"To fight or not to fight? That is the question".........
CPC/Qualicare is a founder member of the IPA Foundation (IPAF)
IPAF is often asked why it works with founders and administrators of medical schemes.
Why don't we just walk away and refuse to meet with them, instead of interacting and thereby legitimizing their operations and by inference, their much to be desired, rates, managed care operations, call centers and generally bad service and poor payment record?
Before IPAF emerged onto the scene, in 2009 there was no formal interaction between Funders and Providers, of an organized nature. Doctors were managed In a top down manner by organizations which offered them fixed fees, irrespective of their ability to influence quality, costs or outcomes. There was no recognition for service excellence, or cost containment. There was little or no liaison between funders and administrators on one side, and organized doctor groupings on the other, except for antagonistic sniping at one another and derogatory posturing by national organisations.
Bankmed was the first Funder which recognized the importance of interacting with organized doctor groupings which were truly representative of the Family Practitioners, and after a well attended meeting in Cape Town, in approx 2008, the IPAF was conceptualized.
Despite a slow beginning, IPAF was able to offer enhanced consultations dependant on the doctors agreeing to peer review and quality assurance, and this resulted in significantly better payments to doctors who acceded to the IPAF Bankmed contract.
More Funders came to the table and now there are 9 major Funder groupings which offer enhanced consultations in return for peer review, as well as cost and quality assurance. More recently there have been further augmentations for annual physical examinations, as well as the facility to perform enhanced preventative care for your patients paid from risk pool funding and not from patients savings thereby making patients far more keen to utilize the benefit.
IPAF was thus able to derive far more from the Funders for their doctors than entering into the well worn and counterproductive market of rhetoric and politics. Doctors voluntarily join and remain members of IPAF by virtue of their membership to their regional IPAs, or may join IPAF directly if they prefer not to be allied to an IPA.
To understand this all better, you need to study the mandate of the IPA Foundation which is to set up networks of doctors, perform cost and quality assurance, and perform peer review , peer mentoring and peer management.
IPAF has to date, set up working contracts with a number of Funders including Bankmed,Medihelp, Polmed, Bestmed, Medshield, Liberty, Discovery, Centre for Diabetes Endocrinology. We also have agreements in place with Metropolitan Health RIsk Administrators and Agility.
All of these contracts are Tripartite type contractual arrangements whereby we contract with a Funder to build networks of doctors willing to abide by the various rules and requirements of the individual Funders. The doctors acceded to the contract by agreeing to accept the terms and conditions required by the particular funding group. Some of these Funders require no balance billing, and in return for this , and doctors subjecting themselves to Peer Review, pay the treating doctor a fee well over the base rate which they offer to non contracted doctors. All however of this is VOLUNTARY , and based on willing Provider - willing Funder. Furthermore the doctor agrees to subject himself to peer profiling , which is the measurement of his individual practice judged against a group of his peers, after both he and the group have been risk adjusted for patient age, sex, ICD 10 codes used and medical plan chosen by the patients.
No one forces doctors to sign up nor to accept , for example , not to balance bill. It is the prerogative of the individual doctor, and although this is severely criticized in certain circles at present, it is based on freedom of choice to contract or not.
The real name of the game however is quality and cost outcomes, and a better deal for doctor and their patients, through a genuine and successful IPAF attempt to stabilize what was a run away situation of costs finding their way leaking out of the primary healthcare arena.
If the doctors outcomes data is grouped into a favorable category, they are awarded an enhanced consultation fee, based upon the findings of the independent actuaries, Insight.
Are we as IPAF strict enough with the Funders with whom we contract?
The answer is an unequivocal YES. We carefully inspect their offerings for fairness,procedural soundness, and achievability and those Funders whose contracts are unfairly biased against the providers, are guided to address these clauses, and invariably consensus is reached.
Is this not far better than throwing stones and insults across the previous Funder - Provider divide? As a result , we are now able to concentrate on realigning benefits ,enhancing payments , and improving outcomes, thereby making it possible for Funders to re channel resources into primary health care delivered by family practitioners, and away from the vortex of specialists and hospitals costs.
We thus believe that we have approached the problem with a new thought process and have moved on from the traditional “us and them” stance of other medical associations.
The proof of the pudding is in the existence of a cost and quality compliant Family Practitioner network of 5000 practitioners of primary health care, resident within IPAF.
With this critical mass, we are now able to constructively highlight undesirable clauses in the contracts to the mutual benefit of all parties.