You probably haven't a clue. Clearly I think you should be, for good reason, because there is a monumental battle going on between medical professionals and the medical aid administrators who sign contracts with 'designated service providers' or 'preferred providers' (DSPs).

This battle is essentially for control of private medical practice. Those who control the profession control all aspects of healthcare delivery. You, the patient, are the prize. It's messy and unpleasant, with casualties in abundance. As in any war, most casualties are not even protagonists. They are 'you' – the innocent healthcare consumer.

My prior posts have explained in depth the reasons for this conflict. To summarise, doctors' services are undervalued by medical aids (especially in comparison to medical administrators' services) and there are intensive efforts to keep these services to a price that is acceptable to them alone. That these fees are unacceptably low and encourage overservicing does not appear to be of concern to the medical aids whose highly profitable business models apply little apparent incentive to change their modus operandi.

From doctors' perspectives, we've done our homework. We know what it costs to run high quality medical practices, and what we should expect as fair remuneration based on our time spent training, lost opportunity costs, and the nature and responsibility of our jobs. Appropriate fees have been independently assessed by actuarial analysis, and found to be significantly higher than those suggested by medical aids. Our slate is clean in this regard.

DSPs are doctors who have signed contracts to agree to stick to a fee structure and to limit treatment options to those determined by the medical aid. These include drug formularies, limitations on investigations, restrictions on treatment options, use of preferred surgical prostheses and not others, use of certain hospitals and more, prompting the HPCSA in March 2013 to publish a press release warning against actions of this nature that could be prejudicial to patients' interests.

A DSP agreement when carefully examined is about control of a doctor's practice, not based on quality, but on cost. A hallmark of any noble profession is the right to control itself – remove that, and one might as well not call it a profession, but rather a 'trade.' The stakes are that high!

All independent organisations representing doctors interests – South African Medical Association (SAMA), South African Private Practitioners Forum (SAPPF) and others – have warned their members by circular notices to be wary of these contracts.

It is hard to see things in any way other than that your DSP has agreed, essentially, to limit your treatment to what your medical aid has decided is best for you. Your membership of a medical aid plan that demands you see a DSP doctor limits your access to a range of options of care unless you are prepared to pay for them in full over and above your medical aid subscriptions. Another problem is the DSP doctor may not even offer alternative treatment options which are not included in the medical aid's list. If your GP is a DSP, he/she is limited in referring you to specialists working at DSP hospitals, for all but extreme emergencies.

What does a doctor gain by becoming a DSP? The main benefits are a guarantee of direct payment by the medical aid at a rate marginally higher than non-DSP doctors are paid by the same medical aids, and a preferred supply of patients. It gives the DSP doctor a competitive edge in an environment where skill and quality of care are not considered, to the extent that some analysts have considered the system to be anti-competitive in nature. If all doctors in an area are forced into becoming DSPs to compete, medical aids have in essence controlled the market place by removing competition, and removing patients' options. The medical aids then control the market place completely, exchanging cost saving for more limited access to healthcare. Good for them – not so much for you. Another aspect of this arrangement is that the medical aids consider a doctor with thirty years of experience is the same 'worth' as one newly qualified. In no other industry or profession is this the case.

 Did I explain all this well enough? A DSP doctor has given up autonomy in exchange for a competitive advantage that he or she does not earn nor display by higher quality of service relative to other doctors. In doing so, he or she has reversed the hard fought gains that organisations like SAMA and SAPPF have achieved in years of effort. On offer to you is a limited range of treatment options, as well as seeing a doctor who may have to do more 'stuff' to you because the consultation fee alone is not fair recompense.

Of course, to test my accusations, you will have to fall sick first. Not the normal, ordinary, 'cough and cold' type of sick, but the 'in danger of being paralysed due to spine compression' type of sick. Or 'seriously ill in ICU' illness. Or the 'severe crippling arthritis that could respond to a brand new drug' kind. Just try having the latest spinal surgery under the care of a DSP orthopaedic surgeon. You'll battle. A non-DSP surgeon will also battle, but will at least try to get the medical aid's approval on your behalf. A DSP surgeon is unlikely even to try, having signed a contract that won't permit it. A DSP's role in being the sole, fully informed and involved advocate for his/her patients, ie you, has been surrendered.

It s difficult for me to believe anything other from these perspectives than that some DSP doctors have sold out to their profession, to their colleagues and last of all to their patients.

One of the cleverest things the medical aid industry has done is to split doctors in this manner into two camps. In so doing they have weakened the most involved advocates that patients have. We really are on your side. Most of us. Your DSP doctor may well be cheaper, but in healthcare, quality is always remembered long after the cost is forgotten.




Martin Young

Martin Young is an ENT surgeon living an idyllic life in Knysna. He is a firm believer that "the unexamined life is not worth living", writes for a hobby and is happy to speak truth to power

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