The following is the service level agreement between Western Cape Health Department and Independent Health Care Specialists signed on 08 June 2020.
THE SERVICE LEVEL AGREEMENT (SLA) BETWEEN THE WESTERN CAPE DEPARTMENT OF HEALTH (WCDOH) AND INDEPENDENT HEALTH CARE SPECIALISTS
This is the first SLA presented to Health Care Providers and the expectation is that this will be used as the template by other provinces. On behalf of SAPPF, Simon Strachan, Adri Kok and Philip Matley, have been able to actively engage with the WCDoH and assist in developing this SLA.
This SLA must be read with the SLA for Private Providers and Administrators. BOTH SLAs ARE LINKED TO THIS LETTER
Here we explain the details of the SLA and some of the thoughts behind the decisions.
RELATIONSHIP BETWEEN THE PARTIES
The Private Providers are the Hospital Groups.
The Administrators are Discovery, Medscheme or MMI.
- These entities sign an SLA with the WCDoH agreeing to provide their facilities to care for public sector patients.
- The Administrators handle the registration and accounting requirements and are tasked with recruiting doctors to sign up to participate in the care of public sector patients in private facilities.
- Specialists sign the Specialist SLA when agreeing to participate.
- Radiology, Pathology and Allied professionals sign their own SLA.Participation is voluntary.
This agreement is only for the treatment of public sector COVID patients by private providers in private facilities.
Clinical Autonomy in decision making is essential.
Access to an Ethics Committee must be available to assist with decisions around the allocation of resources and treatment options.
Indemnity against prosecution or Medical Malpractice Insurance must be in place.
The Private Health Professionals sign an agreement with the Provincial Government.
The Hospital appoints the Administrator and they manage the billing and payments.
The fees are set by the National Department of Health.
MECHANISM OF TRANSFER
COVID positive or suspected COVID patients will be transferred when the public sector facilities are unable to cope. The intention is to keep the highest acuity patients in the public facilities so the triage Guideline will be applied to ensure appropriate transfer at the point of referral. We are expecting that patients requiring ward care or palliative care will not be transferred to the private sector. Only patients needing high care and ICU will be referred. Referrals will be requested and directed by the Joint Operations Centre (JOC) of the Hospital Groups and the Province.
Annexure J deals with the referral pathway in detail and here are some important points contained in that Annexure:
- The WCDOH authorised representative calls the Private Provider’s Operations Centre to confirm that a bed is available. The assessment by the Private Provider’s Operation’sCentre will also include availability and confirmation of a receiving doctor, relevant staff, oxygen, PPE and that other operational requirements are met.
- The WCDOH will then issue an authorisation number for admission to the particular PrivateProvider’s facility, which will be referred to in all future correspondence and claims.
- A doctor to doctor call for discussion of clinical information and hand over must follow.
CONTROL OF BEDS
It is clear that the acceptance of patients by private hospitals is at the discretion of the private hospital whose principals must be willing to accept the patient.
2.1 The referral of Patients shall be subject to the Private Provider being able and willing to provide beds, including whether there are sufficient nursing staff, personal protective equipment, and appropriate medication and other consumables available, at the time when the relevant referral of the Patient concerned is sought in accordance with the process outlined in the patient referral pathway set out in Annexure J, as well as supporting related contracted Independent Healthcare Practitioners being available at the relevant time to treat the Patient concerned.
It essential that treating clinicians retain the right to treat their patients to the best of their ability with due consideration given to the treatment modalities at their disposal and in line with recognised best practice. The clause below gives clinicians this autonomy.
i. While it is the intention that uniform clinical guidelines are to be used across both the public and private sectors to ensure equity of critical care access and it is understood that clinicians will adhere to these critical care guidelines, expressly, for state patients referred, in order to qualify for the fees and indemnity cover afforded by the Department but that the Independent Healthcare Practitioners can, still exercise their independent judgment as to which critical care guidelines to follow and the appropriate treatment regime to adopt in respect of each particular Patient.
A lot has been done to provide indemnity from litigation or assurance that our private medical malpractice insurance will cover us for work outside our scope of practice and for caring for public patients in private facilities. MPS and PPS malpractice insurance have communicated that they will provide cover for work outside scope of practice and for seeing public sector patients in private facilities.
The WCDoH through the Western Cape Treasury is providing a broad indemnity as explained in these clauses:
6. Subject to the requirements of the Public Finance Management Act 1 of 1999, the Department specifically indemnifies the Private Providers who are not Hospitals or Hospital Groups of health care facilities contracted in terms of this Agreement, who are clinicians, such as specialists, general practitioners and allied health care workers, against all and any claims, including claims for consequential damages, which might arise from personal injury, death, loss or damage to property or person, or any other claim of whatsoever nature, arising from negligence, gross negligence or any other cause howsoever, which any person may have or institute against the such clinician or the Department and where the cause of such claim can be directly or indirectly attributed to the rendering of the Services by the clinician, to the extent that they are not indemnified by their own insurance company or statute or other means. In order for these clinicians to rely on this indemnity issued by the Department, it is a condition that they should first seek such indemnity from their own insurance company; seek indemnity in terms of the Medical Malpractice Societies exemption in respect of the treatment of COVID-19 patients outside of their normal scope of practice and when treating such Patients; and/ or rely on an indemnity issued in terms of the Disaster Management Act 2002 or any other law, which pertains to medical negligence claims against the State and private providers who treat COVID-19 patients.
The last step for implementation of this indemnity provision is the signature of the Minister of Finance.
SAPPF through B4SA has commissioned a broad indemnity agreement which has now been submitted to the Minister of Health. If granted this will provide a National blanket indemnity from prosecution for the period of the COVID pandemic.
The components of the fees are:
- 1) HighCare/ICUperdiem(perpatientperday)
- 2) CarveOuts-Feesforservicesnotincludedinperdiem
- 3) GeneralwardperdiemandPalliativecareperdiem
1) High Care/ICU
At the start of the response to the pandemic we expected overwhelming numbers and a huge need for intensive care with intubation and ventilation. The planning therefore calculated personnel needs and fees on a team approach with these teams working in shifts. As the pandemic has unfolded we see that the overwhelming pressure on the heath care sector is likely to be limited to certain geographic locations. Ventilation as a primary therapeutic modality has also reduced. The need for team shift work is now expected to be less of a necessity. The demand of private sector patients requiring care for both COVID and non COVID disease will limit the number of actual beds available to the public sector.
The daily rate for the specialist or team of specialists providing care in ICU or High Care remains R 2,493.00. This is for private specialists seeing public sector patients in private facilities.
The Minister emphasized that that this public/private partnership will be administered and financed by Provincial Governments and that the Western Cape structure would be the model for all remaining provinces.
2) Carve outs
This per diem of R2493 covers basic care but does not cover additional procedures such as surgical operations, cardiac interventions, dialysis, dialysis access procedures and consultation with other specialists such as neurologists and psychiatrists. This is explained in this clause:
7.1 In the event that a Patient admitted to one of the Private Provider’s facilities requiresadditional treatment, other than as envisaged in the ordinary course in treating COVID-19 patients, such as (but not limited to) surgery and/or dialysis treatment, then a request to provide additional treatment shall be referred to the Western Cape Joint Operations Committee for pre-authorisation (subject to available funding) and, if authorised, the Department will pay the Private Provider for such treatment in accordance with the tariff set out in Annexure D2
Mechanisms already exist whereby the Province can purchase these services from the private sector. We have suggested that the GEMS Specialist Network contracted rate of 130% be used as a guide, but this will need to be confirmed. A list of the most common general and vascular surgical procedures with appropriate codes has been submitted to the WCDoH. For emergency procedures, pre-authorisation is required but we have been informed that a representative of the Joint Operations Centre is available on a 24-hour basis to provide this.
3) General ward and Palliation
On 01 June we heard that the NDoH had included per diem fees for General wards and Palliative care. The per diems presented were only for the hospital stay. The WCDoH has been tasked with calculating the Specialist and Allied Health Professionals fee for these levels of care. We have presented them with our suggested fees. These were calculated using the same methodology we used when calculating the ICU and High Care fees we presented to NDoH.
WHAT ABOUT WALK-INS?
The Province will not cover the costs of uninsured patients presenting themselves at private emergency units. These patients will need to be assessed and stabilized and then either sent home (if appropriate) or transferred to a state hospital. If the patient cannot be accommodated at a state hospital it will then be possible to contact the Joint Operation Committee (JOC) and request an authorization for the patient to remain at the private hospital.
DISPERAL OF PAYMENTS
The administrator will submit one invoice to the Department per patient. This amount is then paid to the administrator who will divide the payment between the respective groups based on their submitted invoice. These groups are the hospital, the specialists, Radiology, Pathology and Allied. The invoice submitted by the administrator for the treating specialists will thus be one fee regardless of how many doctors looked after the patient. The administrator will gather data from the hospital to determine who the treating doctors were so that it should not be necessary for individual specialists to provide an invoice. The accuracy of this invoice will be depend on the inputs at local hospital level. This does mean that a mechanism of administrative integrity and capacity is developed at each hospital to record the Health care providers involved in the care of each of these public sector patients.
It is likely that in most facilities these public sector patients will be referred in smaller than expected numbers. This means that only one physician/intensivist may be necessary. Teams will only be required to cope with large patient numbers or when teams are depleted because team members are ill and recuperating. Participating specialists will need to decide on how the payment will be dispersed between them. It is suggested that this be done on an equal basis. We encourage you to arrange this with your colleagues at your hospital and ensure that the hospital management has the necessary administrative capacity in place.
PAYMENT WITHIN 30 DAYS
The WCDoH has a record of clean audits for many consecutive years so they are able to agree to payment within 30 days as outlined in the SLA clause:
7.2 The Department will pay the Private Provider and the Independent Healthcare Practitioners per Patient, in arrears in accordance with the tariffs contained in, within 30 (thirty) Calendar Days of receipt of an electronically submitted account the Administrator Intermediary for the Services inclusive of VAT.
FOR HOW LONG WILL THE CONTRACT CONTINUE?
The contract will continue to the end of September with a provision for extension, but Health care providers can withdraw from the contract with 7 days written notice.
2.6 Notwithstanding the provisions of this Agreement, this Agreement may be terminatedon 7 (seven) Calendar Days’ written notice by either the Department or the IndependentHealthcare Practitioner. In the event that the Agreement is terminated, the Independent Healthcare Practitioner will continue treating the Patient under his or her care until the Patient is discharged or until the Department has agreed in writing that another Independent Healthcare Practitioner or its own healthcare practitioners assume responsibility for the healthcare services provided to the Patient.
CAN SPECIALISTS TREAT PATIENTS WITHOUT SIGNING THE SLA?
Several specialists have indicated their willingness to treat state patients pro bono. This is acceptable but everyone responsible for patient care will need to sign the SLA as there are important registration, governance and indemnity issues.
WHAT CAN BE DONE TO ASSIST WITH ON -GOING PRACTICE COSTS?
The income generated for seeing public sector patients will be minimal. The income generated will depend on the volume of patients referred and this will then determine the need for a team approach. Although it is likely that in most facilities, the resident adult physicians, intensivists and anaesthetists will be able to handle the load, these colleagues will not accumulate sufficient income during this time to sustain their practices.
SAPPF and the Progressive Health Forum are currently involved in an initiative which, if successful, will guarantee a sustainable income stream for all practices without increasing practice debt. Further negotiations are required before we can make announcements in this regard.
Participation is voluntary and SAPPAF respects the fact that every Health Care Provider needs to make their own decision. Colleagues over 60 and/or with co-morbidities should probably not participate in direct care of COVID patients but could assist with administration, counselling, patient and family liaison, and participate on hospital COVID and ethics committees.
Resolution of the clinical, legal and organisational issues in the SLA should give comfort. We are certain that SAPPF members will step up during this defining time and provide their usual level of quality, expert and committed care to all patients.
Chris Archer CEO: SAPPF and Simon Strachan Deputy CEO: SAPPF