME
Our capacity to build in term s of now
the set targets for public sector patients that includes those lower
schemes in Gems and Moto -Health and Metropolitan and so forth,
10
like I said three years ago we started the project and we have
capacity in all facilities to claim for all those.
We also have the assistance of Medi -Credit so many of our
facilities use Medi -Tech system for batching purposes. So in terms
of claiming for patients that we see according to our structure in
20
terms of who pays, who does not pay and also those that are p aying
over the counter, the capacity exists in terms of meeting those
targets.
In the Free State one of our challenges now that you are
Health Market Inquiry
Page 109
18th May 2016
___________________________________________________________________
touching on revenue is those patients that are coming from Lesotho,
but we have identified the challenges, we have iden tified the
referral patterns, we have engaged three months ago with the
Lesotho Government Department of Health and of all the monies
that we are owed up to 60% already had been paid in those three
months.
10
DR NKONKI Okay thank you. My final question i s on the Human
Resources, how you assess them during your licensing and renewal
of licenses.
So on page 6 of your written submission you have
about five criteria that you have outlined, so I would like you to
talk more on that, in particular how you deal with assessing nursing
20
staff for re-licensing.
Health Market Inquiry
Page 110
18th May 2016
___________________________________________________________________
PINKY BERLOT On the issue of the HR we first look at whether
do they have the policies and procedures that guide the processes
because we believe that the facility cannot function well if they are
not havi ng staff and also we will be looking into the staffing
norms, especially in the nursing areas. So they will be monitoring
what they are informing us against what we will be assessing on the
10
day of inspection, like to check how many personnel, the number o f
patients, because mostly they will be working on the Acuity system
to say you know they re -allocate staff accordingly to Acuity. And
also on the issue of the you know the job descriptions, the issues of
the BMS we are all looking into all those things, not only the
nursing staff personnel but the entire facility.
20
have answered.
I do not know if I
Health Market Inquiry
Page 111
18th May 2016
___________________________________________________________________
DR NKONKI
So given the challenges you have outlined on
RWOP’s, have you explored using the opportunity for re -licensing
as one avenue to manage the challenges you have with RWOP’s?
MARCUS MOLOKOMME
We have not at this juncture. What we
are doing we are engaging them outside the licensing framework
10
because what we had realised is that there is an opportunity there to
engage the managers of these private facili ties, hence the meeting
that we were even supposed to have today. We wanted to start from
there. I think the approach in the Free State is that we have always
tried to find common ground, if we fail then we legislate in terms
of including it as part of ou r protocol.
But what we are finding
20
now going forward is that with the people who left the services
RWOP’s is starting to become more controllable because like I said
we lost up to fifty, just on the training platform, up to fifty
Health Market Inquiry
Page 112
18th May 2016
___________________________________________________________________
specialists over the thr ee years since we started controlling this
phase, but yes we will take the point that going forward we might
need to look at that as part of our Human Resources control in
terms of re-licensing.
DR NKONKI Thank you.
10
PROF FONN
Thanks very much.
Yesterd ay we heard from Dr
Ruff, he was presenting an alternative model and part of what you
have been dealing with is the licensing of hospitals and he
presented a model which suggested that in fact one could license
something that was service provision and that was not a hospital,
20
that was a group of people who provide primary and referral
services. And it seems to me that part of the issue around business
plans and Standard Bank and all these things have to do with the
Health Market Inquiry
Page 113
18th May 2016
___________________________________________________________________
viability, the economic viability, of the hospital and we have also
heard evidence of our entire health system being too hospi -centric.
So is there the space, the possibility, to meet need through a model
that is not licensing a hospital and is that something that your
provincial department coul d imagine?
10
MARCUS MOLOKOMME
examples to clarify.
Thank you yes, let me give two
We are currently now, we had advertised
because it is a specialised area chairperson - regenerative medicine
as an alternative to all this invasive treatments that we rende r. So
this is not a hospital, but this is a group of services providers that
are specialists in that area that we want to contract to come and
20
provide a service and now pay them as a group. We are one of the
provinces that started five years ago for male medical circumcision
where we said we will contract IPA’s for example, not individual
Health Market Inquiry
18th May 2016
Page 114
___________________________________________________________________
practitioners, we needed them to organise themselves either into
companies if they could not operate as an IPA because an IPA is
more of a relationship, or create IPA’s as form of a team per area,
per region and Motusi IPA is to give an example was one of the
IPA’s that became a model for the country in terms of how we
contract for services, for male medical circumcision.
They will
10
then place a claim and what we had atta ched there is all the
requirements
in
terms
of
quality
assurance,
adverse
events
management in terms of outcomes and follow ups for patients and
then we will pay you on that basis.
So we would pay it once we
have ticked all those boxes in terms of outcome s, but paying them
as an organised group.
20
We are now, the MEC in his budget speech this year mentioned that
we need to look at triaging service as a service that we can look at,
Health Market Inquiry
Page 115
18th May 2016
___________________________________________________________________
having groups to assist the department, to reduce the waiting times
in our casualties, especially for preventative care so that patients
do not wait in a tertiary hospital because patients do not honour or
respect referral lines.
You see a hospital, you come in if you are
ill. So we need to have that kind of filter to provide a service at a
low cost obviously to try and negate. So we have looked at those
10
mechanisms. At the moment in the Free State we are having two
groups – we have an academic group where it is a group of
specialists that is organised themselves and those group s are the
ones that engage in terms of clinical care in the province will be
the groups.
Those people who are doing RWOP’s, many of them
are participants into those groups because to get an approval for
20
RWOP’s you should, if you are a sole practitioner, j ust on that
basis we do not approve even if you are going to do after hours
because it means the practice out there depends on you solely.
If
Health Market Inquiry
Page 116
18th May 2016
___________________________________________________________________
there is no one else you are going to have to escape to go and see
patients but if it is a group practice, or a t eam, then we know there
are other people who are representing you. The radiologists as well
they formalise themselves into a group, even thought the model is
not what it is supposed to be, but it answers that question in terms
of there are groups already in the Free State that are interacting
10
with the Department, not necessarily through licensing but through
them organising themselves as specialists.
What we need to then
do is to make sure that those interactions are proper.
PROF FONN So it seems to m e that you have identified many of
your own problems and you have also showed stewardship in terms
20
of trying to move to learning from the problems, working out what
might work better and so on, and you have indicated some
interventions to us where you know that something could be of
Health Market Inquiry
Page 117
18th May 2016
___________________________________________________________________
assistance, so for example a national approach to RWOP’s is the
one example you gave us.
Now we are a panel who has to advise
on the private sector and my question to you is what else do you
need from, where could we be of assi stance to you given that we
are looking at the private sector in increasing access to quality
care, what do you need or what can we in your conception of what
10
we are able to do, what can we provide in addition to this example
of the national approach to RW OP’s?
MARCUS MOLOKOMME Thank you. The way the health system
has been operating obviously it has been that segregation between
private and public and I understand the principle of the NHI and
20
personal coverage and so forth, but currently we are working i n a
system that remains separate.
I think the first thing would be to
make sure that we share data – I think that is the first thing that we
Health Market Inquiry
18th May 2016
Page 118
___________________________________________________________________
need to address because like we heard yesterday morning, that
without that data we cannot measure things, we do no t know where
we are at, we definitely would not know the before and the after.
So I think the first thing is to share that.
The
second
thing
is
alignment
in
processes
in
terms
of
10
predetermined objectives. Sometimes when we engage with private
facilities, for example in media liaison – I am just giving an
example – you will find that the public, the private sector will
always say hold on we do not account to you so there is already
that kind of spooky stories about who is who, there is territorialism
in terms of operating within the health system. I think one of the
20
things that we still have not covered here is the role of the
Universities in the Free State and I am of the opinion that there is a
lot of interaction of the health market with the Universi ties that we
Health Market Inquiry
Page 119
18th May 2016
___________________________________________________________________
need to look at. In this case in the particular in the Free State I am
talking about all the clinical trials that get carried out in our
Universities, all the drug tests that gets carried out in our
Universities, and lastly as the Free State where you can assist us is
sometimes the behaviour of the pharmaceutical companies because
it is always portrayed as the Free State as a collapsed system
10
because there are no medications, but there are many instances even
though we have not brought the pre sentation or the proof but we
interrogating the systems, where you find companies are setting
credit limits; something that is unheard of in the public sector, a
credit limit of R1 million for a province. You are basically asking
that province not have me dication because a credit limit of that. So
20
those are the kind of strategic broad issues that I feel the
commission can assist us in interrogating and correcting the way
forward.
Health Market Inquiry
18th May 2016
Page 120
___________________________________________________________________
PROF FONN Let me understand, are you saying that the tests that
are done in clinical trials land up being to the account of the public
sector?
MARCUS MOLOKOMME The arrangements usually you will find
the University holds the account so the research monies for all
10
those tests or monies that come from the private sector end up a t
the
Universities
and
in
the
Free
State
you
would
find
the
Department of Health has no view or has no oversight over such.
So those monies remain in control of the medical faculties and that
is what I am highlighting.
20
PROF FONN
But does the medical fac ulty then pay those
laboratory tests that are done in clinical trials or does the public
sector pick up the cost?
Health Market Inquiry
Page 121
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
The public sector some of those, you
remember that some of those, not some of those, patients or
anything that happens in th e medical schools, 70% of that usually
happens in the public sector – we are the ones who owns hospitals.
So the patients are in the hospitals, the professors and many of the
clinicians are on joint appointments so we are paying them. So the
10
activities that they do within that space, there should be that
component that comes to the public sector, that is our view as the
Free State and that is what we, within the Memorandum of
Understanding, what we are starting to interrogate. So I am not too
sure in other provinces how this pans out, how those monies gets
treated once they are in the accounts of the Universities but in our
20
case those monies sometimes are used to appoint officials on behalf
of the University or sometimes a ward just gets painted from thos e
monies. So we are saying there is a scope there to be explored in
Health Market Inquiry
Page 122
18th May 2016
___________________________________________________________________
terms of monies that are coming from the private sector, entering
the space but remain stuck at the Universities.
PROF FONN No, I do understand what you are saying, but what I
am trying to understand is – so I mean I know the way clinical
trials work, I understand the way hospitals work. A doctor is doing
10
a clinical trial and he is paid for that by the pharmaceutical
industry usually or whatever device industry whatever is being
tested and the patients are admitted as per protocol, I come in, I am
an ordinary patient, but I am also eligible for the trials so I am
entered in the trial. I am sitting in the hospital and I need X and Y
test so that could legitimately be charged to the publi c sector, but
20
for the clinical trial I also have test A, B and C. For test A, B and
C is that paid for by the University from the clinical trial funds or
is that paid for by the public sector?
Health Market Inquiry
Page 123
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
That is the issue interrogating because
by protocol those fees should be carried by the research fund but
what we are interrogating now is to check if our own NHLS bill
does not end up on the public account. So that is why we have not
presented it here yet, because we did not want to come here with
wishy-washy, we wanted... But we are saying it is something to be
10
looked at in answering your question earlier.
PROF FONN
And then just explain to me about the R1 million
credit limit. So if I understand you correctly you are saying I am a
pharmaceuti cal and I will say to you okay I am ready to deliver, but
you have not paid me so I am not delivering.
20
MARCUS MOLOKOMME
Yes, even though that bill might be
fifteen days old, if it is close to R1 million we cannot order with
Health Market Inquiry
Page 124
18th May 2016
___________________________________________________________________
you. So once you set a credit limit you are basically saying it is
C.O.D. and now R1 million for the whole province becomes a
challenge. So what I am saying is that has not happened before and
it is something that has happened from a particular company and
the engagement is that we ca nnot operate in that kind of space. All
our bills have thirty day turnaround time, if we pay in two days
10
fine, but we have thirty days. Now if you set a credit limit and one
batch of order is R920 000,00 it means for that month I will not be
receiving much from you regardless of what you supply – if it is an
essential drug or not. So we are saying that space also needs to be
looked at.
Also taking it further sometimes accounts get frozen
without knowledge, even though you find we have paid for all the
20
ARV’s, but we owe maybe one batch for Panado, the practice has
always been the pharmaceuticals will sometimes we hold their
deliveries. So it is a space that needs to be explored and looked at
Health Market Inquiry
Page 125
18th May 2016
___________________________________________________________________
how you know some of those scenarios do happen, but the credit
limit one is the one that stands out because it has happened just this
year and it is something we have never seen before, especially for a
province. If it is R1 million for one facility I would understand but
if you are one of the biggest suppliers and t hen you set a credit
limit of R1 million you are basically saying that province every
10
thirty days only has R1 million to order and that becomes a
problem.
PROF FONN
So this is an interesting scenario because my sense
is that people need to sell their pro ducts and one of the biggest
consumers of ARV’s anyway is the public sector, so my feeling is
20
they need you more than you need them, unless they are the sole
provider. So if they are the sole provider then obviously they have
got more power than you have, but if you have got the money you
Health Market Inquiry
Page 126
18th May 2016
___________________________________________________________________
have got more power.
So how come the free market works
sometimes, but not other times when it comes to government?
MARCUS MOLOKOMME
I heard yesterday a panel member
making that point, and yes it is a funny sector becau se the general
principle is that the one with the gold sets the rules, but sometimes
10
in health sectors that equation does not work and this is one of
those things where a sole provider who decides to set a credit limit
you are basically their hostage. But we are interrogating that, but
what we are saying is that in essence as a matter of principle this is
not how the public of private health sector should interact with
public.
20
DR BHENGU
Thank you very much for the presentation, I just
wanted to you mad e reference to national core standards and you
Health Market Inquiry
18th May 2016
Page 127
___________________________________________________________________
basically say you are proposing that they be made tougher, is that
more or less that you...
MARCUS MOLOKOMME
Not necessarily tougher, but they need
to be escalated to look at things that are more beyond basi c.
10
DR BHENGU
Now how have your hospitals performed in the at
least with the most recent assessment by the office of Health
Standards Compliance in public service hospitals?
MARCUS MOLOKOMME
Yes, we had one worse hospital in
Diamant in Xhariep, it is a district hospital.
The way the system
20
works it is divided in the extreme measures, those measures are the
measures that must have, you cannot fail those.
So we have one
facility that failed which is almost worst in the country, Diamant
Health Market Inquiry
Page 128
18th May 2016
___________________________________________________________________
District Hospital The other hospitals are almost there but they have
regressed like the big ones. Universitas used to be number one in
the country, in the core standards but they have regressed to around
70% in the office of health standards compliance, but the issues
that were raised are developmental issues that can be sorted out,
like old aging infrastructure that can be addressed. So in terms of
10
[inaudible] also regressed, so as a province we have moved from
being number 3 to number 5 with the current assessment, no w
talking broadly as the entire country. But in terms of ideal clinics
as part of those assessments, ten of the clinics that were enrolled,
all of them are doing very well, two of them are in the top five,
primary healthcare clinics.
20
DR BHENGU How would you sort of, what would you like to tell
us because it is public knowledge that media is usually not kind in
Health Market Inquiry
Page 129
18th May 2016
___________________________________________________________________
reporting on the performance of health services in your province.
You have touched on the drug issue for us, but how would you
explain this – is it fair coverage or there is room to improve?
MARCUS MOLOKOMME Firstly I think let as a team here let me
be the first to declare that there is areas that we need to improve on
10
as a public health system, also in private. But many of the reports
that we get have really been unfair and they are targeted at a
particular individual who is our MEC, Dr Benny [inaudible]. And
many cases, both criminal and otherwise have been opened against
him by these groups that are protesting and feeding the information
to the media.
So I will say many of the reports have not been
20
accurate and even innocent scenarios have been highlighted to
sensationalise. I mean if a lift breaks down in [inaudible] hospital,
just as an example in Bethelehem, and a picture of EMS officials is
Health Market Inquiry
Page 130
18th May 2016
___________________________________________________________________
taken then carrying a stretcher of patients up the stairs and it is
portrayed as the no exception to the rule, this is how things work in
the Free State, you can see the sensational. If lifts do not work we
use the stairs, it is as simple as that but unfortunately sometimes
the way it is being portrayed it is being pitched to represent a
system that is collapsing. Yes, we face challenges. Like I said we
10
lost fifty specialists, I mean no system loses that as an academic
platform and does not get shake n up, but we have equally recruited
two hundred and fifty registrar and most of them are qualifying this
year.
So as these problems come like in any other system we are
mitigating for. I think the biggest problem is that we have not told
our stories as w ell because I do not think we are in the business of
20
reacting to media reports, but I think we need to start telling our
stories because there are many stories from the Free State that we
Health Market Inquiry
Page 131
18th May 2016
___________________________________________________________________
should be telling in terms of the successes as the health system,
also private and public.
DR BHENGU Just on this point, isn’t that... Okay I will begin to
know why the loss of so many specialists at the same time and
where did you lose them to and whether the new, I mean the
10
replacements you talking about will be re gistrars which suggests of
course these are still doctors in training, whether that does not
explain much of the generalisation you are talking about.
I am
aware of the issues because I am not sort of disregarding what you
said, I am just saying does it n ot contribute to that as well?
20
MARCUS MOLOKOMME Yes it compounds the problem. I think
to start from where we started losing specialists, I think the issue
of RWOP’s, when we tackled it it created that toxic environment
Health Market Inquiry
Page 132
18th May 2016
___________________________________________________________________
where many of the established spec ialists felt they would rather
leave the service into private practice.
Many of them are now
returning to do session because now I think we have removed the
toxic part, I think we have managed to engage after the court
ruling, we have managed to share ide as on how this would work.
So many of them are returning and many have left the services, but
10
have entered the University frame, so part of the monies that I am
talking about is those monies that parachuted them into lectureship.
So we have not lost them totally from the service. So in terms of
lecturing and practicals and bedside teaching, many of them still
remained but they have left their posts as Heads of Clinical
Departments, but there are those who left and went to the Western
20
Cape – that was our biggest losses to Stellenbosch. There are many
who just retired, took early retirements, they felt this is too much
for them and they would rather just go and be on a farm. So those
Health Market Inquiry
Page 133
18th May 2016
___________________________________________________________________
we have allowed as well.
So in terms of genirisation yes it is
compounde d by the fact that the most senior people are applying
for posts. I think the other biggest problem the Free State faces is
that when we advertise City Press and the Times, our last advert
was two weeks ago, we hardly get quality people applying, you get
a few chances but that is the problem that we have which is why we
10
are calling for an innovative way of looking at RWOP’s so that we
can tackle that carrot for people to come down to Mangaung and
also Cheetah’s are not doing too well so that is another prob lem.
DR BHENGU In Gauteng you said they lost a block of specialists
if I am not mistaken, the aesthetics department in particular and in
20
no time people started coming back again and we heard yesterday
and it has been coming up now and then that there a ctually maybe
the private sector is, there is an oversupply of specialists. Now if
Health Market Inquiry
Page 134
18th May 2016
___________________________________________________________________
we have such an issue about RWOP’s, I am just asking here your
personal opinion, isn’t that maybe the one way to sort of clean up
and say okay those who want to go, go we w ill suffer in the short
term but the private sector cannot absorb all of those who go but
when they come back they come back on our terms – would that
work?
10
MARCUS MOLOKOMME That was not our plan, but invariably it
has worked because we sometimes you hav e to anticipated these
unintended consequences and celebrate because we never had a
doubt.
We knew when we started that anyways some of these
colleagues when you say RWOP’s they are not necessarily doing
20
clinical care out there, some of them are on their farms, some are
having game farms, I can give a long list so when they leave they
are not necessarily in another clinic, they are doing something else.
Health Market Inquiry
Page 135
18th May 2016
___________________________________________________________________
So when you remove them from clinical care they are bound to
come back because what they are doing out there is not sustainable,
it is not what they are trained to do, it is not what they enjoy – it is
leisure. So people cannot do leisure 100%, maybe at some point
you can but it has brought back a lot of people who are now not
willing to do RWOP’s anymore. They appreciate our approach and
10
it has in a way cleaned out the nest in a way, but there are those
few that still remains because they knew they had nowhere else to
go because it is so saturated out there that they would not survive.
But also this indem nity thing is pushing people back out of
specialities back into the system because it costs you R400 000,00
to practice even though you are part time - just to see two patients a
20
day you need to pay R400 000,00 a year so that you are adequately
covered, but when you work for the State, you have that comfort.
So many people are coming on that basis because out there it is
Health Market Inquiry
Page 136
18th May 2016
___________________________________________________________________
difficult. I think lastly as the Free State our focus has always been
we have shifted to super -specialities and it goes back to that issue
of demand.
We have created demand for super -specialities so we
train fellows almost who can compete with Gauteng just with one
University – remember we have one medical school, but we train so
many fellows and it goes back to that point of demand and nee d. Do
10
we really need?
So we have trained people who are super -
specialists and they cannot survive out there because you will sit
there and wait for a gastro -[inaudible] patient the whole day and
hardly ever see anybody. So people are now forced, because w e
train them so much that they can only work in the services but it
has its own negatives as well that we did not bring here.
20
DR BHENGU Still on RWOP’s – you say you have a system that is
working with the cardiologists in terms of biometrics, for me it
Health Market Inquiry
Page 137
18th May 2016
___________________________________________________________________
seems like a critical step in stabilising in the short term. Is there a
reason that it is not deployed widely and do your employment
contracts provide for that, specifically the biometrics?
MARCUS MOLOKOMME Not at the moment, it is something that
we are exploring through our IT effort as a province to look at how
10
we can institute beyond biometrics, all the HR measurements, not
only for doctors but for all staff.
We have had a presentation
recently on lean management that showed that actually most of our
staff works in 30%, 40% on core business, the rest of the time it is
either I am visiting the next office or I am on the corridor or I am
in the loo an so forth. So we want to introduce proper human
20
resource measurements because if you do that RWOP’s then
becomes a component of that, we did not want to just say people
must check in and out and focus on as if it is a witch hunt for
Health Market Inquiry
Page 138
18th May 2016
___________________________________________________________________
clinicians, we want HR measurements from security services,
cleaners up to the top specialists because Labour Relations Act is
for everybody, it does not recognise specialities.
DR BHENGU
I am towards the end now, when I mean as a
preamble to this case was it you starting to take leaf out of the
10
KZN book to withdraw RWOP’s privileges?
MARCUS MOLOKOMME
That was not our approac h.
We
benchmarked, we spoken to Kwa Zulu Natal with their approach
and we knew that approach would not work in the Free State for a
number of reasons. In Kwa Zulu Natal they have more specialists
20
per capita than us in the private and also in the public, their
production and retention is better than all provinces.
What they
produce they keep because the measure the return on investment
Health Market Inquiry
Page 139
18th May 2016
___________________________________________________________________
with registrars.
We do not.
So we knew that we were going to
have challenges if we approach it in that manner. We did not have
the critical numbers of the critical mass to suddenly wake up and
say no more RWOP’s. So we decided the only way we can do it is
to write to all of [inaudible] who are doing RWOP’s to say going
forward in 2013 we will not approve anybody who is a pplying to do
10
them during office hours, half past seven to four, we will only
approve from 4pm to the next morning unless you are on call we
will also not include RWOP’s because some of the specialists or
medical officers who have been on call that night s o we did not
want to allow that moonlighting arrangement. That was the initial
point and on that basis we were taken to court.
20
Health Market Inquiry
18th May 2016
Page 140
___________________________________________________________________
DR BHENGU
Thank you, I think Advocate said it was on a
technicality that you lost – what does it mean? Is it still back on
your agenda?
ADV FINGER Ja, and this is where sometimes we take forever as
government to approve. Look the mandate form the MEC is that we
10
still should pursue the change of the policy to reflect that we only
approve from four upwards, but I can tell you p ractically that is
what we are doing currently and I think generally being accepted,
although it is not policy as yet but that is what we are doing
currently, only approving after hours.
20
CHAIRPERSON
regulations of 2014?
How
far
is
the
litigation
concerning
the
Health Market Inquiry
Page 141
18th May 2016
___________________________________________________________________
ADV FINGER
The matter is sitting in July, so that is the first
time. So we have closed all pleadings, it will be sitting in July.
CHAIRPERSON I did not get that.
ADV FINGER The matter will be heard in July, coming month.
10
CHAIRPERSON
At the High Court or the Supreme Court of
Appeal?
ADV FINGER That is the High Court, Free State High Court.
20
CHAIRPERSON
What are the implications for the regulations?
Does it mean you cannot apply those until the matter is resolved by
the court?
Health Market Inquiry
Page 142
18th May 2016
___________________________________________________________________
ADV FINGER No, we have not been interdicted from applying the
regulations so we are applying them. Yes, and I just think you had
made reference to maybe just to briefly highlight what are the
issues there. I think the main issue HASA felt that you know with
regards to section 36 they thought that is where we are coming
from, that was our enabling Act but we were able to prove that
10
actually we have our own Hospital Act. So they were coming from
the point of view that they were able to make national department
well almost believe that section 36 is unconstitutional, that is their
view. So therefore because they were able to convince the national
department who are we to come up with our own regulations, they
also felt that two critical issues – we should not issue licenses for a
20
year because they were saying it is not good for business that there
is uncertainty but I mean we felt that health is a critical issue, we
should be able to assess each year and issue a license and indeed if
Health Market Inquiry
Page 143
18th May 2016
___________________________________________________________________
you comply there should not be an y uncertainty.
The issue is
compliance – if you comply, there should not be uncertainly. They
also felt that when there is a change of ownership because this is
one thing that we try to avoid that you come as Justice Finger 100%
black owned, after we giv e you a license then you go to someone
else.
So they also felt that for a change of ownership we should
10
just issue license once and not come when there is a change of
ownership.
So currently in our regulations the license is not
transferable so as and wh en you dilute shares and change, you need
to come as a new application so they also did not want that.
So
overall they basically accusing us of not having listened to all these
matters that they raised and that is why they are asking for a
20
review.
Health Market Inquiry
18th May 2016
Page 144
___________________________________________________________________
CHAIRPERSON As I understand the challenge it is that there was
not
any
proper
consultation
before
these
regulations
were
promulgated, that is one of the challenges.
ADV FINGER
Yes, and we have been able to prove that in fact
there were some changes that we m ade subsequent to that, it is just
10
that you know they felt that everything must agree with everything
but we did consult yes.
CHAIRPERSON One does not know what the court is going to say,
it may set aside the regulations in which event you have to star t the
process all over again.
Okay.
Now and this was in terms of the
20
Free State Health Act which was promulgated in 1996, is it?
Health Market Inquiry
Page 145
18th May 2016
___________________________________________________________________
ADV FINGER Yes, it is the Free State Hospitals Act, 1996, yes.
CHAIRPERSON
What is the situation with the Free State now in
relation to the licenses? You have got the Free State Act of 1996,
then you have regulation 158 which was promulgated under the
1977 Act, then you have the Free State Regulations of 2014 and
10
you also have the Free Stat Act of 1996 – are all these meas ures
responsible for the issuing of the licenses?
ADV FINGER
Correct chairperson except that we no longer
applying regulation 158, we basically now using the Free State
Health Establishment 2014.
20
CHAIRPERSON
But that only relates to the regulations tha t you
made in 2014, only relates to the facilities?
Health Market Inquiry
Page 146
18th May 2016
___________________________________________________________________
ADV FINGER That is correct.
CHAIRPERSON
So to try and rationalise this legislation so that
you have one set of regulations that govern hospital facilities, but
you still have to wait for the High Court s’ decision.
10
ADV FINGER
Actually I think there are two Acts that you have
mentioned – it is the Free State Health Act, but that one was in
2009, but the ones that specifically focus on hospitals is the Free
State Hospitals Act of 1996 which I can tell yo u that we are
starting to review that you know to make sure that it is modern
because it had been almost twenty years that it was, but yes the
20
Free State Health Act, the regulations were issued in terms of that
Act yes.
Health Market Inquiry
Page 147
18th May 2016
___________________________________________________________________
CHAIRPERSON You are familiar with the regulations, are you?
ADV FINGER The regulations.
CHAIRPERSON Perhaps before I get there – there are two groups
of licenses that I want to talk about.
The first group is the ten
10
licenses which were issued but where nothing has happened and
then there are nine licenses which were issues but which have since
lapsed.
So you have got a total of about nineteen licenses which
have been issued between 2012 and 2014, I think between 2008 and
2014 – were any of these licenses issued under the new regulatio ns?
20
ADV FINGER
R158.
No, all of them were issued in terms of the old
Health Market Inquiry
Page 148
18th May 2016
___________________________________________________________________
CHAIRPERSON
Now with regard to those licenses that are not
operational, what is the situation there?
For how long is the
situation going to continue?
PINKY BERLOT I think those that are not functional, others they
are within their timeframes because they would have applied for the
10
extension, most of the submission of the building plans based on
whether finances for the rezoning, but I think in particular there are
two that I think th ey have would say exceeded the timeframes that I
think as a department we need to close that although we are saying
that automatically it lapsed but I think to make sure that they do
not come back we need to say we have not seen your movement,
20
just to inform them officially that their application has lapsed –
there are only two from those.
Health Market Inquiry
Page 149
18th May 2016
___________________________________________________________________
CHAIRPERSON
Does it concern you though that you have got
licenses that were granted in 2012 which in relation to which no
building has commenced?
MARCUS MOLOKOMME
Thank you chairperson.
Yes, it is a
concern as I covered earlier, this is where the municipalities get
10
into the space because many of these applicants are able to prove
that they have submitted their paperwork, it is still stuck with the
municipalities or t he rezoning or the land requisition still has not
happened and that is where we are finding the challenge.
We, in
the regulations, give them an extension but some of them then end
up being caught up by the regulations in terms of time. So it is a
20
concern yes because when we issue them like I said they are based
on need so any delay that we have means we have not created that
access.
Health Market Inquiry
Page 150
18th May 2016
___________________________________________________________________
CHAIRPERSON
Is the position that in relation to these ten
licenses, that have been issued during the period 2012/2013, all of
these licenses nothing is operational because of the need to go
through the approval system – all of them?
MARCUS MOLOKOMME Not all of them, I think in the narrative
10
in the Word document we have singled out one in Mangaung Metro
where we basically have previously disadvantaged owners and
those are the ones that are also struggling in terms of the financial
model. This is one of the reasons why we in the new regulations or
with the business plan interrogation we saying we need to tighten
the belt there so that we do not allow people through that will
20
struggle as much as those ten that are in terms of finances. If it is
the municipal then we must go an engage with the municipalities to
check what the issues are – it is a concern.
Health Market Inquiry
Page 151
18th May 2016
___________________________________________________________________
CHAIRPERSON
I mean does it concern you though that if there
are these licenses that have been issued but where nothing is
operational, somebody else could have been issued with that license
and could have had a hospital up and running by now?
MARCUS MOLOKOMME
Oh yes, we agree Chairperson which is
10
why the other point that we need to tighten is the penalties and also
the inspections because those regulations that issued these licenses
were quite loose in terms of when we inspect. So we are inspecting
by invitation of when yo u compete building. So I mean somebody
can sit with an approval until the last day of the regulations
allowing, even though they never had an intention or capacity to
20
build anything. So what we are doing now in terms of inspections
is to introduce site v isits to check if there is anything tangible
happening so that we are able to revoke a license or an approval on
Health Market Inquiry
Page 152
18th May 2016
___________________________________________________________________
that basis. So we are going to set milestones to be able to check,
unlike wait until three years and only then discover that this is not
going to happen because that is another three years – so that is six
years where that need is not being fulfilled.
CHAIRPERSON
For those licenses who are having difficulty
10
securing the approval of the building plans or the transfer of the
land – what assistance is the provincial government giving to those
individuals?
MARCUS MOLOKOMME At the moment we are not in that space,
all we do is wait for them to bring the plans according to the
20
regulation timeframe and then our infrastructure then interacts with
those plans. So we do not offer any assistance at the moment.
Health Market Inquiry
Page 153
18th May 2016
___________________________________________________________________
CHAIRPERSON What space are you talking about? You say you
are not in the space – what is the space that you talk about?
MARCUS MOLOKOMME
Okay, thank you.
The municipal
arrangement with the ap plicant because the applicant submit the
plans to the municipality, they make the request to transfer the
10
lands with the municipality and the rezoning. So that is the space
that I am talking about.
So that arrangement we are not in – we
only then receive the approvals from the municipality.
CHAIRPERSON
Shouldn’t the provincial government though try
and take some steps to facilitate the process of the consideration
20
and the approval of the building plans so that you could fulfil your
responsibility to mak e sure that health services are available within
the province?
Health Market Inquiry
Page 154
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
I agree it is something we should look
at.
CHAIRPERSON
The regulations contemplate that there will be a
committee which will be dealing with some of these issues, that
committee has been set up?
10
MARCUS MOLOKOMME Yes, I chair that committee.
CHAIRPERSON One of the functions of this committee is among
other things, to oversee compliance with prescribed norms and
standards as well as the quality of services that it provi ded by these
20
facilities. Have you commenced with these duties?
Health Market Inquiry
Page 155
18th May 2016
___________________________________________________________________
PINKY BERLOT
I think it will be the inspections that we are
conducting, that is when we monitor the norms and standards where
the team will have to be determined to conduct such.
CHAIRPERSON What norms and standards are you using?
10
PINKY BERLOT
We are referring to the private facility tool and
norms and standards it will be like the infection control, the health
and safety, all those other related policies attached to the patient
safety.
CHAIRPERSON And these norms and standards?
20
Health Market Inquiry
Page 156
18th May 2016
___________________________________________________________________
PINKY BERLOT No it will be our annexure . I think it is attached,
that is being revised when there is a need to review it on an annual
basis if there is some gaps.
CHAIRPERSON
When you monitor the qualit y of services,
precisely what is it that you are looking for? How do you do that?
10
PINKY BERLOT
We are looking into all the processes like the
governance issues, the HR issues, the clinical issues up to the
support services, the pharmacy, all the areas, maintenance – we are
looking into all those areas
– how the equipment is being
maintained under the heath care technology, so each and every
20
section is being allocated an assessor with a speciality attached
that they will follow what is required in the t ool.
Health Market Inquiry
18th May 2016
Page 157
___________________________________________________________________
CHAIRPERSON
Do you assess the quality of the treatment that
the patients receive at these private institutions?
PINKY BERLOT Yes, when we do the records review that is how
we monitor whether the patient you know has been appropriately
taken care of starting from the admission, that is where we will get
10
the challenge of the clinical records because would not see if... We
do not make the decision whether the document that the patient is
getting is based on the proper assessment, initial assessment by the
doctor, yes we do look into that. Patient records review, we review
and look at the records, patient records.
Yes, randomly we select
the file. We ask for randomly the patient files yes in retrospect.
20
Health Market Inquiry
Page 158
18th May 2016
___________________________________________________________________
CHAIRPERSON The regulations require these f acilities that is the
private facilities to keep these records, to keep records relating to
the treatment and admission of patients, is that right?
MARCUS MOLOKOMME Yes, it is chairperson.
10
CHAIRPERSON And they are required to keep this what? For fiv e
years I think?
MARCUS MOLOKOMME
There is a differential in terms of the
kind of records; for paediatrics on child birth it is up to 18 years,
other occupational and TB’s it can go up to 25 to 30 years.
20
there is in the national prescription all thos e differentials.
So
Health Market Inquiry
Page 159
18th May 2016
___________________________________________________________________
CHAIRPERSON
record?
What is the rationale for them to keep this
Is it to make them available for inspection in case you
need them?
MARCUS MOLOKOMME
Yes, firstly it is just for clinical
governance in terms of being able to do audits and research and
10
also evidence based medicine going forward, but also there is a
legal component because if you do not keep any person born today
can show up within the eighteen years that they received and for
occupational is the same.
So there are many oth er acts that enter
this space and inform how the records should be kept.
20
CHAIRPERSON In terms of regulation 31 I think it is 31.1, every
private health establishment shall ensure that region record relating
to history, assessment and treatment of each patient are kept
Health Market Inquiry
18th May 2016
Page 160
___________________________________________________________________
appropriately and then it goes on to say each private establishment
shall retain a copy of the records described in this regulation for a
period of five years from the date of service of the patient.
And
that in case of a minor it is abou t three years after the minor has
attained maturity, so they are only required to keep them for five
years.
10
ADV FINGER That is correct, that is the time that we thought you
know
is
reasonable
because
you
cannot
keep
them
forever
especially for adults.
CHAIRPERSON Yes, and thereafter they can destroy them?
20
MARCUS MOLOKOMME
No, the expectation is that they should
be archiving them according to the National Prescription but for the
Health Market Inquiry
Page 161
18th May 2016
___________________________________________________________________
purposes of our audits we expect them to keep them for this
prescribed periods – that is what we are capturing there.
CHAIRPERSON
But don’t you think that it would be helpful for
the provincial government if these records are kept and there is a
record of you know how many patients have been treated at these
10
facilities, the kind of treatment they are getting so that you can
assess the outcomes that you are talking about?
MARCUS MOLOKOMME
Yes, I think the struggle here with the
five and three years was for the purposes of these assessments, but
the expectation is as a hos pital themselves, the private facilities,
20
must comply with all other prescription of archiving of the clinical
records. So for the purposes of this process what we are saying is
Health Market Inquiry
Page 162
18th May 2016
___________________________________________________________________
that we can ask for any record within those timeframes for us to do
an audit, a clinical audit.
CHAIRPERSON Now is there a central place where all the records
of these facilities are kept so that they can be accessible?
10
MARCUS MOLOKOMME Not with us, each facility have got their
own archiving arrangement.
Some have more electro nic based
health records, but for such things as consent to treatment and so
forth we expect the more prescriptions, we expect them to archive
those and keep them as we are saying in the act, in the regulation.
20
CHAIRPERSON You have told us today that y ou are going to do
this and do that to improve the system. Now when did this occur to
you? Today?
Health Market Inquiry
Page 163
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
No chairperson, since we got into...
What you are looking at in front is almost 60% of the committee so
what we got in late 2014 these are some of the things that we have
found on the table and we have been interrogating systems,
interviewing people and even past panel members to identify these
challenges and address them.
As an advisory committee we can
10
only submit to the head of the de partment for him to them make
policies where possible, to make other circulars for other facilities
and also engagement with other already licensed private facilities.
So as a committee what we are putting forward here are from the
minutes of our meetings where we are saying this should happen
and that. So it is not something that happened over night, nothing
20
didn’t happen last night – we did not even sleep so.
CHAIRPERSON Why not?
Health Market Inquiry
Page 164
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
In anticipation for today, we needed to
be fresh and alert.
CHAIRPERSON
The beach is not too far from here, I can
understand why you did not sleep.
You were here were you not
when Dr Ruff I think it is, where he made a presentation describing
10
what would be the ideal healthcare system and also describi ng
where we are and how we can get to the ideal system. Now has the
provincial government had the occasion to do that exercise – look
at the healthcare system that you have in your province, look at
what you are required to provide which is set out clearl y in the
Constitution and consider how you might meet your Constitutional
20
mandate?
Health Market Inquiry
18th May 2016
Page 165
___________________________________________________________________
MARCUS MOLOKOMME Yes, thank you Chairperson , yes this is
what we do as a department, we are constantly reviewing how we
run the system. One of the main things that we i ntroduced via our
MEC, it has been four years now, it is the use of the balanced
scorecard to measure our performance and the balanced scorecard
as you know coming from the kind of economic or financial set up,
10
really asks those questions of managers in th e public sector to
behave as if there is a profit to be made. What we are doing is to
assess
ourselves
evidence
based
constantly
management.
on
evidence
The
based
biggest
practice
problem
that
and
we
identified is data management and the use of it in dec ision making
and we found that as a province we have always been struggling in
20
terms
of not just having it, just from capturing, its quality, the
infrastructure to make sure, its archiving and then its availability
in terms of decision making.
With havi ng a pilot sight at Thabo
Health Market Inquiry
Page 166
18th May 2016
___________________________________________________________________
Mofutsanyana we have started quite a number of projects and quite
a number of tests. So to us Thabo Mofutsanyana is both a symbol
and a laboratory so we are able to put it up as an NHI pilot site as a
symbol, but also as our bigg est and poorest and vast, but also look
at it as a laboratory in terms of testing all the systems that are
needed.
So we are not waiting for it to finish its pilot ship, we
10
want to implement as on ongoing concern in all other provinces.
Let me give two quick examples – we first started with a referral
pattern and we learned lessons from there. We secondly went with
connectivity in terms of IT connectivity, we implemented health
information management systems, we even know with what Dr Ruff
was delivering yesterday we looked at financing models in terms of
20
partnerships with private practitioners and we are now engaging
with the private practitioners to see how we can get them into the
system on a capitation set up, not a fee for service.
It was
Health Market Inquiry
Page 167
18th May 2016
___________________________________________________________________
interesting that in all of the models that was put in terms of the role
of the State, what I did not see and I am not here to punch any
holes in any presentation, that is not what I am here for, is that all
those other areas were touched, but the issue of pricing a nd the
financing was not highlighted as where the State must come in and
we are of the opinion with the experience that we have had in
10
Thabo Mofutsanyana that that is where the State needs to be at
because part of the NHI is to protect against catastrophe.
So we
agree with many of the things that we have seen, many of those are
things that we are battling with in terms of our role as the private
facility licensing unit, but we have a model of where we have been
and where we are going.
20
Finally we have prod uced service transformation plan which then
starts to look at the issues of need in terms of private and public
Health Market Inquiry
Page 168
18th May 2016
___________________________________________________________________
beds, ICU’s and so forth and how we can transform what we
already have.
So we are not only looking at building new things,
how we can make what we have work.
CHAIRPERSON A couple of questions ago I asked you about the
need to have the information stored.
One of your concerns now
10
that you are now articulating is your inability to collect data, store
it and have it accessible to make the kind of assessments that you
are required to make, but you have got the regulations which could
have made provision for that but they do not do that.
MARCUS MOLOKOMME
Having set regulations is one thing, I
20
think also the business model in the department had to be looked at
because in terms of...
Health Market Inquiry
18th May 2016
Page 169
___________________________________________________________________
CHAIRPERSON
You are complaining about the fact that you do
not have the data; collection of the data which will enable you to
make these kind of assessments.
What I am saying to you, if you
had made provision in yo ur regulation for the collection of data and
its storage that would have been helpful – that is what I am saying.
10
MARCUS MOLOKOMME Yes, I agree.
CHAIRPERSON
The
problem
of
attracting
specialist, it is a major problem, is that right?
MARCUS MOLOKOMME Yes, it is chairperson.
20
CHAIRPERSON How are you going to manage that?
and
retaining
Health Market Inquiry
Page 170
18th May 2016
___________________________________________________________________
MARCUS
MOLOKOMME
The
biggest
problem
we
face
is
obviously the geography and not being a metropolitan but in terms
of our training platform we have deliberately exp anded many of the
numbers in terms of training, but whilst we are training we need to
link and align that training to the available posts. So the intention
is to, even though people will be a bit junior, is to recruit from our
10
own team like what we produc e because the Free State like I said
competes with many medical schools in production of specialists,
even though there is just one University, the problem is being we
are even failing to retain those that we have produced. So it is two
balls that we need to juggle and balance – firstly we are losing the
ageing population or people are a bit irritated with the way we want
20
to manage RWOP’s, but this side we are producing good quality in
high numbers so we need to now transfer those into those posts, but
the issue with where the Free State is based that have always been
Health Market Inquiry
Page 171
18th May 2016
___________________________________________________________________
issues in terms of our geography because many of those specialists
will have to leave Bloemfontein and our biggest problem has
always been people want to stay in Bloemfontein and not go to you r
Bethelehems, your Harrismith, your [inaudible] and so forth.
CHAIRPERSON
One of the criteria that is set out in the
10
regulations which you apply when you consider a license is the
need to promote high quality services which are accessible,
affordable, cost effective and safe – how do you address the issue
of affordability?
MARCUS MOLOKOMME
The issue of affordability, remember
20
chairperson, once we set those regulations we also sometimes in
our minds have the PPP arrangement that we hold with Netcare
even though it does not influence the final outcome or the final
Health Market Inquiry
Page 172
18th May 2016
___________________________________________________________________
word we put in, the issue of affordability what we are saying is that
there will not be those catastrophes where what we are mentioning
where patients are now dumped into the public sector. We still do
not have a tool of measuring and penalising people for that which is
why we are saying we need to relook at our penalties framework.
Like we heard yesterday your failures should be recognised in the
10
market and dealt with and that is the frame work we are talking
about. So there is no particular way of measuring affordability, but
we cannot expect to allow hospitals to continue to dump patients in
the way they are doing based on funds because that is the
affordability we are talking about.
20
CHAIRPERSON You mentioned a joint venture you know in order
to encourage the establishment of health facilities in what is
Health Market Inquiry
Page 173
18th May 2016
___________________________________________________________________
considered to be less economically viable areas, have you had any
one of those joint ventures so far?
MARCUS MOLOKOMME
At the moment we have a proposal in
Lejweleputswa where an old dilapidated mine hospital with up to
four hundred and fifty beds – there is an offer for a private sector
10
supplier to renovate the whole building and apply for a license for
about one hundred and fifty of those beds and the rest of them we
should enter them as a joint venture because in that area we have
no facility.
So those are the proposals that we have now, but
before we get... We have learned from the wounds of the past, that
we are not going to jump into a lock, stock and barrel in such
20
arrangements without proper regulation and regulatory frameworks.
Health Market Inquiry
Page 174
18th May 2016
___________________________________________________________________
CHAIRPERSON
What is contemplated is that the provincial
government will enter into a joint venture with a private sector to
provide those facilities .
MARCUS MOLOKOMME Correct chairperson.
10
CHAIRPERSON
Do you consider that to be a better alternative
than the PPP?
MARCUS MOLOKOMME
Correct chairperson, we in the current
regulated space we believe we will be able to meet all those
principles that sho uld inform any arrangement, either a joint
20
venture or some sort of PPP.
CHAIRPERSON Is there any precedent for this in any province?
Health Market Inquiry
Page 175
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME Not necessarily. What we have looked at
our own experience, we have looked at Folateng in Gauteng and
then we are looking at all those models and see if we can find a
hybrid of those because there is some good and bad so we need to
learn from both those ones, but there is no particular model where
we can go and learn that this is how it is done because we also from
10
yesterday, all those regional innovations should be looked at.
So
that is why we are not going to jump into it without learning the
lessons.
CHAIRPERSON
Is there anything else that you want to tell us
which you had come to tell us about, bu t which you have not had
20
the opportunity to tell us about?
Health Market Inquiry
Page 176
18th May 2016
___________________________________________________________________
MARCUS MOLOKOMME
No, except to just say thank you very
much for the opportunity to allow the Free State Provincial Health
Department to come and present as honestly and openly as they can.
CHAIRPERSON No, we need to thank you too for your generosity
in coming to come and share with us the experiences of the Free
10
State Provincial Government, but of course one should mention that
this is not the end of the engagement. We anticipate that there ma y
be a need going in to the future to probe some of these issues more
closely than we have done given the limited time that we have had
with each other. Thank you to your members of your team, thank
you so much.
20
Is the Limpopo Provincial Government he re? Yes, okay would you
come forward please if you do not mind.
Health Market Inquiry
Page 177
18th May 2016
___________________________________________________________________
We have just, well good day gentleman.
We are running behind
schedule. Would it be convenient at this stage for us just to take a
fifteen minute tea break whilst you are settling in to yo ur seats and
then we will come back and then listen to your presentation.
Would that be okay?
10
DR KGAPHOLE
Good day chairperson and if you could just lay
out the you know approach of the presentation so that when you
come back we run with it.
We do not mind for fifteen minutes
break.
CHAIRPERSON I think what you have given us quite an extensive
20
oral presentation and we have considered it and we would simply
request you to highlight the key points of your presentation, but of
course I have no intenti on of restricting what you want to say to us,
Health Market Inquiry
Page 178
18th May 2016
___________________________________________________________________
but whatever you say just bear in mind that we have had a look at it
and you need just to highlight that, but again feel free to tell us
whatever you want to tell us. Is that clear to you?
DR KGAPHOLE
Yes chairperson, it is clear.
Like I was
suggesting that as you break for fifteen minutes we will quickly
10
look at a few highlights here and there and then that is it.
CHAIRPERSON
A break and then we will then resume the
hearing. Thank you.
... [END OF SES SION ONE]... .
20
Health Market Inquiry
Page 179
18th May 2016
___________________________________________________________________
SESSION 2 PRESENTATION BY DEPARTMENT OF HEALTH
LIMPOPO.
JUDGE NGCOBO If you could just indicate to us who is making the
main presentation.
DR KGAPHOLE
10
Good afternoon Chairperson and the team, I am
Dr Peter Kgaphole currently acting as Head of Department in
Limpopo. I am here; let me start with my immediate left hand side.
I am with Dr Thabo Pinkoane who is the acting Chief Director of
District Health Services; this is the man who is in charge of the
district hospitals in Limpopo a nd even what we call regional and
specialised hospitals
In the region of 38 hospitals and then immediately on my right
20
hand side there is DDG Deputy Director General for Health Care in
general in Limpopo. That means it includes at last I hear the
programs like HVI Aids and TB and others. And then further more
on the right hand side I have got the Advocate PG Ramothpo, he is
Health Market Inquiry
Page 180
18th May 2016
___________________________________________________________________
in charge of the development of the memoranda of understanding in
the department and mostly again any of the disputes which may
come through any entity or private entity in the department. Then
the last one is Mr James Ramolai he is the Deputy Director for
infrastructure technically he is leading the team when we are here
doing the inspections in terms of whether you know the technical
part of building, it is well done. Chairperson this is actually what I
10
can introduce the group in but it is a one force team in terms of we
have taken people from the two teams in Limpopo which are
currently doing the processing of applying for permissio n to plan,
erect and finally operate. In Limpopo licensing is the last part of
the whole process, Chairperson. I thank you.
JUDGE NGCOBO Thank you. Who is going to lead the presentation?
20
DR KGAPHOLE
Sorry Chairperson, myself who introduced the
team I am presenting. I was currently requested to act as the head
of department and I have been chairing the actual adjudication part
in the committee. So I am going to lead and the colleagues are now
Health Market Inquiry
18th May 2016
Page 181
___________________________________________________________________
and then going to introduce them as they are playing a b ig part of
the process. So now and then, with your permission, I would like
to invite one of them to deliberate more. Thanks.
JUDGE NGCOBO Thank you very much indeed.
I wonder if you
could just spell your surname, just for the record.
10
DR
KGAPHOLE
Um,
my
surname
is
spelt
in
this
way
KGAPHOLE. Ngami would call it Nkgaphole.
JUDGE NGCOBO You are in KZN so should we call you Nkgaphole?
Laugh.
DR KGAPHOLE
Indeed Chairperson, I am in Rome.
20
JUDGE NGCOBO Thank you. Housekeeping matter. We’ve got this
presentation which we have found on my desk and then there is a
presentation that was sent to us some time ago.
Are you going to
make use of the one that has just been presented to us?
Health Market Inquiry
Page 182
18th May 2016
___________________________________________________________________
DR KGAPHOLE
Chairperson, the one that you have just been
handed in is a power point instruction of the main one that was sent
a while ago.
So, indeed, there won’t be any differences but it is
just for the presentations sake that we would want to request
indulgence on using it.
Can I carry on or is there something
Chairperson?
10
JUDGE NGCOBO By all means, please do carry on.
DR KGAPHOLE
Um, good afternoon and like I said I have
already introduced the Limpopo team who I want to heartily and
really welcome. You know the invitation told us to also talk about
our experiences in the Limpopo relating to how we are handling the
applications and Chairperson there are a couple of pages on the
20
document and there are more you know, the story begins with
ourselves and we are telling the team in terms of where we are
coming from. How many people are in there and then in terms of
you know, stats from South Africa, you know how many men and
how many woman are working there, I would humbly request with
Health Market Inquiry
Page 183
18th May 2016
___________________________________________________________________
your permission that we take note of that information and then
maybe for the p resentation, if you allow Chairperson, but by the
way we can always still go back and bring your interrogation to dig
more. If we could immediately start looking at page 20, um, which
is talking about, you know, currently the beds which are available
and in both public and private.
We will be talking about the
processes presenting how we are doing the deal in Limpopo but if
10
you could immediately look at that Chairperson, we have got 5568
public beds in our province and then these are all solely related to
what we call district hospitals.
There are other people who call them level one hospitals.
And
then, then comes what we call regional hospitals which is a level 2
hospitals, these are hospitals that are also having some specialists,
20
general specialist s.
province is 2149.
Now the number of beds available in our
And then the specialised here mainly we are
talking about the three hospitals what is called Mental Health Care
Hospitals, these are three and the total number of beds is 1576.
Then tertiary beds which comprise of two hospitals, they are in one
Health Market Inquiry
18th May 2016
Page 184
___________________________________________________________________
district in our province and then the total number of beds is 1210
and then, private beds, you realise Chairperson that in every
district we have tried to give you information and the total number
of beds is 925, maybe I can quickly mention that in November the
northern part of our province is 44 and the Capricorn districts are
our hub in Limpopo and that is where Polekwane city is and that is
why the high number of 493 and then Mopani that is where Zanin e
10
other towns are 197 and then Sikakone there is 14 and then in
Waterberg
it
is
191.
And
then
Chairperson,
if
you
could
immediately turn over to the next page we have tried to just talk
about how many, the number of hospitals and PAC we have just for
noting.
On page 22 just a correction there Chairperson, um, it is
Limpopo Academic Hospital not Fakamato Hospital, Fakamato is in
Gauteng and there is a Fakamato hospital in Limpopo which we are
20
currently planning to build. We have not actually started with it, it
is a national competancy and then indeed the plan is there.
And
then I am going to briefly and not be lead and talk about the
processes Chairperson how we are handling the process in our
province that we have got two teams which the first team we c all it
Health Market Inquiry
Page 185
18th May 2016
___________________________________________________________________
the technical evaluation committee and the second team is the
Polekwane adjudication team and when the applicant writes a letter
to the HOD then the research form which we give it to the applicant
to fill in and when that form is filled then it goes to the technical
committee.
Which will sit there in that form crudely, it wants to
know the numbers, the resources of how many human bodies in
general, the staffing, and where do you want to have that facility,
10
you know, operating and then why, in that area would you want to
have a private facility and then once that is done with that form.
By the way we do actually technically say that if you scored less
than 37 out of 75, your application will not make it through to the
next level. The next level is where we will be saying you can start
actually consulting your Architects to and start actually making
drawings and everything and which you shall. After doing that you
20
send us that plan and men and woman like Mr Ramolai in that
technical committee look a t your plans and they see if whether
technically it makes any sense and they engage with the applicant.
If there are any issues which we need to raise as a department we
will engage with the applicant to say please, this line this way and
Health Market Inquiry
18th May 2016
Page 186
___________________________________________________________________
this line this w ay until finally you know the application makes
sense.
After that the next level, then the Chairperson of the
technical committee brings the decisions which were made during
the
technical
into
adjudication
adjudication committ ee.
to
formally
present
to
their
Then the Chairperson would be asked
questions by their adjudication committee in terms of clarity
through their processes. Once that is done then adversity is found.
10
In the absence of the Chairperson in the committee then a decision
will be taken by the adjudication committee whether they agree
with the technical committee or not.
Then after that the process
would be taken to the office of the HOD.
Now, um, Chairperson,
you realise that I was not going through point by point but luckily
it is just part of the process, you know, not necessarily going
through it page by page, just describing the whole process.
20
Now,
let’s take the decision has been taken, now let’s look at page 25
Chairperson. If the application has been found to be of approval by
the HOD then a letter will be written to the applicant to say you are
permitted.
It is permission and I want to emphasis this part
because even the people who finally get their letter they are still
Health Market Inquiry
18th May 2016
Page 187
___________________________________________________________________
celebrating it taking it as a licence. The letter will say that you are
permitted to plan, erect and finally operate the facility as you had
planned by yourself. And then you would be sent to the individual
and hold it there and then the next bullet, I would want to apologise
to the team, as you Chairperson know that we didn’t include what if
the application did not succeed for whatever reason which, yes, it is
another process as we will still write a letter to say that your
10
application was not successful.
We normally don’t give reasons.
The reasons are been gi ven by the Authority.
In this case it is
actually the Minister who has delegated and has the authority of the
MEC. Then when you appeal then the reasons are being afforded to
you that here are the reasons why your application did not succeed.
The commonest being where you are applying they are talking
about no available beds in the area you have applied to.
20
That is
also the negative part and further to say you are allowed to appeal.
And yes the appeal can be heard and finally politically a decision
can be taken. We have an example in Polekwane where a politician
was taken because of the outcry by the applicants.
I can indulge
you on that party if you would like to know more about what really
Health Market Inquiry
Page 188
18th May 2016
___________________________________________________________________
finally happened. Then we take the process where not the ap plicant
will now start negotiating with the Municipality in terms of where
they would want to have their site and everything.
Some would
come in slow as the sides referred to by the Municipalities are just
there. Is there any way you could assist the dep artment. The only
assistance that we do Chairperson is we would write a letter to the
Municipality to say these people are working within a time frame
10
and if you could assist, you know, in terms of their requests and
not to push the Municipality to allow them but to just make sure
that a decision is finally taken by the Municipality in terms of
demarcation,
in
terms
of
environmental
everything so that they could do that part.
impact
studies
and
But that Chairperson
still remains a big challenge with some of the big applications
which I will talk to as the pages go on. And then we let the person
20
actually start building and during the building they build under the
regulations of the Municipality where they are building. We come
now and then, they will actu ally invite us and say we are now at
this level, whatever, and then time allowing you you would go and
look at the situation whether they continue complying with the
Health Market Inquiry
Page 189
18th May 2016
___________________________________________________________________
regulation of 158. Um, maybe I could just request Chairperson to
quickly look at page 31, I am sorry I am not going page by page,
most of the things I have already said are captured on all those
pages and then if we could look at page 31, that now these are you
know privately run facilities in our province. The number of beds
with which we h ave allowed them to operate. That Tabazimbe and
Pollale is in Waterberg and Bella Bella and Amanda belt, all of
10
these are in Wartburg.
Then in Capricorn District also likewise,
like I have already alluded to that fact that Chairperson, don’t be
surprised to see so many beds.
It is merely because most of the
beds are within Polokwane itself.
Let’s say it is like our
Johannesburg that is where a lot of private beds are concentrated
in.
And then with a total number of 493 and then in Mobane
District we have only got two facilities which are run, you know,
20
privately, the first one clinic Parabola is not a whole hundred
percent as a private entity it is a triple p which I can talk to a bit
about. But many clinics are one hundred percent privately run and
then in Vhembe we have only got two and they are around
Makhabo, Makhabo is a small town in Vhembe, formerly called
Health Market Inquiry
18th May 2016
Page 190
___________________________________________________________________
Louis Trichardt and these two facilities are there.
And then in
Skakoone there is just one private small entity and in and around
Grobleister and that is it as far as Skakoone is concerned. I have
already spoken about this currently run private entities. But we do
have applications that we have received Chairperson, some of them
in terms of status, you know, they have lapsed, but very few are
still carrying on in terms of finally developing.
10
In Waterberg,
Mollegwane the licence and not necessarily the permission has
lapsed.
Mokhabani private has lapsed. Then Mokomed is still in
Mohabani, this was formerly Pieter’s Rust Town, these have lapse d.
Moleweni this is private. I am sorry the capturer is not showing
that this has also lapsed. And then Capricorn District, um, Polowe
private is in Polokwani which was previously Pietersburg there
were 3,4,5 and 6 applications, all of them have lapsed.
20
And 50
beds which were applied for their application has lapsed also.
Pinlo Rehabilitation Centre the application also is on, we have just
received
the
plans
and
everything,
this
one
is
still
alive
Chairperson. Then in Mopani the applications have lapsed and then
in Sikakoone we did receive applications, you recall in terms of a
Health Market Inquiry
Page 191
18th May 2016
___________________________________________________________________
previous available infrastructure which was run it was only running
at around 14 beds around Grobleister. Applications are in and then
we gave them permission to operate and plan and then their
application has lapsed which is Betterford Private and Platinum
Health, both have lapsed.
In Vhembe it is around Thando, the
applications were received honourable Chairperson, also lapsed,
both applications.
10
And that is it Chairperson wit h regards to the
processing purposes where we are, we must allude to the fact that
we have received fresh applications which we are going to have a
look at and we will make a decision on that. We continue assessing
and then continuing to see the applicant s as they qualify to plan,
erect and finally operate. I am going to skip in terms of the health
personnel as in the state centres we are known that we don’t have a
specialist, they are very few and scanty and that is why we receive
20
applications especially in Polokwane when we ask the applicants
where would you get the specialist from they keep on telling us that
they are going to recruit from Gauteng and to bring those
specialists but we continue in the process to bleed with a few who
Health Market Inquiry
18th May 2016
Page 192
___________________________________________________________________
will be there. We ha ve lost quite key personnel when the facilities
opened recently. In and around Polokwane.
JUDGE NGCOBO
considerations
Is the ability to attract specialists one of the
in
applications
for
permission
to
operate
the
facility?
10
DR KGAPHOLE
Chairperson, yes they do but they are not on a
full time basis in terms of them travelling from Pretoria which is
over 270 kilometres into Polokwane, not on full time basis.
But
mostly Chairperson there are some specialists who are currently
practicing
as
solo
practition ers.
Specialists
in
Polokwane
themselves so some of them are really recruited directly into those
facilities.
20
But I guess I am saying, we also in the department we
also lose key specialists.
I will give you an example we lost a
Geologist that was keen t hen to a recently opened private facility
which is now and then beyond our control merely because of
money.
Chairperson I would want to come to maybe towards the
end, that is page 47 that we are realising that our applicants don’t
Health Market Inquiry
18th May 2016
Page 193
___________________________________________________________________
understand the reason wh y they are making applications to run a
private entity wherever in our province and we have taken it upon
ourselves that they have now understanding.
It is not just to say
that we are having private hospital in this, it is a business entity
but also, us the Department of Health in Limpopo, we are looking
for,
or
looking
at finally benefitting not necessarily having
everything in our facilities.
10
Private entities may have, you know,
MRI scans and we do not have that in Limpopo and our patients
may benefit from that and when an application which was permitted
fails, it really worries us quite a lot and some people go to an
extent, I will give you an example Chairperson, they will even go
around with that paper which is not a licence, soliciting money
from whoever. They may come to you and say that we have got a
licence how about a hundred thousand rand and you can become a
20
partner of the deal.
And it continues till it lapses unfortunately.
You were approached by IDC as a provincial government to say we
did not have anything in writing Chairperson but this is what they
told us that they were mandated by Parliament to go out to start
seeing
how
they
can
support
the
rural
areas
in
terms
of
Health Market Inquiry
18th May 2016
Page 194
___________________________________________________________________
development. They came into our department to say that they hear
that we are receiving applications now and then and what happens
to those people. We told them that some of them are being assisted
by the big three but there is no Life, Netcare and Mediclini and
even in some incidences there can even be some kind of a move
around because this person could walk into a clinic and listen to the
conditions and next thing walk into Netcare and listen to the
10
conditions
and
then
decide
financially and otherwise.
who
is
the
technical
developer
So that is actually our experience.
So
we had thought that guy in the IDC was going to assist applicants
and we feather again as a department to advise all those applicants
who might have been successful in being permitted to plan and
erect to communicate with the IDC in terms of the financial needs
and everything.
20
Up to now, Chairperson everything had just
lapsed, lapsed, lapsed, lapsed and some of these people are people
that I know that have actually advised them, except for the big
three or banks, we advise them to go and approach the IDC f or now
we have not actually found any application having been funded by
IDC. There could have been other processes that we are not party
Health Market Inquiry
Page 195
18th May 2016
___________________________________________________________________
to. I applied for financial assistance with the IDC which made me
fail but we had hoped that as you have seen most of our rural areas
in Limpopo don’t have these private facilities.
They endeavour,
the try has been there, applications which we have already shown
but unfortunately we finally still, for some reasons there is no
success.
The only success has been in and a round Lepalle where
Mediclinic has been operating for some couple of years.
10
So
application was also made to us to increase the number of beds.
Now those beds in Lepalle is booming economically.
requested for more beds and we allowed them.
Mediclinic
So with your
permission I may have to hold it here as engagement I think should
be very important. With our assistant team here we shall listen and
do our best to assist the system so indeed we can assist with the
country. Thank you.
20
JUDGE NGCOBO Thank you. Have you had the occasion to decline
permission of a certain facility because you were not satisfied that
that facility would not be able to attract a specialist.
Health Market Inquiry
18th May 2016
Page 196
___________________________________________________________________
DR KGAPHOLE
Chairperson, we usually always, you know
because the areas where the appl ications are coming out of are
actually being looked at are small towns.
Being small towns we
always think that there can be one or two specialists who may go
there like I said most of the specialists are not going to reside in
the area.
10
So they would co me on specialised occasions and those
ones who are actually practicing as a group. So they would send
this gynaecologist to Polokwane and he would go and spend the day
and be interchanging so we never lost hope and that is the reason
why even when we are a sking how are you going to really going to
get specialists. And this is the motivation that we are going to try
and attract the specialist into the area.
20
JUDGE NGCOBO But you have never declined an application simply
because
you
were
not
satisfied
specialists?
DR KGAPHOLE No Chairperson.
that
they
would
not
attract
Health Market Inquiry
18th May 2016
Page 197
___________________________________________________________________
JUDGE NGCOBO The main problem appears to be the funding.
Is
that right.
DR KGAPHOLE
I would say yes, Chairperson.
I would say
looking historically there are not competition between the business
itself if like in the Pallale Medical Clinic it is already there and
10
any application coming in and in this case it may obviously not be
Mediclinic as they already exist in there.
Any other competitor
may look at it and now does it make any busin ess sense to go and
put another hundred beds in the area unless there is a need. There
is always this fear of not making, you know, the business out of the
area. So, except for let’s say within Polekwane which is our city or
a bigger town or the capital of Limpopo where now generally it is
20
seen that most of the people can afford private services in the area.
But generally fear of competition in the outlying areas also remains
a challenge.
Health Market Inquiry
Page 198
18th May 2016
___________________________________________________________________
JUDGE NGCOBO But outside of the competition what other problems
are faced by potential licences?
DR KGAPHOLE The ruralness Chairperson. In terms of economic
status in an area like if you look at the Skakoone area, not
necessarily talking about Beggersfort, which is also something that
I have been talking about in ter ms of that facility by the ruralness
which is also obviously also directly linked to the economic status
10
of the area, you know, it threatens the potential projects in our
province.
JUDGE NGCOBO The licences that have lapsed, what are the reasons
for that.
Why has these individuals not succeeded with the
operation of the facility?
20
DR KGAPHOLE
Well, where you know again Chairperson the
experience of the applicants when they were actually applying it
was also becoming most fashionable so maybe a couple o f them
wanted to own a private hospital in such an area but the real nitty
gritties of making sure that the project finally you know comes up
Health Market Inquiry
Page 199
18th May 2016
___________________________________________________________________
remains a challenge and you know that is the way I think the
problem would lie.
The people that are with us are m ore dealing
with paper but outside us, now going to have to now operationalise
this permission that becomes a reality that many of the people some
of which I have given an example of Chairperson, it just becomes,
you know, an excitement that we are going t o build a private
hospital in this area but in terms of project plan it fails because
10
they don’t have naturally started to think now the next step is an
everything. I will give you another example, a women’s’ group in
Polokwane which we had given permissi on to really plan and erect.
When in fact they were really just moving around at the meetings
talking about money and how much to contribute and then before
you are a member and then time continues and then unfortunately
the time allowed lapses and the pe rson would run away with the
20
money.
Fortunately some of the people would come to the
department and they said we wrote them this letter which would be
true and we want to know where is Ms so and so because she has
run away with our money. So it is really important Chairperson to
have management planning and it is still a big issue.
And many
Health Market Inquiry
Page 200
18th May 2016
___________________________________________________________________
times this is the reason that there is still a monopolisation of the
big three.
That I go there helpless and they say O.K. I give you
some money and then you give me two percent, this is just another
example, of the entity and we will develop.
what has been happening.
And that is currently
And that is under our first bullet of
challenges and we understand that the whole process entails how
much it will cost you to b uild a 50 beds hospital. So these are just
10
the excitements and we have decided as a team to start talking to
some of these people as some of these applications that have
lapsed, technically they are qualified and there are even fresh
applications in diffe rent names of possibly people that have
reapplied. But we have to make a way to teach our people what it
means as it adds value when a private hospital comes up. We don’t
see it as a competitor from the Governments’ side.
20
That is the
reason why when we are planning for 2010 we counted some of
these private beds which were being planned to be built but
unfortunately two projects could not make it.
Health Market Inquiry
Page 201
18th May 2016
___________________________________________________________________
JUDGE NGCOBO And when you consider these applications do you
take into consideration of the ability of the applicant to finance the
project or the expertise of the applicant to operate a facility.
DR KGAPHOLE Our tool person we had been using as a province
was not yet looking at the financial ability part.
I must say that
like yourself I must get to that fact with all these experiences and
one big challenge is project plan with actually by the applicant
10
which we shall get and make sure indeed that these people but
remember Chairperson in many of these areas were mostly rural
areas. Those people who can actual ly have a good plan to succeed
and everything, maybe amongst ourselves even here who are not
even in those rural areas, just given two leading examples you
know.
A group of woman who are not necessarily by the way
professionals, we are going to have to, I DC was actually prepared
20
to start doing that but unfortunately that part of the communication
went into a little lull last year to make sure that they were
capacitated.
Health Market Inquiry
18th May 2016
Page 202
___________________________________________________________________
JUDGE NGCOBO An applicant for a licence amongst other things
must have learnt on whic h to build a hospital.
There must be
finance to finance the project and then the third thing is the
permission to operate. Now, you can’t get the finance until he has
the land and he can’t get the finance too until he has the licence. Is
that how it wor ks? Is that the reason why, the reason I emphasise
that you must have land you must have, the expertise must have the
10
funding?
DR KGAPHOLE It is agreed Chairperson and we have even made
decisions as a department and not necessarily as a team that when
you are applying in our assessment to the Municipality shall make
it in writing that yes there is an identified land and other processes
of finally demarcation and everything we know it may take a little
20
bit longer but as long as, one the Municipality is ac tually showing
keenness to really assist in such a project.
Number two what the
IDC has actually approached us about where we are going to have
to now form a tracker. The applicant technical developer who will
also be finally someone who is financing you and even managing
Health Market Inquiry
Page 203
18th May 2016
___________________________________________________________________
that hospital because it is not just building and seeing patients
walking in and out, you need to manage that entity.
The
management part, you know, to see that you are part of and
developed into that level.
We have agreed that we are actually
going to have to close that kind of gaps which, you know, are
showing in most of those applications.
Few applications we had
earlier on in terms of no technical support and financial assistance,
10
most of them Chairperson would immediately show tha t I’m
partnered with the Mediclinic or that I am partnered with Medicare.
In such a case with history we don’t actually have, you know, a
query.
But we have an application now where they need it
immediately cleared that they are partnered with this group or
whatever in that we will actually dig deeper and see who has
actually finance here.
20
JUDGE NGCOBO Does this not worry you when you have granted
many permissions to operate these facilities yet these licences lapse
because of inability of the individua ls to secure funding?
Health Market Inquiry
18th May 2016
Page 204
___________________________________________________________________
DR KGAPHOLE
It does your honourable Chairperson.
Like
yourself already alluded that we were already engaged with IDC.
We have appropriately even referred the applicants irrespective of
the outcome before by the way Chairperson, in the way of the
outcome of the technical evaluation.
We referred the freshest.
Most of these lapsed, all these applications, we referred them to the
IDC which we were hopeful that they would break the monotony of
10
the big three in those rural areas. What has happened between the
applicants and, now let’s just say this IDC, we are not privy to
now. But we are not going to leave it because IDC approached us
and we are going to want to know what has happened even if they
are not even saying sorry they so fa iled because of this and of
everything so if they failed we can see, you know, how these
projects can finally succeed.
20
As you said Chairperson, that there is a department where we
always look for some of those projects.
In those outlying rural
areas wh ere a specialist would go into Skakoone.
In those few
hours we are also even agreeing that they can assist us in
Health Market Inquiry
18th May 2016
Page 205
___________________________________________________________________
government in terms of patient care as they are specialists and we
are not having a specialist in that regional hospital at that moment.
So we were hopeful that these projects really would make it but
unfortunately they did not.
example.
To an extent that I can give another
Around Tondo we had received about three applications
only one application, application where we were only looking for
about one hundred beds, which were available.
10
They were all
gunning for that we could only afford one. We approached them to
form a group of themselves to finally make sure that this project
succeeds. Unfortunately still it never went further.
JUDGE NGCOBO I understand, Dr Bhengu.
DR BHENGU
20
Thanks Judge.
Thank you for the presentation.
I
just want to ask here on page 17, it was not in the presentation.
But it is your written submission.
There is a table of health
personnel, I think it is L. Are we there?
Health Market Inquiry
Page 206
18th May 2016
___________________________________________________________________
DR KGAPHOLE
Referring to the written submission and not the
presentation. I think we do have a, if you would allow me, I think
that we do have a slide on human resources.
I am going to just
quickly going to page through and I hope that it is the same and
then. Yes, page 42 on the presentation if you could, I am not sure
if it is the same slide Chairperson.
DR BHENGU
10
this.
No, my question is really just a quick one around
I mean one of the things that we are trying to do here is to
confirm the statistics that we are using for the final report and I
couldn’t help but notice in your footnote here going with the table
here, you seem to rely on the South African Health Review for
statistics about your employees. How is that supposed to work? It
is a publication, that means it says per sal, which is obviously is
the salary system here.
20
But are you using the latest information
from the South African Health Review of 2013 or 2014. I mean the
question is if the department cannot get its own statis tics and relies
on a publication to get statistics about its own employees. Should
we be concerned about the reliability of the statistics that you are
getting?
Health Market Inquiry
Page 207
18th May 2016
___________________________________________________________________
DR KGAPHOLE
May I request Dr Pinkoane to deal with it and I
will also talk to it Chairperson .
DR PINKOANE
Thank you Chairperson.
from our own persel.
In actually fact this is
Not someone sitting elsewhere so also like
persel will assure us that so many medical specialists and medical
staff. So we drew the medical statistics from persel our ow n persel
10
and not something that was brought in from outside the province.
DR BHENGU
I would not have a problem whether it is the
national persel or yours.
I suppose the question is about the
publication of the South African Health Review and relying on it. I
would imagine that to start with that they would have gotten the
stats from you. But I was just asking and I suppose the question is,
20
do you believe that this system is reliable.
DR PINKOANE Thank you Chairperson. Yes, we believe that this
system is reliable because persel is actually updated on a monthly
basis and with that information it is actually the bodies that we are
Health Market Inquiry
Page 208
18th May 2016
___________________________________________________________________
paying every month so we know that they are actually in the
province.
DR BHENGU
Thank you.
Going on to the issue of licen ces.
I
don’t know, when you say that you do the licences last doc. What
do you mean, is there ever a situation where whoever the investor
is can start the construction before the licence?
10
It doesn’t make
sense but I guess I did not get you right?
DR KGAPHOLE
Chairperson, when we are saying licence it is
when now, maybe let me say in Limpopo we also have a team
outside of this team that I have alluded to introduce you.
This
other team is what we call the licensing team and that is the team
that says now you are done with brick and mortar with all the
20
machines and everything painted and you have recruited all the
necessary warm bodies in the facility then they come and visit you
and they do inspections. And after having being satisfied then you
get this licence that you display in this facility which every twelve
months is being renewed.
If something of serious material is
Health Market Inquiry
18th May 2016
Page 209
___________________________________________________________________
found, we don’t allow you to get that licence. We actually request
you to correct that mistake which we are seeing then we finally
licence you.
I can give you an example about a Netcare which is
one of the latest licensed in the province. When we went there we
found that things were not the way we were expecting when we are
doing inspections on you. Then they were not licensed to o perate.
They had to actually quickly deal with all of those concerns and
10
once they are done then we finally give you a document which is a
licence. The first one is permission to plan to operate and to erect.
Once you have finally managed to erect, and the system is ready,
like a car when you start it then we give you that document we call
a
licence.
Which
unfortunately
unfortunately am out there.
I
tried
to
emphasise
that
The first document that the HOD
would sign and then take it as a licence to have a private entity. As
20
you can see now some of them have lapsed. They don’t even have
a foundation of whatever they wanted to build, nothing, so that is
why it is not a licence it is a permission which is taking you to
finally have a licence.
Health Market Inquiry
Page 210
18th May 2016
___________________________________________________________________
JUDGE NGCOBO Has it happened that a structure completely built
and then you find that the Department cannot build which means
that it stands empty, unused, has that happened?
DR KGAPHOLE So far that has not happened but let me introduce
you Mr Ramolai here for him to talk to us about his findings. But
we do not have any project that is still there because of serious
conflicts in terms of infrastructure.
10
MR JAMES RAMOLAI
Thanks.
Currently we don’t have such a
finding.
JUDGE NGCOBO But it is possible?
MR JAMES RAMOLAI If it is possible, the issue is when we do an
20
inspection if there are serious findings then we report these
findings to the appropriator that is engaging in that particular
project so that they could be able to rectify to be able to get that
licence.
We don’t just leave issues where they are but it is a
collaborative effort.
Health Market Inquiry
18th May 2016
Page 211
___________________________________________________________________
DR KGAPHOLE
licence
Maybe as an addition there are two types of
inspections
that
we
conduct.
There
are
existing
establishments that are already operating where we do the an nual
inspections and we renew them. Then we also have the newly built
facilities. But so far we have not had a new facility that has been
built and then we find that they are not compliant with all the
10
requirements.
But what we have had so far, if you l ook at the
presentation, when it comes to Skakoone, the 14 beds, you will see
that we put it there under asterisk.
The issue there is that the
facility has been existing. So with the previous licence inspection
we realised that they are non compliant wit h a lot of issues and
they were given two months to address the issues and when we re inspected them in two months, we saw that the facilities are still
20
the same and the conditions had not improved and as a result we
were left with no option but to withdra w the licence.
In terms of
the R158 it is actually referred to as the Certificate of Registration.
So, we have withdrawn it but we have also made provision for the
facility for them to find themselves having at any point finalised all
Health Market Inquiry
Page 212
18th May 2016
___________________________________________________________________
the issues that we have raised then they can write to the Head of
Department to requesting for us to go and re -inspect and relinquish
that decision. There is also an appeal process that they have been
given.
So that is the only facility so far that we have withdrawn
their licence because of these gross non -compliant issues.
DR BHENGU Thank you. We’ve heard here some of the provinces
10
that the R158 licences are outdated; they don’t cater for the needs
appropriately.
And Western Cape runs on a different sort of
regulations now as this morning we had the Free State.
Um, is
Limpopo satisfied with R158 that it is adequate for the purposes for
which it is meant?
DR
20
KGAPHOLE
We
are
not
satisfied
Chairperson.
Not
necessarily regarding the age of the regulation but that things have
moved on in terms of infrastructure and planning’s and the like. I
must actually inform you that we have formally engaged national in
that way because this is a national issue that we need to urgently
start at reason be at the R158.
Health Market Inquiry
18th May 2016
Page 213
___________________________________________________________________
DR BHENGU You have turned some licences down. What I think
you have given us is I think, what I want to know is do you, have
you worked out, I mean in terms of each region how many beds
each region can actually absolve?
How do you know when
Capricorn is over traded for example?
10
DR KGAPHOLE
Chairperson it is true.
We have turned down
some applications as fresh as late last year or so.
For some
different reasons which I will quickly mention. One, you find that
the recent permission already given to so and so and this person is
moving around as if they are already allowed to and they are
already negotiating with financiers.
As long as people don’t see
the real structure in that area, then there is nothing.
20
Then these
applications will come in and even those regional departments will
say is there a mechanism which we could employ to let people
thinking of applying for a private entity in an area, to let them
know that for now this is saturated. Please consider the following
areas if you are interested at this type of an activity. So we have
Health Market Inquiry
Page 214
18th May 2016
___________________________________________________________________
actually spoken to our MEC about it. It is a matter of logistics how
we really sell out that information.
Where I am, Polokwane was
saturated at such stage where all these lapses. There is technical,
when we go back and see if a ny fresh applications, we see that
three applications had been put off. This one is requesting so many
beds, technically within or just above or whatever and then we
accordingly do that.
10
Lastly, Chairperson to give you another
leading example, where the current Mediclinic in Polokwane had
applied for extra beds on their current structure, we could not give
it to them because there were no more available beds.
Two three
applications had been done and we were expecting them to come
up.
Unfortunately they did not come up and technical Mediclinic
know that now most of those applications have lapsed so they came
and said now we are still requesting for these 20 beds and we had
20
to give because by that time then that number of beds were
available and Mediclinic were available to add 20 more beds. But
generally, yes, like yourself had already alluded to the fact that
where you see all these lapsed applications are where we are saying
looking at both private and public number of beds which are
Health Market Inquiry
Page 215
18th May 2016
___________________________________________________________________
available therefore this entity will succeed in operating.
We do
that, but unfortunately for the reasons that I have told you the
project fails.
DR BHENGU Last one, really regarding the also from your side,
the issue of liabilities is important but I do see, well, the proj ects
have not been taken to fruition, but it seems like it was permission
granted from your side. But, I mean, is a 30 bed a viable hospital?
10
Do you have that in your mind as to before you own a licence, at
least minimum level of viability? Because I se e as a 30 bed I see,
the little I know, it may just battle to be viable.
DR KGAPHOLE Chairperson the beds there are not necessary
referred to a fully fledged regional hospital, it might be 30 beds for
a maternity unit, which we would say would be viable a nd all that,
20
or a rehabilitation centre or specialisation.
Like you will not
generally find therapies for children, 7 for woman and everything is
for specialisation.
Health Market Inquiry
18th May 2016
Page 216
___________________________________________________________________
JUDGE NGCOBO We were supposed to take a lunch break at 1:15
and the time is now 1:30, m y colleague has assured me that we
won’t go beyond 2 o’clock so would it be convenient for you if we
continue until 2 o’clock.
DR KGAPHOLE Yes Chairperson we are ready to continue, mainly
because we are going to fly out of Durban to Limpopo sometime
late in the afternoon.
10
JUDGE NGCOBO Your flight is at 4 o’clock?
We’ve got every
reason than to continue.
DR KGAPHOLE With due apologies Chairperson.
PROFESSOR SHARON FONN Thank you very much Chairperson,
20
um the public private partnership in Polokwane, um, we had a
presentation from the private part of the partnership and the point
that was made was that there has never been a referral of a public
patient to this um, particular facility.
can you explain to us why?
Is that correct?
And if so
Health Market Inquiry
18th May 2016
Page 217
___________________________________________________________________
DR KGAPHOLE Chairperson, I am not sure because the one that is
in Polokwane is the one with renal dialysis and our patients are
benefiting. It is one of the most success triple p. My suspicion is
that you are talking about Parabola?
PROFESSOR
10
SHARON
FONN
Yes,
you
are
correct,
sorry
Parabola?
DR KGAPHOLE To speak briefly about Parabola, Chairperson, in
that we have gone into that partnership with you know private
entity clinics and unfortunately, you know, in their part they are
expecting us to send every patient in o ur next door hospital which
is about 10-13 kilometres away could manage. Our looking on the
20
partnership was on speciality and for some reasons we suspect that
this government they are running away from liability.
One, they
did not want to admit orthopaed ic patients, those ones with broken
legs and arms. Two, they did not want to admit patients who were
most delivering with some conditions.
So as a potential liability
Health Market Inquiry
Page 218
18th May 2016
___________________________________________________________________
and when we are looking at them, like I was saying earlier on, as a
private entity that comes into the area, our benefit would be to
actually tap into the specialists who will be actually servicing that
entity but they were expecting us to send any patient, even if they
were just having ordinary diarrhoea and just to give an example.
Then we may as well just close our facilities as a government in
that area.
10
That is actually where the biggest problem started, not
by the way, I know I have been signing off requests for payment,
we do now and then send patients of need to that hospital but we
can’t reach their target.
Mainly because they refused the areas
where they would be adding value to that area.
You can imagine
all the pregnant woman cannot be operated on by an ordinary
general practitioner in our hospitals who need an obstertrition, b ut
they say no. We did not see any need really. But we are currently
20
awaiting for them to look at these areas of service that is patients
with surgical or are pregnant and need an obstertrition.
agreement has been done the project will survive.
Once an
And we are
optimistic and I think that it will make them too, I am sorry to say
the words, wake up because we can’t now send every patient who is
Health Market Inquiry
Page 219
18th May 2016
___________________________________________________________________
supposed to be serviced in a township into the hospital. But we are
currently negotiating to see how we can finally do that. Thanks.
PROFESSOR SHARON FONN Thank you it is good to have your
side of the story as well.
I just want to check, two questions on
page 42, again on that graph on employment, um, question one, is
do you employ clinical associates and whe re are they on this table
and then the second question, is your community health workers,
10
your final column is annual cost per staff member and I think that
there must be an error here as otherwise these are the best paid
community health care workers in, possibly the world. Um, at half
a million a year, so can we correct, am I right that this is an error?
DR KGAPHOLE Yes, you are right, we will actually correct the
payment here.
20
Yes, we do employ clinical associates, although
very minimal. This current year we are also starting to train some
of them. We do have them in two to three hospitals and I will not
mention their names now.
district hospitals.
These are actually working in our
They add value wherever they are, that is the
information that we h ave got.
Health Market Inquiry
Page 220
18th May 2016
___________________________________________________________________
PROFESSOR SHARON FONN
So, just for clarity are they then
captured under all other personnel or are they missing?
DR KGAPHOLE Yes, they are included Chairperson.
PROFESSOR SHARON FONN
The last question was um, the first
thing that you list, w ell one of the things that you list is that you
10
bleed um, specialists and practitioners into the private facilities.
Um, you have also explained to us that the population is very rural
and that the density can be a challenge for viable services and the
question is whether the department needs to spend a lot of time
thinking about hospitals, or is it something else that you might
need that will meet your needs.
Um, for example, a very good
referral system to actually move people from more peripheral areas
20
to more central areas which do have capacity and if the province is
keen on or has the ability to or if there are any obstacles to stop
you from engaging in different kinds of interactions or contracting
with different kinds of providers that are not hospi tals that could in
fact meet the needs of the province and its health.
Health Market Inquiry
18th May 2016
Page 221
___________________________________________________________________
DR KGAPHOLE I will just comment a bit and request both doctors
Pinkoane and Ndambi to quickly talk about it.
You know
specialists you need in the province but from my side just too
quickly mention that yes, we are currently engaging groups of
individuals, specialists, mostly within the Polokwane city, um,
there is already a group of orthopaedic surgeons that have grouped
10
themselves
and
communications
we
are
engaging
with
them.
The
that
we
have
with
them,
because
had
last
of
indemnities and everything they were looking at negotiating that
part.
We
are
also
looking
at
signing
a
memorandum
of
understanding per every grouping because I can write you an
indemnity letter and the day you go away from Limpopo that letter
is gone. So we are going to have a memorandum of agreement per
20
group of specialists so that we agree with them when they will be
assisting us in our hospitals.
But in terms of recruitment I am
going to request Dr Ndambi to t alk about the recruitment part and
Dr Pinkoane if there is anything to add onto that.
Health Market Inquiry
Page 222
18th May 2016
___________________________________________________________________
DR NDAMBI
I thank you Chair.
Um, yes, well within our
province it has been difficult and we have put plans in place and
some of them have been working and one of the i ssues that we are
trying to do is to actually reduce the turnaround times in terms of
the recruitment in the sense that sometimes we headhunt.
And
when we headhunt it does not mean that we do not interview. We
actually look at the C.V.’s and we actually set up an interview as a
10
matter of urgency but over and above that with these people
because we have had bad experiences before where people have
come from far away states and I think that everybody knows what
they do and they actually employ the wrong peo ple. Now, the thing
is the office of the HOD had actually put up a team who looks at
the people who are about to retire and then they get assessed to see
if maybe they can be given further contracts to see if they can
20
actually continue to work. Now, as e verybody knows doctors have
families as well, so the other issue is the timing of our recruitment
is important as they need to move their children in terms of
schooling and so on.
So if you recruit in March it may not be of
good help unlike if you start r ecruiting in July or August where you
Health Market Inquiry
Page 223
18th May 2016
___________________________________________________________________
can start negotiating the movement of their children to appropriate
schooling.
We have now put into place plans to target medical
schools and the registers qualifying specialists knowing full well
that they may not im mediately get a specialist post.
And we
negotiate with the specific professors, in particular at UCT, where
for instance, we negotiate that maybe the specialists go with us,
even if it is a minimum of two years in rotation, um, as long as we
10
pay them. An d also to allow some of the registrars who will put on
our payment roll to pay to go to UCT, or Stellenbosch or anywhere
else so that when they come back we can actually utilise them. We
have been engaging with the National Health Department, um, for
this issue that relates to the following; when you look up at the
OSD dispensation where everything is now drawn to assume that
things are normal, where you find that the head of department is
20
supported by the head of clinical. You need a specialist and so on .
That is for the luxury of Tigersberg and Groote Schuur you will
find that the head of department is alone in the entire department so
the directive is that the head of department in terms of time can
only qualify and maybe for 8 hours. So we have been negotiating
Health Market Inquiry
18th May 2016
Page 224
___________________________________________________________________
that maybe we should relax that part a bit where it is informed by
the volume of work being done. So if the head of department has
to get up more often or figuratively speaking ahead of the any
department in Tigersberg, for instance, he should be compensated
for 16 hours instead of 8 hours. That would perhaps keep them to
stay with us. The MEC has actually instructed us to continuously
with everybody who is a specialist in a meeting which is going to
10
be involved in a way to also try to pay th ose that are there. So that
if there are problems they can approach them as a matter of
urgency. I think that we are doing relatively well because, I think
a few days ago Dr Pinkoane and I had been implementing some of
the directives as instructed by the department and already in two
weeks, at least by this Friday, we will be interviewing the first
three very highly ranked specialists.
20
One is an obstetrician and
gynaecologist and the other one is an anaesthetist and the other one
is an urologist as well. So, um it may bear some fruit. Thank you.
DR PINKOANE
So, medicine addition,
we have formed a
collaboration with UCT and the department of internal medicine
Health Market Inquiry
Page 225
18th May 2016
___________________________________________________________________
where Professor Myosi is actually assisting us in training some of
the specialists for us.
A lready we are having a specialist that is
training for us as an urologist and this doctor, after he has qualified
we are paying him a salary and everything so for six months he is
at UCT and working and everything and then for six months he
comes to the pr ovince to assist. So what we are intending to extend
is the collaboration so that we get more specialists and so that we
10
get more in the other departments as Dr Ndambi alluded. Now the
other thing that we have been doing is that we also have been
having programs that they were participating in like the UNV
where there are doctors participating (United Nations Volunteers)
where there is an agreement that was signed by the late President
Mandela and the UNV where the UNV come and then we mainly
send them to our district hospitals in our rural areas, we actually
20
provide quite a good service to those communities.
We are also
engaged in another Cuban program where the department has a
memorandum of agreement with the Cuban government to provide
us with the doct ors.
Mainly we get those that are specialising in
the various disciplines. And we have allocated them mainly to the
Health Market Inquiry
Page 226
18th May 2016
___________________________________________________________________
regional hospitals and the district hospitals so as to address the
issue of referrals. I must say it is a little difficult to implement a n
ideal referral policy because of the rural nature and the geological
location of some of these hospitals. Because you may find that in
some of these districts the peripheral pattern will not work because
for instance in Capricorn there is no regional ho spital and the only
hospital that is around there is a tertiary hospital and then there is
10
next a district hospital about 10 kilometres. So then if we have to
formulate ideal referrals patterns, it is going to create a lot of
problems there.
However, we are trying to accommodate as much
as possible where we will even provide different levels of care even
in tertiary hospitals so as not to inconvenience patients.
But to
derive at these levels there are the plans that we have already put
into place and the active recruitment is actively going on. Even as
20
we were sitting here last night, we were busy speaking to some of
the specialists so there will be more that we will be bringing in.
DR LUNGISWA NKONKI
Thank you for your presentation, um,
my first question is on the presentation, I think it was on slide 35,
Health Market Inquiry
18th May 2016
Page 227
___________________________________________________________________
you had the Skikoone district, um, and their certificate was
suspended for non compliance. Could you talk about in what areas
where they non-compliant.
DR KGAPHOLE Thank you Chairperson. The facili ty was actually
having 14 beds and they were licensed to provide maternity care
and also to look after HIV Aids and TB patients.
10
Now when we
inspected their facility, it was actually one ward, which was
divided by a swinging door which was leading form th e HIV TB
wards leading to the delivery room.
It was just next to the said
demarcation which was actually the delivery room. And the issues
that really of serious concern were issues of infection control and
the cleanliness.
We found the place to be very dirty and the
policies were not there. Issues of security, they did not even have
20
cameras or security at the entrances, especially for children and all
that, especially outside the security was not that adequate.
Also
patients that were in the TB ward, there were not policies like, I
mean, no ventilation, they did not have any standard operating
procedures, no windows and all that and some of the observations
Health Market Inquiry
Page 228
18th May 2016
___________________________________________________________________
that we made. Like one, they were not there, they just delivered a
baby next door and the nurse delivering the baby went to the ward
wearing gloves which was touching everything, opened the door
and went to the baby with the very same gloves. And we found that
those prevention control procedures are very serious as part of our
inspection we put mor e emphasis on the seriousness of cleanliness
and sterilities.
10
And if things are not correct there we issue
penalties and we did request that they could not mix HIV Aids and
TB patients with freshly born babies. It is a very serious risk. But
they did no t correct that.
Now, when we also went to other areas
like the laundry we found that they were just using these domestic
irons, you know, to iron the linen.
In terms of infection control
these are not effective. We expected them to be using those which
would assist. So those are some of the wide issues that we picked
20
up which we thought were very gross and will compromise patient
care if we don’t suspend the licence.
DR LUNGISWA NKONKI
Thank you,um, my further question on
your written submission you h ave outlined the licensing process to
Health Market Inquiry
18th May 2016
Page 229
___________________________________________________________________
be run in three phases. On page 10 one of your criteria on phase 1
is
whether
the
public
institutions
would
be
a
disadvantage
especially in attracting rival staff and manpower. Having explained
your difficulties in a ttracting specialists in your area, how do you
apply these criteria?
DR KGAPHOLE
10
I think the issue of bleeding in terms of staff is
quite a difficult one like HOD has already said. When they apply,
we are promising that we will be attracting staff from all over and
elsewhere and we are not necessarily going to approach you. But it
becomes very difficult again when people become, or people send
in their letters of resignation, we cannot stop them if they want to
resign and move onto what they say are gre ener pastures. With the
opening of this new facility we lost quite a number of people
20
because, I think what the private sector did is they put a very good
package for them, to say that we will give you a facility that is
fully equipped and everything and you are not going to pay for a
certain amount of time and all of that and many people thought that
this was the opportunity for them to start with and go into a private
Health Market Inquiry
18th May 2016
Page 230
___________________________________________________________________
practice.
And we lost quite a lot of specialists that went there.
Even those that we had that were doing sections for us because
there was this new opportunity for them and unfortunately this is
the problem. But we always try by all means to keep them within
the public’s sector as well.
But unfortunately we cannot have
much influence on what they finally decide. If they want to leave,
unfortunately there is no mechanism, or no policy we can use to
10
stop them from leaving.
DR LUNGISWA NKONKI Thank you.
DRS CEES VAN GENT Dr Kgaphole I am following up on a
question that the Judge asked yo u on the lapsed licences, um, have
you ever drawn up a report and done research yourselves on the
20
background, on the, we talked about the IDC and the finance and
about finding medical specialists ect.
Is there any report or any
sort of research been done and can we have that?
Health Market Inquiry
18th May 2016
Page 231
___________________________________________________________________
DR KGAPHOLE
Chairperson our engagement with IDC is of
recent especially relating to most of these applications we have just
followed on and that is the reason that I have already alluded to the
committee that we are planning to visi t IDC, even if they are not
saying the Dr Kgaphole’s application fell off because of whatever
but that we would want to know and see the reasons.
like to see some of these projects really succeeding.
10
We would
So for now,
yes, we have not actually formal ly engaged with the IDC and it is
of
our
interest
because
we
are
seeing
a
different
way
of
approaching the way it has been carried out especially in rural
areas.
We are going to visit the current department which is the
acting head of department.
It is m y plan to make sure that it is
done.
DRS CEES VAN GENT To be sure, there is no comprehensive
20
research being done on the reasons for the lapsed licences over the
last five years or so?
DR KGAPHOLE No Chairperson.
Health Market Inquiry
18th May 2016
Page 232
___________________________________________________________________
DRS CEES VAN GENT Thank you very much. Yo u were here this
morning and you alluded to fact that also Municipalities could also
have something to do with the fact that the parties can’t proceed
after they have received a licence.
You even mentioned the fact
that you would go as far as send a sort of letter of recommendation
to the municipality and explain to them how important it is to co operate with this group that wants to invest.
10
And also, this
morning we heard the same from the Free State, where sometimes
the municipality does not co -operate. So that sounds really strange
to me because I know that every suburb is struggling with
unemployment and I think that I am from a country where if there
would be a plan to invest in a hospital in a municipality, the Mayer
of the municipality would send o ut all the beautiful young woman
with flowers and try and welcome this company.
20
What is the
background, I don’t really grasp, what would be the reason that the
municipality
investments.
would
not
be
co -operating
with
this
types
of
Health Market Inquiry
Page 233
18th May 2016
___________________________________________________________________
DR KGAPHOLE
Chairperson this will be more as an opposition
really, in the sense when Mr Kgaphole makes an application to
municipality X, is this person known in his community and
everything. I have many leading examples in Mpokane in the town
area where a group of, starting no w to look like a group of
racilistics and whatever, I think I’ve got to say this, a group of
Indians with a few Whites, they have been knocking on the doors of
10
the municipality for some time now.
Till now literally they have
been joined by somebody else a nd now we see some movement in
terms of a resolution been taken by the Counsel for that particular
municipality. So this is the little experience that I have seen. They
also look at the name and see who is that, even before looking at
what you are saying in terms of the benefits to the community.
They don’t look at the business part as, I don’t want it to go to
20
rumours but, it will also be like well what will I be getting, which
some of them they tell us.
Health Market Inquiry
18th May 2016
Page 234
___________________________________________________________________
DRS CEES VAN GENT So what you are saying if I un derstand it is
that political interest trump the interest of the people that are being
represented at the municipality level?
DR KGAPHOLE
Well the level that I am talking about is the
stability has been there for a bit long.
media.
It has been there for the
May I access in there today with the Counsellors, who
come in now and again and then a new one comes in and finds some
10
of those things.
area.
Those are realities and are unfortunate in that
But generally in the rest of the province where the biggest
challenges be the waiting for the request.
But it takes long for
Counsel sittings and prioritising such requests. They are maybe in
the need of water and electricity in the area, so it takes long. But
in that area it was most unfortunate that we experi enced those
challenges.
20
DRS CEES VAN GENT Thank you. So you are, Limpopo, consists
of five districts, five municipalities, isn’t it? So you could invite
the municipalities in a small room together and talk to these people
Health Market Inquiry
Page 235
18th May 2016
___________________________________________________________________
on the importance of the expedi ting of these.
Have you ever had
this sort of discussion with them?
DR KGAPHOLE
Chairperson we went about four or five months
ago, let me safely say late last year, we called all the departments
in the province and all the municipalities to actually sha re the
issues that have bearing on us. Unfortunately those meetings were
10
poorly attended for reasons unbeknown to the department. But now
we have decided to take it on by visiting the Department of
Education and sit with it and even we are having a lette r of
memorandum drafted for a letter of understanding by Advocate
Ramothpo. And finally then we will sit with you and discuss where
we can co-operate in terms of government co -operation and then we
will sign that memorandum of understanding as well as wit h the
20
municipalities Chairperson.
So it is a process that is now on that
we hope that some sort of co -operation will come of it and sure
they are also looking for something from us, from health, which
can also assist.
But by the way we want to see some p rojects
coming through IDP. Currently IDP infrastructure is only relating
Health Market Inquiry
18th May 2016
Page 236
___________________________________________________________________
to public/government infrastructure where you are building a
community clinic and hospital or you know, health centre. During
our engagement we will be looking at some kinds of del iberations,
you need to start recognising this type of activities from health.
DRS CEES VAN GENT Thank you very much.
10
JUDGE NGCOBO
Some of these licences lapsed because people
have no access to land, is this one of the problems?
DR KGAPHOLE Yes Chairperson I can give you an example in
Polokwane.
JUDGE NGCOBO Please do.
20
DR KGAPHOLE A project in Polokwane I know that they have
been battling to finally purchase land.
Remember like my
colleagues have already alluded that some land will already belong
to the municipality and most will be on privately owned land. And
Health Market Inquiry
Page 237
18th May 2016
___________________________________________________________________
when you knock you want to build a private hospital with a person
who will want a lot of millions and now, that is what the problem
is. But yes availability remains a bit challenging.
JUDGE NGCOBO
That is a separate problem but there is the
problem of the processing of the building plans and the transfer of
the lands. Does this also lead to the lapsing of these licences?
10
DR KGAPHOLE Well, Chairperson we open our doors in this way
so that applicants communicating with us telling us that the
municipality has not taken a decision on demarcation or an EIA and
therefore please extend, we do. And I have got examples where we
have now and then we would give them six extra months to ensure
that that process is done.
20
communication.
We do that Chairperson, key is
They need to tell us that they are battling to get
the land or that we have a piece of land but it is not formally
demarcated by the concerned municipality, please we are still
negotiating and we are requesting for an extension. We do do such
extensions Chairperson.
Health Market Inquiry
18th May 2016
Page 238
___________________________________________________________________
JUDGE NGCOBO
The EIA is that the Environmental Impact
Assessment?
DR KGAPHOLE That is correct, Chairperson.
JUDGE NGCOBO Now you have set out at least a report for broad
issues that you say are of concerns to the province.
10
One of these
and the first issue that you draw attention to is the urgent need to
review the current regulation 158.
This is on page 18 of your
written submission.
DR KGAPHOLE Thanks Chairperson indee d, like I say we have
already mentioned during our presentation as a Limpopo provincial
department we actually want to engage with national and sit with
20
the R158 so that it is freshened up.
JUDGE NGCOBO
problems?
What ability is there to review the current
Other provinces, like the Cape has its own regulations
and the Free State, you heard this morning have their own
Health Market Inquiry
Page 239
18th May 2016
___________________________________________________________________
regulations with dealing with the licensing of facilities.
Gauteng
has its’ own statute but it has not come into operation.
What is
holding Limpopo from taking this initiative?
DR KGAPHOLE Indeed Chairperson I would want to take this
concern to Limpopo.
But the rest is assured that we have been I
think in 2014 we have been called by the NCOP for health and
10
private licensing which we pre viously mentioned. Our approach is
Limpopo and that is why we are saying that we are engaging with
national. Not that we can’t do it but that we would want to be part
and everything.
There are three provinces that can take the
initiative and we will actu ally benchmark on everything.
But
finally where we are it should be a national document that should
be standardised to avoid Limpopo from doing its own thing and that
20
is why we are still living unfortunately with the old R158. But we
are taking note and we have realised that we actually need to
urgently engage with national and then there could be a plan where
we could take what is currently happening and move on.
Health Market Inquiry
Page 240
18th May 2016
___________________________________________________________________
JUDGE NGCOBO At national level the legislation which was
activated in 2003, you know some of those provisions have still
needed to come into operation.
In particular the very provisions
that you have been talking about to standardise the issuing of
licences are not yet in operation and there is no indication when
these are going to come into ope ration.
10
DR KGAPHOLE Chairperson, yes indeed.
We agree with your
observation and I guess we are not saying national, do it. We are
saying let’s do it and then we want to make sure that this project is
done.
It is not only this one Chairperson where we ha ve been
engaging on national levels on the policy issues.
But we will
always, and by the way when we say national we mean us, even in
other provinces. So we are happy that other provinces have taken
20
up the initiative so we can only see what is happening like, there
might be good things that we can take in and there might be some
good things that they might have missed so we bring in everything
and that is why we are talking about standardisation. But in that it
is of critical importance that this regulat ion is national reviewed.
Health Market Inquiry
Page 241
18th May 2016
___________________________________________________________________
Limpopo can try and do it here and there but in our way of looking
at it is the entire country.
JUDGE NGCOBO What I am suggesting to you is that more than 13
years ago there was a legislation that was enacted.
One of its
purposes was to standardise issuing of the licences by entrusting
that responsibility on the national government.
10
have yet to come into operation.
Those provisions
An attempt was made to bring
them into operation in 2014 but last year that attempt was struck
down by the court because there were no regulations 13 years later
to bring these provisions into operation. The other provinces in the
meantime have taken the initiative to settle the situation. Now, my
concern is if Limpopo is going to stand by and wait for how long
are they going to wait?
20
DR KGAPHOLE Chairperson we take note of the seriousness of the
matter especially in Limpopo. One, we will quickly, by the way I
am talking here as an acting HOD which is going to make sure that
the commitments are im mediately implemented.
I am sitting here
Health Market Inquiry
18th May 2016
Page 242
___________________________________________________________________
with the committee, the Chairpersons and colleagues of the
department representing the province but the one quickly within the
first week or two will communicate with the other provinces and
see how they feel about the issue and take lessons from there.
Number two, lastly that we will continue, like I said when I say
nationally I say it is us, including other provinces we will make
sure that
10
we
include nationally we
do
have
this
regulation
reviewed. Irrespective o f whether our other colleagues have taken
the initiative to appreciate and we are going to immediately
benchmark on that and move on, definitely in that I can commit to
the Limpopo department of health.
JUDGE NGCOBO The forum where you can raise this issu e is the
forum of the Minister of Health, mixed with the MEC’s of all the
20
provinces at which your MEC is represented.
You could speak to
your MEC to raise this issue when all the other MEC’s are present
to witness it.
option.
The issue can be expedited, that is just another
Health Market Inquiry
18th May 2016
Page 243
___________________________________________________________________
DR
KGAPHOLE
Definitely,
Chairperson,
the national Health
Counsel with the Deputy Manager and the MEC’s are sitting with
the HOD’s of which I am a part of and I will escalate it after this
engagement so that it can be a proper discuss ion to be added to the
Agenda. I will definitely raise the concern that the Chairperson is
raising as it is correct.
10
JUDGE NGCOBO the other concern that you raised is finding ways
of facilitating the underserviced rural areas. As I understand it, is
it about 80% of Limpopo which is rural areas?
And how many
people are there, the population that is there roughly?
DR KGAPHOLE Chairperson, um, I would be, unless if I actually
classified, unless I say in Capricorn, Capricorn is around and
20
measurably like v ery rural but the rest is over 85% to 90% that is
rural. We might have a little light in small towns where are where
these applications are imitating from.
But history states to move
slowly in both Mopolane and Bergersfoot where there are a lot of
mines coming up.
In the next couple of years, there will be
Health Market Inquiry
18th May 2016
Page 244
___________________________________________________________________
definitely economically a little bit of an improvement.
This
economically, you now, coming up of an area, and the rest you can
drive 5 kilometres out of Bergerfoot and you are in the villages of
serious poverty.
So, I would say nothing less than 90% of
ruralness in there.
JUDGE NGCOBO
10
the
right
of
And people who live there are entitled to have
access
to
health
care
services
and
it
is
your
responsibility to facilitate the achievement of that right in these
areas. Do you have a strategy for that?
DR KGAPHOLE Yes Chairperson in both ways Dr Pinkoane has
just alluded to enter into government, you know, collaborations
with Cuba being number one in this respect.
20
months ago we received 22 Cuban specialists.
About two or three
Out of those 22 I
think that actually only 1 specialist was left in Capricorn and the
rest were sent out to these rural areas to go and try and close the
gap but the gap still remains here and there. But the other reason is
the reason that we allowed, you know, these applications to go
Health Market Inquiry
Page 245
18th May 2016
___________________________________________________________________
through, we are looking at that. We can’t afford 25 or 5 MRI scans
in those districts.
Private entities can have that with their
specialities visiting in terms of that kind of collaboration that when
the specialists visit the clinic in Skakoone, definitely there will be
patients that are in need and agree in terms of fee
.
JUDGE NGCOBO I am not too sure whether you are familiar with
10
this matter. There is an initiative that was made in Limpopo which
involved a consortium consisting of a group of black doctors,
Keystone Company and Netcare where they were going to set up a
hospital. Are you are aware of that initiative? Is anyone aware of
that initiative?
DR KGAPHOLE Yes Chairperson I am aware of th at.
20
That is the
one that I alluded to when we were planning for the 2010 World
Cup, we were even counting the number of beds from that entity.
JUDGE NGCOBO In whose name was the licence issued at the time
when this initiative was formed?
Health Market Inquiry
18th May 2016
Page 246
___________________________________________________________________
DR KGAPHOLE Chairperson I can only recall the leader in the
team, unfortunately he has passed on, the late Dr Bena. He was an
OMG specialist and leading the entire team of black specialists.
When I was saying that an application was politically decided on
that time when there were no number of beds but politically it made
sense for these group of people, you know, to plan and to finally
operate a private entity, but unfortunately it fell through the cracks.
10
The
members
started
fighting
amongst
themselves
and
unfortunat ely we even lost the key team leader the late Dr Bena
who was their project manager.
JUDGE NGCOBO
But at that time the building of relations had
commenced there. At least the foundation had been carved.
20
DR KGAPHOLE Yes, definitely and we are looking forward.
JUDGE NGCOBO Now that hospital was eventually completed, is
that right?
Health Market Inquiry
18th May 2016
Page 247
___________________________________________________________________
DR KGAPHOLE No, knowing these things but a totally new
application was looked at which happened to have used the same
site that was belonging to the previous groupings.
JUDGE NGCOBO Are you saying that the application for a licence
in respect of those premises, did it lapse?
10
DR KGAPHOLE Chairperson are you referring to the current
project?
JUDGE NGCOBO The proposed hospital that was going to be built
by this consortiu m of black doctors, keystone and Netcare, I think
it was.
20
DR KGAPHOLE Yes, Chairperson it unfortunately lapsed like I
have
been
themselves.
saying
they
started
actually
disagreeing
amongst
Health Market Inquiry
Page 248
18th May 2016
___________________________________________________________________
JUDGE NGCOBO So a new licence was issued in connection with
the same premises?
DR KGAPHOLE A new licence was issued and this licence used the
same site.
JUDGE NGCOBO To whom was this new licence issued?
10
DR KGAPHOLE Um, it is Paul Shaw and Netcare but both names
are there Chairperson.
JUDGE NGCOBO
And Netcare was part of the group that was
supposed to build it the first hospital?
20
DR KGAPHOLE The first group, Netcare was part.
JUDGE NGCOBO Now, is there anything else that you would like to
draw to our attention. Something that you set out to come and talk
Health Market Inquiry
Page 249
18th May 2016
___________________________________________________________________
to us about but which you have not had the opportunity to draw to
our attention?
DR KGAPHOLE Um, Chairperson I am sitting here with colleagues
and I have been engaged mostly with the rest of you and I would
humbly request them to say before I answer because I wo uld like
them to be afforded that opportunity through you allowing us to
10
request the colleagues if there is anything else really that they want
us to carry the message to the committee.
DR PINKOANE
In terms of reaching out to the patients that
cannot afford the medical care, the province had embarked on
introducing a Telemed scheme that was set up in those areas that
are far out. Um, the last active size was 14 of which one of them
20
was a private size clinic sitting in Waterberg in an area where no one could reach easily in terms of consulting with specialists.
ADVOCATE RAMOTHPO About the review of resolutions on the
R158.
Around the 7 t h or the 8 t h of April the South African Law
Health Market Inquiry
18th May 2016
Page 250
___________________________________________________________________
Association
met
the
Dilikwaan
hospital
where
the
Limpopo
Department of He alth and the Mpumalanga Department of Health
made presentations and raised issues of the need for the review of
the revelations.
So taking from what the commissioners indicated
to us. We will liaise with the law commission and also contact the
other brother departments and in light them with the view of
looking at the regulations.
10
JUDGE NGCOBO And I think that you need to understand that the
real issue here is that, you know, the present regulation which is
R158 as you point out yourself, does not set ou t the criteria for the
establishment of a facility and the result is that people who have a
private licence will have no way of knowing what criteria you will
be applying and the result will be the granting of permits which end
20
up lapsing. So that is real ly where the concern is. Yes, thank you.
DR KGAPHOLE Um, from me Chairperson, um if there could be a
way of communicating with the big three, Lifecare, Netcare and
Mediclinic. Looking at such kinds of needs only not for I hate to
Health Market Inquiry
Page 251
18th May 2016
___________________________________________________________________
say, not necessarily fo r profit. We know they would want to make
some money in the process but when are they going to start looking
out in the rural areas.
Not only concentrate in the big towns and
cities where we know, obviously open today and quickly start
making some bit of cash. Then the province will start adding, you
know getting some value. The issue relating to the national health
insurance, you know, since this song has been sung, everyone is
10
thinking that they will be guaranteed some money of some sort, that
better I have a private hospital or clinic.
I think if we could just
remove that part of notion and remember that we are partners in the
health care industry and we are not looking at private entities as
enemies, we are seeing them as a partner in making sure th at life
becomes better for all of us. Thank you.
20
JUDGE NGCOBO Yes, thank you gentleman for sharing with us the
problems that you are encountering in Limpopo. We wish you good
luck and we will take into consideration the issues that you have
raised with us and thank you so much for taking the time to come
Health Market Inquiry
Page 252
18th May 2016
___________________________________________________________________
here and make your presentation and I think Dr Kgaphole you can
take a moment the minute you take your flight. Thank you.
[END OF SESSION TWO 0 2:10]
10
20
Health Market Inquiry
Page 253
18th May 2016
___________________________________________________________________
SESSION 3: PRESENTATION BY THE NATIONAL PATHOLOGY GROUP.
JUDGE NGCOBO: Good afternoon, we are just one panel member who is on his
way and perhaps in the meantime we can just deal with the housekeeping matters.
Now perhaps the leader of the group will at some point you know just at the
beginning introduce the rest of the team and also indicate who is going to be leader of
the team.
10
DR. TJAART ERASMUS: Chair should I begin or should we wait for your final
panel member?
JUDGE NGCOBO: Whenever you see a red button up here switch off yours and
whenever I see a red button there I will switch off mine. Those are the rules of
engagement here. Very well, do you want to introduce the team members?
20
ADVOCATE GOTZ: Yes, good afternoon Chairperson and members of the panel.
Thank you very much for inviting the National Pathology Group to give their
presentation to the Health Market Inquiry. My name is Anthony Gotz. That is GOTZ,
I am an Advocate with the Johannesburg Bar. I will simply be introducing the
Health Market Inquiry
Page 254
18th May 2016
___________________________________________________________________
participants from the NPG this afternoon and then making one small observation
which we believe is important. Our primary presenter this afternoon is Doctor Tjaart
Erasmus, during the course of our presentation we have asked three pathologists to
come and give a brief presentation in their areas of specialty. Those are Doctor Anil
Bramdev. That is spelt BRAMDEV. Doctor David Rambau, that is RAMBAU. And
Doctor Shameema Khan. Doctor David Rambau will also give a presentation on a
particular issue later on in the presentation and we will also here from Mr. Andrew
10
Good. We have a presentation which we have provided a hard copy to the Health
Market Inquiry this morning and it runs to approximately 120 pages. We anticipate
that it will take an hour and a half to run through the presentation.
JUDGE NGCOBO: You can assume that you know we are familiar; you have sent us
the documents. You do not have to read everything that is here. If you could just
summarize it for us so that you leave the balance of the time for questions. As I have
20
indicated it to you when we met we do not expect to go through the process of
somebody reading the entire document to us. I think the main thing is to give us a
sense of what the presentation is about, highlight the important issues in your case
because I mean if you are going to read the entire 119, we will be fast asleep by the
time we get to page 40. So I think the way we should manage it is this, I think you
Health Market Inquiry
Page 255
18th May 2016
___________________________________________________________________
should highlight the key points of your presentation and then we will engage in the
discussion. Because as I understand, how many people are going to make a
presentation?
ADVOCATE GOTZ: Chairperson, it is 5 people in total but we will make a
concerted effort to limit the presentations of each of the people. I think they have
heard Chair what you have said and they will keep it as short as they can.
10
JUDGE NGCOBO: At the end of the process of engagement if people feel that there
is something that did not come out at the course of the engagement they should feel
free to add those and I will give you that opportunity. But I am just concerned that we
shouldn’t limit the amount of time for the engagement. There will be ample time to
read the document in the light of what you have given us. Which is fairly
comprehensive, okay. But with that said you must make sure you must tell us
20
everything that you have set out to tell us.
ADVOCATE GOTZ: Thank you Chair, before I hand over to Doctor Erasmus; I need
to highlight one point of importance and that is that the party that is presenting to you
today is the National Pathology Group which is made up of competitors of
Health Market Inquiry
Page 256
18th May 2016
___________________________________________________________________
pathologists. Because they are competitors, it is a strict rule of the National Pathology
Group that matters relating to pricing and location in markets are not matters which
are discussed at the association level. For that reason, there may be questions, or
maybe issues which are appropriately addressed to the members themselves. So for
example how a particular member will negotiate with a medical scheme particular
issues relating to pricing. Those are issues which the National Pathology Group feels
quite strongly it is not an area which the group itself as an association of competitors
10
is comfortable or competent to address. But we are happy to take questions on those
issues and then direct those questions, such questions to the individual members for a
version to the Health Market Inquiry.
JUDGE NGCOBO: But do you, there are individual pathologists who will be
making presentation. Isn’t that right.
20
ADVOCATE GOTZ: Yes, indeed Chair. It may not be those individuals are able to
answer the particular questions that you may have. And so they may be a process
whereby with respect we say it can be...
Health Market Inquiry
Page 257
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: Answer them. I mean I can understand the group not being able
to tell us what the kind of, what negotiations go on between you know the individual
members and you know the medical schemes, or whoever they contract with. That I
understand. But to the extent that there are individuals who you have brought to us to
talk to u. I mean are we not entitled to ask those individual members how they
negotiate those tariffs or are you claiming confidentiality. Because if you are
claiming confidentiality I am prepared to sit here and just listen to your argument in
10
that issue.
ADVOCATE GOTZ: Chair it is not a question of confidentiality. It is a question of
what we understood was the reason for the National Pathology Group being called in
the engagements with the Commission personnel. We understood that this
Commission was interested in particular on the role of pathologists its various
interactions with various stakeholders at the level of principle. But the details in
20
relation in relation to how a particular laboratory for example Lancet may engage
with a medical scheme is not something that we believe or understood will be an
issue for this session to be answered by the present panelists. So we haven’t prepared
and we believe quite strongly Chair we have made this point in correspondence in
advance of the hearing to the personnel of the Health Market Inquiry that we
Health Market Inquiry
Page 258
18th May 2016
___________________________________________________________________
understood the remit of this panel to be informative as to the role of pathologists in
the Health Market system. Not to go into the precise details relating to the way in
which a particular group may negotiate with a particular medical scheme for
example. It is not that we do not deal with issues which as a matter of principle...
JUDGE NGCOBO: You see you are here to make a presentation to tell us how you
interact with other stakeholders. That interaction includes how you interact with
10
medical schemes. If you are able to answer the question you will answer the question.
Do you understand that? Yah, I understand.
ADVOCATE GOTZ: I hand over to Doctor Tjaart Erasmus.
DR. TJAART ERASMUS: Chair, thank you very much Chair and your panel
members for the opportunity for us to speak here. I will as you have been presented
20
with the full slide package as well as our previous written document. I will touch on
aspects that I believe are important. The National Pathology Group is the official subgroup of the South Africa Medical Association for pathology. It is affiliated with
SELMA. We have 295 members and it is essential or it is a prerequisite that our
members; that members of our group are registered pathologists. The prime purpose
Health Market Inquiry
Page 259
18th May 2016
___________________________________________________________________
of our group is to promote specific standards in pathology with the objective of
improving the quality of patient care. We will touch on the role of Pathologists.
There is a quote here by Sir. William Aslow, who said as with your pathology as with
your medicine. That quote is nearly 100 years old. And as much as it was true then it
is true now. Pathology is the critical to on which at least 70% of medical diagnosis is
based. 20% of medical care subsequent to the diagnosis is based on pathology. Not
only for the establishment of the diagnosis but also in the process of caring of the
10
patient in terms of its efficacy. We have a slide here which I believe unfortunately
you do not have sound which is part of a humorous clip but I do apologize if you find
this incorrect. But we will move to the next slide.
You will see the slide unfortunately you will not hear the sound. It is very short about
30-40 seconds, thank you. The pathologist or the lady is now being examined by this
person who says let’s see what month it is. It is that money and he says well it is easy
20
we will just run a couple of tests. He shakes his hands and there is sound going and
he asks her to hold the egg. She is obviously rather doubtful about the process and he
rings the symbols and he essentially say oh he knows exactly what the problem is
then, He looks at her and she is obviously incredulous about the process and he says
well he surely knows exactly where to go. And he says well we will attend to your
Health Market Inquiry
Page 260
18th May 2016
___________________________________________________________________
diagnosis soon. He turns around obviously and the result is clear. And the message is
clear that if the pathologist did not exist, where would the answers come from.
And in essence that is the fundamental aspect of our presentation. And in terms of
were the pathologist is placed in terms of the bridge between the laboratory and the
clinician. You need to remember that pathologists are trained medical practitioners.
The have spent pregraduate time at University, who have subsequently done an
internship and subsequently two years’ community service. Only then can a
10
pathologist specialize for four or five years in a specific discipline and possibly
subsequently in a sub-discipline. This may take up to 15 years for a pathologist to
qualify.
There are a Number of pathologists sub-disciplines. The primary and we have in our
presentation and we will have three pathologists who will be dealing and their focus
is primarily to give an amplification of these sub-disciplines in pathology. The
20
categories of pathologists which exist, are registerial specialties within at the Health
Provisions Council. An anatomical pathology, chemical pathology as well as medical
microbiology and virology. In addition to that there is also the branch to forensic
pathology. Largely not really with the presence in private pathology laboratories
although there are certainly laboratories in South Africa who have forensic
Health Market Inquiry
Page 261
18th May 2016
___________________________________________________________________
pathologists within their grouping. As a focus of those mostly in medical legal
aspects. Then of course we go on to super specialists in fields of pathology being
neurologist-pathology which speaks for itself and then a field which becoming
increasingly important; molecular diagnosis or molecular pathology and genetics.
This field is developing rapidly and the reason for its rapid development is obviously
increasing pace of technological development and the scope with which this
development offers us. The advantage of extremely rapid diagnosis, extremely
10
accurate diagnosis and also what one could even call the business of prediction in a
very long term because one is looking at the genetic profile of an individual which
will give you an indication of the pre-election of a disease. And more and more this
will become part of the services which pathologists offers. Using an example there of
the BRCA gene which is indicative of the potential development of the ... and that
has now changed the whole outlook for women in terms of the selection of how to
care for themselves. It is just a note that the area of molecular biology resorts within
20
the biology practice environment that is largely the degree of skill required is that
largely of medical scientists.
Now going on to the role of the pathologists. What is important, we believe to make,
the important point to make is that pathology is a referral specialty. Many specialists
Health Market Inquiry
Page 262
18th May 2016
___________________________________________________________________
see patients off the street. They see patients, gynecologists do, pediatricians do; many
other disciplines see patients without referral from a general practitioner. A
pathologist is, does not; it’s in the rarest circumstances that patients present
individual at the pathology laboratory, I will touch on that a little bit later. Very
shortly.
The primary role of the pathologist is to oversee a professional pathology laboratory
10
and to take responsibility for the diagnostic laboratory. The technical aspects of a full
laboratory functioning lie within the control and the expertise of the pathologist. As I
have indicated to you before pathologists are trained clinicians and then they become
trained laboratory specialists. They are therefore placed in this unique position of
being able to extend a hand to the clinician on one hand and on the other hand to the
laboratory and understand the value of a specific diagnosis. How much attention
should be attached to that and also what the problems and complexities are around
20
that.
In addition to that there are also in the South African health care environment, there
are also medical laboratory technologists, technicians and medical scientists. And this
skill is an essential skill in the totality functioning of the laboratory service. There are
Health Market Inquiry
Page 263
18th May 2016
___________________________________________________________________
a number of sub-disciplines in pathology as I have indicated before and one of the
advantages of this sub-disciplines is the skill to look at a specific perspective or
component but then to communicate with one another to act as a diagnostic team.
Which would not be possible if these pathologists were in separate compartments.
And one of the beauties of private pathologists fortunately is this level of interaction
within practices between the disciplines.
10
We will now go on to an example and we will ask Doctor Anil Bramdev who is a
histopathologist to give you a short overview, to be followed by Doctor Rambau and
after that by Doctor Khan. So over now to Doctor Anil Bramdev, thank you so much
sir.
DR BRAMDEV: Chair, ladies and gentlemen. My name is Anil Bramdev. I am a
histopathologist by profession having qualified from the University of Natal in 1987.
20
For the last 27 years I have been practicing as a private histopathologist. My task
today is to in a nutshell explain to you the responsibilities of a histopathologist and
where he fits in, in the health care delivery system. Essentially a histopathologist also
referred to as an anatomical pathologist has the responsibility of making a diagnosis
of disease by analyzing tissue samples. Now the kind of disease diagnosed includes a
Health Market Inquiry
Page 264
18th May 2016
___________________________________________________________________
variety of conditions but the most important one being cancer. And usually the
biopsy specimen would be a... biopsy or an excision of a lump but in addition the
pathologist also looks at other samples for example smears like pap smears as well as
analyses bodily fluids like urine, CSF and sputum. Now the diagnosis on histology
involves a close interaction with the entire health care team. And this will include
consultation with the referring Doctors, looking at other lab tests, looking at x-rays
and once a diagnosis is made the clinician looking after the patient then can decide on
10
the level of medical care which can be medical or surgical and that will then
determine the prognosis.
By the way of example, I would like to take you through an actual case to show you
what happens in histopathology lab. The case I want to talk to you about is a 45-yearold African female who presented to a Doctor with a lump in the breast, The Doctor
decided to remove the lump, send it to the laboratory to make sure if it is cancer or
20
not. And as you will see in the slides ahead we have a mass which is 3cm in diameter
and pathologists’ 1st task is to analyze this mass including slicing the mass to look at
its proper characteristics. And these slides show the actual lesion being cut and
analyzed and described in detail. The next step after the microscopic examination is
the processing of the tissue. Now this is a complex procedure and it involves a
Health Market Inquiry
Page 265
18th May 2016
___________________________________________________________________
processor which runs over 6 to 8 hours and the tissue is subjected to a whole lot of
chemical steps before a slide can be made. The next slide will show you the tissue
being sliced into tiny sections; 3-5 microns in diameter and a micron being 1000 of a
millimeter. The tissue is then placed on a glass slide and eventually stained and cover
slipped. And thereafter it come to the pathologist to analyze the tissue under the
microscope. At this point I just want to make the point that a pathologist needs to
know what is normal for each organ of the body from head to toe. And he needs to
10
know what kind of abnormalities are visible under the microscope. When it comes to
cancer there are many types of cancer which involves every single organ and the
pathologist when he is training, when he is experience as well as constant updating of
information will be able to work out what the pathology is.
In our index patient, the following is a slide of the breast cancer and the background
pic is a normal breast trauma and you can see the cancer cells present as the blue
20
straining glandular structures invading the tissue. So in this patient we have come to
the diagnosis of a breast cancer. And in addition to make the diagnosis, the important
role of the pathologist is to grade the tumor. We need to decide is it low grade, is it
high grade. This is crucial for planning of management. High grade tumor being very
Health Market Inquiry
Page 266
18th May 2016
___________________________________________________________________
aggressive. In addition, the pathologist has to comment on the excision margins
because if the tumor is incompletely excised you need to go back and excise wider.
In addition to this cancer the buzz term today is target treatment for cancer. And it is
the pathologist’s role to look at each cancer and determine what special molecular
and genetic features are available. This is called profiling of the tumor and this is
absolutely crucial for management purposes. And in our patient the next slide will
show we subjected the breast tumor to a whole lot of special strains. The 1 st one is
10
estrogen receptor which is a molecular protein and the brown staining there indicates
positivity. So this tumor is estrogen receptor positive.
The next strain that we do on breast cancer routine is her two gene stains. And on the
right hand slide you see the bright red staining that indicates positive signal for her
two gene. Now this is crucial for breast cancer because identifying her two gene
means an oncologist will use specific targeted drugs to stop the tumor growing. Now
20
the drug Herceptin is now regarded as the magic drug in breast cancer. It has
dramatically improved outcomes and lives of patients with breast cancer and the only
way to identify which patients are suitable for this drug is for the pathologist to look
for this gene and molecular expressions.
Health Market Inquiry
Page 267
18th May 2016
___________________________________________________________________
So coming back to our patient the final report will read as such. The patient has a
breast duct adenocarcinoma that is actually a type of cancer, its 3cm in diameter, it is
low grade, the excision is complete and it expresses ER estrogen receptor,
progesterone receptor and ...2. With this information the oncologist is now armed and
will know exactly how to treat this patient. In summary this slide demonstrates the
flow where the specimen is examined with the naked eye under the microscope.
Special procedure is done before the final report is released.
10
This principle applies to all cancers and not just breast cancer. And targeted therapy
for cancer is the new way of treating cancer today. Just as an example if you look at
brain cancers, 5 years ago patients with malignant brain cancers there was nothing
understands could do for them. They had a few months to live and that was about it.
But today after we understand the biology and morphology of these tumors we can
identify certain tumors which express certain receptors or certain genes and new
20
specific drugs to control that and that has really improved the survival rates in
patients who were previously regarded as terminal. Just a quick note the other job of
a histopathologist is to analyze smears. The pap smear being the classic smear that
we analyze. I am sure the panel is aware cancer of the cervix is the commonest
malignancy in South Africa. In fact, it is rampant and it is estimated that one in nine
Health Market Inquiry
Page 268
18th May 2016
___________________________________________________________________
women in South Africa will get cancer of the cervix in a lifetime. The pap smear is
crucial to screen for this before the lesion becomes apparent and that is the job that
the histopathologist has on his hands. An example of a normal pap smear on the left
hand side compared to an abnormal smear on the right hand side. You can see the
blue dots represent the nuclei show great variation. And in this way the Doctor knows
that this is an abnormal pap smear. He can act on this before the cancer develops. So
screening is a crucial place to prevent cancer.
10
And lastly I just want to touch on the value of frozen sections. This is another
technique that the histopathologist performs in theatre while the patient is under
anesthetic. So a sample of the tumor is given to the pathologist who analyzes it in
theatre and gives the surgeon an immediate answer. This then empowers the surgeon
with the full knowledge knowing exactly what he is dealing with. How intense to
take the surgery for example. It also has the distinct advantage of having one
20
procedure done as opposed to calling the patient back to have a repeat anesthetic.
And the next slide shows a cristek which is an instrument placed in most theatres
were the pathologist performs a frozen section. With that I thank you.
Health Market Inquiry
Page 269
18th May 2016
___________________________________________________________________
ADVANCE GOTZ: Chair, thank you. Doctor Rambau will now continue. He is a
chemical pathologist. We ask him to continue, thank you.
DR. RAMBAU: Thank you Chairperson and the panel for the opportunity. My name
is David Rambau and I am a chemical pathologist. I have got a but 20 years’
experience in private practice. I am going to outline my talk by way of examples and
try to stay out of the technical jargon. My objective is to try and get the panel to
10
understand what we actually do in the laboratory.
The 1st example I have got, it’s a case of a patient who came to South Africa. Who
for many years was being treated for having removed the thyroid. This patient had
cancer and the thyroid was resected, removed it and had to replace the hormones
which the thyroid gland normally provides in the body. And this patient was put on
eltroxin that is thyroid hormone replacement therapy. So when this patient came to
20
South Africa they did the normal thyroid function test. When the Doctor received the
results the Doctor was very unhappy because it appeared as if the patient was being
over treated. The results show that the TSH was suppressed, the ... was elevated and
that is a sign of over treatment. Now on discussion with the Doctor, I specifically
asked the Doctor why is this patient getting the treatment? That is when the story of
Health Market Inquiry
Page 270
18th May 2016
___________________________________________________________________
the cancer came in. Now although this results indicates over treatment, ordinarily any
other patient who has had the thyroid removed; in this specific patient this treatment
was proper because you have to suppress; you must give suppressive therapy to
suppress the TSH. Because the TSH is a stimulant for cancer cells. If this Doctor
didn’t contact the laboratory and went ahead to alter the therapy, to normalize the
TSH, this could have put the patient at risk. Because whatever cancer cells are
lingering in the body will be stimulated by TSH and start growing. Now after that
10
advice, telling the Doctor that this was suitable an additional test was recommended.
We suggested that this patient needs a thyroglobulin which is also a cancer marker.
This will tell us if this patient has got less cancer cells because if there is increased
burden of cancer cells you will have a more thyroglobulin circulating in the body.
The other responsibility of the chemical pathologist is in reviewing results. So we
have got an information laboratory system which we use; which we program so that
20
the majority of results which are produced by these automated systems can be
checked against the rules set by the pathologist and released. Those with failed the
rules will be returned for the pathologist to look to view them physically to decide on
whether additional information is necessary from the Doctor or to compare with the
previously results or to interpret with other results which are produced on the same
Health Market Inquiry
Page 271
18th May 2016
___________________________________________________________________
request. And this helps the Doctor interpret correctly what the most likely diagnosis
and what is most likely results are for that particular patient.
Now I have put the next slide on interpretation of test results using cholesterol as an
example because cholesterol is a very common test which is requested on early basis.
This is a patient who had very high cholesterol level of 6ml per liter. The Doctor
decided to put this patient on anti-cholesterol therapy which is... And four weeks later
10
the Doctor wanted to know how effective the treatment was and the cholesterol
results was 7.1ml per liter. The question is the patient is on treatment, why does it
appear as if the cholesterol is increasing. So the Doctor contacted the laboratory to try
and understand what the issue is here. Now in the interpretation especially in
monitoring of results specifically cholesterol, one needs to understand the variability
that occurs with the analysis and also the variability that occurs within an individual
biologically. Cholesterol tends to be that good example of ... which are naturally
20
found in the body which have that biological variation. Now cholesterol has got that
biological variation of about 6.1% and analytically it is recommended that the
variation when you analyze it should not exceed 3%. It is 3% and less. So the
majority of laboratories aim at 3%. Now when you look at variability of cholesterol
within the body and the variability analytically. It will give you a combined expected
Health Market Inquiry
Page 272
18th May 2016
___________________________________________________________________
significant change of 21%. So in other words any variation of a cholesterol measured
repeatedly in an individual at different times you will get numerically different
results. If they do not exceed 21% it means, there is no change. Now in this particular
patient cholesterol which appears to have moved from 6 to 7.1ml per liter is actually
no change. What it means is the Doctor requested the monitoring too early. The
Doctor should have waited at least two to three months before the test is repeated.
Now the other problem related to that is that repeat because the Doctor doesn’t
10
believe the results repeated testing tends to happen unnecessarily and that
unfortunately the patient has got to pay for. So the interaction with the pathologist
does cut some of those costs. Because in this no further testing was necessary but just
an explanation why the two results are numerically different but actually the same.
The last part I am going to talk about briefly is dynamic functioning testing. In other
words, we do not only technically look at what has been measured using instruments.
We do interact with patients. There are certain investigations which require the
20
pathologist to interact directly with the patient through consultation by a specialist.
Now this is one case where a patient who has been taking a tablet which was
unidentified for a skin condition happened to have undetected levels of cortisol and
undetectable levels of STH which is a pituitary hormone; a hormone from the brain.
Now the Doctor was wondering if this patient has got some organic disease which is
Health Market Inquiry
Page 273
18th May 2016
___________________________________________________________________
causing this suppression. So what was necessary was for the laboratory, the
pathologist to test the function of the adrenal gland and the function of the pituitary.
So we started with a short sinaxtihin, in other words testing the adrenal glands. We
stimulated that and there was no response. So we needed on a longer because it
depends on the patient will respond on a shorter or longer one. You can’t make
conclusions based on the short one if there is no response. So we had to do a long
STH stimulation and there was a phenomenal response. Which meant the organ was
10
intact, it was responding. Now we were left with the pituitary functioning. We had to
do an insulin stimulation test which showed a phenomenal response as well. So
which means the two systems were intact. Now from this one can deduce one small
tablet the patient has been taking for a long time for this skin condition was actually a
steroid which suppressed the two systems. With that I thank you.
ADVOCATE GOTZ: Chair we will now continue with Doctor Shameema Khan the
20
microbiologist. Thank you.
DR KHAN: Good afternoon Chair, ladies and gentlemen. I am a medical
microbiologist with about 20 years in medical microbiology. So just to introduce
what is medical microbiology. It is that branch of pathology concerned with the
Health Market Inquiry
Page 274
18th May 2016
___________________________________________________________________
diagnosis, treatment and prevention of infectious diseases. This specialty involves
four types of organisms which cause infections and that is bacteria which is referred
to as bacteriology, viruses referred to as virology, parasites referred to as parasitology
and fungi referred to as mycology.
The study of these infections staining and cultures of samples to assess whether
infection is present or not. And if a bacterium is present then we identify this in a
10
laboratory and we perform further tests whether they are susceptible to antibiotics or
not. Secondly infections can also be diagnosed using molecular methods. These
molecular methods are generally rapid, more accurate methods used specifically to
diagnose certain infections such as viruses, micro bacterium, tuberculosis and these
bacteria may take weeks to grow on cultures. Molecular methods are also used to
monitor certain infections. For example, we perform viral loads such as in HIV to
assess whether the anti-retroviral in HIV positive patient is working or not.
20
The third method used to diagnose infection is detecting antibodies. And this falls in
the subsection of serology which detects antibodies not only two infective organisms
but also to diagnose non-infective conditions. The infective conditions for example
that serology will use is HIV, hepatitis B and the non-infective viruses such as lupus.
So in addition to infections microbiologists are also involved in the field of allergy
Health Market Inquiry
Page 275
18th May 2016
___________________________________________________________________
and immune deficiency conditions. So what do we do? In the laboratory qualified
technologists analyze patient samples on a 24/7 basis and the medical microbiologist
gets involved once the results are available for clinical action. And these results may
either be preliminary results or final results. And all results are verified by a medical
microbiologist. This ensures that the results are correct and allows the medical
microbiologist to interpret the findings and we add interpretive comments and
therapeutic advice on the reports.
10
These comments may include for example we suggest the antibiotic with the correct
dose with the correct duration that antibiotic should be given for. It is vitally
important that the report for the various health care providers caring for patients are
presented in a clear, concise and clinically relevant manner. This verification process
of laboratory results in general takes up about 50% time of medical microbiologists.
Clinicians phone for consultations with the microbiologist on a wide range of issue.
20
So the other 50% of our time is to serve as consultants for health care providers. For
example, how to diagnose and the treatment of infective anti... which antibiotics to
use as therapy for certain infections, which antibiotics to use before the laboratory
results are available, what dose to use and which drugs to use for example in antiretroviral regiments.
Health Market Inquiry
Page 276
18th May 2016
___________________________________________________________________
The clinicians also phone to discuss which tests to perform to confirm their suspected
clinical diagnosis. In some situations, these clinical consultations may involve ward
runs with the clinical team responsible for the patient. So these telephonic
consultations may account for about 20% of our time.
About 20% of our working day is to phone out life threatening results to the clinician.
And this we phone out all cases of meningitis, we phone out all cases of positive
10
blood cultures better known as septicemia, if there is an Ebola infection in pregnancy,
if a patient has a recent hepatitis virus infection and infections caused by resistant
bacteria which may not respond to the normally used antibiotics. Thus the
clinicalizing of the medical microbiologist with the clinician is done anytime during
the day either proactively or at the clinician’s request. And at each clinical interfacing
opportunity focus is placed on the entire clinical context and not necessarily just the
microbiology and viral result of the patient.
20
As an example there was an Ebola scare in Durban and one had to take into
consideration the travel history, the signs and symptom of the patient before testing
for the Ebola virus. We had a number of phone calls from various clinicians and we
Health Market Inquiry
Page 277
18th May 2016
___________________________________________________________________
had to actually go through the history and the signs and symptoms and actually refuse
testing for Ebola during this time.
And another example I would like to use of our clinical interaction with a clinician on
one of the Mondays a pediatrician called me. And he had an 8-year-old child that had
nausea, vomiting, diarrhea and he had severe abdominal cramps. And when he called
me he told me he had done investigations for example a CT scan, he had done an
10
ultrasound and he had sent to the laboratory a full blood count and a stool
examination. And he thought that this child had an appendicitis, at the time that he
called I looked at the computer the results of the full blood count and I saw that the
lymphocyte count was low. So the patient had lymphopenia. And I told him that this
is unlikely to be an appendicitis because there was no... I then told and he also told
me he had referred this patient to the surgeon. And then I told him I would look at the
culture results of the stool and phone him back. I had a look at the culture results of
20
the stool and we have a preliminary result that this bacterium was a salmonella and I
was happy that we had the diagnosis and I phoned the clinician and told him we have
got the diagnosis and it is definitely not appendicitis but the salmonella infection
which gives you this picture. Then we started on a broader spectrum of antibiotics
and the following day I told him based on the susceptibility of the results to start the
Health Market Inquiry
Page 278
18th May 2016
___________________________________________________________________
patient on a narrow spectrum of the antibiotics and the patient could be started on IV
antibiotics and went on to oral and was discharged home a day later.
So about 5-10% of our time is involved in management issue which includes Human
Resources, IT, instrument placement, region changes, implementation of new tests
and deleting obsolete tests. Medical microbiologists also offer a consultative focus on
hospital prevention and control. This entails various meetings with the different
10
infection control personnel of the multiple private hospitals. These meetings occur at
the premises of these various private hospitals.
And most hospitals have antibiotics stewardship meetings which we also actively
involved in. So apart from consulting we give various talks on appropriate
management to Doctors. We train nurses, we train pharmacists on antibiotic
management to work in a multi-disciplinary team, to manage infections in a patient.
20
As an example in one of the hospitals we attended an infection control and antibiotic
stewardship combined meeting. In this meeting there is generally there is a
pharmacist, there is an infection control nurse, the medical microbiologist as well as
other clinicians. The pharmacists had presented their utilization of their antibiotics in
that particular hospital and I noted there was a very toxic drug that was used which
Health Market Inquiry
Page 279
18th May 2016
___________________________________________________________________
was taken off the market and the drug is called colistin and it is not, we need special
permission from the medical control council to use on patients. And the pharmacy
had about 5 patients who were on this drug. I later presented the microbiology of the
institution and noted that there were a lot of bacteria called pseudomonas which was
multi-drug resistant and only susceptible to this drug. The infection control nurse
then told us that in the ICU there were 5 patients with these multi-drug resistant
organisms which constituted an outbreak. So with the multi-disciplinary team we
10
went into the ICU and with observations, testing and a lot of collaboration we
discovered that the pseudomonas that was spreading to all the patients found in the
drain pipe of a few sinks in the ICU. The maintenance had changed those drains and
subsequently strict infection control and antibiotic stewardship antibiotics we had
eradicated the pseudomonas in that particular hospital.
In conclusion medical microbiology is about managing patients’ infection related
20
diagnostic, therapeutic and infection control needs. A result is only meaningful based
on the therapeutic interpretation by a medical microbiologist. Thank you.
DR TJAART ERASMUS: Chair, thank you very much. Just that it has broadened the
perspective from one being a pathologist which is a laboratory with a piece of paper
Health Market Inquiry
Page 280
18th May 2016
___________________________________________________________________
with numbers on it as opposed to giving some indication of the range of pathologist
services. But pathology laboratories would be nothing without the persons who work
in the laboratories. And I am not referring to the pathologists now but to the other
personnel who are there. These groups are mostly registered with the Health
Professions Council Board of Medical Technology and the they are medical
laboratory scientists, medical technologists, medical technicians, lobotomy
technicians and laboratory assistants. In addition to that the category of nurses and
10
nurse sisters are enrolled are enrolled with the South African National Council also
forms a significant group of persons employed in the laboratory.
In our next slide, you will see a summary, maybe this is a bit slow. In our next slide
you will see a summary of the groups of persons employed in the laboratory. And
this, the data reflected here is from the National Pathology Group membership
laboratories.
20
JUDGE NGCOBO: That is in hospitals, the individuals who have testified; where do
they work from? Do they work from home, do the work from hospitals, where do
they work from?
Health Market Inquiry
Page 281
18th May 2016
___________________________________________________________________
DR TJAART ERASMUS: Chair, they work from laboratories
JUDGE NGCOBO: Which laboratories?
DR. TJAART ERASMUS: The laboratories are placed in different parts of the
country. We could ask them which laboratories they work in but maybe if I could just
note that we requested the presence of these pathologists based on their fields of
10
technical skill in their fields of discipline as opposed to their involvement in the
management of the laboratory services. So they, maybe just as a background please
question me if you like. Must I continue, I beg your pardon.
JUDGE NGCOBO: Yes.
DR. TJAART ERASMUS: Chair, I am a bit confused. Should I continue? Thank
20
you, I am getting confused with the buttons I am so sorry. What we are trying to
present here is the employment statistics of the members of our group. You will note
there that there are 10 000 employees who are employed by these laboratories and
that we have; sorry there are 295 pathologists, 3 000 laboratory technologists, 1 000
technicians and 200 lobotomy technicians. That is a skill which was developed within
Health Market Inquiry
Page 282
18th May 2016
___________________________________________________________________
the private pathology laboratory environment and trained, about 50 medical scientists
and approximately 3 000 nursing sisters. So it is a fairly significant group of persons
who are involved in the laboratory services.
Now I would like to touch on what happens in practice in the laboratory. And the
perspective I have tried to give is the perspective of the patients, the clinician who is
not directly associated with the laboratory and the next group of patients who are I
10
some way referred to the laboratory or the tests were requested for the laboratory to
be done on specific patients.
The Doctors in clinical environment refer the patients’ specimens and these are the
Doctors who are distant from the laboratories and will perform specimen collection
themselves. Are distant from the laboratory and they make a selection of tests based
on their clinical diagnosis and what they believe is the specific field of expertise
20
which the laboratory office which they wish to refer the test to and in addition
obviously the skills that are involved as well the turnaround times and quality of that
laboratory.
Health Market Inquiry
Page 283
18th May 2016
___________________________________________________________________
The clinician indicates how urgently this specimen must be analyzed and that is
indicated on the form. And an important point we wish to make is that no practitioner
may receive any financial gain for referring any patient to a laboratory. The
specimens, the referring Doctor selects tests based on the provisional diagnosis. What
he or she does is that they use a laboratory sheet which contains tick boxes. He ticks
or he or she ticks in the tick boxes and decides which tests are to be done.
Why do we have tick boxes? The tick boxes reduce the error rate on the clinician and
10
on the other side of the pathology laboratory knowing exactly what is being requested
and what should be done.
JUDGE NGCOBO: How do Doctors decide to which pathologists a patient will be
referred to?
DR. TJAART ERASMUS: I noted a short while back that my understanding is that
20
the referral laboratory will be based on physical proximity. The laboratory which is
in the area, the laboratory which has the skilled expertise to do the analysis, the
laboratory which has to do with the quality and is accredited with that quality. I
would say those are the most important aspects why a specific laboratory will be
used. And turnaround time.
Health Market Inquiry
Page 284
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: Patient consulted in the process? Given options?
DR. TJAART ERASMUS: Chair, now I am obviously speaking on behalf of the
clinician and that is not my role. But we absolutely would insist that there is a
preference that the patient be given a preference. That patient may not always be
made aware and I am not sure whether each clinician informs the patient of the
choice and in certain areas there are competing laboratories in the same geographical
areas.
10
JUDGE NGCOBO: When a patient goes to a pathologist or to these laboratories,
does anyone there explain to the patient why he or she is there and what is going to
happen in the entire process, how much blood is going to be taken from him or her
and what is going to happen to the blood, how long he may have to wait for the
results?
20
DR. TJAART ERASMUS: Chair, the section I am referring to now is the section
where the specimens are collected by the Doctor. What you are referring to now is
when the patient arrives at the laboratory? Would you like me to comment about
that? Chair, I am unable to answer that question fully. I do know the laboratories
request, having been a patient at the laboratory myself and I am currently not
Health Market Inquiry
Page 285
18th May 2016
___________________________________________________________________
practicing and having been a patient myself, arriving at the laboratory requested to
sign an informed consent. The other aspect probably or not dealt with in terms of
how long it would take unless the patient asks as a routine; there are many pamphlets
in the laboratory environment. I think frequently patients will ask as a; because if
there are a number of tubes, why are there so many tubes. The answer may be simple.
Because different tubes are required for different analytical processes and that
improves the quality and simplifies the whole analytical flow within the laboratory.
10
JUDGE NGCOBO: A patient will be concerned about how the specimen would be
handled so as to avoid a situation where you know a wrong label is put to a wrong
specimen with different results. So those are the kind of questions I am trying to
understand whether those processes are explained to the patient.
DR. TJAART ERASMUS: Chair, I am not sure they are specifics explained to every
20
patient. But the general process is that as I indicated earlier what I was busy telling
you was the specimens collected by the Doctors outside who are not associated with
the laboratory. So now let us move on to and I want to make sure that I do not; do
you mind if I come to your question in 15 seconds, finish this section on specimens
that are collected by the Doctors in the periphery?
Health Market Inquiry
Page 286
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: No, you can deal with the question at some point whenever it is
convenient to you.
DR. TJAART ERASMUS: Thank you very much Chair, I will do so. Again returning
to when the Doctor collects the specimen and I mention now about tick boxes
because it is important to understand because the accusations made against
laboratories is that all they want is a form with as many tick boxes as possible so the
10
as many tests ca be requested as possible. I will attend to the request forms again a bit
later. But also to note that tests can be requested in groups. In other words, there
would be something and I am using this by way of example. There could be a liver
function test which can take 6 or 8 different tests or there could be a tests for excuse
me, blood lipids, blood fats which contains 4 or 5 different tests within that. But
those tests can be requested individually should the Doctor prefer to do so. The
Doctor always has a choice of what is to be done. And we will touch on the request
20
forms a bit later.
But I would like to just comment on something that is specific as well that is also
often suggested, why do laboratories not use blank request forms? Why do they not
just have a form with the patient’s name on top the laboratory and let the Doctor
Health Market Inquiry
Page 287
18th May 2016
___________________________________________________________________
write out the tests requested? In fact, experience; firstly, the error rate is significant.
Point number 1. The irony is experience shows that blank request form generates
more tests than tick box request forms do. And this is not only in South Africa, this is
worldwide. So the tick box gives a level of certainty and clarity for all parties
involved.
Now I would now move to the area where specimens are collected from by the
10
laboratory personnel with a laboratory request form having been sent, given to a
patient to go to a specific laboratory. The patient would arrive at the laboratory, the
demographic data will be collected and the tests completed on the form and the
patient will see a nursing sister or the lobotomist who collects the blood. And at that
point and now I will get to the point where you were referring to the concern about
specimen tubes mixed up. and that is really understandable and that is obviously of a
great concern.
20
You may have noticed if you have been to a laboratory yourself which I am sure you
have that when you enter the area where the blood is collected; on the request form
there is a collection of barcodes to be attached. That barcode is split between the
same barcode on the form is attached to a different tube. And after that in essence it
Health Market Inquiry
Page 288
18th May 2016
___________________________________________________________________
really doesn’t matter how those tubes go away from one another because that unique
identification remains linking that request form with that tube and that patient result.
The great Number of tubes collected are largely a reflection of achieving efficacies
within the laboratory, different tests require different specimen collection protocols.
In some the patient may have a ... on their arms for the test to be collected; in others
there must be a free flow of the blood. There are a number of test requirements and
that influences the test tube aspect which sometimes looks overwhelming. The
10
Doctor will at that time indicate whether they wish to have the test done urgently or
on a routine basis and an additional note that absolutely makes no difference in terms
of the price that is eventually paid by the patient. Or whether the test is done within
hours or out of hours. All results, all testing is done at the same rate.
I have mentioned the signed consent; I do not have to touch on that again. Eventually
the focus is to get the report back from the clinician which has referred the test. When
20
the specimen arrives from the laboratory, the specimen needs to be processed. The 1 st
aspect is the data capture of the patient demographics and the tests which have been
ordered. If there are ICD10 codes which have been included by the referring
clinician, these are captured. I will touch on that later.
Health Market Inquiry
Page 289
18th May 2016
___________________________________________________________________
The request forms are scanned to have a copy of the tests requested by the Doctor so
that there is a, should there be a query or an enquiry by the medical schemes or the
patient. And then subsequently the specimens are transported to theatre main
laboratory. Now where does the analysis occur? The analysis on fact happens in most
large laboratories have central core processing facilities and a Number of smaller
processing facilities which are geographically distant from that. And in between or
mixed this would be emergency laboratory that are also part of the overall process.
10
The focus of the emergency laboratories obviously is testing for immediate results
and immediate availability when there is a critical clinical need. As the specimen
moves up the laboratory chain from the smaller to the larger laboratory; the degree of
automation of the laboratory process increases and obviously this improves the
efficacy of the instruments in terms of the volumes that are required for the analysis
and also improves the quality of the outcome of the result.
20
Some tests however; are manual. They need always to be done individually and they
always require a one to one relationship between the person doing the test and also
the test being done. So instrumentation varies from high throughput automated
instruments which are interfaced with the laboratory computer systems to thee
manual testing methodologies. The different types of tests which are, I do believe we
Health Market Inquiry
Page 290
18th May 2016
___________________________________________________________________
do not the waste time to touch on. These analytical machines are produced by
instrument manufacturers of International stature, the quality is excellent and the
results produced are absolutely excellent.
It is more cost effective for a laboratory to centralize analysis on specimens that are
not urgent. So the focus will be in general terms to move the laboratories to the, to
move the specimens to a central processing facility. But that is, I would say that rule
10
that comment is flexible and that is always dealt with in terms of the individual
requirements.
Laboratories are extremely dependent on information technology systems. Without
the integration of an information technology system which can pull all of this
together from the point of the barcoding of the patient, the requesting of the test, the
doing of the test to the ultimate point of the test resulted as we have the mention from
20
the colleagues how these results are viewed and verified by the pathologists up to the
point now this is available as a totality and which may be which will be made
available to the clinician.
Health Market Inquiry
Page 291
18th May 2016
___________________________________________________________________
So the critical role, the role of the pathologist is the integration of all aspects of
laboratory service, analysis and diagnosis. What is also, yes, it was touched on the
issue of normality I am not going to deal with it here. I do not want to duplicate and
waste time.
A key component of the pathologist’s work is to communicate with the clinicians
even in terms of an individual result which has become available or in terms of
10
consulting to a clinician when there is an enquiry or in instances when an unexpected
combination of tests are pointing to a specific diagnosis which the clinician may not
be aware to or sensitive to. Some of the instruments of pathology like the
histopathologist we have heard interact with each specimen on a single one to one
basis. The advantage of multi-disciplinary practices is the fact that there are
pathologists in the disciplines who are in the same practice who can interact with one
another in terms of discussing patient diagnosis and diagnostic needs of the clinician.
20
I want to touch on some statistics again, I have referred to those slightly earlier but
here specifically analytical aspects. Approximately 90% of all pathology laboratories
within our group are accredited. Doctor Rambau will speak about that just now and
this is an aspect that we are very proud of which is critical for quality patient care.
We travel about three and a half million kilometers a month collecting specimens.
Health Market Inquiry
Page 292
18th May 2016
___________________________________________________________________
We do 300 000 tests a day on 60 000 patients of these about 20% are collected from
the rural areas and 48% of the tests are done in the hospital. 44% my apologies.
I will now touch on aspects pertaining to consolidation because we believe this has
been a concern that has been raised. Most pathologist laboratories started 90-100
years ago. Started with one or two-person practice. Over time these laboratories were
consolidated, amalgamated with one another. The amalgamated groups amalgamated
with other groups. What was the purpose? The purpose was to improve the quality, to
10
improve the quality of the diagnosis and to improve the cost efficacy of patient care.
The centralization of laboratory services is a logical response to the health care
requirement in South Africa and the disease patterns in South Africa. Only through
this human resources, skilled human resources be effectively utilized. You need to
note that this consolidation of laboratory services is not an only within the private
laboratory arena but also has happened at the same level of the national health
laboratory services and it is also indeed a reflection of what happens worldwide.
20
In addition to these larger, these increased amounts have led to the development of
laboratories sub-specialists as I have referred to earlier on. And only in a large
practice can you have the luxury in inverted commas of having sub-specialists. If are
a one or two man practice it is impossible to cover the range of services and have the
Health Market Inquiry
Page 293
18th May 2016
___________________________________________________________________
depth of knowledge that is available within these specialist groups. The staff are
highly trained and salaries are commensurate. And I am not referring to the
pathologist Doctor but the other staff or highly trained persons and the salaries are
commensurate with these skills.
The medical ideology has increased dramatically over the last century. Diagnostic
needs have grown and there is an increased requirement on professionals and it is
10
critical that the sub-specialties have developed to be able to deal with these needs.
Pathology tests range from a simple to a highly sophisticated and the only way
pathologists to deal with this whole range is to amalgamate and to form larger
practices. What is being the benefit? The patients are benefitting significantly from
this. Tests have become more rapidly available, more widely available, more cheaply
available and with a greater need for immediacy and a range of tests have increased
significantly. Inevitably we work with all our equipment are imported, ... are
20
imported, so we are exposed in terms of the cost structure to the ever depreciating
value of the South African currency.
I have noted before that laboratory runs have to be consolidated in order to save costs
and also touched on the question of the infrastructure required to transport these
Health Market Inquiry
Page 294
18th May 2016
___________________________________________________________________
laboratory specimens from the ...areas to the central laboratories both by roads and
flights. But the wonderful thing for us has been the development of information
technology because the is the backbone of which the technology practices exists and
functions. Without that it would not be possible to have this level of result
availability in terms of its immediacy and in terms on how widespread it is available
for the clinician. It would have been impossible to manage otherwise.
We are now going to touch on accreditation and I will ask Doctor David Rambau
10
who presented before to do the section of laboratory accreditation which is extremely
important for us.
DR RAMBAU: Thank you once more Mr. Chairperson and panel. I am going to talk
about laboratory accreditation. This is the cornerstone for the quality of services
rendered by the medical laboratories. What is accreditation? Accreditation is the
formal recognition of the competence of a laboratory to produce reliable results and
20
this is done by an authoritative body in South Africa. That authoritative body is
SANAS. And anywhere around the world the authoritative body which normally
performs this function has to be a member of ILAC, that is International Laboratory
Accreditation and Cooperation and the standard which is applied in accreditation,
there are two main standards that the laboratories have to comply by with. They have
Health Market Inquiry
Page 295
18th May 2016
___________________________________________________________________
to conform to ISO15189 and ISO22870. Now South Africa healthcare was ranked
Number 6 by the International Monitor Group. In the year 2000 when the
accreditation started in South Africa, the private pathology groups were the 1 st the be
accredited. They embraced it and to date we have over 90% of private pathology
groups accredited and this has become; it has actually stopped being a competitive
part of the business. It is a must for you to produce good quality results you have to
undergo accreditation.
10
Why should we get accredited? Why should we accredit the medical laboratories? It
is in the interest of all of us including governments that our laboratories produce
results of an international standard which are comparable across geography, across
borders. And it is also in the interests of the competent laboratories, laboratories
considering themselves to be offering international standard service that their
competence is independently verified. And that is why most of the majority will
20
choose to get accredited and this has become an industry standard because whenever
you do businesses or companies select laboratories to do businesses with, one of the
prerequisites is that you have to have accreditation because that means you have
proven your competence through an independent body.
Health Market Inquiry
Page 296
18th May 2016
___________________________________________________________________
Now why is ISO15189 standards so suitable for the medical laboratories? This
standard focuses on the patient outcome without necessarily compromising the
required accuracy in the measurement and it also looks at the totality of service
which is inclusive of the consultation, the advisory services I referred earlier on, the
turnaround time as well as the cost effectiveness. So these are addressed by the
standard as well.
10
Now what is the main purpose of these standards? There are three main areas where
these standards can well serve the community. Firstly, these standards are adopted by
laboratories to conduct self-assessments. We call these internal audits. Every
laboratory has got to conduct internal audits. They have got to have self-assessments
whether they are going for a third party accreditation or not. They need to have a look
at themselves whether the systems are intact, the systems are able to deliver good
quality results. And secondly this standard is used by accreditation bodies like
20
SANAS, they use this standard to conduct voluntary accreditation. Accreditation is
still voluntary in South Africa; you can choose not to but the majority of laboratories
especially in private practice have chosen to subject themselves to that independent
verification of competence.
Health Market Inquiry
Page 297
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: When do they do this?
DR. RAMBAU: Okay, when these bodies accredit laboratories they look for quality
management systems if they are in place and there are many components of these. In
my presentation I do have a list of what they look at. Broadly, the look at the
management and the technical aspects.
10
JUDGE NGCOBO: Do they look at patient satisfaction? Do they look at outcomes,
patient outcomes?
DR. RAMBAU: Yes, they do look at patient satisfaction. Every laboratory is
mandated to keep a record and during accreditation this is what the Accreditation
bodies look at. Any complaints related to patients, every laboratory has got to do that.
Now in terms of outcomes...
20
JUDGE NGCOBO: They keep a record of what?
DR. RAMBAU: They keep a record of a patient’s comments, complaints, the
compliments. Every laboratory has got that division.
Health Market Inquiry
Page 298
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: But you know they can comment on the quality of treatment?
DR. RAMBAU: Yes, they can do that.
JUDGE NGCOBO: But when does that occur? Are you given forms when you get
in?
DR. RAMBAU: The patients through our staff members whenever there is a
question, a complaint raised it is logged into the system by anyone of our staff
members can do that. We also have a call center. The patients can contact the call
10
center. We do get a lot of comments coming through telephonically at the call center.
JUDGE NGCOBO: But is there anything though that tells the patient when he or she
goes to these laboratories that if you have any complaint about the treatment that you
have received here this is who to contact and this is how you lodge your complaint?
DR. RAMBAU: In the facility there are two areas. Either at the initiation of a request
20
with the Doctor in the Doctor’s rooms the Doctor has full information about the
laboratories. The contact numbers are available there. In the second option where the
patient walks to the lab to be bled or for the samples to be collected by the laboratory
staff the information is available there in the facility. It could be a depo that is a nonlaboratory facility but it is an outlet for the laboratory to collect specimens.
Health Market Inquiry
Page 299
18th May 2016
___________________________________________________________________
JUDGE NGCOBO: But what I am asking you is, is there anything that indicates to a
patient who goes to these laboratories which says to the consumer if you are unhappy
about the treatment that you have been subjected to whilst at this facility here is a
number to let complaint or this is how you go about lodging a complaint?
DR. RAMBAU: That will vary from laboratory to laboratory. I will not be able to
speak broadly on that because individual member laboratories will handle it
10
differently. Should I continue? Thank you.
The 3rd purpose for this standard is governments can adopt these standards and use it
to enforce accreditation within their territories to make it a basic requirement that any
laboratory operating within that particular country should undergo accreditation.
Now I have a list of what the standard looks like. I am not going to go through the
list. This is just to display to you that this is the list which accreditation bodies go
20
through in detail when they conduct accreditation. It varies, it can take a day to 3
days depending on the size of the test menu, the size of the facility, the size of the
accrediting team. Obviously the more people the shorter the time because various
people will look at various aspects within the laboratory. But the two categories they
look at that is the management as well as the technical side.
Health Market Inquiry
Page 300
18th May 2016
___________________________________________________________________
Now I would like to briefly talk specifically on the technical aspects because...
JUDGE NGCOBO: The quality of the services that pathologists offer to the public?
DR. RAMBAU: I didn’t get that?
JUDGE NGCOBO: Do they look at the quality of the services that pathologists
offer?
10
DR. RAMBAU: Yes.
JUDGE NGCOBO: That information from?
DR. RAMBAU: It is the responsibility of the laboratory to keep records of what they
do. One of the central issues in the, the central requirements in any laboratory is
20
proficiency tasting which I am going to talk to in the next slide. That defines one
aspect of the quality required. Obviously because the standard looks at the totality of
the service this includes what we call the turnaround time. This is the point; from the
point the request is made to the point a result is delivered. Now laboratories are
expected to document the turnaround times of various tests they offer in the
Health Market Inquiry
Page 301
18th May 2016
___________________________________________________________________
laboratory. They would bring accreditation; laboratories would have to produce such
evidence depending on what tests they are looking at. And that is considered to be
one critical point in quality measurement.
JUDGE NGCOBO: Yes, continue. I mean I understand measuring efficiency of this.
But I am only interested, I am interested in whether; do they consider the quality of
the treatment that is offered to the consumers and if so how do they get that
10
information because from what you have told us. You have told us that the practice
of keeping these records of these complaints from laboratory to laboratory.
DR. RAMBAU: Yes, when you look at the list; can we go back one slide. Yah, that
slide I have got there you will notice that they do look at how the complaints have
been resolved. Resolution of complaints. How this is done it differs from one facility
to the other but the standards accommodate that. So when the assessors come into
20
your facility, they would like to look at the evidence related to that. Thank you.
Now I have extracted this part which deals specifically with the technical aspects of
the measurement in the laboratory, the quality of the result. Unlike other industries
the laboratory tends to be different. In other industries if you produce a product
which is tangible whether it is a loaf of bread; you can touch it, you can weigh it, you
Health Market Inquiry
Page 302
18th May 2016
___________________________________________________________________
can smell it, you can do all sorts of things because the quality of measurement stays
with the product. But in laboratory measurements the quality of the results stays with
the system that produced it. So there are certain system requirements which one has
got to document. You can buy instruments from wherever you get them but when
they come to a laboratory there are certain basic requirements. You have got to
validate the system in the environment to make sure that it measures what you want
to measure.
10
And secondly and very important is the traceability of scale of measurement. What
are you going to use as calibration? Because the calibrator is the ruler, it is the
standard of which the measurement is made. Now without being too technical let me
just give you a practical example. If you have a drum full of water let us say it is 400
liters of water and you want to express this in cup units. So if you have got let us say
three individuals and say tell me how many cups this 400 liters is? One might say it
20
is 1600, another one might say it is 2600, another one might say it is 1300. Now the
question is who is correct? Who is giving you the correct answer? The answer is they
are all correct because we haven’t defined the size of the cup. And that is what
traceability is all about. If we say the size of the cup is traceable to a standard cup,
then we would expect similar results and not these different results. Now in
Health Market Inquiry
Page 303
18th May 2016
___________________________________________________________________
measurements in the laboratory it is important to note whether the yard stick, the unit
of measurement you are using is traceable to some international standard.
I would show you in the next slide the significance of this. Why consistency is
important?
JUDGE NGCOBO: Is there a way the rest of these presentations can be summarized
so that we can get on with the rest of the presentations. Can you summarize the rest
10
of that or is it too much to demand? Please, so that there will be sufficient time for
others who are still remaining.
DR. RAMBAU: Thank you. So the issue about uncertainty is how you feel the cup
because if you define that the cup is 250ml no one knows exactly if the cup has been
filled to exactly 250ml mark. There will be over fillings and under fillings and that
creates variability. This speaks specifically to the cholesterol example that I gave you
20
that there is variability in the measurement. So a single number, it tells us about the
quality of a number which is produced from the laboratory. If 5 is, if I say black
sugar is 5ml per liter; what other numbers represent equally that amount of black
sugar? That is set into a measurement.
Health Market Inquiry
Page 304
18th May 2016
___________________________________________________________________
Right this is the slide I was talking about. If you have that traceability, this is about
the HB1C in treating diabetics. HB1C will tell you about the risks of developing
complications in a diabetic. Now in 1993, there was no traceability of the scale of
HB1C measurement. So patients who were healthy could have been told that they
were diabetic and vice versa. Now after the B1C study, the BCCT was published, the
method used in that study was used as a reference method and it took over 10 years to
perfect this traceability of unit of measurement. From 2012 we could now see the
10
fruits of that traceability that all over the world these are participants from all over
the world. From Russia, from Japan, from US, from Europe. On the same specimen
given to them they are producing comparable results. What this means is the HB1C
results are portable, they are transferable, they can cross borders. A traveler from the
US who normally undergoes monitoring using HB1C can come and continue
monitoring in South Africa so that we can compare the subsequent results which are
produced in South Africa against the results which have already been measured in the
20
United States provided they are done by a laboratory which participates in this
programme.
Now just to finish off, after successful assessment that is the end you know the end of
the assessment of the laboratory for accreditation and Accreditation is certificate is
Health Market Inquiry
Page 305
18th May 2016
___________________________________________________________________
issued to the laboratory and that certificate will be valid for four years but there will
be an interaction of every year or two-year period an assessment to show that every
laboratory complies with the standard. And it is important to note that of all the
health, of all the medical disciplines pathology is the one subjected to accreditation.
And if you want to know which laboratories are accredited in South Africa and this is
open to patients, any consumer one can go on the SANAS website you will see the
scope of tests accredited and the name of the laboratories. With that I thank you.
10
DR GENT: You can also see on the website what the differences in quality between
the laboratories. I mean the certification sets a basic standard isn’t it. It explains 70%
of the quality without 100%. 100% is explained by individual brilliance by excellent
teams, by super specialization without fragmentation etcetera. We live in a
commercial world isn’t it. Can we see it; can consumers see which laboratories are
better than the other.
20
DR. RAMBAU: Unfortunately, the accreditation is not about who is better than the
other. It is about who conforms to the standard.
Health Market Inquiry
Page 306
18th May 2016
___________________________________________________________________
DR GENT: My question was not that. I understand certification. It is a worldwide
phenomenon. My question is you live in a commercial world isn’t it? Pathology
groups and laboratories differ in quality in term of however; they organize, how the
organize super specialization of fragmentation come up with the best results
compared to other competitors. Can consumers benefit from that knowledge? Is that
knowledge available in South Africa by the pathology groups and the laboratories
and can consumers benefit from the fact that you represent the commercial industry?
10
DR. RAMBAU: That information will be available for individual laboratories
because what you will find on the laboratory is that this laboratory participates in
proficiency testing for the following tests without which you will not get those tests
accredited. But if you need detailed performance characteristics for that particular
laboratory you will get it from the individual member laboratory.
DR GENT: I will have a look, thank you.
20
JUDGE NGCOBO: Can I just press this question? Dr. Erasmus or somebody
suggested that you decide on the pathologist based on the distance you know from
where you are or the Doctor’s. But take a case of laboratories which are located at the
same hospital, how do I know as a consumer which pathology group to go to? How
Health Market Inquiry
Page 307
18th May 2016
___________________________________________________________________
do I make that choice because I need to be able to know who is better than the other?
That information is not available, is it?
DR. TJAART ERASMUS: Thank you, let me think for a minute. I think one of the
issues, aspects that you have touched on are one would call soft issues. Not that they
are not important, that is not what I am trying to say. And the access for the average
patient to this kind of information to even interpret this kind of information is not
10
available and I do not believe it is possible.
JUDGE NGCOBO: This question as simple as I can. If I am a patient and I am
consulting with my Doctor. We are trying to decide to which pathologist must I go.
Now one of the factors that will weigh heavily with me apart from the distance is the
quality of the service. Accreditation doesn’t tell me anything other than you are
competent to do this. The quality of the services, is that information available which
20
will enable consumers to decide whether if I go to this particular facility and you
know this because there are facilities that have got at least two groups of pathologists.
So the distance doesn’t matter there. And I need to go there and I need to decide
which one to go to. Now is there any information that tells me what Group A is going
to charge me, the quality of the services that I am going to get from Group A, what
Health Market Inquiry
Page 308
18th May 2016
___________________________________________________________________
Group B is going to charge me and the quality of the service that I am going to get
from Group B? Is that information available to the public?
DR. TJAART ERASMUS: Chair, the charges of the laboratory are available for the
individual laboratories to the patient. So those are very clear and easily available.
Maybe one to put this into perspective if one would say if you go and see a surgeon
or if you see your clinical practitioner who decides if he or she wishes to refer you to
10
whatever other medical discipline. I would think that largely your trust is in that
referring clinical practitioner who is probably the best informed to be able to make
that decision or suggest a decision for you as opposed to being able to on a
quantifiable basis do that decision the patient themselves.
JUDGE NGCOBO: I will not take as is what I am told. I need to make an
independent decision and that is why I need to make this decision. So the question is,
20
is this information available concerning the quality of the services that pathologists
offer?
DR. RAMBAU: Chair, if I could answer that question. I think the short answer is, no.
There is no independent verification standard to compare one laboratory with the
Health Market Inquiry
Page 309
18th May 2016
___________________________________________________________________
another. In the same way there is no independent standard to compare one’s surgeon
with another or with any other health care provider with another. It is not available I
think in the South African context.
JUDGE NGCOBO: Why is it that so?
DR. RAMBAU: I am sorry I cannot answer that. I think. I know if you go to the
10
States for example you can open a magazine and they will tell you which is the top
ranking plastic surgeon in the country. That kind of instrument is not available in this
country.
JUDGE NGCOBO: Does it have to do with the fact that there is no independent
evaluation of the quality of the services that you render?
20
DR. TJAART ERASMUS: Chair, we believe that SANAS is the independent
evaluator and accreditor. It may not be available consequently in a digestible format
for an average lay person in all respects to be able to digest or understand. And we
think that we are street aid in any other medical discipline in terms of quality and in
Health Market Inquiry
Page 310
18th May 2016
___________________________________________________________________
terms of accreditation. There is nobody who even comes close. The deficiency
undoubtedly is this level you are referring to.
JUDGE NGCOBO: We understand that but surely the information concerning the
quality of the service that one group offers compared to the other surely cannot be so
complex that it is completely inaccessible to everyone except the pathologist. I mean
surely somebody must be able to tell me that for example I went to that pathologist
you know, they mixed my blood sample with somebody else’s as a result I got a
10
diagnosis that I had cancer when in fact I did not have cancer. It turned out to be it
was a mistake. That is what I am talking about. I mean surely you do not need to be a
radiologist to know that, that is wrong. So that is what I am talking about. How does
one evaluate? How does one decide? I mean it must be simpler and the question is
why has it, why is it not being done?
DR. TJAART ERASMUS: Maybe to allude to what I have said earlier, specimens
20
are referred to us by clinical colleagues. That clinical colleague is probably the best
place to make that decision or to make that recommendation. But given what you
have said I suppose one as a professional must always have a level of sensitivity
about these issues and about services to the public. Whilst this is a high focus of what
we do and I believe we set ourselves very high standards there is certainly something
Health Market Inquiry
Page 311
18th May 2016
___________________________________________________________________
we can take away from here and try and understand what the need really is and see if
it is possible to attend to that need because it is for us an urgent matter. If it were not
so, we wouldn’t have embarked on this process of accreditation and measurement
which is not simply putting a bunch of stars beyond your name. That is not the
purpose.
JUDGE NGCOBO: Accreditation is one thing. Now if the information as you
10
suggest is not available I mean it is so complex that only pathologists can understand;
how then will my Doctor be able to understand that? Because he is supposed to
advise me and how will he or she advise me on quality if he or she can’t even
understand this?
DR. TJAART ERASMUS: Chair I think we maybe we are forgetting the fact that
there is an independent accrediting body.it has nothing to do with the laboratory. It
20
gains or losing nothing by accrediting the laboratory. So it is like in the old terms like
the South African bureau of standards. It is a stamp of quality. That is at least there
comparable which does not exist in other medical discipline. Clearly for what you are
saying it is deficient in that level but again I would think that it is important that the
referring clinician is aware the quality of results that he gets back. He or she gets
Health Market Inquiry
Page 312
18th May 2016
___________________________________________________________________
back, quality of interaction with the laboratory which is a very dynamic and intuitive
process.
DR GENT: Doctor Erasmus I am from the Netherlands and we did a lot of research
on what is known to Doctors and what is not known to Doctors and Doctors have no
clue. If they have no information they have no clue. They only have individual
experience and that is how fast can we get results or whatever. Whether the results
10
from one group is better and more consistent from other groups, he or she has no
clue. So without a specific system of generating information on outcomes Doctors
have no clue. Hospitals have no clue even within hospitals Doctors have no clue
about the quality of care being provided by colleagues so that is out the question. The
question is not whether the standard of the certificates provide a basic quality level,
that is okay of course. We understand but if you take this reason further you can say
nationalize pathologists because then we all need to comply to a grade 7 or I do not
20
know what you call it in South Africa. A double A standard, that is it. Everybody
complies to that and then there is no need for competition within the groups and the
hospitals and pathology groups and pathology. You could nationalize it. But that is
not the world we live in and people live in commercial world and they offer their
Health Market Inquiry
Page 313
18th May 2016
___________________________________________________________________
services on a commercial term. So to do that we need, I think in the system we need
the differentiation both on process of course and on quality
DR. TJAART ERASMUS: Okay, Chair can I ask if such a system exists through you
to Doctor van Gent in the Netherlands and how is it dealt in that area because we
would love to learn by example.
10
DR GENT: Yes, there is quite a bit of information and I have been responsible for
that for 4 years in trying to generate that information. It is a step by step process
which is quite complex but it is a process that is inherent to a commercial world. I
mean if you liberate the prices of oranges, if you can’t see the quality of oranges then
the quality of oranges will also go down and you will just buy the lowest prices isn’t
it. This is a very simple example and healthcare is much more complex. But in
principle you can’t do without and maybe in this case it is not the consumer that
20
directly decides, it is the intermediate and in some cases it is the medical schemes of
course that contracts and of course it is the hospital that the referring Doctors that are
involved. They haven’t got a clue of quality. In fact, you yourself have a clue of
course because of your basic quality. I enjoy being proud of the system that you work
in, I do acknowledge it but the differences in quality are there and you can bet there
Health Market Inquiry
Page 314
18th May 2016
___________________________________________________________________
are there. And quite important differences and there are not known to you, to us, to
referring Doctors, to everybody. And there are systems in the world that are trying,
that are working hard on this new... there is an extended system. In Holland we have
that, in Sweden, in the United States of course but it is an ongoing process. It has
been ongoing for now more than 10 years.
DR. TJAART ERASMUS: Chair, we are happy to note the concerns raised and we
10
will try to do our best to deal with them in the appropriate manner because we are
serious about the discipline which we practice. May we continue then and ask
Doctor. Andrew Good now who will add aspects about utilization. Thank you.
DR. GOOD: Thank you for the opportunity today. The slides have been prepared
about our company called Prognosis. Prognosis is an actuarial and consulting entity,
assists companies’ life choice which is a data warehousing expert company. We have
20
been assisting National Pathology Group to contextualize pathology trends since
2010. When a large scheme within the industry took out adverts in national
publications reflecting pathology in particularly a poor light by showing certain
trends that were there and encouraged their colleagues to address pathology trends by
working together to ensure sustainable health care. National Pathology Group
Health Market Inquiry
Page 315
18th May 2016
___________________________________________________________________
approached us to say can we firstly, are the trends are correct and if the trends are
correct can they be explained. And we were successful, and we had to show that the
trends were not actually correctly reflected. In fact, that they were other aspects that
should be addressed sooner than actually starting to focus on pathology.
Subsequently we produced an annual report using the base available public data and
publish it so that National Pathology Group members have the ... to say these are
trends in the pathology landscape and these are the factors that are driving these
10
trends and that need to be borne in mind before you decide exactly how you going to
approach pathology related interventions.
The way we produce our reports is the Council of medical schemes produces a
significant amount of information and we have taken that information and using our
data warehouse expertise and we have loaded that data into data warehouse. The
analysts and statistical experts have developed modules that allows to extract the
20
trend lines and produce these reports. Our actual colleagues in that regard that is the
report.
Our presentation that was included, well the last annual report that was included you
know is an example of the reporting. Today’s presentation is based on the sort of the
Health Market Inquiry
Page 316
18th May 2016
___________________________________________________________________
methodology used. But we have actually chosen to extend it forward to 2002 because
the inquiries already had a presentation that actually shows pathology trend lines and
it is important to contextualize those pathology trend lines based on the various
dynamics within this industry. So if you look at our 1 st slide here we have a trend line
that is chosen to reflect pathology with the increasing cost of pathology. It runs from
2002 and it was chosen and I think the point that was trying to be made is there is a
perceived specific concern about the trend of pathology. If we and perhaps the fact
10
that they have chosen to show pathology in red they really want to highlight the
specific perceived concern.
I think it is important when we look at the slides, this slide looks at the increases in
expenditure the medical schemes are experiencing since 2002. In contextualizing that
the trend let us have a look at that. This slide shows a differential of about 140%
between pathology cost increase schemes and that of medical specialists between
20
schemes. Then contextualizing the costs; we first use the information that our
warehouse has loaded and it has been scrubbed and cleaned. Next slide. You see in
the next slide that when information comes out of our data warehouse we pretty have
the same trend lines we expect because it is the same as being analyzed. We have
added an additional year because an additional year is where the data has been ... and
Health Market Inquiry
Page 317
18th May 2016
___________________________________________________________________
we see pathology has increased by 360%, medical specialists around 200% and a
140% differential. But I have go to stress that this is a cost that schemes are
experiencing.
If we actually look at the next slide, what we have simply done is we have actually
looked at where pathologists reclaiming and if you actually look at what pathologists
are claiming rather than the schemes are paying we see that the trend lines of
10
pathology are not too different right. Why, what is going on, on the background that
you know is impacting that. But before we do that I think it is important that we look
at inflation; next slide sorry, it is tricky not being able to control your slides. Yah,
once we adjust from inflation we see that 140% differential drops to a 14%
differential when you look specifically the what is being claimed by the discipline
and adjusted for inflation. What is going on in the background or what a lot of people
fail to look at and see is the perceived problem with pathologists is that the portion
20
that the scheme is paying towards pathology costs versus the portion that the
members are paying the pathology costs has changed. If we look at it in terms of if
you look the data that goes all the way back to 2002 and you only have data that goes
back to 2006, you see that in essence the main portion that the members are paying
from their own pocket has dropped to 67% and that the scheme portion has gone up
Health Market Inquiry
Page 318
18th May 2016
___________________________________________________________________
14.5% which actually if you multiply what that portion was you know has a huge
impact on the scheme costs. And the reason behind this I think with regulation means
more schemes are obliged to cover pathology almost in total which actually causes
what blunt people perceive as a specific problem. Let’s go to the next slide.
Before we can actually... is there a problem which is not a problem we have to
actually go and look at other factors. One of the other factors that one has to
10
understand is that if clearly something is going up then there is utilization of the
service. If you look at the utilization relative to other various other... we are
comparing about. So once again using Council of medical schemes data we produced
utilization trend lines here going back to 2002. You can actually see pathology
utilization trend alright we see a significant increase vis a vie the other specialists of
16%. So if you were correct you can always conclude that pathology increases are
pretty much in line with the increases we are seeing in the broader specialists’ arena.
20
And are generally are in line. Can I have the next slide please.
So what other factors could be driving the utilization of pathology services. Now if
we look at, there is a lot of information available at the Council of medical schemes
data but the Council of medical schemes kind of also have to put out reports now and
Health Market Inquiry
Page 319
18th May 2016
___________________________________________________________________
then and they had to put out a report in December last year were they looked at the
general survey of chronic diseases. And in that data they give us drivers of utilization
and they give us the prevalence of certain conditions and once again this data is only
available from 2006. But they actually report when we look at HIV and medical
reports, we see that HIV and medical schemes has gone up by 135%. If we look at
diabetes type 2 it has gone up 90%. Now hyperthyroidism 34%, hypertension 39%,
hyper... 32%. So certainly given the information that is there we should expect an
10
increases in utilization pathology just based on the disease burden the is prevalent.
The CDO conditions actually ignore things like cancer that also have a major impact
especially considering the technology advances. If I can have the next slide, please.
Another significant change that the industry or the medical schemes are experiencing
that also impacts the utilization and services is the industry age profile. What we have
done here is to show you in red how the relative number in the age bands in 2002 and
in blue the relative number of people in age bands in 2014. And I think what is quite
20
striking is if you look at the age bands that lead sort of 0-5 up to sort of 24 we see a
significant drop off in younger members. If we look across we can actually see past
50 we see a rising number of people in the blue bands. If I can have the next slide.
Now I think we did have, when molecular schemes was implemented there was talk
about medical schemes risk equalization fund. I was fortunate to participate in that
Health Market Inquiry
Page 320
18th May 2016
___________________________________________________________________
risk equalization fund with the technical advisory panel. There were various models
that were out in place to actually address that there shouldn’t be any risk transfer. We
viewed one of those simpler models to say what is the likeness of this case scenario
and that case scenario impact to that aging from a risk perspective of a medical
scheme and you can actually see that there certainly should account for a 10% growth
in utilization molecular risk profile. Next slide, please.
10
So in summary scheme costs have increased, pathology costs are not out of line with
the general trends if you correct appropriately. One of the drivers are age in disease
burden. We certainly need interventions to protect the existing members in the
medical schemes because of those changes that we see. Also the PMB impacting
schemes we need some intervention there and I think that also comes out in the trends
that we see. The impact of these various drivers will differ by discipline and we just
asked when people consider pathology any other costs the analysts must correct the
20
increase and decreases in the member portion, inflation and utilization. And I think
what is really important in the context of pathology is that we need to consider costs
and benefits. And within the South African context we spend 5.1% on pathology of
the total contributions that come in. And I think we mustn’t underestimate the
Health Market Inquiry
Page 321
18th May 2016
___________________________________________________________________
importance of this 5.1% in you know creating certainty around diagnosis, directing
treatment and effective monitoring within the system.
And certainly in my opinion there is lower hanging fruit in adjusting our schemes to
make them more affordable to members in pathology. If I could have the next slide.
So we should expect pathology cost increase as they have increased and are
continuing to increase. The change in age profile, the reality of our country’s
10
environment and the change in disease profile is a reality. Access to specialists we
have a system were people access to specialists directly, that was an impact on. We
also have a change in climate in mitigation in terms of in the last 10 years the number
of employers you see on adverts advising you, asking you whether you want to see
your Doctor has changed significantly. And then we also need to bring in a change in
technology and that impacts certain aspects.
As my colleagues have said, the National Pathology Group members have said
20
practically, is all pathologist services result from clinician referrals. I think as a
scheme in the industry we need to explore models that move to coordinated care
where we improve referral to appropriate conditions, we improve clinical pathology
referrals, we improve the appropriate use of pathology in terms of pathology in our
context possible examples we could use less pathology but there are certainly other
Health Market Inquiry
Page 322
18th May 2016
___________________________________________________________________
examples were we actually not utilizing the full value of pathology in terms of
managing our HIV and Diabetes collaborate our national surveys do not suggest that
at all and I think we need to improve transparency of costs included by all clinicians.
Thank you Chair.
DR TJAART ERASMUS: Chair, for us to continue we have given our concern about
time we thought that we will skip aspects of our presentation and touch on a few of
10
the points which were raised. Wait I interrupted myself. The formally structured part
of our presentation is really over now. There are a number of aspects that were raised
by other parties previously in submissions to the Commission which we wanted to
touch on. We may not touch on all of those. I am not sure what the position is in
terms of time because I want to touch on the aspects specifically about employment
of Doctors by hospitals and specifically about an aspect called reflex or what we
prefer as reflexive testing. These tests so called added on tests the I would like to
20
touch on those. Please I need to be guided by you. We are comfortable to continue
but we do not want to waste time of the Commission. Thank you.
JUDGE NGCOBO: I think you better continue with your presentation.
Health Market Inquiry
Page 323
18th May 2016
___________________________________________________________________
DR. TJAART ERASMUS: Chair, just give me a minute to relocate myself.
JUDGE NGCOBO: Do you perhaps want to take a 5 minute or a ten-minute break?
DR. TJAART ERASMUS: Chair, certainly given my age my bladder will appreciate
it very much.
10
20
JUDGE NGCOBO: I understand. Okay, shall we take a ten-minute break then.
Health Market Inquiry
Page 324
18th May 2016
___________________________________________________________________
Session 4 National Pathology Group continued
DR ERASMUS
Thank you for the break, that we had.
We
believe that most of the aspects of our presentation have really
been dealt with in one way or another, as it has flowed through.
There are aspects which we have available should there be
questions, but there is one aspect that we feel we would like to
10
touch on specifically and that is the slide 114 and that relates to the
employment
by
hospitals
of
practitioners,
of
doctors
and
specifically in our instance, obviously we are talking about
pathology.
20
JUDGE NGCOBO
And also the add -ons.
DR ERASMUS
Yes I will talk about that with the greatest of
pleasure, but we will deal first with the issue of the employment of
doctors and then maybe I just need a minute to get to that slide
again, but we will talk about that with the greatest of pleasure.
Health Market Inquiry
Page 325
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
Before you proceed, can I just raise one or two
questions with Mr Wood if I may?
The information that’s
contained in these graphs that you’ve presented, does it come from
your members?
DR GOOD
The Council of Medical Schemes makes a lot of
information available and the background to the Council of Medical
10
Schemes information is t hat scheme is required to submit annual
statutory returns and those returns have a specific format and have
a lot of information available.
Those annual statutory returns to a large extent are available on
specific requests through the access to the Acces s of Information
Act.
20
We access those and they need to convert that information
into a structured data format to our analysis, so it’s actually
information from across the industry as submitted by schemes.
JUDGE NGCOBO
I mean one of the issues that has e merged in
the course of these hearings is the reliability of the data that’s
Health Market Inquiry
18th May 2016
Page 326
___________________________________________________________________
available. So one thinks that there has to be a way of verifying the
accuracy of the data that’s available, now I understand that this
information would be information that’s sub mitted by the schemes
to
the
Council
of
Medical
Aids,
but
do
you
keep
data
independently?
DR GOOD
10
Through our work with various schemes, we do
work for a number of different players within the industry. We do
have access to schemes specific data, but obv iously depending on
how big the schemes are that you’re consulting to, that limits your
ability to actually verify specific trends off a significant sample.
JUDGE NGCOBO
I’m just thinking here of the way one can
verify some of the information that’s conta ined by the Council of
20
Medical Schemes in so far as example, it relates to pathologists.
Would you have a way of verifying the accuracy of what is with the
Council of Medical Schemes in so far as it relates to pathologists?
Health Market Inquiry
Page 327
18th May 2016
___________________________________________________________________
DR GOOD
Perhaps I can give you more of a bit of a comment
and insight.
I think the Council of Medical Schemes has been
collecting information for quite a long time.
I think the fact that
some of the trends we can only back to 2006, reflects the
improvements that are being made in the collection process.
Certainly the questions are raised around, sometimes we deal with
10
the data and sometimes we can actually see that there is no ways
that the data can be correct in specific areas, but I think significant
progress is being made through the Council of Medical Schemes
and the manner in which they collect data.
I think we are starting to get a very reliable source of information
for analysis of this nature to be done and I think the real trick is to
20
make sure that the Council of Medical S chemes continues to make
that data available, so that people can actually verify, because one
of our concerns is that they are going to be more restrictive in
giving access to the data for people to actually verify trends.
Health Market Inquiry
18th May 2016
Page 328
___________________________________________________________________
JUDGE NGCOBO
Perhaps if they know that it’s, because what’s
important is to work with data that is accurate and reliable, because
if you are working with data that is unreliable, the results that you
are likely to get and the assumption that you are going to make,
will be unreliable, woul d be wrong perhaps, so it’s a way of trying
to find out how does one ensure the accuracy of the data and its
reliability.
10
What information in the course of your practice, do you normally
collect that would assist in the collection of data?
DR GOOD
Where we have scheme clients, scheme clients
obviously they have administrative processes and managed care
processes which produce data points.
20
We do assist schemes by
taking the information and structure the information and do have
the ability on those specifi c clients to run the exact same models
and
same
exact
progressions
to
understand
utilisation and what do the trends say.
what
is
driving
Health Market Inquiry
Page 329
18th May 2016
___________________________________________________________________
One can verify, but obviously we don’t have the luxury of a sample
size of 8.8 million.
JUDGE NGCOBO
Would, you be so upset if you were required to
keep data as an independent body?
DR GOOD
I think the question is for MPG?
DR ERASMUS
Chair I am not exactly sure, would you please
10
repeat that, I am not exactly sure whether I understood what you’re
saying?
JUDGE NGCOBO
Would it be so disruptive of your practice if
you were to be required to keep data of what you are doing?
20
DR ERASMUS
Chair I am not sure that it is the MPG’s
responsibility to keep data.
It would of course be the obligation,
the obligation would then fa ll on the individual members to provide
that data.
I understand that each of the members has provided
Health Market Inquiry
18th May 2016
Page 330
___________________________________________________________________
significant amounts of data to this Inquiry, but I just wanted to
emphasize the point that it would be inappropriate for the MPG as
an entity, to keep th at data.
JUDGE NGCOBO
The
issue
responsibility to collect data.
is
not
so
much
who
has
the
All I’m asking is would it be
disruptive of your practice. These are your members and I have no
10
doubt that you would be interested in the trends and what is
happening with regards to your discipline. Won’t you be interested
in that?
DR ERASMUS
Chair
that
information
surely
would
be
competitive information and I personally would definitely like to
be entrusted with the various sources of information put together
20
for me to combine in any manner whatsoever.
The practices
certainly keep their data and deal with the data in a very
appropriate manner and that is available from them, but as the
group, I do not believe that is our role.
Health Market Inquiry
Page 331
18th May 2016
___________________________________________________________________
That is why we depend on public s ources of data being specific to
the report of the Council for Medical Schemes and the use of a
company like Prognosis Life Choice who have found significant
objective outside value to that data and gives us a perspective of
the position of where we stand thank you.
JUDGE NGCOBO
10
Do not misunderstand me, no one is suggesting
that you have that responsibility, whether that’s your responsibility
is not the issue. The issue is would you be prepared to take part in
the exercise of ensuring that the data, which relates to pathologists,
is accurate. If you are not, it’s okay.
DR ERASMUS
Chair the answer to that would have to be a
qualified yes, but one always needs to understand greater detail,
20
but I suppose that’s the best way I can do given the circumstances
thank you.
JUDGE NGCOBO
I’m asking this because the new Act which is
the National Health Act has a provision which deals with the
Health Market Inquiry
Page 332
18th May 2016
___________________________________________________________________
collection of data, the format and so on.
In due course, I would
imagine which must be collected by the service provider th at is
including the radiologists, so all that I am trying to find out, is
your preparedness to help in the exercise of ensuring that the data
that is being collected, in so far as it relates to pathologists, is
accurate.
10
DR ERASMUS
Chair I think the answ er to that, can only be in
the affirmative definitely thank you.
We will then continue with the 2 aspects, the one which we
specifically mentioned, the issue of employment of doctors by
hospitals and then also move on after that, to the in quotation
marks, the add-on testing.
20
Many groups have suggested that the employment of doctors and
specifically pathologists, would lead to cost savings.
Now we do
not believe that that is a solution, or we do not believe that that is
appropriate.
Health Market Inquiry
Page 333
18th May 2016
___________________________________________________________________
Firstly, the current e thical rules of the Health Professions Council
preclude that and not only does it go as far as saying that this is
unethical, but in addition, it isolates pathology and radiology
practices and indicate that and this was based on a request from
ourselves an d from in other words, pathologists and radiologists,
that we wanted it specifically included that these practices may
have no outside shareholding of any person other than a pathologist
10
or a radiologist, to preclude any possibility of an unethical conduct
or a kickback system which could flow from that.
The difficulty with employment of doctors by commercial entities
would be that the doctor is placed with a split and a dual loyalty.
On the one hand, the loyalty towards the patient, the ethical
responsibility of the patient and then if the doctor was employed by
20
another party, the commercial entity with a loyalty to your
employer who may or may not, but certainly the possibility exists
that there could be pressures on you to reduce the number of staff,
to use cheaper reagents, to use inferior quality equipment and also,
possibly, to reduce the number of pathologist ratio to the test.
Health Market Inquiry
Page 334
18th May 2016
___________________________________________________________________
You have noted before when we said that there are three hundred
pathologists who are currently managing this large volume of tests
with all the complexities around there and all the difficulties
involved, so that is a very real risk and we believe that this is an
area that we cannot see why it would lead to any reduction in cost,
because the costs for all the parties would be t he same and we
believe there is a very real risk of unethical conduct following this,
10
so that ends as much for the employment of doctors.
I will then touch on the aspect of the add -on testing.
JUDGE NGCOBO
Mr Erasmus, I think they raise it in the context
of fragmentation of healthcare.
MR ERASMUS
Chair excuse me, I’m lost now.
JUDGE NGCOBO
Employment of doctors by hospitals, they have
20
raised that in the context of the fragmentation of healthcare
services which they say is fragmented, whereas if you empl oy, if
Health Market Inquiry
18th May 2016
Page 335
___________________________________________________________________
you allow hospitals to employ doctors, everything would be done
in-house.
MR ERASMUS Chair in fact it is done in -house now. They get the
service right inside their hospitals.
JUDGE NGCOBO
If that is so, why do you object to it then?
10
MR ERASMUS Chair I will not react to that if you will excuse me,
thank you. Slide 117 is what I am referring to. You used the term
add-on testing.
Now I suppose that is a descriptive term and in
substance what it is, but we believe that an appropriate term is
reflective testing.
20
Some parties, who want to do this in a derogatory manner, say
reflex
testing.
Now
for
me,
a
reflex
is
where
you
react
involuntarily in a specific direction or manner over which you have
no control and that is absolutely not what reflective testing is in a
laboratory.
Health Market Inquiry
18th May 2016
Page 336
___________________________________________________________________
The international term is reflective testing.
It is a worldwide
practice. I suppose one could compare it to the fact that should a
gynaecologist or a surgeon do a laparotomy and find a tumour on
examination and find other pat hology, the patient is primarily being
operated for tha tumour, but find other pathology, it would be
irresponsible of that surgeon or gynaecologist not to attend to that
condition.
10
Now
we
believe
when
a
pattern
emerges
within
a
specific
diagnostic set of circumstances, that it is appropriate and would be
irresponsible if the pathologist did not add -on that test, but we
know this is a potential minefield and because of that, because of
the potential of these accusations that are levied against laboraties
and in fact, it is really unfair.
20
In fact, these reflective tests result in no more than 1% increase in
laboratory testing and one needs to understand that within that, are
the group of tests that doctors themselves specify to the laboratory,
if you find this or that, continue to do the following.
Health Market Inquiry
Page 337
18th May 2016
___________________________________________________________________
Laboratories do not want to act on their own.
They would prefer
not to do so. In such circumstances, it would be irresponsible not
to do so and in some circumstances, it is ideal to do so because it
saves the patient a re-visit, the cost of a re -visit to the doctor, the
cost of another specimen being taken is saved by having the test
added.
10
To be in specifics, an area where these tests is added on, is in the
area of allergy.
We have in our previous submission a nd in also
our current submission, we refer to our guide to coding where the
National Pathology Group guides our members in terms of which
codes to use, also having included a protocol that was negotiated or
rather agreed to between ALSA, the Allergy Socie ty of South
Africa and these are allergologists who function in different or
20
come from different disciplines.
Ear nose and throat specialists, paediatricians, physicians, general
practitioners have agreed to a specific protocol in terms of
approaching patients with allergic conditions.
What this proposal
Health Market Inquiry
Page 338
18th May 2016
___________________________________________________________________
has done in totality, it has reduced the average overall cost per
patient and it has improved the specificity of the eventual result
which the patient receives, so it has definitely improved patient
care.
This perspective that there is a spray painting kind of approach in
terms of added-on testing, is not appropriate and I think with that,
10
there are other aspects also to be noted in other conditions, auto
immune conditions and of course the total or the f ree PSA and a
number of other specific issues, but allergy is probably fairly high
up on the list which doctors are aware of.
As far as I know, I have dealt with everything now.
I think the
other issues are really not specific, or they are there, but if you
20
would like to raise any questions, I think we have covered of what
we have said, but we are open to questions thank you.
JUDGE NGCOBO
Thank you Dr Erasmus.
My colleagues are
going to raise issues with you. We will start with Dr van Gent.
Health Market Inquiry
Page 339
18th May 2016
___________________________________________________________________
DR VAN GENT
One minor issue and it is about the
robustness of the data and the Judge alluded to that question. Yes I
am a bit hesitant to do that, but I will. Dr Good you used Siemens
data, Siemens data are normally very good, robust, but it is also of
course what you do with the data and we will come back, we do our
own analysis on even deeper data than the Siemens data and we
will find out what is really happening.
10
Just a minor question, in your presentation you show us some
graphs and I get quiet nervous if I se e something of a 20% drop
from 2013/2014 claims or an increase in one year, 20% in
utilisation. You must have been more nervous than me seeing that
drop or increase. What is behind that?
20
DR GOOD
I agree with you in terms of when one sees
within data sets, fluctuations like that and obviously when one sees
the drop, one does the various tests to check that the data you’ve
received, you’ve run properly to actually try and interpret what is
behind it.
Health Market Inquiry
18th May 2016
Page 340
___________________________________________________________________
That is where it is very difficult to, in terms of if we were actually
specifically looked at some of the graphs, I mean the starting point
of 2002, I was also going to show you that, I also wasn’t very
comfortable at the starting point of 2002, because if you looked at
the pathology costs in 2001, they were actually higher than 2002
and then they suddenly dropped, so I think while we must credit
that
10
the
Siemens
data
process
is
improving,
we
will
also
acknowledge that there are sometimes concerns with the patterns
that come out.
DR VAN GENT
We will find ou t, you can’t answer my
question. I am a bit nervous on the robustness of the analysis done.
Dr Erasmus I really want to understand what the employment by
hospitals and the resistance by individual pathologists is all about.
20
I am not really sure what your relationship is.
Are some of the
pathologist’s members, or do you have relations to one of the three
big pathology groups? Are you employed, or are you a partner of
one of the pathology groups?
Health Market Inquiry
Page 341
18th May 2016
___________________________________________________________________
DR ERASMUS
Chair no I am not associated with any practic e
at all. I have now for in 2001, I left Ampath, I was a haematologist
before that, but subsequent to then, to that point, well up to now, I
have only been involved with the national pathology group and not
any specific practice thank you.
DR BRAMDEV
I’m a partner at Lancet Laboratories.
10
DR RAMBAU I’m a partner at Lancet.
DR VAN GENT
So partners of organisations like partners in
lawyers, partners in a law firm or in an audit firm or a consulting
firm, can be under considerable pressure within their orga nisation
in terms of the turnover they have to come up with. I remember a
20
friend of mine was a partner in a law firm and I was really feeling
pity with the guy about the pressure he was on and in some years,
probably not adhering to the targets that he wa s set, so you are all
part of a commercial organisation.
Health Market Inquiry
18th May 2016
Page 342
___________________________________________________________________
You have pressure to produce, so how is that different from being
under pressure, possibly under pressure from a hospital if you are
employed by a hospital, not even being a partner within that
hospital, but just being employed by a hospital. I ask that question
because so I am from the Netherlands, we have a private healthcare
system, so private hospitals, private insurance companies. Half of
our medical specialists are employed by hospitals, half of them are
10
self-employed.
They are free they can do what they want. I think there is a light
preference from the government for employed doctors, precisely
because
of
the
question
that
the
Judge,
because
of
the
fragmentation point that has been put forw ard to us, the fragmented
nature of healthcare in South Africa.
20
In the UK, exactly the same, the private healthcare sector in the
UK, doctors can either be employed or not be employed, it is their
choice.
Even within your own reasoning, I find inconsiste ncy in
the sense that you explain to us that there is a concentration of
Health Market Inquiry
18th May 2016
Page 343
___________________________________________________________________
pathologists in pathology groups and I do understand that there is a
technology driven part of that, but there is also the complexity, the
super-specialisation etcetera, so you have t o come up with that and
working in multi -disciplinary teams.
Exactly
the
same
goes
for
within
hospitals,
also
there
the
complexity is enormous I think and it has grown enormous and the
10
same argument applies for working in these teams, these multi disciplinary teams within hospitals, so the same argument that
applies to your group, could apply and it applies I do think to
hospitals.
Why would a pathologist or a medical specialist, give in to pressure
from a hospital?
20
Why would a journalist that is being p art of a
commercial group or a commercial firm like almost all journals and
journalists are employed by journals that are part of the commercial
group, why would they not be, I mean full grown and ethical
themselves, not pointing to the ethical rules of so me organisations
somewhere, but pointing to your own ethical rules.
Why would
Health Market Inquiry
Page 344
18th May 2016
___________________________________________________________________
they be compromised because of the fact that they are employed by
commercial organisations?
DR ERASMUS It is obviously not an absolute.
One of the
interesting things, I was in the pathology partnership for about
twenty years and you speak about pressure on turnover. Now in all
that time, never ever, were there issues of pressures of turnover.
10
There were concerns about turnover, there were concerns about the
fact that there ar e fewer patients coming for testing and is there
something happening, but the focus is on quality and the other
paradox about a pathology practice, it consists of equal partners
and it is in a sense, some of the most chaotic components that exist,
because they all have an equal opinion.
20
But the risk of an outside group who employ you, it is different, it
is just very different.
You are beholden to that person for your
pension, for whatever, so I do believe and you say that that
ethicality intrinsic of you , I think all humans have a difficulty with
these aspects and the risk of this going wrong.
Health Market Inquiry
Page 345
18th May 2016
___________________________________________________________________
It is an opinion and obviously we cannot talk about absolutes, but I
think there is a very real risk thank you.
DR VAN GENT
We are repeating actually the arguments put
here, but I gave you a number of other arguments and I would like
you to just comment on that?
10
DR BRAMDEV
I think as a doctor, the fact that you work for a
corporate entity like a hospital group, I think the bottom line is that
corporate entities are driven by profit.
As a doctor, you have an
ethical and clinical responsibility to your patient.
The biggest
concerns for doctors working for corporates, I think would be the
loss of your clinical performance.
In other words, there would be restrictions on the way you practice
20
and there would be protocols put on the way you can treat, there
will be limitations, because it is all driven by the cost and I think
that is the biggest concern not just amongst pathologists, but among
all clinicians and we just w ant independence to practice proper
Health Market Inquiry
Page 346
18th May 2016
___________________________________________________________________
clinical care without any business or economic reasons to curtail
the way you treat a patient.
DR KHAN
As a Microbiologist, I do deal with hospitals, I do
train pharmacists and infection control sisters and I am proud t o
say that in working in Ampath, I am not driven by any cost
whatsoever and I don’t have to produce based on turnover how
10
many specialists or what I do.
I enjoy my work and the one
problem I do have and I know there are some hospitals here, but as
a microbiologist, when I have to deal with a physician looking after
a patient, for example, if I am employed by a corporate by the
hospital, I’ll have argument every day.
They are driven by costs, so the antiobiotics that they use, are
20
probably generics and in micro terms, we can see if a patient is on
a particular antibiotic, by the blood results, we can see whether
they are responding or not.
Health Market Inquiry
Page 347
18th May 2016
___________________________________________________________________
Many times, we ask the clinician, he is on the appropriate
antibiotic, but why is he getting worse looking at the num bers and
9 times out of 10, the patient is on a generic antibiotic and we fight
in some circumstances to use the ethical proper antibiotic and many
times, we have seen that once the ethical antibiotic is used, the
patient responds dramatically, so I defini tely will have a fight with
them.
10
DR RAMBAU As a pathologist, you have got a responsibility at all
times, to act in the interest of the patient and you have to keep
yourself uptodate and employ evidence based medicine, the current
evidence based medicine.
Now there is a process of continual improvement to look at the
20
system and within Lancet, I am very much responsible in looking at
the new tests, looking at the new methods when technology
improves, we have to look at it and see how best we can serve the
patient.
Health Market Inquiry
18th May 2016
Page 348
___________________________________________________________________
Now if I am under a corporate, or under a non -laboratory
employment, that may not fall within my responsibility. Someone
else will take the responsibility to look at the capital investment
which will suit the company or the corporate.
I will not have the
free hand to look at what is quality, what can I experiment with,
because currently within the Lancet group, we have got a free hand
to look at what is available out there.
10
We test them, we reject
some, we accept some based on their performance.
We benchmark ourselves against the international groups in order
to be uptodate at all times.
20
DR VAN GENT
Thank you very much.
JUDGE NGCOBO
Can I just press this point a bit, you know the
example that we were given as I recall, is the case of a patient who
suffers from a heart condition, chest condition, maybe something
wrong with the brain, so that it would be desirable to have that
patient who is at a facility to have access to only the specialists
Health Market Inquiry
Page 349
18th May 2016
___________________________________________________________________
that he might need as opposed to being treated by one specialist,
only to find out that the other condition requires another specialist,
whereas if they all work together, they can all have equal access to
that particular patient.
DR BRAMDEV
I think Mr Chair if I could answer that, I think
what you are descr ibing certainly exists.
10
I don’t think you need
employment by a corporate entity to have that existence, because
they already exist. Most of the facilities have multiple disciplines
in one place, including pathology labs and complex specialised
centres as well. So you don’t need to be employed by an entity to
have that in existence.
JUDGE NGCOBO
20
On a different matter, as I understand it, you
practice in a group and within the group, there are different
disciplines right, microbiologists and the others th at you have
described this afternoon.
complex cases?
Now do you come together to discuss
Health Market Inquiry
Page 350
18th May 2016
___________________________________________________________________
DR KHAN
We do, we need other disciplines, probably we
will walk to them, so I will probably have to correlate for example,
chemistry, if the liver functions are up, I would want more
information from the Chem Path and discuss with him, my clinical
case, whether it’s infection, whether it could be a hepatitis,
whether it could be an auto immune condition.
10
I also speak regularly probably with the haematologists like wi th
the case of appendicitis, there was a lymphophenia and I wanted the
haematologist to have a look at the slide and to advise me further
on the lymphophenia whether we’re missing something else on this
patient and spoke to the haematologist about that cli nical case in
particular.
20
We also walk to the histopathologists and they have like multi header microscopes and often if we have a pathology that we want
to tie in with what they see, we have that report available, or vice
versa, they may call us to have a look at what they are saying, not
that we understand what they are saying in any case, but we
Health Market Inquiry
Page 351
18th May 2016
___________________________________________________________________
correlate with the clinical findings and many times, we need
multidisciplinary input and assistance from the various disciplines.
DR NKONKI
Thank you very much for your presentation, my first
question is on that you are an industry body and I would like to
know if you do have any concerns or interests in monitoring
perverse incentives that your members might be prone to?
10
DR ERASMUS Dr Nkonki I think if there is one expert on perverse
incentives in South Africa, I think it’s me. Now that sounds rather
ridiculous, I am not saying that in a facetious manner, but there
was an issue of perverse incentives which arose in the laboratories
in the late 1990’s. I was at that time, the Chair and really carried
the can for what was happening or what was supposedly being
20
exposed with different practices.
I am very grateful to say that the practice that I was involved in at
that time, Bouwer and Partners, which was not yet at that time, part
of Ampath, there was absolutely no issue about that at all.
Health Market Inquiry
Page 352
18th May 2016
___________________________________________________________________
Nevertheless, we were faced with this pathologists with this very
negative image that had been painted of kickbacks that had
occurred in the profession, or that were believed t o have been
occurring.
I never was ever personally seen anything of that nature at all, but
was told that this was happening.
10
At that time, I said to the
members, this is absolutely totally impossible for us to continue
practicing if this is an issue wit hin our profession and it is totally
unacceptable for me to continue functioning in the role that I am in
if this was the way that things were going to happen.
At that time, we requested the assistance of Professor [Sus] Strauss
at the University of South Africa and he created a new constitution
20
for us, a peer review component of that constitution, but then
specifically our code of ethics.
Now that code of ethics, we
submitted eventually to the Health Professions Council and it
appeared on the advice of P rofessor Strauss and this is who
compiled it, that we were possible exceeding our powers in
Health Market Inquiry
Page 353
18th May 2016
___________________________________________________________________
quotation marks if you could call it that, because in essence, this
was changed then to indicate that our code of conduct was
supplementary
to
the
Health
Profession s
Council,
but
could
obviously never replace this.
This was never the intention for that to do so, it was the creation of
a document which gave clarity in concrete terms to issues that
10
pathologists had to deal with at a practical level.
This code is
available. The code was included in our submission and everyone
of our members is obligated when becoming a member, to agree to
abide by that code of conduct.
So I do not believe it is an issue at all in the profession anymore.
Where it is an issue, that pe rson should simply be reported, thank
20
you.
DR NKONKI
I see that on slide 119, you do talk about the peer
review process, so what I would like to know, is what do you, you
mentioned that you have both the [inaudible] and the peer review
Health Market Inquiry
Page 354
18th May 2016
___________________________________________________________________
process, what do yo u do with the findings from the peer review
process?
DR ERASMUS We have a formal peer review process which is
accessible to anybody who should complain and it’s a rather
complex structured process and in fact, to be honest with you, I
have never ever had a complaint which has to go through a formal
10
peer reviewed structure as indicated in the document of ours, but
there have been concerns raised either by patients, or by colleagues
about another colleague where one deals with an issue in an
informal manner amongst the groups who are involved, requesting
for instance, feedback from a practitioner, that is a patient who is
unhappy about a specific cost or a specific result and resolving that
more at a level of an Ombudsman as opposed to a formal peer
20
review process.
So we do not have a monitoring process for results in the broad
sense in terms of monitoring whatever components of the process.
There is the formal accreditation which exists, but there is not a
Health Market Inquiry
Page 355
18th May 2016
___________________________________________________________________
formal monitoring process that exists, but the peer review process
is there should anybody wish to complain and of course their
complaints could always be lodged with the Health Professions
Council.
DR NKONKI
So you don’t have any sanctions for, if you were to
find a member who is not practising appropria tely?
10
DR ERASMUS We are not allowed to have any sanction. The only
sanction which we may have is to request a member to leave and
not be a member of our group anymore.
I think that does weigh rather, the irony is that members are aware
that other member s look out for them and look at them, so that
20
awareness of your group, that peer group around you, I think is a
very important mediator and motivator to act in a specific manner,
so we are not legally or in any way, able to act in a disciplinary
manner tha t belongs to the Health Professions Council of South
Africa.
Health Market Inquiry
18th May 2016
Page 356
___________________________________________________________________
DR NKONKI
My final question is with the issue raised by other
stakeholders around charging specialist fees when the tests were
not
done
by
a
pathologist,
but
maybe
done
by
a
medical
technologist.
DR ERASMUS In
teamwork.
10
fact,
our
total
discipline
in
fact
exists
of
A laboratory is a team of people working together.
You’ve seen the numbers of specimens involved. You’ve seen the
numbers of medical technicians and medical technologists who are
involved and the number of pathologists, so pathology by its
nature, does not mean that I have to tighten the bolt on the car
that’s going off the assembly line.
My involvement could be the totality of the process whereby the
20
assembly occurs and that could b e simply intellectual information.
It does not have to do with anything I do, so pathology is a totality
of a service, of which the analytical component is but one.
You’ve heard earlier from Dr Khan how much time is spent by the
pathologists interacting n ot with an individual result, you heard
Health Market Inquiry
18th May 2016
Page 357
___________________________________________________________________
about the infection which happened in the neonatal ward in the
infection
control
meetings
that
are
held
in
hospitals.
The
involvement of pathologists at the National Cancer Registry, all
these aspects are contributi ons that we make in a very broader
sense, so we believe it is a very superficial perspective to say a
pathologist did not do that one test, but the fact remains that that
test was done within the environment and control and within the
10
parameters set by the pathologists.
So we believe it is perfectly appropriate to charge a specialist rate
for that thank you.
DR NKONKI
In a case where the results ae generated by a
computer and there is no interpretative report accompanying the
20
test, do you still think that in principle?
DR ERASMUS Sorry my apologies, my attention was lost there for
a minute. May I ask you to repeat that please?
Health Market Inquiry
Page 358
18th May 2016
___________________________________________________________________
DR NKONKI
So in instances where the results are generated by a
computer and there is no accompanying interpretative report, do
you still that in principle, that should be reimbursed the same?
DR RAMBAU I have addressed this on my slide in the reviewing
of results.
There is a section on auto -verification.
It is the
responsibility of the pathologist to set up the rules on the IT sys tem
and this is based on the common conditions, it is based on the
10
performance of the systems in the laboratory and these get
reviewed regularly.
The other component includes the previous results and also, the
accompanying results, the core testing that h appens at the same
time, so in other words, you set up the roles, the algorithm which
will pull for example the LFT, it will pull the UME and this is
20
specific in that particular laboratory.
It is not transferable. What you have set up in that laboratory, you
can’t copy and apply it in another laboratory and it is only valid for
a certain period, after which you have to review that, so it is a tool
Health Market Inquiry
18th May 2016
Page 359
___________________________________________________________________
a pathologist uses, so it still falls under the pathologist, so the
section on the slide, I have indicated th at there are those which fail
this auto-verification and they fall to the screen for the pathologist
to actively do that, because you can’t possibly code everything.
You
can’t
programme
for
everything,
but
those
which
are
programmed, according to the rule s, they will go, but they will pick
up the relevant comment and go out.
10
It is not that they go without a pathologist, adding any value to
them thank you.
20
DR NKONKI
Thank you.
PROF FONN
I am going to pick up on some of the questions from
my colleagues.
The one is the issue you say working for a
corporate, but you all work for a corporate, it’s called Lancet, it’s
called Ampath, so I don’t quite get where the line suddenly
changes?
Health Market Inquiry
18th May 2016
Page 360
___________________________________________________________________
DR BRAMDEV
I think the pathologist who work for a company
like Lancet, own the company, it is all owned by doctors and
pathologists.
There is no outside party there is no shareholding
with anybody else but the partners.
PROF FONN
I understand that fully, it only means that your
interests in terms of profit are even more perfec tly aligned?
10
DR BRAMDEV
I think the point that I made earlier, I think the
key issue is that the doctor partnership is only interested in clinical
care as a primary objective. In as much as it may sound that there
is like a corporate, some financial ince ntive, but I think as Dr Khan
has clearly stated, there are many examples in pathology which
shows that if you work for a corporate, you’ve got restrictions in
20
terms
of
what
kind
of
tests
you
can
do,
what
kind
of
recommendations you can make without the cl inical interest of the
patient at heart.
Health Market Inquiry
18th May 2016
Page 361
___________________________________________________________________
PROF FONN
I hope you’re right that all these doctors are
apparently so pure, because even the individual doctor working by
himself or herself, is just as likely to decide to do additional
investigations where the i nterest of the patient might not be
compromised, but it might not be entirely necessary either.
So I think this notion of this doctor, being one myself, as being a
10
perfect human being who has never a conflict of interest or would
never imagine over -charging or doing an extra test here and there,
doctors income is determined by the activities they do, particularly
in a fee for service environment and under these conditions, the
potential to increase your fees exists.
DR ERASMUS Proff
20
Fonn
obviously
everyth ing
that
you
are
saying, is true, because none of these are absolutes, otherwise the
answers would be very simple.
The one advantage is that in
pathology, it is a referral specialty.
We do not go and catch
patients and collect blood. The specimens are s ent to us by doctors
who have absolutely no arrangement with the laboratory in terms of
Health Market Inquiry
18th May 2016
Page 362
___________________________________________________________________
financial aspects at all and I believe that that is a huge difference
compared to other clinical disciplines who see patients off the
street.
We do not see patients of f the street and I think that is a feather in
our cap, thank you.
10
PROF FONN
The other question I want to ask in terms of
decisions around purchasing of latest equipment and those kinds of
things,
keeping
up
with
standards,
being
internationally
competitive, in relation to that, do you do formal health technology
assessment?
If you do, do you include cost benefit analysis and then if you do
20
do cost benefit analysis, what denominator population do you use
and thirdly, are these available in the public domai n? Can I come
and get it? Can a patient come and get it? Can a competitor come
and get it? Can a doctor who refers to you, come and get it? Can a
hospital group who uses you, come and get it?
Health Market Inquiry
Page 363
18th May 2016
___________________________________________________________________
DR RAMBAU Now in the introductions new technology, we follow
the CLSI guidelines, the majority of the member laboratories use
CLSI as standards and we don’t do the cost benefit analysis as you
would find for example, with the European laboratories or with the
NHS, where they publish those detailed evaluations.
We largely would do the verification which is a downgrade on the
10
validation.
Now the validation is performed when there are
completely new tests which are not on the market, it’s a new test
which has just been developed where you have got to do the
clinical validations and those we rarely do.
If they are available, they will be done in conjunction with the
universities, but because we test, we verify for use, we only verify
20
it for suitability in our environment to try and verify whether the
manufacturers’ cl aims hold, whether the total error allowables in
other words, the performance specifications are met.
We do not
have regular training environment, where we have to meet certain
Health Market Inquiry
Page 364
18th May 2016
___________________________________________________________________
things like you have with the [inaudible], we don’t go to that
extent, we only do just for implementation and that is limited.
We do the stability testing, accuracy testing, just comparing the
two methods, one against the other.
PROF FONN
So then I am correct in assuming that basically what
you do, is test and see that the machine says it does and that in fact
10
it is quite possible, although we might be having state of the art,
we might be having something that is totally inappropriate and
unaffordable for our population, because we’ve never tested it, if it
is in fact something that is cost effective and therefore brings
health benefit, given opportunity costs.
DR RAMBAU The suppliers we use, commonly the same suppliers
20
which are used, worldwide, now they would have information
which they gained from the validation of these analyser s, although
the costs may not be transferable to our country, so that element,
that aspect, we really don’t look at at all.
Health Market Inquiry
18th May 2016
Page 365
___________________________________________________________________
PROF FONN
And then still on the cost issues, these reagents that
you use in your industry, how complicated are they?
What is so
special about them that there is no industry in South Africa that can
produce them, or is it that there is international copyright on them?
I mean why is it that we have to import everything?
DR RAMBAU Yes the majority of reagents, maybe with a few
10
exceptions in microbiology where you can have you own media,
nearly all reagents we use on our platforms, are imported and they
are patented, so you can’t use them across platforms.
If you’ve got a Roche platform, you can’t use the Abbot, so there is
exclusivity.
There is certain information which we can’t get even
if we request from these suppliers.
20
In fact, reagents are not
compatible with each other, to an extent that if you do try, some
reagents from one platform will damage another platform if you do
try another laboratory, so it is very exclusive.
Health Market Inquiry
Page 366
18th May 2016
___________________________________________________________________
DR ERASMUS As I said, I was a haematologist and there was a
time in the early phases of these flow cytometric type of analytical
machines that became available, that Lennon, the group who make
the little whatever bottle drops, started making what they believed
to be largely water containing not too significantly complex
chemicals and we certainly tried them locally here and we burnt our
fingers badly.
10
We burnt our fingers badly in terms of damage to the machine,
unreliable results, in the end it was not worth the salt at all. That
was my personal one very bad experience.
PROF FONN
Well, that seems to be very clever of the suppliers.
The other question that I have and it might be in your code. I have
20
read it, b ut I don’t remember.
Do you encourage the members to
make their quality control processes or protocols available to the
public?
DR ERASMUS Not specifically, no.
Health Market Inquiry
Page 367
18th May 2016
___________________________________________________________________
PROF FONN
Would you be surprised if they refused to give it to
someone who asked for it?
DR ERASMUS I am not exactly sure, I would love to answer, but I
don’t know exactly how to answer, what the question is. I am a bit
lost.
10
PROF FONN
So if I came and said I want to know exactly what
happens after my specimen from a swab came into your laborat ory,
what is your protocol until such time as it arrives in your
laboratory and I get my result?
DR ERASMUS I am sure nobody would object to that at all.
DR RAMBAU I just want to confirm that yes, that is available, that
is not confidential information, be cause that is what the doctor
20
would get if the doctor wants to know what the quality control
procedures, or what have you done to make sure that this result is
reliable and it is valid.
PROF FONN
And patients?
DR RAMBAI
Yes the same applies to the patient.
Health Market Inquiry
Page 368
18th May 2016
___________________________________________________________________
PROF FONN
I am sorry I want to ask some questions and this
arrived this morning when we had started which is your document
in spite of asking for it in advance, so I haven’t had time to read it
and it is not the same the document that I have in front of m e,
particularly in relation to the various actuarial investigations,
because the document that I could look at before, went back to
2009 and not 2002, so if you don’t mind, I have no choice but to
10
refer to the other document.
So I understand from the writ ten document that you gave us, it is
not paginated, so I can’t tell you which page to look at, but it is
where your section is, that is all I can say.
You say that when
correcting for increase in utilisation, it is found that pathology
costs per utilisati on, have increased by 19% in real terms.
20
So I understand this to mean that you have taken utilisation into
account, so in addition to utilisation, there is still an increase in
costs?
Health Market Inquiry
Page 369
18th May 2016
___________________________________________________________________
DR GOOD
In the extended version of that report, we do
specifically d eal with utilisation, because the Council for Medical
Schemes report utilisation figures, actually need to be understood.
The ideal thing to use would be actually the number of claims. The
utilisation reports is actually the number of visits, so when one
sees that increasing amount of 19% per utilisation, one is unable to
take the analysis deep and say is that an increase in the number of
10
actual items tested per visit, or is the number of items per visit
constant.
PROF FONN
The costs have gone up in addi tion to utilisation,
that you’ve taken utilisation into account, isn’t that what the
sentence means?
It might not mean what you meant, but that is
what it would mean by taking utilisation into account, it means you
20
have nullified the effect of utilisation .
DR GOOD
I think the correct position, is that all we are
able to, the only aspect of utilisation that we are able to sort of
correct for, is the number of visits. Obviously within these visits,
Health Market Inquiry
18th May 2016
Page 370
___________________________________________________________________
there could be a significant number of tests.
There is s till a
component of utilisation that cannot be corrected for.
PROF FONN
So then you say this could be a result of more tests
being requested per visits, or more expensive tests being requested,
or simply charging more, which is what you have left off?
10
DR GOOD
One
could
add
that,
but
obviously
when
dealing with scheme data, one has a sense of in terms of what the
changes have been across the industry from tariff perspective and
how tariffs have increased and by and large, in our experience,
what we have seen, is that the tariff components have really got
inflationary or pretty close to inflationary linked increases and
there haven’t been significant charges in increasing a specific
20
tariff.
PROF FONN
I was wondering if you work for the national
pathology group, why couldn’t you use the actual data?
Why did
you have to rely on CMS data? You work for the groups, they are
Health Market Inquiry
18th May 2016
Page 371
___________________________________________________________________
asking you to do it, they, have the data, why didn’t they just give
you their data?
DR GOOD
We did indicate to the national pathology
group, that the ideal would be to get all the various memebrs’ data,
so that you can actually check what is happening to the case mix,
what is happening to tariffs etcetera, but I think that given South
10
Africa’s entry, or fears around what we constitute an ti-competitive
behaviour, most of the groups weren’t comfortable to embark on
such an exercise.
PROF FONN
I wonder if their lawyer wants to comment, given
that they could give it to you totally anonymised, you would have
no idea and pooling the data, woul d have absolutely no affect on
20
competition.
ADV GOTZ
I am involved in no less than 5 cases at the moment,
where industry exchanges through an external party, or an industry
association,
have
raised
concerns
amongst
the
Competition
Health Market Inquiry
18th May 2016
Page 372
___________________________________________________________________
Commission.
There are o f course ways to do it, but the moment
individual members start to channel data to either the MPG or to an
external service provider who at some point, is expected to
aggregate that data and report back, you are in dangerous waters
and in dangerous terrain and I think that has been the concern.
I also point out that in terms of the exercise that is being conducted
10
here,
of
course
the
pathology
groups
would
not
have
the
information in relation to other medical specialities and so, it may
not be appropriate to use data from the pathologists to compare to
CMS data for the radiologists.
I expect one would want to get one’s data from a similar source, so
in
20
terms
of
the
exercise
being
contemplated
here,
I
would
respectively say that the CMS data is probably th e most appropriate
to use given these exercises.
PROF FONN
Certainly, if you were going to compare with other
specialties, but if you want to look at pathology costs, it is not. I
Health Market Inquiry
Page 373
18th May 2016
___________________________________________________________________
wanted to explore something you said earlier where you said well
the things that make people decide where to go, is how close and
how their quality and the turnaround time and I would put it to you
that certainly in the big metros and in the big cities, the answer is
they are equally close, we apparently know nothing about their
quality, so we know they are accredited, so they meet the minimum
standards and I would suspect that they have pretty much exactly
10
the same turnaround time, so given that those things are constant,
why does Dr X go to Lancet, Dr Y refer his patients or he r patients
to Path Care or to Ampath, or to one of the other groups? Do you
have any idea on that?
DR ERASMUS I would imagine that personal relationships in a
sense of you heard earlier in the presentation, how much the
20
pathologists intereact with their clinicians in terms of telephone
calls, either phoning them, or receiving telephone calls, so I would
imagine there would be a natural trend for the person who you
know that laboratory you would tend to use.
Health Market Inquiry
Page 374
18th May 2016
___________________________________________________________________
There is no obligation obviously, but it would m ake your process of
communication easier, I would imagine, but there are undoubtedly
areas of pathology which are even super specialised where specific
pathology practices have expertise which the others do not have,
although with the amalgamation of the p ractices currently, the
practices are all very large and really are largely commensurate in
terms of the availability of their professional resources and the
10
quality of work that they are rendering, so I think they would be
very comparable and I think we a re in a fortunate position for that
competition to be there and for this choice to exist thank you.
PROF FONN
One of the issues we had quite a lot of feedback on
from the schemes I think, I think all of them, was the issue of Z
codes, Z codes.
20
So I notic ed, I read through, it wasn’t that
interesting, but I can see it is very helpful, I read through the
national pathology group coding guidelines.
Unfortunately it
didn’t have the insomniac effect I was hoping for, but nonetheless
and it says there, that me mbers must ensure that the appropriate
Health Market Inquiry
18th May 2016
Page 375
___________________________________________________________________
descripted code is used for each investigation for tests performed in
their laboratories.
Now I thought this was at odds with what we had heard and then I
thought well maybe it is actually the linkage to the ICD10 co de that
is missing.
Is that correct?
So you code the test right, but you
don’t put the link code in and that is where the Z code comes in, is
10
that correct?
DR ERASMUS Yes the ICD10 coding, now we are dependent on the
clinician sending us an ICD10 code a nd by far, the majority do not.
Now one can appeal to them in circulars. This is done constantly,
because that is not what we want to do.
We are going through a
whole data collection process in any event.
20
Whatever we get, we
transfer to the medical sch eme, because that goes through with the
account to the scheme via the code that is used.
That is the code we get and then the other sets of codes which we
make ourselves.
The one set of codes is in the histopathology
Health Market Inquiry
Page 376
18th May 2016
___________________________________________________________________
environment, they code, they, diagnose and they code specifically,
because they know it is in their control.
Then we move to the clinical environment where often, or mostly
the results are not specific and unfortunately we have to use the Z
codes, the non-specific codes.
To do anything else would be
irresponsible and untrue.
10
PROF FONN
So this is where I come to the long description that
you gave us of what you do and how you add value and I know we
need pathology in decision making and I am really aware of that, I
am not questioning that for one second, but you also implied that
you interpret and if you don’t know at least differential diagnosis,
then what value and I am not talking about histopathology, because
20
often the diagnosis is made at histopathology, then how can you
interpret somethi ng meaningfully, or give any meaningful feedback
to a practitioner if you don’t know what the differential diagnosis
is?
Health Market Inquiry
Page 377
18th May 2016
___________________________________________________________________
DR ERASMUS It would be wonderful if we had that differential
available from the clinician, they say how can one do that, I believe
there are certain patterns that are visible, but these patterns are not
necessarily absolute, so on the basis of that and this is where the
interaction with the clinician frequently happens, is a telephone
call to say what is going on, what is wrong with this patient, can
we assist, there is a specific pattern here.
10
Unfortunately, one sometimes has to say the possible causes are, to
be looked at an excluded, so at least that assists the clinician.
In
the ideal world, it should be better, but unfortunately tha t does not
happen.
PROF FONN
20
There is an alternative explanation which is that in a
whole number of pathology tests, actually the referring physician
or GP or nurse, actually doesn’t need your interpretation. They can
interpret it themselves, because it is pretty straightforward and we
all know what normal levels for a hemaglobin are, because even if
we forget, you put them on your reports and so on.
Health Market Inquiry
Page 378
18th May 2016
___________________________________________________________________
There are a number of automated, I mean we are very fortunate
with the advance of technology and there are a huge number of
automated tests, so where I’m leading to here, is that what we are
interested in this Inquiry, is the soaring costs of healthcare and the
fact that they are becoming increasingly unaffordable for increasing
numbers of people which is exac tly the opposite of what we are
trying to achieve in the country and that, well let me put it this
10
way, is it not reasonable to assume that task shifting in relation to a
whole series of tests, is possible, that good diagnosis is possible
without the inter pretation of a pathologist and I would say that in
many instances, it is not.
I am not saying this is true for the entire industry or for the entire
specialty and that we have seen this happening in a few different
20
ways. The automation and the producti on of a once your machine
is calibrated, spits out the results, so you stick it in, it goes through
a whole series of tubes. In fact, there are half of us who don’t even
know anymore what to mix with what to make the real answers and
it spits out an answe r which can then be emailed in an automated
Health Market Inquiry
Page 379
18th May 2016
___________________________________________________________________
way to whoever receives it on the other end and they can interpret
it.
That seems to me, offers a potential cost saving. Further, we know
that there are many point of care tests, where in fact we don’t even
go through the pathology loop. I agree they have to be calibrated
and there certainly is a skill and a cost in that and that it seems to
10
me also that technology, new technology, clearly people who
develop it, put a patent and a premium on it, but technology has
become cheaper and cheaper.
We pay less and less for more
sophisticated computers, less and less for more sophisticated cell
phones and yet, we see absolutely no transfer of this in benefits.
Isn’t that surprising?
20
DR ERASMUS I disagree that you see no transfer. You see transfer
consistently in the availability of pathology services at levels
which increase below the level of inflation.
If you compare the
price increases in pathology per unit, I am talking per unit of
service, to the clinical servi ces, there is no comparison. Pathology
Health Market Inquiry
Page 380
18th May 2016
___________________________________________________________________
is at the lower rates, so the fact that pathology costs, this increased
automation and increased efficacy has been past through to the
patient already and is constantly being passed through to the
patient, both in qu ality and availability and in price increase which
is less than what would have been otherwise.
It is possible to rip out a piece of pathology, to say only that is
10
going to be done by the pathologist, all the rest is going to be
automated, but that single piece that you then have to pay for that
you dearly need, will be completely unaffordable.
You will just
not be able to pay for it at all.
You’ve seen the ratio of pathologists to specimen and that puts us
where we are at the moment, so if you reduce th at even further,
20
thinking that if you take the pathologist out of the permutation, you
are going to reduce your costing, I think that is a dream.
PROF FONN
I don’t want to get rid of pathologists that, is not
where I am going with this.
I suppose if any of the submissions
Health Market Inquiry
18th May 2016
Page 381
___________________________________________________________________
people had presented to us some of these data where costs had gone
down, then we could see that and then that leads us to the next
question which is in relation to, so is all the increase in costs then
ascribed to the new testing that is going on?
So where are these costs if for routine stuff which we are doing a
lot, you know the kind of stuff you speak about for example, where
10
we know chronic disease, hypertension, diabetes, these are the big
disease burdens we are worrying about.
The se are not new tests,
these are old tests, so we have to do and if the tests are going
down, even if the numbers are going up, there shouldn’t be such an
increase from this burden, so then the increase in costs, must be
coming from somewhere else and then the only other thing that we
have been told about, has been about the new tests, so the various
20
tests around biologicals and specificity around cancers and all these
kinds of things, so is that what is driving the cost?
Is it all new
technology and again if we ask these questions because we don’t
know the answers, it is because when we asked the questions, we
didn’t get the data.
Health Market Inquiry
Page 382
18th May 2016
___________________________________________________________________
DR ERASMUS I am not sure whether one can answer that question,
except that utilisation is increasing, but utilisation also adds
benefits to the patient in terms of reduced hospitalisation, less
morbidity, improved mortality, so the quality aspects that are spin offs of these, are definitely there.
PROF FONN
10
I’m not arguing that they are there, but in order to
claim that they are t here, then you need to be doing the cost benefit
analysis and these are not very complicated things to do.
DR ERASMUS The irony is if one looks at chronic diseases, you
look at the chronic diseases that you have mentioned and how poor
the control is of pa tients who are diabetic and I mean that is not a
complex thing to do, but the pathology cost in that is not the big
20
issue.
The cost of the complications is a big issue and it is just
simply not done, so and that is an issue of management of the
medical schemes.
That is where that should be more effectively
done and the services that are there should be better used.
Health Market Inquiry
Page 383
18th May 2016
___________________________________________________________________
PROF FONN
I’m sure you are right, that there are other places,
but you are not a medical scheme and you are not doing that stuff,
you are pathologists and you do what pathologists do and if you
want to make the argument, then you need to present us with the
evidence and it is not that I am disputing it.
Personally, I have done that work.
10
I am the person who did the
research that said we need t o spend millions every year on cervical
cancer screening, because I did the cost benefit analysis to show it,
so I am just suggesting that it is much more helpful if you had
given us the data, if you had shown us that in fact the unit costs for
old tests is going down and here is the costing that is on new
technology.
Then we would have this information to hand and on
the utilisation rates.
20
DR ERASMUS The brief for this group, could not include the
costing.
It is not possible, we do not have access to th e data, we
could not share that data, so that data you should enquire from the
Health Market Inquiry
Page 384
18th May 2016
___________________________________________________________________
specific individual practices concerned, I think that is more
appropriate, thank you.
PROF FONN
I think you are quite right and I am using this
opportunity for those people who are here from those places, to say
to them please do it and if you want to encourage your members to
cooperate, that would be very nice.
10
DR BRAMDEV
Sorry could I add to that, I think Dr Good
showed in one of his slides, that the chronic diseases like
hypertension and diabetes is on the increase.
The number of
patients who are being treated, have grown dramatically and
therefore, there is more of those simple tests you talk about, being
done and that is pushing utilisation and also I disagree when you
said there is no new tests.
20
There are lots of new tests that can be used today which were not
available twenty years ago and new technologies as well within the
same test, so I think it is just not that the price is going up.
Health Market Inquiry
Page 385
18th May 2016
___________________________________________________________________
PROF FONN
I agree with you and it would be nice to see it.
I
wanted to understand one thing about coding and that has to do,
now we’ve heard a lot that coding is very old, it hasn’t been
updated and no one is taking control of that, no one is showing
leadership around that and in one of the submissions, it was clear
that for radiology, the codes don’t differentiate between when a
technician is doing it, a scientist or a technician compared to when
10
what would be a pathologist in this environment is doing it. Is that
the case in pathology, that the code whether a technician, a
cytologist, or a pathologist is doing it, is the same code used?
DR ERASMUS The coding system and to use a descriptor, the
billing coding system that we make sure that we are referring to,
the copyright for that belo ngs to the South African Medical
20
Association and used to be the doctors’ billing guide which is now
called the Medical Doctors’ Coding Manual, of which in pathology,
in clinical pathology, there are about seven hundred and forty tests
approximately and his tology, a small number, so less than eight
hundred.
Health Market Inquiry
Page 386
18th May 2016
___________________________________________________________________
I am also a director on the South African Private Practitioners
Grouping which is largely a group of specialists.
I am not sure
whether you are aware of the initiative that has been attempted
from there with great opposition in the establishment of a group
called SACHI.
Now I just hope I get the acronym right, it is the
South African Coding of Healthcare Interventions, it is in essence
that.
10
A company was established for this with participants being the
doctors, the medical schemes [interjects]
PROF FONN
Can I interrupt you, I do know the history of that
and I do understand the attempts and I understand the frustrations,
which I was hoping to indicate in my introduction to my question
20
and I apologise if I didn’t make that clear.
The question I am asking, is the current codes, do they differentiate
depending on who the person is who did the test?
Health Market Inquiry
Page 387
18th May 2016
___________________________________________________________________
DR ERASMUS I am sorry I got myself into a flat spin, I am sorry,
the same code can be used whether you are a medical technologist,
or a medical scientist or a pathologist, provided that that area is
within your scope of practice. Certain areas of pathology may not
be done by a medical technologist or a medical scientist, so even
though the codes may be used, it is not appropriate.
Does that
answer your question?
10
PROF FONN
Well I want to follow up, so if I’m paying, I pay the
same amount no matter who did the test.
DR ERASMUS Are you referring to within a professional pathology
environment, or are you saying i f a medical technologist does the
test in a medical technologist private pathology or a private
20
laboratory practice, is that what you are asking?
PROF FONN
Let me explain my problem and then you tell me
what the answer is.
Here is what I am thinking, the cost of
something depends on the infrastructure and the tubes and the
Health Market Inquiry
Page 388
18th May 2016
___________________________________________________________________
bottles and the stuff that comes out of it and the machine it goes
into and the person who does it, so if I am a technologist, I have
studied for lesser time, I can do tests A to C, if I am more skilled, I
can do tests A to L and if I am a pathologist, I can do tests A to Z
and so the costs are related, so if I am paying for test whatever and
it is a test that anyone can do, if a technologist did it, then the total
cost to company for pr oducing that test, is lower than the total cost
10
to company of a pathologist doing that test and is that reflected in
the price or not?
Is the price the same, no matter who does the test?
DR ERASMUS Pricing is freely done on a competitive basis, so the
persons who supply the service, will charge the price that they
20
prefer. I am not exactly sure where I am getting this maybe I could
just give you the background.
Originally, medical laboratory
technologists were not allowed to practice indepently. In the early
1990’s, they presented a case to the Health Professions Council that
Health Market Inquiry
Page 389
18th May 2016
___________________________________________________________________
they wanted to be able to practice independently and that they
wanted to be able to send accounts for their own services.
This was eventually agreed to with a number of proviso’s by the
Health Professions Council and one of the proviso’s at that time,
was that the fee should be less than that of a pathologist and my
recollection which is I am not absolutely sure of, that it should be
two thirds of that of a pathologist.
10
In practice, medical technologists now practice independently
provided their board has approved them to be able to do so and they
would set the fee that they believe to be appropriate and we set the
fee that we believe to be appropriate for our practice. Maybe I was
missing the one aspect that do you mean that let’s say in a
pathologist practice, which employs medical technologists now, if a
20
medical technologist does the test, or when a pathologist does the
test, the same test, there would be one price, whether the
pathologist or the medical technologist does the test, it would be
the same price, but by the nature of it, pathologists would do
certain things and medical technologists would largely do other
Health Market Inquiry
Page 390
18th May 2016
___________________________________________________________________
things,but that doesn’t mean the fact that the pathologist is no t
doing the individual test mixing the tubes or stirring the bottle, that
there is no pathologist involvement.
You have heard the background which has been given before.
PROF FONN
10
We’ve been told that in relation to charges, when
hospital nurses take, as far as I understand and I might not be right,
my understanding is that if I send blood specimen to a laboratory, I
pay whatever I pay for my test R1 and that that from the laboratory
point of view includes the collection, so if I collect it myself and
send it to you I still pay R1? Is that right?
MR ERASMUS Whether we collect or do not collect, it’s the same
20
rate, we don’t differentiate the rate, or we do not differentiate the
time either. Whether we do it in the middle of the night, or in the
middle of the day, we do not differentiate.
Health Market Inquiry
18th May 2016
Page 391
___________________________________________________________________
PROF FONN
It seems silly to me, can’t I pay less if I wait longer,
or do part of it myself? No I can’t?
DR ERASMUS I can’t answer that.
PROF FONN
I suppose that brings me onto the next thing is why
can’t that be negot iated do you think?
10
I mean it does sound
reasonable, that is the point about the market.
supposed to work.
The market is
I’ve got the money, you’ve got something to
sell me, I say to you, I want to wait a bit longer, I’ll take it myself
and I don’t want to pay so much and you say too bad. How come
that can happen?
DR ERASMUS You
20
will
take
the
specimen
to
the
laboratory
yourself, it will lie on the dashboard on your car while you are
shopping for food, stopping at the robot, the specimen will
deteriorat e and you will get a result which is unreliable and which
you cannot use for any diagnostic purpose at all, because you do
not know what you are busy doing.
Health Market Inquiry
Page 392
18th May 2016
___________________________________________________________________
PROF FONN
I think you are going off on a tangent. I take it to
your thing, I take the blood myself , so you haven’t had to pay the
nurse to take my blood, I am not bringing it to your thing, it’s got a
quality control arrival.
I mean I don’t want to argue about that
point. What I want to know is why the market doesn’t work, why
am I with the money, un able to negotiate with you as pathologists
and say I will wait 2 days, I don’t care, I don’t want it
10
immediately, don’t rush, don’t charge me overtime hours, I don’t
mind if you sleep tonight, I don’t want to be charged for somebody
else who wants it immed iately, so I don’t want your night staff to
do it, I don’t want your overtime, I will take it in normal hours,
why can’t that happen in this market?
DR ERASMUS There is negotiation with the individual practices
20
where funders have specific disease profiles that they deal with,
whether it is going to happen with one individual patient walking
in, I don’t know, but I suppose you could try, there is nothing
precluding you.
Health Market Inquiry
18th May 2016
Page 393
___________________________________________________________________
PROF FONN
I just want to clarify one point, so there are codes
that medical scientists c an use and if they are approved, they can
work independently and they can claim from medical schemes for
their work, is that correct?
DR ERASMUS That is absolutely correct, provided they have been
approved by the board of the medical laboratory technologi sts to
10
practice independently, and/or the board of medical scientists
which
paradoxically
Professional Board.
falls
under
the
Medical
and
Dental
There are slightly different boards involved,
but yes, the answer to that is yes.
PROF FONN
Thank you, becaus e people had complained to us,
that was one of the submissions and so I just wanted to understand
20
if that was correct.
So I just want to check something again. The Ampath data that we
have, we had a whole breakdown, but in general, they were saying
3 things and I suppose I want to check with you.
The aging
Health Market Inquiry
18th May 2016
Page 394
___________________________________________________________________
population, the increased risk profile and the third one was the
residual, explained the increase in costs.
So you would agree then that the age profile hasn’t changed
significantly, then that would no t be a driver of costs, am I right?
DR GOOD
If an age profile hasn’t changed in the current
environment, there could still be an anti -selection driver, because
10
the absence of mandatory cover means people can elect to stay out
until they are going to win in the system and then join.
PROF FONN
And then I have one quibble, I am sure it is just me
and this is the very last thing I want to ask.
do statistical testings on their slopes?
Why don’t actuaries
You present us with these
data, so I come from an epi demiological background and I just
20
don’t understand why you never do statistical tests to tell us if the
change is significant or not.
you?
Is this something they don’t teach
Health Market Inquiry
Page 395
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
The pathologists don’t have to answer this
question unless they wa nt to take it to the laboratory and give us
the answer in due course.
DR GOOD
I must confess in terms of the preparation of
our reports, is once again similar to pathology, it is a team effort
where the data gets loaded and the actual person who puts tog ether
10
the graph and the presentation, whose background is a Bachelor of
Commerce with Stats Cum Laude, so I will take it up with her and
ask her.
PROF FONN
I think it would be really interesting, because you
know something can look like something and as y ou know the
longer the period, the lower the slope. The increase looks like this,
20
but if you have a significant period, it is actually not such an
increase and so for me, it seems to be in all the stuff, but since you
are here, I am going for you.
It seems to me to be a real missing element in the way that the
actuarial data is presented.
Health Market Inquiry
18th May 2016
Page 396
___________________________________________________________________
DR ERASMUS Our apology about our presentation only reaching
you this morning. We certainly made the deadline of last week for
our written submission which was given to u s, we did it on time.
We requested that we allowed to only, bring, the presentation this
morning, so I am sorry if it inconvenienced you.
JUDGE NGCOBO
10
We understand. You see it is always dangerous
to be in bad company, this is what happens.
You get to answer
questions.
DR BHENGU Thank you very much for the presentation, without
belabouring the point on the utilisation, we can still go through it
obviously in focussed hearings with the companies themselves, but
I think the utilisation factors that you q uoted in my mind, just as a
20
passing comment, is that they apply to all practitioners really. The
interest would be why, even allowing for that increase for all other
specialists
that
there
is
such
a
significant
differential
for
pathologists over and above that, but that is not for discussion.
I
Health Market Inquiry
Page 397
18th May 2016
___________________________________________________________________
am just saying, but we didn’t get enough chance to analyse the
response and you know you speak too fast sometimes.
I mean just to confirm MPG is really the only association for
pathologists?
DR ERASMUS Yes, we are the only society, as far as I am aware
there is no other society, certainly not of any significance and by
10
far, the majority of pathologists are members of our group, but the
NHLS were at some stage, members of our group, but decided not
to continue, I do n’t have the reason.
DR BHENGU The two hundred and ninety five members, I read
that to mean these are two hundred and ninety five specialists.
How many practices are in that number?
20
DR ERASMUS The three large pathology practices Ampath, Path
Care and Lancet are members and then a smaller histopathology
only practice, Doctor [Gritspen] and Partners and as far as I am
aware, you also requested data from them earlier, but they are also
Health Market Inquiry
Page 398
18th May 2016
___________________________________________________________________
in one of our groups.
Periodically there are isolated persons who
apply for membership, but don’t really follow up their application,
so as far as I am aware, there is nobody else other than associated
with these 4 practices.
DR BHENGU So about three
hundred specialists
in about
5
practices really?
10
DR ERASMUS I suppose roun ding off with three hundred and 4
practices really, 3 large ones of varying size and 1 smaller practice.
DR BHENGU Why is it essential that your members be members
of SAMA as well?
20
DR ERASMUS The national pathology group has come a long way.
I think it was started in 1948 somewhere approximately and there
are a number of other specialist groups within SAMA. Some have
larger left SAMA and have joined the South African Private
Practitioners Forum for whatever complex reasons there may be,
Health Market Inquiry
18th May 2016
Page 399
___________________________________________________________________
but the SAMA statute and I am using the wrong terminologies, so
please excuse for that, so whatever the name would be, the rules of
SAMA, I am not sure if it the constitution, but I will use that word
for the purposes of statement, that’s for a specialist group to be
affiliated with SAMA, we are affiliated with SAMA, for that to
remain, we have to have a minimum number of members being
SAMA members, so that is the answer.
10
Firstly they have to be pathologists, they have to be SAMA
members and they have to be registered wit h the Health Professions
Council, so it is because of the SAMA statute that that exists.
There
are
other
professional
groups
who
are
completely
independent, but we are not.
20
DR BHENGU I think the point one just needs to understand if you
are the only part y that represents
pathologists,
we need
to
understand further what happens in that black box that is MPG and
we need to be comfortable that there aren’t any anti -competitive
issues that should raise a flag.
Health Market Inquiry
18th May 2016
Page 400
___________________________________________________________________
Now the natural question is, if all members are members of SAMA
that we know handles practice issues, is that by extension a
problem if the membership mirrors each other in that way, so that
is fine, but today you didn’t cover what you do for your members,
but I think from your previous submission and website, it says you
promote
the
practice
and
professional
interest
and
establish
professional relationships, so among pathologists with medical aid
10
schemes, what actually is it that you do in establishing that
relationship among your members in medical sc hemes? What does
that entail?
DR ERASMUS That is far more of a historical statement than a fact
on the ground.
Historically speaking there were times when of
course the pathology, or the pathologists negotiated as groups with
20
the Council for Medical Sch emes and represented the practices at
the Council for Medical Schemes and periodically also with
interaction with individual medical schemes.
Health Market Inquiry
Page 401
18th May 2016
___________________________________________________________________
There have discussions over the past few years with medical
schemes about the establishment of a laboratory reque st form for
instance, where we decide, where we agreed to limit the number of
tests on the request form, or create a compacted or create a reduced
request form. We have mentioned that in our submission.
Other than that, the interaction with medical schem es is currently
10
extremely limited, if not non -existent, so our focus is really to
create a standard an agreed quality standard for pathology in terms
of the various activities which we have sketched out for you and
that is really the primary role.
DR BHENGU If you don’t get involved on tariff issues, what was
your involvement in the case against the Department of Health all
20
about, because if I am not mistaken, MPG was a player, or an
applicant or whatever the legal term.
Health Market Inquiry
Page 402
18th May 2016
___________________________________________________________________
DR ERASMUS We are members of the S outh African Private
Practitioners Forum and as such, we contributed to the costs
involved in the case, so does that answer the question?
DR BHENGU It was just that contributing to the costs, not so
much that you were involved in practice studies and anyth ing else,
no role at all in the case other than just contributing towards the
legal fees, is that what you are saying?
10
DR ERASMUS To be really honest with you, I think in fact we did
not even pay our share of the legal fees to be really honest with
you, so I think that is a bill we have outstanding.
DR BHENGU Now you say this is historical, but the other point,
your code of conduct seems to be quite ancient if it was 2002.
20
It
was amended and adopted in 2002. We have heard how the practice
of pathology has changed. Surely it can’t still be relevant? Why is
it not seen to be important?
Dr Nkonki raised the question about
what do you have as a means of discipline and effectively you said
Health Market Inquiry
Page 403
18th May 2016
___________________________________________________________________
nothing and we’ve got here a code of conduct and it is a 2002
edition.
Is it because you don’t really see your role as instilling discipline
among pathologists?
DR ERASMUS It is impossible for us to discipline pathologists.
10
We are not legally entitled to do that. That is the role of the Health
Professions Council.
At best, we can entice pathologists and we
can set standards that we believe are appropriate, standards that
have been agreed to by the members of our executive committee
and held up as a mirror which every practice can use in which to
view itself.
But essentially, it is a process whereby the parties involved, police
20
themselves, but at least there is an attempt to create a set of clear
rules, even though it may have been established in 2002, I can
assure you amongst my membership, there is high value attac hed to
that as a document reflecting ethical standards.
Health Market Inquiry
Page 404
18th May 2016
___________________________________________________________________
DR BHENGU Let me just ask a few questions that have come up
in the past. I understand that I cannot ask if you do know if there
is market allocation among your players, but I can ask factually as
to the distribution of the practices of your members relative to
hospitals.
If I were to basically say here for example, if I say let’s just say
Ampath, where are most of Ampath’s practices relative to the
10
hospital groups? Is there a sort of trend that one c an determine and
mind you, I am not asking if there is an improper relationship, it is
just a statement of fact.
DR ERASMUS I am really unable to answer that question.
The
different practices are now so wide -spread throughout South Africa
and in so many different areas, that no practice has a discreet
20
geographic area or location and to be really honest with you, it
does not interest me at all where the practices are. That is not what
I do, or try and be involved, so from my point of view, that is a
practice issue, I have absolutely nothing to do with that at all.
Health Market Inquiry
18th May 2016
Page 405
___________________________________________________________________
DR BHENGU No that is fine, I accept it, but it is obviously
something we can follow up on.
JUDGE NGCOBO
have
knowledge
All that you are being asked, is whether you
of
that
and
we
assume
that,
because
your
organisation prides itself as the only organisation that represents
the pathologists, prides itself as being the organisation with
10
members who are accredited by international organisations.
We
would have thought you would have known this info rmation.
DR ERASMUS I did not mean that in a derogatory manner. I rather
meant it in the sense that there has been an anxiety amongst
membership about anti -competitive behaviour and a great concern
that whatever activity we are busy with, we should make sure that
20
there is no risk of that involved at all, so my statement of saying
that I have no interest in it, is linked to that aspect specifically, so
I do apologise, I was not trying to be offensive at all, thank you.
Health Market Inquiry
Page 406
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
you mean?
And when you say I have no interest, what do
Are you suggesting that the national pathology group
has no interest, or you personally don’t have any interest?
DR ERASMUS No I was referring to my capacity in the national
pathology group and the fact that I would rather not have data
which could be of such a nature that it could be considered as being
10
of an anti-competitive nature, that is all that I was saying. It is not
that I am not interested in where the pathology services are, not at
all, but it is not an area wher e we involve ourselves at all. It may
be a deficiency I do not know.
JUDGE NGCOBO
I understand, I was curious to hear you suggest
that I am not interested, whether you were saying that as an
20
individual, or as the organisation, but you have clarified that you
are speaking on behalf of the organisation I understand.
DR BHENGU Some of your members have indicated that have got
shareholding in group practices, is that if your code of conduct
Health Market Inquiry
Page 407
18th May 2016
___________________________________________________________________
were to be updated, what would your position be around this? Is it
something that you would encourage or you have no view about?
The groups like Health Works like Inter Care.
DR ERASMUS Dr Bhengu I am unaware of the detail of that at all.
The only comment that I could make or could say is that one must
be very careful of any risk of possible perverse incentives. I don’t
10
know the detail and I am not able to comment about that at all.
DR BHENGU Ja the question I’m asking, but I assumed you had
read the submissions of your members to the Health Market Inquiry
before you came to represent them?
DR ERASMUS No, I did not read the submissions.
20
JDUGE NGCOBO
Are you suggesting that the submissions that
have been made to us by some pathologists, you didn’t read those?
DR ERASMUS Chair I have not read the submissions which were
made by the individual practices to the Commission, not at all, no.
Health Market Inquiry
Page 408
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
You only read, I mean the one that you
responded to, those are the submissions made by some of the
practitioners, the hospital groups, which talked about the reflexes.
DR ERASMUS Chair sorry I was misunderstood, I thought you said
had I read the submissions of the other pathologists groups and by
that I meant the pathology practices who are members of our group,
being the ones who are around the table, which I have not read, b ut
10
I did read some of the submissions that were made by a company
specifically called [Verirad], I also read summaries that were made
by parties of
activities that occurred in submissions to the
Commissions in the broader sense of the word, yes I did.
JUDGE NGCOBO
20
I think that is what Dr Bhengu was asking you.
DR ERASMUS I’m so sorry, I am lost now, I don’t know where we
are, what did you request of me Chair please?
Health Market Inquiry
Page 409
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
Your response was that you did read some of
the submissions, so what I was s uggesting to you, is that that is the
question that Dr Bhengu was asking of you.
DR BHENGU Now when I open a new hospital, what process do
your members go through in bidding to be the laboratory that gets
space in my hospital?
10
DR ERASMUS Unfortunately I cannot answer that, you will have to
ask that of the individual members, I cannot comment on that at all,
I do not know.
DR BHENGU They are on your panel.
20
DR BRAMDEV
I think in general, when a new hospital opens,
they invite presentations from the variou s laboratories, so there is a
tender process in place and the laboratory is invited to make a
presentation in terms of what kind of services you offer etcetera, so
Health Market Inquiry
Page 410
18th May 2016
___________________________________________________________________
ultimately I think it is left to the owners of the hospital or the
hospital group to make th at decision.
DR BHENGU Are they usually open tenders in the sense that
anyone can sort of come, or is it up to just the 4 practices?
DR BRAMDEV
In my experience, it is an open tender.
You
often get presentations from all the laboratories involved.
10
DR BHENGU Does MPG among the guidance that it gives it
members, does MPG feel it is an obligation to drive transformation
in this sector?
I mean for all intents and purposes, you are
companies do you have an idea if any audits have been done and
what is the ge neral level of BEE status among your members?
20
DR ERASMUS No I do not know that, I think also maybe to
understand that, that the MPG is an organisation which consist of
me and one personal assistant, that is the sum total of the
organisation, so the resour ces are limited and dependent on the
Health Market Inquiry
Page 411
18th May 2016
___________________________________________________________________
members for the majority if not all of the activities, where the
expertise lies as well.
The individual practices would report on their BEE status. We are
aware of the requirements.
We have offered the services of th e
private pathology laboratories in terms of training to the national
health laboratory service to encourage circulation of the registrars
10
through the pathology practices.
In fact, many of the practices are involved in training of registrars
and that registrar intake would be determined by the standards set
by the NHLS, so we would accept all the registrars and train
registrars as they are available.
20
So other than that, in a pro -active sense, the answer to that would
be from a specific MPG, individual per spective, the answer to that
would be no.
Health Market Inquiry
Page 412
18th May 2016
___________________________________________________________________
DR BHENGU I think Judge I will stop here, because it seems as if
many of the questions are not known.
JUDGE NGCOBO
Were you here this morning?
DR ERASMUS We were here this morning, we greeted you this
morning, but we did not sit in on the presentations.
JUDGE NGCOBO
10
Did you hear the presentation by the Free State
Provincial Government?
DR ERASMUS No I did not attend that. We came about 1:00, so we
saw part of that, but that was all.
JUDGE NGCOBO
They referred t o some issue which affects
radiologists in the Free State, who it was suggested had lent their
20
practice number to be used by the Department in return for getting
something like 63% of the fees gathered from that practice and the
Department only getting 33% despite the fact that the equipment
being used, were those of the Department, do you know anything
about that? No? Okay.
Health Market Inquiry
Page 413
18th May 2016
___________________________________________________________________
The group of the radiologist society which was here, I think we
heard them 2 weeks ago, they urged us to consider the issue of
regulating the prices or the tariffs. Do pathologists have any view
on that, regulating the tariffs?
DR ERASMUS Chair as a group, I have no specific view on that,
except that we believe our members negotiate now and there is very
10
stiff competition with the members with the schemes that they
negotiate with, so I believe ultimately, that regulation, but that is
from a very philosophical perspective, that regulation is not a good
thing personally.
I believe it would be counterproductive in the longer term, so I do
not believe that regulation is the right way to go. I think the free
20
market competition is a far better situation which we have now.
JUDGE NGCOBO
Within a group, is there a concern about lack
of work at times when there is a drop in the amount of w ork that
you guys get?
Health Market Inquiry
18th May 2016
Page 414
___________________________________________________________________
DR RAMBAU I think the answer to that is no, beause in this
country, there is a shortage of pathologists.
I think in all fields,
certainly in the field I practice in, histapathology, there is a critical
shortage of pathologists.
In fact, there is more work than we can
do for the number of pathologists out, so I don’t think there is a
real concern in that regard.
10
JUDGE NGCOBO
And then the partners, do they get a salary
from the practice, or do they get a dividend, how does it work?
You are very opposed as I understand to being employed by a
hospital group, beause you believe that there is a commercial
interest on the one hand and there is an ethical issue on the one
hand, now how does it work within the group?
20
DR BRAMDEV
I can speak for our practice.
As pathologists,
we get a salary and as partners, we get an annual dividend as well
and
the
salary
performance.
is
usually
commensurate
with
the
level
of
Health Market Inquiry
Page 415
18th May 2016
___________________________________________________________________
JUDGE NGCOBO
When a request for pathological analysis or
tests lands at the labora tory, how does it get allocated? Does it get
allocated based on what is required from the test, or is it just a
random allocation?
DR BRAMDEV
Well I can speak for histopathology, which I
am involved in, when specimens come to the laboratory, it is
10
divided among pathologists which have got expertise in certain
area, so if you get a brain biopsy, it will tend to go to a certain
pathologist as opposed to another specimen, but in general, there is
an equal allocation of work, except for where there is a speci al
interest.
JUDGE NGCOBO
20
Is there someone who is responsible for the
allocation of work, or how does it work?
I can understand where
allocation is based on the speciality. What about those where it is
just a general matter?
Health Market Inquiry
Page 416
18th May 2016
___________________________________________________________________
DR BRAMDEV
I think the head of each department makes that
decision, that allocation, so there is somebody who supervises in
terms of the work distribution.
JUDGE NGCOBO
To make sure there is an equal distribution of
work?
DR BRAMDEV
Yes, that is true.
JUDGE NGCOBO
There are no complaints that so and so is not
10
pulling up his or her socks?
20
DR BRAMDEV
That’s true.
JUDGE NGCOBO
Do you decide what to charge for a particular
test, or does somebody else make that decision outside of your
practice?
DR BRAMDEV
Ultimately, it is the pat hologist when he signs
the report, he has got to ensure that the charge is correct.
For
Health Market Inquiry
Page 417
18th May 2016
___________________________________________________________________
histapathology, the charge is determined by the complexity of the
case and the level of service and [inaudible] you do, so it is the
pathologists responsibility, it is not an automated feature in
histapathology.
The MPG has got billing guidelines that cover most of the
procedures.
10
JUDGE NGCOBO
Those guidelines are available to the public,
are they?
DR ERASMUS Chair I am not exactly sure what you asked now,
could you just repeat that please that I understand clearly what you
are requesting?
20
JUDGE NGCOBO
I am talking about what pathologists charge for
tests. Is there a guideline about what to charge? Who determines
those guidelines? Are those guidelines available to the public?
Health Market Inquiry
Page 418
18th May 2016
___________________________________________________________________
DR ERASMUS Chair what we have, is what is called the guide to
coding which is the SAMA medical doctors’ coding manual, so it
will have in that, I am just referring to that guide to give you
clarity, it wil have a test with a number 1 2 3 4, adjacent to that
test, it will have what is called an RVU, a reference value unit and
then there is no price attached to that, but all that that does is that
it says test 1 2 3 4 as opposed to test 5 6 7 8, may have 10 RVU’s,
10
the other one may have 4 RVU’s , so that just gives the relative
value units between the two different tests, so it means that the one
test will cost twice what the other one is, but it doesn’t say what
the actual cost may be, because that conversation, that Rand
multiplier, is determin ed by negotiations between the practice and
the medical scheme.
20
So that is how the price is ultimately determined.
JUDGE NGCOBO
Is it available to the public?
Health Market Inquiry
Page 419
18th May 2016
___________________________________________________________________
DR ERASMUS The medical doctors’ coding manual, one has to
purchase it from SAMA to gain access to it, but it is a public
document.
JUDGE NGCOBO
I am referring to the one that is used by the
pathologists?
10
DR ERASMUS What we have, is a guide to coding which we
submitted to you previously last year and what that guide is used
for, it uses the number codes within the SAMA doctors’ medical
coding manual.
It then says that if you are going to do a lipid
investigation, so a lipid investigation would use the following
codes as tests within a component.
20
But that is simply the codes and the code names, bu t the price that
is attached to that, is not appended to that, because there is no
price, because the price is based on the individual practice
concerned, but that document is publically available for anybody
Health Market Inquiry
Page 420
18th May 2016
___________________________________________________________________
who wishes to use it, or to gain access to it, because we promote
that as the basis, but that is not going to help you very much.
You will know what the test number is and you could enquire from
the practice, what that cost would be for that number, I don’t know
whether that answers the question, but I think one of my colleagues
wanted to add something.
10
JUDGE NGCOBO
What I want to know is this, if I go to any of
your practices and say before I submit myself for any test, please
let me know what your charges are, will you be able to give me
that?
DR ERASMUS The answer to that is yes.
20
JUDGE NGCOBO
So there is a price list what you charge for this
particular test, which is kept by a practice, is that right?
DR ERASMUS That practice would have a list for that specific
service, but it is possible that tha t price may vary given which
Health Market Inquiry
18th May 2016
Page 421
___________________________________________________________________
medical scheme you are a member of.
It is possible that the one
medical scheme may pay less for the service.
JUDGE NGCOBO
So
each
individual
practice
has
its
own
pricelist which may differ according to the medical scheme to
which one belongs?
10
DR ERASMUS Chair I think that detail, we are going into very fine
detail now, but there is a pricelist available and you as an
individual patient, will have access to that if you want it.
It is
available, but then the subtle differences within the medical
scheme, I am not able to comment on, you will have to ask the
individual practices about that.
20
DR BRAMDEV
Just to clarify, I think the prices that individual
practices charge, depends on what they have negotiated with each
medical aid, so it varies from practice to practice.
The second
point is you mentioned is there a guide to how you bill and I think
the point Tjaart is making, is that we have got codes, but not
Health Market Inquiry
18th May 2016
Page 422
___________________________________________________________________
necessarily with the prices attached, which gives you a guide to
which t est you can do. For example if you have a stool specimen,
what are the acceptable organisms to test for as a guide and then
you attach a value, so those guides are available to the public.
JUDGE NGCOBO
Each practice determines what prices it would
charge for for specific tests?
10
DR BRAMDEV
Yes, that is correct based on the negotiation
with the funders.
JUDGE NGCOBO
And it is the partners who decide that after
listening to the medical aid scheme?
20
DR BRAMDEV
That is correct.
JUDGE NGCOBO
Are
there
any
co ncerns
that
you
have
concerning the regulatory framework that regulates either the
health profession in general, or pathologists in particular?
Health Market Inquiry
Page 423
18th May 2016
___________________________________________________________________
DR ERASMUS Chair a very broad philosophical comment would be
the and this is not really my field of specific exp ertise, but the acts
pertaining to the medical schemes that many of the parties who are
involved with medical schemes, they say that the Act has not been
fully implemented in terms of, in other words, an aspect where by
the schemes, would cross -balance the risk profiles and there is a
specific word for that and many of the actuaries are of the opinion
10
that should this Act be fully implemented, it will lead to a
significant increase of individuals who are covered under the
Medical Schemes Act. I think that could be one aspect.
JUDGE NGCOBO
The word risk equalisation ring a bell?
DR ERASMUS Thank you Sir, I would certainly also love to be in a
20
position whereby we are not in this impasse with the medical
schemes in terms of implementing a proper coding syste m.
Our
coding system is deficient, we are in the process of creating a new,
you heard that we have about 750 odd codes and these codes are
insufficient for the needs at the moment. They also only contain 4
Health Market Inquiry
Page 424
18th May 2016
___________________________________________________________________
digits and are not structured in a manner that i s really logical in
terms of its flow, so it would be wonderful to be able to have a new
coding system and we are in fact working on such a coding system
which only has the code and the descriptor, there is no RVU
attached to that, because we are concerned about the issue of
competition, but what we want to agree on, is that the same code
number be used and that the same descriptor be used, so that at
10
least as a point of departure and once we have completed this task,
we are in process, it is a task of inor dinate magnitude, but it is
progressing well.
Once we have that, we would like to enter into discussions with
funders about the principles of such a process.
Some already
indicated interest in this because it can only add value to all of us
20
if at least we agree as David has said earlier, what is one cup and
what are we measuring with it.
JUDGE NGCOBO
Who should be responsible for the revision of
the code, should it be an independent body?
Health Market Inquiry
Page 425
18th May 2016
___________________________________________________________________
DR ERASMUS Chair you have heard my reference to SACHI
earlier. The difficulty around that is that ultimately the input into
such a body, must come largely from the professionals who know
and understand the system, so you often enter and this is the same
problem that we had previously when we were submitting codes to
the SAMA private practice committee.
10
You would submit a code and you would sit amongst peers, but the
peers that you sat amongst, knew nothing about pathology, they
were really not able to act in a manner of peer reviewing you
efficiently, they were depend ent on your providing the data in an
honest manner being questioned about the data and accepting or
modifying it, whilst it is easier for them in a clinical environment,
a group of surgeons are more able to understand what the other one
20
is doing, or the ot her person is doing, or physicians whatever, you
know they are more comparable.
We and the radiologists tend to be outliers or different in that
respect, but all that notwithstanding, a group like SACHI I believe
Health Market Inquiry
Page 426
18th May 2016
___________________________________________________________________
can be at least a central point where thes e points are agreed to or at
least the differences are agreed to and at the moment, that does not
exist, so that is a huge deficiency I believe in the current market
and it should be addressed soon.
JUDGE NGCOBO
Would
an
independent
body
which
is
representative of the various discipline, not cater for your concern?
10
DR ERASMUS The question now, would those disciplines be only
the medical disciplines because there are also many other services
in medicine.
Would there be representatives from the medical
schemes, how widely does it go. I think it certainly has potential,
because a body, because at the moment, there is a state of paralysis.
20
JUDGE NGCOBO
Is there anything else that your team would
like to raise with us?
Okay, well that being the case, then t hank
you for coming here and for sharing your knowledge with us and
for the presentation which I thought was quite informative in the
Health Market Inquiry
Page 427
18th May 2016
___________________________________________________________________
beginning.
I know more about how pathologists function than I
was when I first say here today, thank you so much.
DR ERASMUS Chair thank you so much for inviting us over this
morning early and setting our minds at rest, it helped a lot,
although it has been a tiring long afternoon and I would also like to
say thank you to my colleagues who have been here, who have
10
presented and we appreciate the questions that have come from the
panel. We have tried to answer them as best we can and thank you
very much for the opportunity thank you.
[END OF RECORDED PROCEEDINGS]
20