Barely noticed in most of the media comment on the ‘final findings and recommendations report’ of the Health Market Enquiry published towards the end of last month is the proposed establishment of an entirely new regulatory body to monitor ‘health outcomes’.
Most reporting on the recommendations of the enquiry, which was set up by the Competition Commission at the end of 2013, has focused on the proposed new Supply-Side Regulator for Healthcare (SSRH) to be appointed by the health minister to oversee the private health sector. One of the functions of this regulator will be to enforce compliance with the requirements of a new Outcome Measurement and Reporting Organisation (OMRO).
This is designed to allow patients ‘to compare and select care and providers’ on the basis of ‘past results’. Practitioners and patients will be invited to report on ‘health outcomes’. Participation by practitioners and facilities will initially be voluntary. In the ‘second phase’, however, health professionals who do not provide ‘outcomes information’ will not be able to renew the ‘practice numbers’ which are required for reimbursement purposes by medical schemes and the proposed national health insurance fund.
The report of the enquiry, under the chairmanship of Sandile Ngcobo, a former chief justice, says that ‘health outcome’ refers to ‘changes in health status which result from the provision of health (or other) services’. The report wants the OMRO to be fully functional within the next three to four years.
Putting a ‘reliable’ outcomes measuring system in place, the report says, will include defining the quality of outcomes indicators, measuring how treatments improve patient health, and disseminating the results to providers and ultimately the general public and the funding sector. The ‘active’ participation of doctors and facilities will be ‘critical’.
The report adds that ‘OMRO is supported by all participating stakeholders’ in its enquiry. It also says that there are international exemplars to ‘inform’ the process.
South Africa at present has no such reporting requirements. One general practitioner described the whole idea as ‘spurious’. He pointed out that apart from the competence of doctors, there were ‘numerous variables’ in health outcomes. They included responsiveness to medication, along with how soon symptoms presented themselves.
A specialist commented that specialists might have the worst outcomes, because they sat with everyone else’s ‘failed care’ which they needed to rectify. It was also ‘extremely difficult to adapt outcomes reporting to consider the complexity of the patient on an ongoing basis and sometimes also if the patient comes off a low health base to start with’.
Moreover, ‘a rich demanding patient might have much higher expectations from surgery than a poor unassuming patient and might give worse self-reported scores, even if the clinical outcome was better than that of the poor patient’. The specialist warned that doctors who normally had follow-ups with patients might stop doing so, because it might look as if their patients were not getting better, thereby ‘instantly improving their results if additional care is used as a measure’. Conversely, if doctors were forced to report on outcomes, ‘you might find a lot of patients having to return for a follow-up consult simply so that outcomes could be measured’.
‘Quality data in health care is very subjective’, said the specialist, which was why it was so difficult to measure and why it had not been implemented much more widely. There were no peer-reviewed international outcomes measures available.
There is also of course a possible perverse incentive: putting the interests of patients first is not necessarily the same as chasing favourable ratings on which the right to practise depends. And, this being South Africa under rule by the African National Congress, adverse ‘health outcomes’ will no doubt sometimes be blamed on ‘racist’ doctors.
Quite apart from these objections is the Ngcobo Report’s assumption that the answer to regulatory failure is simply more regulation. It claims that the private medical sector is ‘neither efficient nor competitive’ and blames this on ‘inadequate stewardship’ by the state, even though that sector is subject to a ‘myriad of statutes, regulations and by-laws’, among them 107 statutes administered by the national Department of Health.
Yet the Ngcobo Report wants a department which cannot run public health care to be given more powers over private health care, including the entirely new set of powers to withhold licences from practitioners failing to report ‘health outcomes’ to OMRO.
Moreover, a government supposedly worried about lack of competition in the private sector is bent on creating a state monopoly via its proposed national health insurance system. This will not be a good ‘health outcome’ for anyone other than the bureaucrats, deployed cadres, tenderpreneurs, and trade unions in whose interests it will be run.
Kane-Berman is a policy fellow at the IRR.
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