Private family practitioners in South Africa generate 45% of direct and indirect healthcare expenditure, often via inappropriate hospitalisation and surgery, even though they only account for six percent of medical scheme claims.

This is according to Barry Childs, joint CEO of Insight Actuaries and Consultants, who works intimately with the Independent Practitioners Association Foundation, IPAF, to manage healthcare quality and contain costs.

He was speaking alongside Dr Tony Behrman, CEO of IPAF, on the second day of the International Society for Quality in Healthcare, ISQua, conference in Cape Town on Monday (21 October). Together with IPAF Chairperson, Prof Morgan Chetty, the duo outlined how data and information from profiling primary care doctors is used to enhance quality and outcomes of care, plus manage costs.

While conceding that doctors were wary of profiling, Dr Behrman drew a strong distinction between forensic profiling done by funders and IPAF’s identifying variations to the peer norm in distinct areas and populations.

Side-stepping a duty of care

He said GPs tended to shift care to hospitals and specialists, either because they were too busy or because they felt insufficiently competent to manage a patient any further. IPAF identified this and attempted to mitigate lower quality /high-cost care on a quarterly basis by sending detailed peer-reviewed data feedback to its 5 500 members (nearly 69% of all registered GPs in the country).

Recent polls showed that the need for primary healthcare above secondary and tertiary healthcare was ‘massive,’ hence the strong public sector focus on this ahead of the full implementation of an NHI.

“We want to rehabilitate doctors on a voluntary basis by showing them the all-round benefits of improvement, on a solid scientific basis – and keep them in the network,” Dr Behrman said.

Barry Childs said he had seen some significant behaviour changes by doctors, even though most of these were incremental and evolved over time. A question he and his colleagues had to ask themselves was whether to evaluate IPAF members relative to other doctors, or according to some fixed benchmark, which created, “a bit of a moving target” and elicited uncertainty among doctors.

“The reason is that the system can move forward and everybody needs to pull in that (same) direction,” he added.

Doctors unaware of driving costs

By way of example, he cited a gynaecologist whose costs his organisation found were way higher than his peers when it came to Caesarean sections.

“He was using a particular type of expensive staple – and from then on we saved thousands of rands. You have to keep on at it – it takes persistence,” he stressed.

Dr Behrman said doctors were incentivised to perform better via tiered incentives, with those showing up in the top portion of the bell curve being more highly remunerated, providing greater value for providers, patients and funders.  

He added that aligning the clinical burden and challenges individual doctors faced with the available statistics was crucial. He cited rural and peri-urban doctors not enjoying access to the screening and monitoring devices that their urban-based colleagues did.

“They’re compromised for something they don’t have any control over. We have to see what their challenges are and why they’re not performing like their peers – and then adjust for this. We want to help them become more efficient and deliver a high quality of care within a cost framework a patient can afford,” he stressed.

Dr Behrman said both the Competition Commission and the Health Market Inquiry had lauded IPAF for its independent stance and contribution to improving quality, lower-cost healthcare.

“We’re an index foundation to which others should look for transparent behaviour,” he added.

Better care via support, not policing

Prof Chetty said the term peer review was eschewed in favour of ‘peer mentoring,’ to better reflect the guided support given by their peers and to de-emphasise the idea of a constant, highly critical eye being kept over them. In spite of this, Dr Behrman said, doctors’ behaviour improved ‘the moment they know they’re being monitored.”

Prof Chetty said reviews had to be ethical and scientifically sound with a best-evidence-supported approach. Trends observed and reported on included costs, overuse of antibiotics and/or compound analgesics, excessive laboratory and radiology use and increased referral for secondary and tertiary care. All evaluations were based on the appropriateness of clinical decisions. Health practitioners were informed, and this complemented with evidence-based literature that looked at similar International and national trends.

Addressing a question on patient-demand-driven use of antibiotics, Dr Behrman said doctors needed to stand their ground and provide more patient education that would result in better patient outcomes.

Prof Morgan strongly agreed, adding that, “the future is patient-centric. Patient have to be informed inside the management process, not outside. We have this failure of communication. Actually, that’s why the World Health Organisation, WHO, changed the terminology from patient-centric to people-centred. Healthcare must prevent a person from becoming a patient. We’re treating patients in a sick-care system not in a healthcare system,” he added.

He said that for far too long in South Africa, the emphasis had been on the funder and provider of care, and not on the patient.