Utilisation of pathology procedures in the South African private pathology sector between 2003 and 2005.

OBJECTIVE To analyse the patterns of pathology procedures performed in the private pathology sector in South Africa. To determine what the differences between the individual practices are and to attempt to explain any differences. DESIGN A retrospective analysis of claims from pathology laboratories submitted by electronic interface to a medical aid administrator between January 2003 up to December 2005 were analysed. The data were sorted according to the practice number of the pathology laboratory and referring doctor, account number, laboratory number, beneficiary number and the origin of the claim (in hospital or out of hospital). The number of claims for every procedure was compared across different laboratories. RESULTS Sufficient data were available on 5.4 million claim lines over the 3-year period (92% of the total lines submitted over the period). The total amount claimed increased by 2.5% and 9.9%, the number of test procedures increased by 1.4% and 17.7%, and the number of accounts increased by 4.8% and 0.9% in 2004 and 2005 respectively. These increases occurred despite a decrease in active beneficiaries of 1.6% and 4.0% in 2004 and 2005. The average cost per active beneficiary per month varied between R494 and R611 in 2005. A relatively few common test procedures (30) contributed disproportionately to the total number of procedures (67.8%) and cost (56.9%) of laboratory testing. The utilisation of individual procedures varied between laboratories with large differences in the performance of common tests such as erythrocyte sedimentation rate, reticulocyte count, protein electrophoresis and creatinine. CONCLUSION The differences in the cost of pathology claims between individual laboratories were larger than expected. There was evidence of inappropriate test utilisation. Part of the differences between laboratories under control of the laboratories and are a result of request form design, test profile content and reflexing of tests.