4.3 THE FLOW OF FUNDS FROM THE FINANCING INTERMEDIARIES TO
4.3.7 Utilisation of Services by Medical Scheme Beneficiaries
4.3.7.1 The Burden of Disease
Table 44: Real percentage increase/decrease paid by registered restricted medical schemes from the savings account from 2003 to 2006
Registered Restricted Schemes 2003 ® 2004 ® 2005 ®
vs 2004
2005 ® vs 2003
2006 ® vs 2005
2006 ® vs 2004
2006 ® vs 2003 General Practitioners 0.00 7.91 18.62 28.00 -8.18 8.91 17.53 Medical Specialists 0.00 15.65 10.76 28.09 -11.32 -1.78 13.59
Dentists 0.00 14.66 18.66 36.05 -8.42 8.66 24.60
Dental Specialists 0.00 6.83 10.40 17.95 7.16 18.31 26.39
Supplementary And Allied Health Professionals 0.00 7.73 81.71 95.76 -39.33 10.24 18.76 Total Hospitals 0.00 -79.48 15.35 -76.33 44.17 66.30 -65.88 Private Hospitals 0.00 -78.14 31.33 -71.29 39.51 83.22 -59.95 Provincial Hospitals 0.00 -84.58 -73.34 -95.89 180.58 -25.19 -88.47
Medicines 0.00 3.92 -43.08 -40.85 45.40 -17.24 -13.99
Ex-Gratia Payments 0.00 460.51 -56.11 145.99 2696.51 1127.30 6779.14 Other Benefits 0.00 22.05 13.85 38.95 -45.16 -37.56 -23.80 Managed Care Arrangements
(Out Of Hospital Benefits)
0.00 0.00 0.00 0.00 0.00 0.00 0.00
Total Benefits 0.00 3.02 2.42 5.52 -5.09 -2.79 0.14
®: Real values (medical inflation removed)
primary care benefits. Conditions covered by the Prescribed Minimum Benefit package would be treated according to a pre-determined therapeutic algorithm which defines the scope of diagnosis, treatment and medical management of them. The regulations governing Prescribed Minimum Benefits were promulgated in 1999 but came into effect on 1 January 2000. An extensive list of the 270 conditions is included and from 1 January 2004, 25 chronic conditions were added to the chronic disease list which is complementary to the Prescribed Minimum Benefits.23
The conditions include: Addison’s disease, asthma, bronchiectasis, cardiac failure, cardiomyopathy disease, chronic renal disease, chronic obstructive pulmonary disease,
coronary artery disease, Crohn’s disease, diabetes insipidus, diabetes mellitus type 1 and type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosis and ulcerative colitis. Antiretroviral therapy for HIV was included in January 2005.23 Data has also been collected on bipolar mood disorder.
Figure 45 shows the distribution of the five major chronic disease conditions amongst the beneficiaries of consolidated schemes from 2003 to 2006. These five include asthma, diabetes mellitus type 2, HIV, hyperlipidaemia and hypertension.
21
9
1
23
62
25
16
2
34
91
21
15
4
29
69
24 19
11
42
86
-5 5 15 25 35 45 55 65 75 85 95
Asthma
Diabetes mellitus type 2 HIV
Hyperlipidaemia
Hypertension Chronic Disease
Number per 1000 beneficiaries
2003 2004 2005 2006
Figure 45: Burden of disease per 1000 beneficiaries of consolidated medical schemes from 2003 to 2006
It is evident that hypertension is the commonest chronic condition with 86 per 1000
beneficiaries being treated for the condition in 2006. This is then followed by hyperlipidaemia, asthma, diabetes mellitus type 2 and HIV.
Hypertension, hyperlipidaemia and diabetes mellitus type 2 are all strong risk factors for the development of coronary artery disease which is a chronic disease of poor lifestyle
management. Thus coronary artery disease is the sixth most common condition. In 2003, 8.8 per 1000 beneficiaries were being treated for ischaemic heart disease, as it was then named. In 2004 and 2005, 13.6 and 11.9 per 1000 beneficiaries respectively, were being treated for the disease. This then increased to 17.1 per 1000 beneficiaries in 2006. Coronary artery disease covers a spectrum of conditions from angina to myocardial infarction which can be fatal if not appropriately treated.
Since the population covered by medical schemes has been fairly stable over the four year period, a possible reason for the increased burden of disease observed since 2004 is due to the fact that these conditions became part of the prescribed minimum benefit package. These
results must still be interpreted with caution since certain medical schemes did not submit data and the criteria for defining the condition may have changed. However, overall the quality of data reported by medical schemes to the CMS has improved with time.
The prevalence of HIV appears lower than the national average (29.1% according to the
antenatal sero-prevalence survey)7 among members of medical schemes. Although this disease is more common among the poor and the vulnerable, it was largely unreported among private health care patients on medical schemes because the schemes had restricted access to
antiretroviral therapy to dual- and in some cases mono-therapy. These restrictions to access to treatment and care were largely due to financial limits but such a restriction could have dire consequences on a patient living with HIV since it could lead to the development of viral resistance.55 As mentioned earlier, antiretroviral therapy for HIV has been included as a PMB since January 2005. Beneficiaries, who are HIV positive and require treatment, are now able to access antiretroviral therapy despite the ceiling on their medical savings account. This is likely to have led to an increase in the number of cases reported as seen in 2006 when 11 per 1000 beneficiaries were recorded as being treated for HIV.
Medical schemes manage HIV-positive beneficiaries through Disease Management
Programmes (DMPs) and community treatment programmes e.g. Aid for AIDS, Lifesense, Discovery Health, Right to Care and the Treatment Action Campaign. An estimated 67 600 patients are on Highly Active Antiretroviral Therapy (HAART) in the private sector.61
However, a challenge facing the private sector is that Disease Management programmes do not provide integrated management of HIV, AIDS, Tuberculosis and Sexually Transmitted
Figure 46 shows the prevalence of the five major chronic conditions amongst beneficiaries of both registered open and restricted schemes from 2003 to 2006. Although the registered open medical schemes have a larger number of beneficiaries, those belonging to restricted medical schemes have a higher burden of chronic diseases. This could imply that the members
belonging to open schemes, like Discovery Health, are often younger, healthier individuals who are at a lower risk for the development of chronic lifestyle diseases. Open schemes also offer incentives to its beneficiaries like subsidized gym subscriptions and other lifestyle management programmes in the hopes of encouraging healthy lifestyles and keeping its beneficiaries low risk.
0 20 40 60 80 100 120 140
Asthm a Diabetes m ellitus type 2 HIV Hyperlipidaem ia Hypertension Asthm a Diabetes m ellitus type 2 HIV Hyperlipidaem ia Hypertension
Open SchemesRestricted Schemes
Chronic Disease
Number per 1000 beneficiaries
2006 2005 2004 2003
Figure 46: Burden of chronic diseases amongst beneficiaries of both registered restricted and open schemes from 2003 to 2006