REPORT ON ANALYSIS OF MEDICAL SCHEMES CLAIMS DATA A FOCUS ON PRACTITIONERS 15 DECEMBER 2017

Transcription

1 REPORT ON ANALYSIS OF MEDICAL SCHEMES CLAIMS DATA A FOCUS ON PRACTITIONERS 15 DECEMBER 2017

2 DISCLAIMER The Competition Commission Health Market Inquiry (HMI), through an open tender, appointed Willis Towers Watson (Pty) Ltd (WTW) to assist with the storage, warehousing and analysis of part of the data collected from stakeholders. This report relies upon the information supplied to the HMI by various stakeholders and this report takes no account of subsequent developments after the date of the submission of that data. The HMI Panel with the assistance of WTW has exercised reasonable professional skill and care in evaluating the information and data provided by the stakeholders accurately, nevertheless WTW and its directors, officers, employees, sub-contractors and affiliates accept no responsibility and will not be held liable for any errors, omissions or misrepresentations made by stakeholders and/or any other third party, or for any resulting errors or misrepresentations in the work undertaken. The HMI has ultimate responsibility for any findings it makes regarding the subject matter of this report. In the event of inadvertent errors or omissions in this report, or should there be unintentional misinterpretations of certain aspects of the information provided by the stakeholders, this report will be amended, as necessary, based on relevant data and information that justify an amendment. i

3 CONTENTS LIST OF TABLES... iv LIST OF FIGURES... viii ABBREVIATIONS... xi INTRODUCTION... 1 DATA AND METHODOLOGIES... 2 Data Used... 2 In-hospital Attribution Analyses... 2 Other Analyses... 3 Methodologies... 4 Some Methodological Considerations... 5 PRACTITIONER CLAIMS TRENDS... 6 Out-of-hospital Claims Trends... 6 Out-of-hospital Payment Trends In-Hospital Claims Trends PRACTITIONER DETAIL ANALYSES Practitioner Consultations Analysis Out-of-hospital Consultation Trends In- hospital Consultation Trends Pre-Admission Consultations Medical Practitioner Affiliation Analyses Clustering of Fees Analysis General Practitioners Fees Clustering Analysis Specialists by Affiliation Specialist Admission Analyses by Affiliation Analysis of Supporting Medical Practitioner Disciplines Case Studies Cataract Surgery Age Analysis Procedures Performed by Location Gastroscopies and Colonoscopies Specialist Physician Admissions Multiple Attending Doctors Distribution of Procedures across Practitioners Caesarean Sections and Deliveries ii

4 Cataract Procedures Hip Replacement Procedures CONCLUSION ANNEXURE A: SPECIALIST CLUSTERING ANALYSIS ADDITIONAL FIGURES iii

5 LIST OF TABLES Table 1: Out-of-hospital Cost Trends, All Schemes (Narrow Disease Burden) 6 Table 2: Out-of-hospital Cost Trends, All Schemes (Broad Disease Burden) 7 Table 3: Unadjusted Out-of-hospital Claim Cost Trends by Use of Medical Practitioners, Table 4: Total Claims Cost Trends by Out-of-hospital Disciplines, Largest Proportion Table 5: Total Claims Cost Trends by Out-of-hospital Disciplines, Highest Increases Table 6: Total Claims Cost Trends by Out-of-hospital Disciplines, Largest Contribution Table 7: Out-of-hospital Claim Cost by Medical Practitioner Disciplines, Largest Proportion Table 8: Out-of-hospital Claim Cost by Medical Practitioner Disciplines, Highest Increase Table 9: Out-of-hospital Claim Cost by Medical Practitioner Disciplines, Highest Contribution Table 10: Visits per Lives and Cost per Visit by Medical Practitioner Discipline, Table 11: Trends in % Claimed Amount paid from Risk, Out-of-hospital Claims Table 12: Trends in % Claimed Amount paid from Savings, Out-of-hospital Claims Table 13: Trends in % of Claimed Amount Unpaid, Out-of-hospital Claims Table 14: Trends in % Claimed Amount paid from Risk, Medical Practitioners OH Table 15: Trends in % Claimed Amount paid from Savings, Medical Practitioners OH Table 16: Trends in % Claimed Amount Unpaid, Medical Practitioners OH, Table 17: Day Admission Rate Trends by Discipline, Table 18: Overnight Stay Admission Rate Trends by Discipline, Table 19: Day Admissions Cost per Admission Trends by Discipline, Table 20: Overnight Admissions Cost per Admission Trends by Discipline, Table 21: Day Admissions Medical Practitioner Cost per Admission Trends, Table 22: Overnight Admissions Medical Practitioner Cost per Admission Trends, Table 23: Day Admission Total Cost per Life Trends by Discipline, Table 24: Overnight Stay Admissions Total Cost per Life Trends by Discipline, Table 25: Day Admission Medical Practitioner Cost Trends by Discipline, Table 26: Overnight Stay Admissions Medical Practitioner Cost Trends by Discipline, iv

6 Table 27: Day Admissions Summary Trends by Medical Practitioner Discipline, Average Table 28: Overnight Admissions Summary Trends by Medical Practitioner Discipline, Average Table 29: All Admissions, Total Cost and Cost Increase Breakdown by Discipline (Narrow Disease Burden), Part 1 41 Table 30: All Admissions, Total Cost and Cost Increase Breakdown by Discipline (Broad Disease Burden), Part 1 42 Table 31: All Admissions, Total Cost and Cost Increase Breakdown by Discipline (Narrow Disease Burden), Part 2 43 Table 32: All Admissions, Total Cost and Cost Increase Breakdown by Discipline (Broad Disease Burden), Part 2 44 Table 33: Out-of-hospital Consultations per Beneficiaries Trends, Table 34: Out-of-hospital Consultations per Beneficiaries by Diagnoses, Table 35: In-Hospital Consultations per Beneficiaries Trends, Table 36: In- Hospital Consultations per Beneficiaries by Diagnoses, Table 37: All Admissions Pre-Admission Consultations Trends, Specialist Physicians 50 Table 38: Short Stay Admissions Pre-Admission Consultations Trends, Specialist Physicians 51 Table 39: Long Stay Admissions Pre-Admission Consultation Trends, Specialist Physicians 51 Table 40: All Admissions Pre-Admission Consultations by Month, Specialist Physicians 53 Table 41: Short Stay Admissions Pre-Admission Consultations by Month, Specialist Physicians 54 Table 42: Long Stay Admissions Pre-Admission Consultations by Month, Specialist Physicians 55 Table 43: All Admissions 30 Days Pre-Admission Consultations Trends, Specialist Physicians 56 Table 44: All Admissions 60 Days Pre-Admission Consultations Trends, Specialist Physicians 56 Table 45: All Admissions Pre-Admission Consultations Trends, General Surgeons 57 Table 46: Short Stay Admissions Pre-Admission Consultations Trends, General Surgeons 57 Table 47: Long Stay Admissions Pre-Admission Consultation Trends, General Surgeons 58 Table 48: All Admissions Pre-Admission Consultations by Month, General Surgeons 59 Table 49: Short Stay Admissions Pre-Admission Consultations by Month, General Surgeons 60 Table 50: Long Stay Admissions Pre-Admission Consultations by Month, General Surgeons 61 Table 51: All Admissions 30 Days Pre-Admission Consultations Trends, General Surgeons 62 v

7 Table 52: All Admissions 60 Days Pre-Admission Consultations Trends, General Surgeons 62 Table 53: General Surgeon Admissions Trends by ASSA Membership 93 Table 54: Otorhinolaryngology Admissions Trends by ENTS Membership 94 Table 55: Consulting Disciplines Admissions Trends by FCPSA Membership 94 Table 56: Ophthalmologist Admissions Trends by OSSA Membership 95 Table 57: Psychiatrist Admissions Trends by PsychMG Membership 96 Table 58: General Surgeon Admissions Trends by Surgicom Membership 96 Table 59: Statistical Significance Results, Affiliation CPA Analysis 2014 (Narrow Disease Burden) 97 Table 60: Statistical Significance Results, Affiliation CPA Analysis 2014 (Broad Disease Burden) 98 Table 61: Affiliation Analysis Results Summary, Total Cost per Admission (Narrow Disease Burden) 98 Table 62: Affiliation Analysis Results Summary, Total Cost per Admission (Broad Disease Burden) 99 Table 63: Affiliation Analysis Results Summary, Specialist Cost per Admission (Narrow Disease Burden) 100 Table 64: Affiliation Analysis Results Summary, Specialist Cost per Admission (Broad Disease Burden) 101 Table 65: Admission Trends, Anaesthetists 103 Table 66: Anaesthetist Cost per Admission Trends, All Schemes (Narrow Disease Burden) 104 Table 67: Anaesthetist Cost per Admission Trends, All Schemes (Broad Disease Burden) 104 Table 68: Anaesthetist Cost per Admission Trends, Open Schemes (Narrow Disease Burden) 106 Table 69: Anaesthetist Cost per Admission Trends, Open Schemes (Broad Disease Burden) 106 Table 70: Anaesthetist Cost per Admission Trends, Restricted Schemes (Narrow Disease Burden) 107 Table 71: Anaesthetist Cost per Admission Trends, Restricted Schemes (Broad Disease Burden) 107 Table 72: Anaesthetist Admissions and Claims Summary by SASA Affiliation, Table 73: Anaesthetist Cost per Admission Affiliation Analysis, (Narrow Disease Burden) 109 Table 74: Anaesthetist Cost per Admission Affiliation Analysis, (Broad Disease Burden) 109 Table 75: Pathologist Claims Trends, : All Schemes (Narrow Disease Burden) 110 Table 76: Pathologist Claims Trends, : All Schemes (Broad Disease Burden) 111 Table 77: Pathologist Claims Trends, : Open Schemes (Narrow Disease Burden) 112 vi

8 Table 78: Pathologist Claims Trends, : Open Schemes (Broad Disease Burden) 112 Table 79: Pathologist Claims Trends, : Restricted Schemes (Narrow Disease Burden) 113 Table 80: Pathologist Claims Trends, : Restricted Schemes (Broad Disease Burden) 113 Table 81: Pathologist Utilisation Trends, : All Schemes (Narrow Disease Burden) 114 Table 82: Pathologist Utilisation Trends, : All Schemes (Broad Disease Burden) 114 Table 83: Radiologist Claims Trends, : All Schemes (Narrow Disease Burden) 115 Table 84: Radiologist Claims Trends, : All Schemes (Broad Disease Burden) 116 Table 85: Radiologist Claims Trends, : Open Schemes (Narrow Disease Burden) 117 Table 86: Radiologist Claims Trends, : Open Schemes (Broad Disease Burden) 117 Table 87: Radiologist Claims Trends, : Restricted Schemes (Narrow Disease Burden) 118 Table 88: Radiologist Claims Trends, : Restricted Schemes (Broad Disease Burden) 118 Table 89: Radiologist Utilisation Trends, : All Schemes (Narrow Disease Burden) 119 Table 90: Radiologist Utilisation Trends, : All Schemes (Broad Disease Burden) 119 Table 91: Radiology Cost Trends by Modality, : All Schemes 120 Table 92: Cataract Admission Rates by Age Band, Table 93: Cataract Admission Rates by Age Band, Table 94: Gastroscopy Procedure Rates, Table 95: Gastroscopy Procedure Rate Trends, Table 96: Colonoscopy Procedure Rates, Table 97: Colonoscopy Procedure Rate Trends, Table 98: Specialist Physician Admissions per Lives by Admission Group, Table 99: Specialist Physician Admissions per Lives Trends by Admission Group, Table 100: Specialist Physician Admissions per Lives by Number of Attending Practitioners, Table 101: Specialist Physician Admissions per Lives Trends by Number of Attending Practitioners, Table 102: Specialist Physician Admissions Average LoS by Number of Practitioners, Table 103: Specialist Physician Admissions Average LoS Trends by Number of Practitioners, vii

9 Table 104: Specialist Physician Admissions Cost per Admission by Number of Practitioners, Table 105: Specialist Physician Admissions Average LoS Trends by Number of Practitioners, Table 106: Caesarean Section Procedure Trends, Gynaecologists and General Practitioners, Table 107: Caesarean Section Rate Trends for Gynaecologists and General Practitioners, Table 108: Cataract Surgery Procedure Trends, Ophthalmologists, Table 109: Hip Replacement Procedure Trends, Orthopaedic Surgeons, LIST OF FIGURES Figure 1: Out-of-hospital Claims Split, Figure 2: Consultations Frequency Distribution, : All Schemes 65 Figure 3: Consultations Frequency Distribution, : Discovery Health Medical Scheme 66 Figure 4: Consultations Frequency Distribution : Government Employees Medical Scheme 67 Figure 5: Consultations Frequency Distribution, : SA Police Services Medical Scheme 67 Figure 6: Consultations Frequency Distribution, : Bonitas Medical Fund 68 Figure 7: Consultations Frequency Distribution, : Medshield Medical Scheme 68 Figure 8: Consultations Frequency Distribution, Anglovaal Medical Scheme 69 Figure 9: Consultations Frequency Distribution, : BP Medical Scheme 70 Figure 10: Consultations Frequency Distribution, : University of the Witwatersrand Medical Scheme 70 Figure 11: 0109 Frequency Distribution , General Surgeons 72 Figure 12: 0109 Frequency Distribution by ASSA Membership, 2014: General Surgeons 73 Figure 13: 0109 Frequency Distribution by Surgicom Membership, 2014: General Surgeons 73 Figure 14: 1653 Frequency Distribution, , General Surgeons 74 Figure 15: 1653 Frequency Distribution by ASSA Affiliation, 2014: General Surgeons 75 Figure 16: 1653 Frequency Distribution by Surgicom Affiliation, 2014: General Surgeons 75 Figure 17: 0190 Frequency Distribution , Otorhinolaryngologists 76 Figure 18: 0190 Frequency Distribution by ENTS Membership, 2014: Otorhinolaryngologists 77 Figure 19: 1101 Frequency Distribution, : Otorhinolaryngologists 78 viii

10 Figure 20: 1101 Frequency Distribution by ENTS Affiliation, 2014: Otorhinolaryngologists 79 Figure 21: 0109 Frequency Distribution , Specialist Physicians 80 Figure 22: 0109 Frequency Distribution by FCPSA Membership, 2014: Specialist Physicians 81 Figure 23: 0173 Frequency Distribution, , Specialist Physicians 82 Figure 24: 0173 Frequency Distribution by FCPSA Affiliation, 2014: Specialist Physicians 83 Figure 25: 3047 Frequency Distribution , Ophthalmologists 84 Figure 26: 3047 Frequency Distribution by OSSA Membership, 2014: Ophthalmologists 85 Figure 27: 0190 Frequency Distribution, : Ophthalmologists 86 Figure 28: 0190 Frequency Distribution by OSSA Affiliation, 2014: Ophthalmologists 87 Figure 29: 2974 Frequency Distribution , Psychiatrists 88 Figure 30: 2974 Frequency Distribution by PsychMG Membership, 2014: Psychiatrists 89 Figure 31: 2975 Frequency Distribution, : Psychiatrists 90 Figure 32: 2975 Frequency Distribution by PsychMG Affiliation, 2014: Psychiatrists 91 Figure 33: 2957 Frequency Distribution, : Psychiatrists 91 Figure 34: 2975 Frequency Distribution by PsychMG Affiliation, 2014: Psychiatrists 92 Figure 35: 1587 Frequency Distribution, : General Surgeons 137 Figure 36:1761 Frequency Distribution, : General Surgeons 137 Figure 37: 0190 Frequency Distribution, : General Surgeons 138 Figure 38: 0173 Frequency Distribution, : General Surgeons 138 Figure 39: 1675 Frequency Distribution, : General Surgeons 139 Figure 40: 0009 Frequency Distribution, : General Surgeons 139 Figure 41: 1210 Frequency Distribution, : General Surgeons 140 Figure 42: 0147 Frequency Distribution, : General Surgeons 140 Figure 43: 1036 Frequency Distribution, : Otorhinolaryngologists 141 Figure 44: 1052 Frequency Distribution, : Otorhinolaryngologists 141 Figure 45: 3213 Frequency Distribution, : Otorhinolaryngologists 142 Figure 46: 0191 Frequency Distribution, : Otorhinolaryngologists 142 Figure 47: 1105 Frequency Distribution, : Otorhinolaryngologists 143 ix

11 Figure 48: 1018 Frequency Distribution, : Otorhinolaryngologists 143 Figure 49: 1022 Frequency Distribution, : Otorhinolaryngologists 144 Figure 50: 1030 Frequency Distribution, : Otorhinolaryngologists 144 Figure 51: 1210 Frequency Distribution, : Specialist Physicians 145 Figure 52: 0192 Frequency Distribution, : Specialist Physicians 145 Figure 53: 0190 Frequency Distribution, : Specialist Physicians 146 Figure 54: 1206 Frequency Distribution, : Specialist Physicians 146 Figure 55: 1851 Frequency Distribution, : Specialist Physicians 147 Figure 56: 0191 Frequency Distribution, : Specialist Physicians 147 Figure 57: 3622 Frequency Distribution, : Specialist Physicians 148 Figure 58: 1204 Frequency Distribution, : Specialist Physicians 148 Figure 59: 3202 Frequency Distribution, : Ophthalmologists 149 Figure 60: 3049 Frequency Distribution, : Ophthalmologists 150 Figure 61: 3009 Frequency Distribution, : Ophthalmologists 150 Figure 62: 3201 Frequency Distribution, : Ophthalmologists 151 Figure 63: 3099 Frequency Distribution, : Ophthalmologists 151 Figure 64: 3632 Frequency Distribution, : Ophthalmologists 152 Figure 65: 3052 Frequency Distribution, : Ophthalmologists 152 Figure 66: 3028 Frequency Distribution, : Ophthalmologists 153 x

12 ABBREVIATIONS ASSA BHF CMS CPC CPI ENTS FCPSA GPMG HMI IPAF LoC LoS NHRPL NPG OSSA PMB PsychMG SASA WTW Association of Surgeons of South Africa Board of Healthcare Funders Council for Medical Schemes Cape Primary Care Consumer Price Index Ear, Nose and Throat Society Faculty of Consulting Physicians of South Africa General Practitioner Management Group Health Market Inquiry IPA Foundation Level of Care Length of Stay National Health Reference Price List National Pathology Group Ophthalmological Society of South Africa Prescribed Minimum Benefits Psychiatric Management Group South African Society of Anaesthesiologists Willis Towers Watson xi

13 INTRODUCTION 1. The Competition Commission s Health Market Inquiry (HMI) is an inquiry into the general state, nature and form of competition within the South African private healthcare sector. The HMI was initiated as there was reason to believe that there are features of the private healthcare sector that prevent, distort or restrict competition, and in order to achieve the purposes of the Competition Act. The Statement of Issues, published on 1 August 2014, identified a number of potential sources of harm to competition in the South African healthcare sector. Subsequently, the HMI published a Revised Statement of Issues on 11 February 2016, which further elaborates on the HMI s areas of focus. The HMI seeks to assess whether, and (if so) to what extent, these potential sources of harm exist. The HMI will then make recommendations on how competition within the private healthcare sector can be promoted. 2. This report, which is the fifth in a series, outlines trends and details relating to practitioners, specifically medical practitioners. 3. This report should be read in conjunction with the previous analysis reports published, which dealt in detail with the dataset being used for analysis conducted for the Health Market Inquiry (HMI), the methodology used to build analysis dataset and the overall industry cost trends over the analysis period. 4. This report is based on work done for the HMI by Willis Towers Watson (WTW). 1

14 DATA AND METHODOLOGIES Data Used 5. For the practitioner analyses outlined in the later sections of this report, the analysis datasets which have been built by WTW for the HMI and described in the Report on Analysis of Medical Schemes Claims Data Descriptive Statistics (Descriptive Statistics Report) have been used. The process of building these datasets was outlined in detail in that report. The datasets were built using the detailed claims and membership data which was requested by the HMI from the medical schemes and their administrators. In-hospital Attribution Analyses 6. The admission rate attribution analyses outlined in this report use individual medical scheme beneficiaries as the base unit of the statistical analyses. These analyses therefore use the beneficiary file built by WTW for the HMI analysis as a base. This file is structured at an individual beneficiary level and contains demographic information about each beneficiary in each year analysed, summary details of their claims for that year and some other usage indicators which have been built off the claims and membership databases. Of specific interest for the attribution analyses are: 6.1. The demographic information about each beneficiary, specifically age and gender; 6.2. The clinical profile and reporting status indicators, which are built using claims and utilisation data with the associated medicines and diagnoses and aim to build two different pictures of the disease burden within the industry; 6.3. The member movement indicator (joiner, stayer, leaver, switcher) which was built to assess how benefit option selections by members impact healthcare costs; and 6.4. The medical scheme and medical scheme plan selected, which have been grouped using the methodology described in the Report on Analysis of Claims Data Initial Cost Attribution Analysis (the Cost Attribution Report) and used as analysis variables. 2

15 7. The LoS and LoC attribution analyses on the other hand use individual admissions as the base unit of the statistical analyses. These analyses therefore use the admission file built by WTW for the HMI analysis as a base. This file is structured with one line for each hospital admission, and contains some demographic information about the patient as well as information about the facilities and medical practitioners treating the patient, some clinical information about the admission itself as well as cost and utilisation factors within each admission. Of specific interest for the analyses contained in this report are: 7.1. Again, the demographic information about the patients, specifically age and gender; 7.2. The clinical profile indicator as outlined above, which is transferred from the beneficiary file; 7.3. The diagnoses provided and procedures performed by the treating medical practitioners, which are used to build a so-called case-mix indicator; and 7.4. A Prescribed Minimum Benefit (PMB) diagnosis indicator, built using the claims data and the PMB diagnosis list published by the Council for Medical Schemes (CMS) and taking into account the PMB flags provided by the medical scheme administrators. Other Analyses 8. The other practitioner analyses are mostly descriptive in nature, and use the various indicators built into the analysis data files created by WTW for the HMI analyses. However, to run the specialist discipline and affiliation analyses specifically, additional variables needed to be created for disciplines and affiliations. These were created as follows: 8.1. The discipline groups were created using the discipline codes outlined in the Board of Healthcare Funders (BHF) submission and commonly used by medical scheme administration systems; and 8.2. The affiliation indicators (one for each of the affiliations analysed) were created from membership lists provided to the HMI by the groups concerned. 9. These additional variables were combined with the beneficiary, admission and discipline files created for the WTW analyses as outlined in the Descriptive Statistics Report in order to 3

16 produce the analysis results outlined in this report. The clustering of fees analyses however required returning to the original data as each claim line needed to be analysed separately. Methodologies 10. For this practitioner report, no new methodologies have been defined, and the methodologies used in the first two analysis reports produced are applied to specific aspects of practitioner and in-hospital claims. However, additional specific variables of interest have been defined as follows: Length of Stay (LoS) is defined as the number of days spent in hospital (inclusive of admission and discharge dates) and is therefore calculated by subtracting the admission date from the discharge date and adding one i.e. a single day admission would have an LoS of 1; Level of Care (LoC) is analysed in two ways; As outlined in previous reports, the admission dataset contains an indicator showing how many days were claimed for in each ward type (day ward, general ward, maternity ward, high care and intensive care). To the extent that no days are claimed or the days claimed do not match to the LoS defined above, the extra days for a same-day admission are assumed to have been spent in the emergency room i.e. no ward and those for an overnight admission are assumed to be spent in a general ward; In order to attribute LoC, each of these ward types have been assigned a numeric acuity factor based on the tariffs charged under the erstwhile National Health Reference Price List (NHRPL) structure, relative to a general ward e.g. a general ward has an acuity factor of 1, high care 2.65 and intensive care 4.1; Case Mix is defined as outlined in The Cost Attribution Report; Practitioners have been grouped into disciplines and affiliations using the BHF and practitioner association submissions as outlined above; and Geographical regions will be defined by aggregating so called Enumeration Area (EA) codes, noting that a complete geocoded dataset was not available to us at the 4

17 time of preparing this version of the report. An updated version of this report will be scheduled as soon as a complete geocoded dataset becomes available. Some Methodological Considerations 11. When calculating the figures contained in this report, the following further definitions have been applied: When the report refers to members or beneficiaries, it counts total covered lives on any scheme in a given year, as opposed to the average exposed membership used in financial reporting Claim or cost figures are calculated using fees charged as opposed to benefits paid. Thus, claim estimates will include claims rejected and paid out of pocket by beneficiaries as well as those paid from medical savings accounts. We note that true out of pocket expenditure will still be understated in our estimates since claims not submitted to medical schemes and paid out of pocket will still be excluded Open and Restricted schemes are defined as in the CMS annual reports All calculated inflation figures are annualised, i.e. when an inflation figure from 2010 to 2014 is quoted as x%, it should be read as x% per year. This will be consistent throughout all of the reports produced as part of the expenditure analysis, and any exceptions will be noted accordingly Where claims figures are summarised by an analysis variable, the definition will correspond to those used in the first report. 5

18 PRACTITIONER CLAIMS TRENDS Out-of-hospital Claims Trends 12. Table 1 & Table 2 are reproduced from the Cost Attribution Report and shows the overall trends in out-of-hospital claims together with the contribution of the various explanatory factors defined. It shows that out-of-hospital claims have increased on average by 7.28% a year, 5.60% of which is made up of Consumer Price Index (CPI) increases, 1.00% by the various explanatory factors which mostly relate to beneficiary risk profiles and the remaining 0.68% by so-called unexplained factors. These unexplained factors could include price increases above CPI as well as increases in the volume and/or intensity of services utilised per average beneficiary. TABLE 1: OUT-OF-HOSPITAL COST TRENDS, ALL SCHEMES (NARROW DISEASE BURDEN) OH Claims, All Schemes Average Total Increase 7.59% 5.23% 6.96% 9.33% 7.28% CPI 5.00% 5.60% 5.70% 6.10% 5.60% All Explanatory Factors 2.49% -1.22% 1.50% 1.14% 0.98% Age 0.43% 2.14% 1.00% 0.73% 1.08% Gender -0.01% -0.01% 0.03% 0.03% 0.01% Disease Profile 1.46% -0.85% 0.90% 0.62% 0.53% Member Profile 2.24% 0.04% 0.09% 0.28% 0.66% Plan Mix -1.63% -2.54% -0.51% -0.51% -1.30% Unexplained Factors 0.10% 0.85% -0.23% 2.09% 0.70% 6

19 TABLE 2: OUT-OF-HOSPITAL COST TRENDS, ALL SCHEMES (BROAD DISEASE BURDEN) OH Claims, All Schemes Average Total Increase 7.59% 5.23% 6.96% 9.33% 7.28% CPI 5.00% 5.60% 5.70% 6.10% 5.60% All Explanatory Factors 4.44% 0.38% 2.09% 1.99% 2.22% Age 0.43% 2.14% 1.00% 0.73% 1.08% Gender -0.01% -0.01% 0.03% 0.03% 0.01% Disease Profile 3.04% 0.25% 1.53% 1.53% 1.59% Member Profile 2.51% -0.16% 0.02% 0.25% 0.65% Plan Mix -1.53% -1.84% -0.48% -0.54% -1.10% Unexplained Factors -1.84% -0.74% -0.82% 1.24% -0.54% 13. Table 3 is reproduced from the Descriptive Statistics Report, and shows the cost increases broken down across two dimensions, namely the type and number of medical practitioners seen by each beneficiary (using the medical practitioner usage and multiple medical practitioner indicators outlined in that report), and the expenditure categories outlined in the report. It shows that: As outlined above, the out-of-hospital claims have increased annually by 7.28% on a membership adjusted basis; The categories which show the highest annual increase are pathology (12.38%) and radiology (10.12%), followed by specialist services (9.07%); 7

20 13.3. Those beneficiaries visiting only specialists show higher cost increases than the remaining beneficiaries, with the group visiting multiple specialists showing the highest increases of all; and It is noted that fewer beneficiaries are falling into the no medical practitioners category. This implies that over time larger proportions of the population are being managed by and/or accessing the services of medical practitioners. 8

21 TABLE 3: UNADJUSTED OUT-OF-HOSPITAL CLAIM COST TRENDS BY USE OF MEDICAL PRACTITIONERS, Annual Increase Lives Specialist GP Meds Pathology Radiology Auxiliary Other Total OH No Medical Practitioners -2.4% 7.81% 12.22% 12.17% 9.41% 5.78% 7.42% GPs only - single 1.5% 5.72% 6.67% 11.73% 9.55% 8.13% 3.04% 6.05% - multiple 0.1% 4.84% 6.94% 11.26% 12.00% 14.45% 2.51% 6.26% Specialists only - single 0.0% 8.33% 5.43% 13.79% 9.99% 6.63% 5.39% 7.50% - multiple 0.0% 19.47% 9.14% 12.31% 21.74% 8.30% 7.94% 13.38% GPs and Specialists - single 0.7% 7.84% 6.01% 5.49% 10.95% 8.65% 5.78% 4.31% 6.45% - multiple 0.0% 9.97% 5.78% 5.97% 10.92% 10.21% 9.47% 5.17% 7.39% All Lives 0.0% 9.06% 6.58% 6.83% 12.38% 10.12% 8.20% 4.56% 7.28% 9

22 14. Figure 1Figure 1 shows the proportion of expenditure (in 2014 terms) which is made up by each of the expenditure categories outlined above. It shows that medicines are the highest contributor (40%), followed by general practitioners (13%) and specialists (11%). FIGURE 1: OUT-OF-HOSPITAL CLAIMS SPLIT, Other 17% Specialist 11% Auxiliary 5% GP 13% Radiology 5% Pathology 9% Meds 40% 15. In order to assess the claiming patterns of practitioners within their individual disciplines, the overall out-of-hospital claims have been broken down by disciplines as outlined in the BHF data (as opposed to the summary groups used above). Table 4 shows the 20 disciplines which have contributed the most materially to the total out-of-hospital claims. The results are as expected given the information in the tables above, with pharmacies the largest contributor followed by general practitioners. 16. Dentistry and optometry (which would fall into the Other category in the above table and figure) are also significant expenditure components. Of the medical specialists, the highest spend out-of-hospital was in respect of Radiation Oncology, followed by Gynaecology, Specialist Physicians and Paediatrics. 17. It is noticeable that dentistry and optometry show annual increases which are significantly below average, while pathology, radiology, clinical technology and some of the specialist groups show much higher than average cost increases. 10

23 TABLE 4: TOTAL CLAIMS COST TRENDS BY OUT-OF-HOSPITAL DISCIPLINES, LARGEST PROPORTION Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total Pharmacy % 36.88% General Practitioner % 16.30% General Dental Practice % 6.31% Pathology % 6.01% Optometry % 5.34% Radiology % 5.33% Clinical Technology % 2.61% Radiation Oncologist % 1.87% Gynaecologist % 1.64% Physiotherapist % 1.42% Physician % 1.51% Psychologist % 1.36% Ophthalmology % 1.07% Speech Therapy and % 0.92% Audiology Paediatrics % 0.75% Orthodontics % 0.70% Psychiatry % 0.74% Clinical Services % 0.75% Orthotists and Prosthetists % 0.56% General Surgeons % 0.49% All Other Practices % 7.46% All Practices % % 11

24 18. Table 5 shows the 20 disciplines which have experienced the highest cost increases over the five-year period analysed. The majority of these disciplines show increases off a very low base, but the large increases in cost for clinical technology are noted. TABLE 5: TOTAL CLAIMS COST TRENDS BY OUT-OF-HOSPITAL DISCIPLINES, HIGHEST INCREASES Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total Ayurveda % 0.00% Registered Counsellors % 0.07% Medical Scientist % 0.00% Ambulance Services % 0.00% Basic Clinical Haematology % 0.05% Radiography % 0.11% Dental Technician % 0.15% Ambulance Services % 0.32% Advanced Cardio-Thoracic Surgeon % 0.03% Clinical Technology % 2.61% Rehabilitation Centres % 0.12% Medical Technology % 0.06% Registered Nurses % 0.27% Social Workers % 0.13% Dieticians % 0.13% Group Practices % 0.01% Osteopathy % 0.00% Anaesthetists % 0.11% 12

25 Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total Psychiatrists % 0.74% Clinical Services % 0.75% All Other Practices % 94.35% All Practices % % 19. Table 5 gives no indication of the materiality of these increases, since most are off a very low base. This is evidenced by the fact that the other disciplines not included in the 20 highest cost increases make up over 94% of the dataset i.e. these disciplines only represent just under 6% of total claims. 20. Table 6 shows the top 20 disciplines contributing the most to the cost increases experienced. This contribution is calculated as the increase in cost for the discipline multiplied by the weight the discipline carries in the data i.e. the proportion of claims it makes up. The table shows that again, pharmacies and general practitioners are key drivers of the increases in out-of-hospital expenditure. Pathology, radiology and clinical technology are higher rated than in the top 20 by cost due to the high increases experienced, while dentistry and optometry have fallen down the list slightly, due to their low increases as outlined above. 21. A number of the medical specialist disciplines have become visible in this list, particularly general surgeons and ophthalmologists. A number of manufacturers and dispensers of medical devices (audiology, clinical services, orthotists and prosthetists) are also evident in this table, and show higher increases than the average. 13

26 TABLE 6: TOTAL CLAIMS COST TRENDS BY OUT-OF-HOSPITAL DISCIPLINES, LARGEST CONTRIBUTION Claim Cost per Beneficiary per Annum (Rands) Practice Trend Contribution Pharmacies % 36.02% General Medical Practitioners % 13.44% Pathologists % 7.47% Radiologists % 6.85% General Dental Practitioners % 3.04% Clinical Technologists % 5.43% Optometrists % 1.36% Radiation Oncologists % 2.10% Physicians % 2.48% Gynaecologists % 1.35% Psychologists % 1.66% Physiotherapists % 1.33% Ophthalmologists % 1.83% Speech Therapists and Audiologists % 1.39% Clinical Services % 1.28% Psychiatrists % 1.28% Paediatricians % 0.65% Orthotists and Prosthetists % 0.80% General Surgeons % 0.79% Orthodontics % 0.36% All Other Practices % 9.10% All Practices % % 14

27 22. Since this report focuses mainly on medical practitioners due to their central roles within the healthcare system, the next set of tables shows the same trends, but for the top 10 medical practitioner disciplines by cost, increase and contribution to increase. The same trends as outlined above are evident here again, with general practitioners being the largest contributor to increases in out-of-hospital expenditure, followed by radiation oncologists and gynaecologists. 23. Large increases and significant contributions to the increases are recorded for specialist physicians, ophthalmologists, psychiatrists and general surgeons. The increases for anaesthetists and cardio-thoracic surgeons outlined above are off a very low base, and these disciplines do not materially contribute to the overall increases, which are mostly attributable to general practitioners due to the high proportion of claims they constitute. 24. These results appear to suggest that, out-of-hospital at least, the majority of medical practitioner services (over 60%) are still being provided by general practitioners as opposed to specialists. Further analysis of general practitioner claims will be outlined in later sections. TABLE 7: OUT-OF-HOSPITAL CLAIM COST BY MEDICAL PRACTITIONER DISCIPLINES, LARGEST PROPORTION Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total General Medical % 61.44% Practitioners Radiation Oncologist % 7.06% Gynaecologist % 6.18% Physician % 5.69% Ophthalmology % 4.04% Paediatrics % 2.81% Psychiatrists % 2.77% General Surgeons % 1.85% Dermatologists % 1.47% 15

28 Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total Orthopaedic Surgeons % 1.42% Other Medical Practitioners % 5.27% All Medical Practitioners % % TABLE 8: OUT-OF-HOSPITAL CLAIM COST BY MEDICAL PRACTITIONER DISCIPLINES, HIGHEST INCREASE Claim Cost per Beneficiary per Annum (Rands) Practice Trend % of Total Cardio-Thoracic Surgeons % 0.11% Anaesthetists % 0.40% Psychiatrists % 2.77% Ophthalmology % 4.04% Physicians % 5.69% General Surgeons % 1.85% Urologists % 1.12% Orthopaedic Surgeons % 1.42% Radiation Oncology % 7.06% Neurosurgeons % 0.31% Other Medical Practitioners % 75.23% All Medical Practitioners % % 16

29 TABLE 9: OUT-OF-HOSPITAL CLAIM COST BY MEDICAL PRACTITIONER DISCIPLINES, HIGHEST CONTRIBUTION Claim Cost per Beneficiary per Annum (Rands) Practice Trend Contribution General Medical % 52.11% Practitioners Radiation Oncologists % 8.15% Physicians % 9.60% Gynaecologists % 5.25% Ophthalmologists % 7.10% Psychiatrists % 4.95% Paediatricians % 2.53% General Surgeons % 3.06% Orthopaedic Surgeons % 1.66% Dermatologists % 1.30% Other Medical Practitioners All Medical Practitioners % 4.28% % % 25. Increases in medical practitioner costs in particular can come from two sources an increase in the number of visits to practitioners per covered lives or increases in the average cost per visit. The next analysis breaks the costs shown above into these component parts to assist in determining the contribution of each of the components above to the overall increase. 26. Table 10 shows the 2014 figure as well as the average annual increase since 2010, by practitioner type, in both the number of visits and the cost per visit. 17

30 TABLE 10: VISITS PER LIVES AND COST PER VISIT BY MEDICAL PRACTITIONER DISCIPLINE, 2014 Visits per Trend Cost per Visit Trend General Medical % % Practitioners Gynaecologists % % Physicians % % Paediatricians % % Ophthalmologists % % Psychiatrists % % Orthopaedic Surgeons % % Dermatologists % % General Surgeons % % Otorhinolaryngologists % % Other Medical Practitioners % % All Medical Practitioners % % 27. Table 10 shows that, on average, the number of visits has increased only marginally, except in the case of specialist physicians, psychiatrists and ophthalmologists. The cost per visit has increased by 5.23% for general practitioners, and by significantly more than that for most of the specialist medical practitioners, with the highest increase of 11.82% recorded for general surgeons. Out-of-hospital Payment Trends 28. In this section, the patterns of how and where claims are paid by the medical schemes which supplied the data is analysed. The preceding section summarises what was claimed from schemes by the various groups and disciplines of practitioners. This section attempts to analyse how those claims were processed and ultimately paid by the schemes. It also explores some trends over time in how claims are paid, and highlights some differences between the various disciplines. 18

31 29. For the purposes of this sub-section, claim payment sources are defined as follows: A payment from Risk is any amount paid from the schemes funds, including from hospital benefits or major medical benefits, any insured benefit limits in traditional type options and above threshold benefits; A payment from Savings is any amount paid from the personal medical savings account of a member; and An Unpaid claim amount is an amount which claimed by a service provider, but was not paid by the scheme. 30. Table 11 below shows the proportion of claims for each of the 20 disciplines with the highest claim cost (as outlined in Table 4) which were paid from risk. 19

32 TABLE 11: TRENDS IN % CLAIMED AMOUNT PAID FROM RISK, OUT-OF-HOSPITAL CLAIMS % Claimed Amount paid from Risk Practice Trend Pharmacy 70.93% 71.58% 71.42% 71.54% 71.08% 0.15% General Practitioner 73.00% 73.17% 73.61% 72.82% 72.43% -0.57% General Dental Practice 60.12% 58.61% 57.89% 57.68% 57.52% -2.60% Pathology 73.26% 73.88% 74.68% 73.93% 74.55% 1.29% Optometry 54.88% 53.03% 49.20% 43.93% 43.50% % Radiology 80.87% 81.71% 81.85% 81.67% 81.30% 0.43% Clinical Technology 98.79% 98.64% 98.83% 99.08% 98.95% 0.16% Radiation Oncologist 98.50% 98.42% 97.82% 97.92% 98.04% -0.45% Gynaecologist 58.07% 58.52% 57.71% 56.63% 55.43% -2.64% Physiotherapist 65.35% 65.82% 64.45% 64.13% 62.85% -2.51% Physician 76.16% 77.64% 78.01% 78.47% 79.41% 3.25% Psychologist 71.05% 70.77% 71.85% 72.91% 73.72% 2.67% Ophthalmology 68.70% 69.75% 71.50% 72.91% 73.86% 5.16% Speech Therapy and 71.31% 70.18% 72.00% 71.77% 72.63% 1.32% Audiology Paediatrics 59.30% 59.60% 59.66% 59.08% 59.05% -0.25% Orthodontics 56.57% 53.57% 52.41% 50.81% 49.45% -7.12% Psychiatry 77.04% 77.99% 79.65% 81.40% 80.77% 3.73% Clinical Services 87.53% 88.53% 88.33% 88.85% 89.66% 2.13% Orthotists and Prosthetists 76.36% 79.77% 84.64% 76.05% 76.11% -0.25% General Surgeons 66.19% 67.86% 69.41% 70.69% 72.22% 6.03% All Other Practices 68.67% 68.09% 69.49% 69.67% 70.38% 1.71% All Practices 70.51% 70.86% 71.09% 70.89% 70.74% 0.22% 20

33 31. Table 11 shows that, across all practices, payments from risk for out-of-hospital claims have remained stable at between 70% and 71%. However, there are some variations within this, notably reduced payments from risk for optometrists, general dental practices and orthodontic practices, with increased payments from risk made to some of the specialist groups as well as psychologists. 32. Table 12 shows the corresponding trends for claims paid from savings accounts. TABLE 12: TRENDS IN % CLAIMED AMOUNT PAID FROM SAVINGS, OUT-OF-HOSPITAL CLAIMS % Claimed Amount paid from Savings Practice Trend Pharmacy 19.85% 19.88% 19.70% 20.25% 21.12% 1.27% General Practitioner 23.29% 22.87% 22.79% 23.29% 24.15% 0.86% General Dental Practice 30.62% 31.83% 32.61% 32.70% 33.37% 2.76% Pathology 23.53% 23.37% 22.98% 23.34% 22.96% -0.57% Optometry 38.08% 39.73% 42.25% 46.09% 46.33% 8.25% Radiology 15.50% 14.94% 14.59% 14.60% 15.01% -0.50% Clinical Technology 0.68% 0.61% 0.55% 0.49% 0.46% -0.22% Radiation Oncologist 0.51% 0.37% 0.39% 0.42% 0.51% 0.00% Gynaecologist 31.85% 31.14% 31.06% 31.91% 32.49% 0.64% Physiotherapist 31.03% 30.78% 32.38% 32.82% 33.84% 2.81% Physician 16.66% 15.45% 14.71% 14.27% 13.46% -3.20% Psychologist 24.69% 24.71% 23.72% 23.25% 22.20% -2.48% Ophthalmology 24.65% 23.43% 21.37% 20.32% 19.84% -4.82% Speech Therapy and 14.63% 14.91% 13.84% 14.39% 14.36% -0.26% Audiology Paediatrics 32.56% 32.36% 31.80% 32.48% 32.75% 0.19% Orthodontics 33.58% 35.23% 36.44% 38.37% 39.50% 5.92% Psychiatry 18.88% 18.06% 16.24% 15.08% 15.34% -3.54% 21

34 Clinical Services 5.88% 5.30% 5.24% 4.70% 4.71% -1.17% Orthotists and Prosthetists 13.97% 12.43% 8.79% 14.45% 13.73% -0.24% General Surgeons 17.96% 16.26% 15.18% 14.20% 13.31% -4.65% All Other Practices 21.15% 20.95% 20.38% 20.27% 19.87% -1.28% All Practices 22.34% 22.18% 21.89% 22.23% 22.66% 0.32% 33. Again, although the All Practices trends are relatively flat, significant variations between practices are evident. Specifically, increased payments from savings are recorded for optometrists, orthodontics, general dental practices and physiotherapists, while reduced payments from savings are evident for some of the specialist groups and psychologists. These trends are almost the inverse of the risk payment trends as may be expected. 34. Table 13 shows the corresponding trends for unpaid claims. TABLE 13: TRENDS IN % OF CLAIMED AMOUNT UNPAID, OUT-OF-HOSPITAL CLAIMS % Claimed Amount Unpaid Practice Trend Pharmacy 9.22% 8.54% 8.88% 8.21% 7.80% -1.42% General Practitioner 3.70% 3.97% 3.61% 3.89% 3.41% -0.29% General Dental Practice 9.26% 9.56% 9.50% 9.62% 9.10% -0.16% Pathology 3.21% 2.75% 2.34% 2.74% 2.49% -0.72% Optometry 7.04% 7.24% 8.55% 9.98% 10.17% 3.13% Radiology 3.63% 3.35% 3.56% 3.73% 3.69% 0.06% Clinical Technology 0.53% 0.74% 0.62% 0.43% 0.59% 0.06% Radiation Oncologist 0.99% 1.21% 1.79% 1.66% 1.45% 0.45% Gynaecologist 10.08% 10.34% 11.23% 11.46% 12.08% 2.01% Physiotherapist 3.62% 3.40% 3.16% 3.05% 3.31% -0.30% Physician 7.18% 6.90% 7.28% 7.25% 7.13% -0.05% 22

35 Psychologist 4.27% 4.52% 4.42% 3.84% 4.08% -0.19% Ophthalmology 6.65% 6.81% 7.13% 6.77% 6.30% -0.34% Speech Therapy and 14.06% 14.92% 14.15% 13.84% 13.00% -1.06% Audiology Paediatrics 8.14% 8.05% 8.54% 8.44% 8.20% 0.06% Orthodontics 9.85% 11.21% 11.15% 10.82% 11.06% 1.20% Psychiatry 4.09% 3.95% 4.11% 3.52% 3.89% -0.19% Clinical Services 6.58% 6.17% 6.44% 6.46% 5.62% -0.96% Orthotists and Prosthetists 9.66% 7.81% 6.57% 9.50% 10.16% 0.50% General Surgeons 15.85% 15.87% 15.40% 15.12% 14.47% -1.38% All Other Practices 10.18% 10.96% 10.13% 10.06% 9.75% -0.43% All Practices 7.14% 6.96% 7.02% 6.88% 6.60% -0.54% 35. Table 13 shows that the proportion of claims remaining unpaid has reduced marginally over the period when all practices are included. However, notable increases in unpaid claim amounts are recorded for optometry, gynaecologists and orthodontics, while notable decreases in the proportion of claim amounts unpaid are recorded for pharmacies as well as general surgeons. 36. As in the previous section, the analysis is repeated for medical practitioners given some of the trends outlined in the overall table. Table 14 shows the proportion of claimed amount which is paid from risk for the ten medical practitioners with the highest claim costs. 23

36 TABLE 14: TRENDS IN % CLAIMED AMOUNT PAID FROM RISK, MEDICAL PRACTITIONERS OH % Claimed Amount paid from Risk Practice Trend General Medical 73.00% 73.17% 73.61% 72.82% 72.43% -0.57% Practitioners Radiation Oncologist 98.50% 98.42% 97.82% 97.92% 98.04% -0.45% Gynaecologist 58.07% 58.52% 57.71% 56.63% 55.43% -2.64% Physician 76.16% 77.64% 78.01% 78.47% 79.41% 3.25% Ophthalmology 68.70% 69.75% 71.50% 72.91% 73.86% 5.16% Paediatrics 59.30% 59.60% 59.66% 59.08% 59.05% -0.25% Psychiatrists 77.04% 77.99% 79.65% 81.40% 80.77% 3.73% General Surgeons 66.19% 67.86% 69.41% 70.69% 72.22% 6.03% Dermatologists 48.04% 47.54% 47.12% 45.38% 44.37% -3.68% Orthopaedic Surgeons 54.69% 55.92% 55.82% 54.99% 53.83% -0.86% 37. The table shows mixed trends, with some medical practitioners, notably specialist physicians, ophthalmologists, psychiatrists and general surgeons, receiving increasing payments from risk while other medical practitioners show no change or decreases in payments from risk, with gynaecologists and dermatologists showing notable decreases. 38. Table 15 shows the corresponding table from payments from savings accounts. 24