Company news: Medscheme and doctors reach breakthrough agreement

“The relationship between healthcare professionals and healthcare funders has traditionally been uneasy. However, Medscheme has long held the view that structured, constructive collaboration between healthcare professionals and healthcare funders is essential for a sustainable private healthcare industry. Fundamental to this view is that general practitioners are key to managing the escalation of healthcare costs”, says Pieter Dorfling, Divisional Managing Director of Medscheme Health Risk Solutions, Medscheme's health risk management Division.

“We have been able to successfully establish common ground and concluded a breakthrough agreement with the major IPAs which, we believe, will be a win-win for patients, doctors and healthcare funders alike. The agreement allows for a permanent forum to develop strategies to deal with the delivery and funding of cost-effective quality healthcare,” adds Dorfling.

At a practical level, the forum will support the largest voluntarily contracted general practitioner's network in South Africa incorporating approximately 6 500 of South Africa's practicing general practitioners. “All the major IPAs enjoy equal representation on the forum and the national and regional footprint is by far the most extensive in South Africa. Medical scheme members should have little difficulty in finding an IPA Forum doctor in their area,” say the IPA representatives.

Doctors will be properly remunerated in a differentiated, scheme-specific manner according to mutually agreed tariffs and could, in some instances, participate in a network model which allows for retrospective bonuses based on the achievement of agreed clinical and financial targets. The contracts with individual medical schemes will vary in the detail but essentially they specify that the members of the IPAs will receive differentiated remuneration according to acceptable performance criteria with agreed fee-for-service tariffs based on the National Health Priced List (NHRPL). This will be supplemented by retrospective bonuses once clinical and financial targets are met.

Individual general practitioner's performances will be measured using a combination of Medscheme's Risk Equalised Performance Indicator (REPI) tool and the IPAs' own bespoke systems. Professor Morgan Chetty who represents the South African Managed Care Co-operative (SAMCC) explains; “General practitioners will receive detailed feedback on their individual performance based on the quality and value of the care they deliver to members of medical schemes contracted to Medscheme Health Risk Solutions. Mentoring, if indicated, will be carried out by peers and not the healthcare funders,” he says.

The IPA Forum includes representative members from the major IPAs including Drs Lex Visser, Morgan Chetty, Dennis Dyer, Tony Behrman , Buddy Modi, Jeff Govender, Elijah Nkosi and Sugen Naidoo. Medscheme Health Risk Solutions will also be represented.

Dr Visser, Interim Chairman of the IPA Leadership Forum says that a watershed in the relationship between Medscheme and the IPAs National Associations has been achieved. “Undoubtably the IPA Forum will deal with strongly held points of view and seemly intractable issues, however we are confident that we have achieved enough common ground to successfully deal with whatever challenges lie ahead.”

”The implications for the healthcare industry and consumers are profound. With general practitioners empowered and supported to balance cost, quality and access to care, medical scheme members can be assured that they are receiving the best quality of care. It is only through proactive sharing of information that health risk management can be taken to a new level and this agreement creates the opportunity to support general practitioners on a large scale” says Dorfling.

Dr Visser and Prof Morgan Chetty are upbeat about the future of the Leadership Forum. “This is only the beginning. We are committed for the long haul and we believe that the IPA Forum will pave the way for exciting and innovative doctor network products and services, which will ultimately benefit patients and make quality healthcare more accessible to more South Africans,” they conclude..

A number of major medical schemes have already signed contracts with the IPA Forum which will come into effect from this year onwards.