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Ethical issues to ponder

Accreditation Number: ODO xxx/xxx/xx/2019

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What’s in a name?

One can only wonder how it came about that optometric practices in South Africa started adopting commercial names, in spite of the HPCSA rules dictating otherwise. Moreover, what is to be achieved with these names? Will they entice the consumer? I am reluctant to pull some names out of the hat as examples in fear that I may offend some practitioners who are in fact using these names. But let me play it safe by erring on the ridiculous with names such as Square Eyes Optometrists, Round Eyes Optometrist and Optical this and Spectacle that. As it is, it is difficult to attain a differential advantage in optometry because everybody has access to the same products. However, in terms of differentiation, a silly commercial name can detract from the professional standing of the optometrist. At the end of the day, the patient wants to consult the Eye Care Professional whom they trust and respect. The one untouchable mode of differentiating can only be clinical skill, delivered in a professional manner. This will of course, include bedside manner.

Great practices have in the past been built on an optometrist’s name alone. Mullers, the oldest practice in South Africa, was established well over a hundred years ago and still going strong. There are others such as Saks and Taylor in Pretoria, the late Grant Jenkins and Dirk Booysen to mention a few. In some instances, a commercial name can make sense, as is the case with SpecSavers who trade on price as “The affordable optometrists”. The branding and uniformity is required right across the franchise group. Spectacle Warehouse, Unlimited Choice, is another case in point where the name denotes, plenty, to drive home their large selection and all-inclusive service in very large premises. As is the case with Torga Optical, a franchise group can be established on the name and reputation of an individual. The late Torga Buchannan was an outstanding optometrist and the expansion took place based on her approach to optometry. The moral of the story is that the name must drive a concept, but for most solo or partnership practices, it is best to brand the practitioner’s name.

It is curious to note that what is happening out there as far as naming of practices are concerned, is not in line with what the HPCSA regulation below states.

Naming of a practice – HPCSA rules

A practitioner shall use his or her own name or the name of a registered practitioner or practitioners with whom he or she is in partnership or with whom he or she practises as a juristic person, as a name for his or her private practice.

A practitioner may retain the name of a private practice even if another practitioner, partner of such partnership or member of such juristic person is no longer part of such private practice: Provided that the express consent of the past practitioner or, in the case of a deceased practitioner the consent of the executor of his or her estate or his or her next-of-kin, has been obtained.

A practitioner shall not use, in the name of his or her private practice, the expression “hospital”, “clinic” or “institute” or any other expression which may give the impression that such private practice forms part of, or is in association with, a hospital, clinic or institute.

It further states that a practitioner is allowed to display, apart from his or her name, the professional qualifications plus a speciality or a sub-speciality.

Here is the definition laid down by the HPCSA, for touting, which adds more fuel to the fire.

“touting means, but is not limited to, conduct which draws attention, either verbally or by means of printed or electronic media, to one’s offers, guarantees or material benefits that do not fall in the categories of professional services or items, but are linked to the rendering of a professional service or designed to entice the public to the professional practice.”

It follows that your signage should not entice the public by stating that you are cheaper, quicker or better. In some cases practice names can fall within the realm of touting. After all commercial practice names are mostly designed to tout or entice the consumer, suggesting that this practice is better at something or other. In some cases the commercial names are just kitsch, and conveys no meaningful message.

The story goes further. A practitioner shall not canvass or tout or allow canvassing or touting to be done for patients on his or her behalf. Yet, we know that word of mouth is the biggest source of patients for all health care professionals. The difference is, if you pay or incentivise patients to spread the word that you are wonderful, it would be overstepping the mark.

Moreover, the rules applying to your front of house signage carries all  the way through to your office stationary.

Cancellations and no-shows

The nature of certain professions or specialties registered with the HPCSA may make it difficult for practitioners to sustain their practice if patients do not honour their appointments. As a result, some practitioners charge patients for failing to arrive for their appointments.

There has been some confusion on the ethical basis of this practice. There is currently no ethical rule prohibiting practitioners from charging patients for failing to honour their appointments. The practice of charging for a no-show is well articulated in Section 17 of the Consumer Protection Act which states that; a consumer has the right to cancel any advance booking reservation or order for any goods or services to be supplied. It states that a supplier who makes a commitment or accepts a reservation to supply goods or services may impose a reasonable charge for cancellation of the order or reservation, and a charge is unreasonable if it exceeds a fair amount in the circumstances, taking into account:

  1. The nature of the goods or services that were reserved or booked.
  2. The time the notice of cancellation was provided by the consumer/patient.
  3. The reasonable potential for the service provider, acting diligently, to find an alternative consumer between the time of receiving the cancellation notice and the time of the reservation that was cancelled.
  4. The general practice of the relevant industry.

This Consumer Protection Act further states that a supplier may not impose any cancellation fee in respect of a booking, reservation or order if the consumer is unable to honour the booking, reservation or order because of the death or hospitalisation of the person for whom or for whose benefit the booking, reservation or order was made. In view of this, the Medical and Dental Professions Board has reviewed its ethical ruling of October 2001 and ruled on this matter as follows:

A patient reserves the right to cancel a medical or dental appointment, and a medical or dental practitioner may not charge a consultation fee or a procedure fee for such a cancelled appointment unless:

  1. A cancellation was made less than 24 hours for a specialist appointment and less than two hours for a general practitioner appointment, before the appointment time.
  2. A practitioner can provide evidence of failure to find an alternative patient between the time of receiving the cancellation notice and the time of the cancelled appointment.
  3. The practitioner can provide sufficient proof that the patient was informed about the cancellation of appointments policy.
  4. The practitioner has first established the reasons for the patient’s failure to cancel or honour the appointment.

The HPCSA advises practitioners who have a cancellation or no-show policy to inform their patients at the time of booking that there will be charges incurred for failing to arrive for an appointment.

Split-billing

Split-billing occurs when a medical supplier provides two accounts for the same service. One is sent to the medical scheme, listing the medical scheme tariff amount, and another to the member or patient. The member will pay the supplier what they think is a co-payment, but the amount paid does not appear on the claim sent to the medical aid by the supplier. This is unethical practice.

The HPCSA remind healthcare practitioners that they have an obligation to inform the patient about the cost of services before rendering the services. It should be noted that this has nothing to do with the benefit option the patient has purchased with their medical aid or the scale of benefits of the medical aid in relation to the service to be provided.

Healthcare practitioners also have an obligation to furnish their patients with detailed accounts for the services rendered as prescribed in terms of Regulation 5 of the Medical Schemes Act. The account should include the nature and cost of each relevant health service rendered. Should there be an amount paid by the patient, that same amount should reflect on the account. The same account should be sent to both the patient and the medical scheme for the purpose of reimbursement.

Patients have an obligation to pay for the services rendered to them irrespective of the method of payment, whether through their medical schemes or out of their own pockets. If a medical aid is a method of payment, the Medical Schemes Act places an obligation on the medical scheme to do so within 30 days of receiving the claim.

Split-billing would occur if a patient is billed separately for the amount to be paid by the patient or member which the scheme does not cover, and the medical scheme is billed separately in line with the medical scheme tariff amount. In other words, the account to the patient reflects only the amount for which the patient is responsible, while the claim or account to the medical scheme reflects only the amount equal to the benefits the medical scheme is prepared to pay for the service rendered and does not reflect the out-of-pocket payment by the patient. Split-billing is unethical and practitioners

Keeping the record straight

HPCSA registered practitioners are advised to adhere to the following guidelines on record keeping that will also improve clinical outcomes, reduce waste, and ensure stakeholder engagement and satisfaction.

Basic patient information requirements:

  1. Personal (identifying) particulars of the patient.
  2. Bio-psychosocial history including allergies and idiosyncrasies.
  3. Time, date and place of every consultation.
  4. Assessment of the patient’s condition.
  5. Proposed clinical management of the patient.
  6. Medication and dosage prescribed.
  7. Details of referrals to specialists, (if any).
  8. Patient’s reaction to treatment or medication, including adverse effects.
  9. Test results.
  10. Imaging investigation results.
  11. Information on the times that the patient was booked off from work and the relevant reasons.
  12. Written proof of informed consent.

Time constraints and patient care can complicate accurate documentation – a practitioner may treat the patient with the best intentions but only lacks the records to rely on in the event of a complaint or legal case.

Protocols:

  • Develop a system that will streamline the process and alleviate the pressure of having to record absolutely everything. Standardise and try to automate documents as far as possible – with the first form completed by the patient while sitting in the rooms during the consultation.
  • Once the identifying particulars and biopsychosocial history has been obtained, the patient’s current medical status should be recorded during each visit.
  • The detail and accuracy is important in the event of the treating practitioner, or another medical practitioner, needing to refer back to the notes at a later stage to understand the patient’s medical history.

Legibility

Another issue of concern, especially in a court of law, is that of illegible handwriting. Again, pressed for time, the practitioner writes faster with resulting deterioration in handwriting.

With records being important in complaints and lawsuits, poor handwriting puts practitioners at risk.

A practical way to overcome this is with the aid of technology. A patient’s consent can be obtained to record the consultation on a recording device.

Thereafter, the recording can be typed up by a staff member in the practice. This can be used to augment and support the notes the practitioner is still required to take during the consultation. The process of the voice recording and subsequent transcript will make record keeping easier and legible.

Consent 

An informed consent form can go a long away in assisting a practitioner to prove what the patient was aware of, in and during the consultation.

An informed consent form will also assist in showing that a patient was made aware of the aspects of their treatment. A court of law takes cognisance of the documents signed by a patient when they allege that they were not made aware of aspects of their treatment. The most practical answer is to have standardised forms developed specifically for your practice which cover the procedures that patients will undergo. On signing these forms; patients acknowledge that they have read and understood the contents of the informed consent, thereby protecting the practitioner and focusing the patient’s attention on ensuring that they really do understand their treatment.


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