OF GP & SPECIALIST COSTS
Provider Networks consists of a comprehensive,
multi-disciplinary network of established health service
provider groups that are linked together via agreements with MHS
for the purpose of providing rational, appropriate, cost
effective healthcare to members of contracted Medical Aid
Schemes/ Administrators in return for certain pre-negotiated
benefits. The Networks include GP Groups, Dental Groups and
Clinical Specialist Groups.
principles that govern the processes of
are largely the principles of collaboration and include the
– Central to any collaborative process is the principle that initiatives
that influence the lives or livelihood of other persons, should
be designed and managed in conjunction with representation from
the affected parties.
– Products and services that are developed jointly with the
affected parties are much better accepted and instill a sense of
ownership and loyalty with the affected parties. Such sentiments
are not only absent from imposed products but such imposed
products are more often than not viewed with suspicion and
resentment by the affected parties.
– Contentious issues must be debated but decisions on the
ultimate courses of actions must be vested with the most
appropriate person to make the decision and accept
accountability for the decision. E.g. Clinical decisions should
reside with Clinicians and actuarial decisions with Actuaries.
However combined clinical-actuarial debate promotes insight and
understanding, leading to decisions emanating from a broader
– The courage to accept accountability in ones own field of
expertise must be balanced with constructive debate around
issues outside ones own field of expertise, culminating in a
respect and understanding for final decisions and support of the
– If the industry can regulate itself, design and promote
self-regulation but facilitate such self-regulation with
information and expertise and co-opt Networks of Providers that
promote self-regulation, quality assurance and cost
CPN Processes are divided into five components, viz.:
Forum for Health Promotion and Accountability
– is an alliance between representatives of the Clinician
Networks and senior Fund management. Recognition is given to the
interdependence that exists between Clinicians and the
Healthcare Funding Industry. The Forum meets three times a year
in order to debate problems and seek joint solutions in line
with the principle of “Leaders and Followers” as described
above. The ultimate purpose of the Forum is to develop mutual
understanding and trust.
Evaluation of Cost Effectiveness
– This is primarily a review of utilisation trends as tariffs
and prices are set separately. The tools consist of high-level
Benchmarks that are risk-adjusted to accommodate variations in
age and gender as well as the varying demands of different
chronic conditions. With the Benchmarks as a point of departure,
further drill-down options include more detailed practice
profiles, summaries of the transaction details that make up the
Benchmarks as well as access to the individual transactions that
made up each Benchmark – the latter is subject to measures to
protect patient confidentiality. It must however be emphasised
that these utilisation evaluation tools are never used to pass
judgement. They merely serve to focus questions for the purpose
of assisting quality assurance.
– This function is performed by Local and Regional Area
Managers that are appointed for the task by MHS in consultation
with the Networks. These managers are practitioners that are
held in high esteem by their peers and that have a sound
understanding of the circumstances of practice in their area.
Their functions include:
Evaluation of the nature of practice, using the
Benchmarks as a point of departure. Appropriate practice is
motivated as such to the Funds.
Peer Mentoring in instances where inappropriate practice
Training programmes and marketing of the CPN processes.
– are used as a last resort when all else fails. The reviews
are coordinated by the Local and Regional Area Managers and are
held within the Network to which the practice under review
belongs in conjunction with Fund representation. The outcomes
could include a finding that the practice indeed practiced
reasonably, a warning could be given or the suspension of direct
payment may be recommended. In extreme situations a practice may
be handed over to the relevant authorities.
Managed Care Fee
– Achievers of the Benchmarks receive a managed care fee per
consultation (in the case of General Practitioners). Other
disciplines are remunerated according to the most appropriate
model for that discipline e.g. Dentists are remunerated per
patient managed. The purpose of the managed care fee is to
remunerate active and successful participation towards realising
the goals of Managed Healthcare.
tangible results are measured as savings achieved. There are
three phases to savings. These are:
where the processes are set into motion and participation is
facilitated. This phase may last for six to nine months but in
instances where the processes are known and accepted, usually is
a shorter period.
which entails a reduction in utilisation volumes as well as a
shift from expensive to less expensive but equally effective
options. This lasts for about eighteen to twenty four months.
which starts by agreement on a new (lower) level of acceptable
utilisation patterns and a maintenance of such a level of
utilisation forward in time, allowing for tariff/price increases
at a constant utilisation trend.
of savings is based on sophisticated projection models based on
the age and gender as well as the epidemiology of the
beneficiary base as far as can be ascertained by the data on
hand. Targets for realistic savings are set and once achieved
are maintained in order to prevent under servicing. Maintenance
of savings is measured by means of a model that evaluates
utilisation trends around the previously determined ideal