In my last post here I made the observation that I practice medicine in a fee-for-service private system that is dysfunctional. Consumers of healthcare are the obvious losers, being subject to the perversions of the current system that translate into significantly higher cost.

I stated that one of the drivers of this system is that doctors who earn disproportionately low fees for medical services require large volumes to increase their turnover, and that the main incentive to keep medical fees low comes from the medical administrators, who are unable or unwilling to apply the same discipline to themselves.

Now is the time to put my money where my mouth is, and to make a suggestion to change this situation. It is a brave one, and a bold one, bound to be challenged on many fronts. I really do not see any alternative that preserves the proud autonomy of the medical profession and which should directly translate into better healthcare for all.

The following requirements would be obligatory for any chance for a new way of doing medical business to succeed: that the medical profession retains its autonomy and polices itself, that a new system is one that invites willing participation by doctors and is not enforced upon anyone, that the patient remains the centre point of medical practice, and that the system should be economically viable, stable, and resistant to abuse. It’s a tall order.

I suggest it’s time for a grading system for doctors, based effectively on how well we treat our patients. It could be a star system — 1 to 5 stars — or similar to credit ratings — AA+, AA, AB, BB etc. I could aspire to be an AA+ rated ENT surgeon, and would be able to market my skills on that basis.

The rationale behind this idea is this: the vast majority of doctors in private practice stick to ethical norms and values — it is the renegades and crass commercialists who bump up the overservicing for which we have been so heavily criticised and by whose brush we have been equally tarred. My idea is that we separate into two groups — one of doctors who want business to remain as it is, and another of doctors who seek change and are willing to subject to peer review by our own professional organisations to practice ideal medicine and to be recognised for doing so.

There is a very good way to identify who the doctors who overservice are. For all its faults, the medical funder industry has got one thing disturbingly (and unpopularly from a doctor’s perspective) right. Every medical consultation, treatment and intervention carries a code, and for an account to be paid, that code has to be submitted to the funder. As an industry, that code data has been centralised into a database that is able to present a practice profile of every medical practitioner. As a result the funders know more about their “service providers” than we ourselves do. They already know who the good and the bad guys are.

So within a specialty, there is a distribution curve of “normal” behaviour based on those codes and the exceptions stand out. For example, if an ENT surgeon sees 20 new patients a week, and operates on 15 of them, where the norm in all other ENTs would be to operate on an average 4, that behaviour has to be explained. There may be a good explanation — eg that the ENT doctor’s practice is limited to kids or cancer, but if not, something is amiss. The idea is that the medical aid industry would provide the data, and the judgment call is made by the doctor’s own professional society ie by peer review. Different specialities have different procedure rates of course — a cardiac surgeon will operate on a higher percentage of patients than I will, as would a breast cancer specialist — but each speciality would have its own norms, and the current data set would be able to identify those norms by statistical analysis. The data could be applied to all areas of practice — the tests ordered, the medication used, and the operations performed.

So here is how it could work, using my own field as an example. The ENT Society, representative of all ENTs in the country, would adopt a set of standards that define ethical practice of the highest quality and start a group practice with open invitation to members. A first requirement for membership would be that the applicant doctor’s practice data, collated by the medical aid schemes into one central database, is openly and transparently analysed to see that there is conformation to an accepted norm. A second prerequisite would be that the surgeon keeps equally open and transparent records of good clinical practice — this could be in the detail of medical records kept, the process of informed consent, and recording of surgical procedures. A third could be the keeping of data to record the success rates of treatment. A fourth could be a monitor of patient feedback. All these parameters would be used to justify the doctor being in a separate and higher class of practice and entitled to remuneration at higher value.

Doctors at this level could be tasked by the funders with embracing new technologies and surgical techniques as part of introducing them gradually into the medical marketplace. So here, doctors set the norms, and not medical administrators as happens at present.

The carrot on the stick in a differential system is that a doctor can earn a higher income defined by his or her worth, and not determined by the need to overservice. A rating system would come with open recognition easily identified by patients and referring doctors that would in turn encourage further growth of that doctor’s practice. The incentive to join would be high — the egotist in every doctor would be unlikely to accept a lower ranking in a medical community, and the driving force would be to adopt the same style of practice. The incentive is thus to raise our game, not to lower it by overservicing and churn as is the present.

The benefits of a system like this should be apparent. There is a good prospect of reducing the 30% of total health expenditure now deemed to be unnecessary. The total “cake” of health expenditure need not grow, just the slices be resized. Patients will be able to identify the doctors who buy into this idea by themselves if the rating system is transparent.

Several things would have to happen beforehand. The medical aids would have to be prepared to come on board. They already apply differential payment schemes (Designated Service Provider agreements) but these are based on cost and control, not on quality of service. The Competition Commission would have to agree to a set tariff and standardised payment arrangement. The professional societies of each medical discipline would have to be prepared to put an effort into making the change.

The consequences of not doing so are already apparent. The minister of health has indicated that National Health Insurance will require participation by private doctors to be successful. He has already suggested that procedure fees would be in the range of 20% LESS than NHPRL — a significantly backwards step. In light of all I have said in this and the previous post, should that become a reality we will see a feeding frenzy at government expense that will make our present dysfunctional system look positively glowing in comparison and will bring NHI to its knees before it ever has a chance to succeed.

The most startling point of this idea however is this: for so long doctors and medical funders have been at loggerheads, with a relationship that has failed abysmally. There is an opportunity here that is doctor-driven that says to the funders, “Work with us, help us set a new standard, help us clean up the industry, and to remove the perversions. Let’s make a new start and get this industry right.”

Consumers of healthcare can only benefit in the long term, and as doctors we owe it to them. To you.



Martin Young

Martin Young is an ENT surgeon living an idyllic life in Knysna. He is a firm believer that "the unexamined life is not worth living", writes for a hobby and is happy to speak truth to power

Leave a comment