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The implementation of the National Health Insurance (NHI) scheme will place pathology services under increased pressure. Improvement of access to healthcare will increase demand for diagnostic testing, both for clinical diagnosis in disease states and for screening of healthy people. It is unlikely that the publicly funded budgets for pathology diagnostic services under the National Health Laboratory Service (NHLS) will increase to keep up with the demand. Furthermore, developments in new tests and the introduction of new technology in laboratory medicine will increase the overall costs. Coupled with the progressive decline in the teaching of pathology and laboratory medicine in the undergraduate curriculum, there is likely to be a tendency towards inappropriate usage of laboratory tests in clinical management. In South Africa, approximately 3.5% of provincial budgets are directed towards meeting the costs of pathology services in the public sector. In the 2011/2012 budget, R121 billion was spent on healthcare by the government. Pathology services received approximately R4.2 billion. In the UK, the National Health Service budget is currently at approximately £106 billion and laboratory testing costs approximately £2.5 billion (2.3%). The review of the UK pathology services by the Carter Commission estimated that approximately £500 million could be saved by more efficient use of pathology services, i.e. 20% of the expenditure could be saved despite a projected increase of 8 - 10% in laboratory testing. Extrapolating these figures to South Africa, potentially R800 million could be saved. In Canada there are similar pressures on pathology laboratory services within a publicly funded national healthcare system. Laboratories are being asked to perform increased numbers of tests without a comparable increase in laboratory budgets. Will this also become a feature of the era of NHI in South Africa? Given the aforementioned scenarios, the need for demand management of laboratory testing becomes paramount. Pathology services will have to formulate strategies to address both under- and overutilisation of laboratory tests and ensure that the proper use of clinical laboratory testing contributes to improved patient care. Increasingly laboratories will have to monitor test usage for costeffectiveness and appropriateness, in the best interests of clinical care and in the spirit of evidence-based laboratory medicine. 1-3

Containing costs in the era of National Health Insurance - the need for and importance of demand management in laboratory medicine