Healthcare has always been an issue in South Africa; an issue which was complicated further by the scrapping of medical tariffs by the Competition Commission as it conducts its legal battle over supposed price fixing in the medical sector.
This has caused rampant price increases in the industry which has made quality healthcare out of reach for certain people. In an effort to address the cost of healthcare, the Council for Medical Schemes (CMS) released a report regarding thequality of care in medical schemes.
Control and manage
According to the CMS, over the past few years, the bulk of medical schemes expenditure has been spent on in-hospital treatment, particularly private hospitalisation. In the 2015 financial year, 37.1% of the total benefits paid were for hospitalisation.
In order to reduce healthcare expenditure in the long term, it is vital to effectively control and manage the medical treatment for patients with chronic disease list (CDL) conditions.
Already much attention has been given to the management of treatment for patients with CDL conditions through specific intervention programmes. If the management of treatment for these patients is effective, the associated hospitalisation expenditure should decline at an increasing rate.
The CMS hopes to expand the monitoring of quality of care to conditions which contribute to hospitalisation, but that are not part of the CDLs.
Beneficiary visits to GPs and specialists
The CMS has included the proportion of unique beneficiaries visiting general practitioners (GP) and specialists. The proportion of unique beneficiaries visiting GPs at least once is strongly correlated to the coverage ratios – this is expected.
This suggests that the GPs are the provider mainly managing the chronic patients. The proportion visiting a GP at least once is just higher than the coverage ratios of process indicators for all chronic conditions.
The proportion of beneficiaries visiting a specialist at least once is lower compared to the proportion visiting a GP at least once for most chronic conditions except for chronic renal failure (CRF) where these are similar.
The visits to specialists are also positively correlated to the coverage ratios, though the proportion visiting specialists at least once is lower than some coverage ratios for some specific indicators.
Congestive Heart Failure
Congestive Heart Failure (CHF), or heart failure, is a condition in which the heart is unable to adequately pump blood throughout the body and/or is unable to prevent blood from backing up into the lungs. This causes blood and fluids to back up in the body – particularly in the liver, lungs, hands, and feet.
According to the CMS, there are many causes of this condition, which include hypertension and ischemic heart disease. The prevalence of CHF increased from 8.5 per 1 000 beneficiaries in 2014 to 8.8 per 1 000 beneficiaries in 2015 across medical scheme beneficiaries.
The coverage ratios for CHF has increased from 2014 to 2015. The number of unique beneficiaries receiving at least one electrocardiogram increased marginally from 19.0% to 19.2% in 2015; coverage ratios for the flu vaccine and the renal function tests increased by at least 1%.
The coverage ratio of the flu vaccine is very low at 7.3% in 2015. There could be several reasons for this which includes poor member compliance or missing data as members maybe paying for this over the counter.
Hospitalisation was relatively unchanged increasing by 0.3%, from 19.8% in 2014 to 20.1% in 2015 for in-patient hospital admissions where patients stay for longer than 24 hours. The in-patient hospital admissions, where patients stay for less than 24 hours, were 8.7% for both 2014 and 2015.
This information is important for life insurers as heart disease related deaths are major sources of claims.
Chronic renal disease
Chronic renal failure (CRF) is a condition characterised by gradual weakening of kidney function; poor kidney function leads to high levels of waste in the blood of the patient. The loss in kidney function often results in patient developing other chronic conditions.
The CMS reports that the prevalence of CRF increased from 4.2 per 1 000 beneficiaries in 2014 to 4.5 per 1 000 beneficiaries in 2015 across medical scheme beneficiaries.
It adds that the coverage ratios of CRF patients increased on all process indicators. The proportion of CRF patients receiving the creatinine test increased from 12.4% in 2014 to 13.4% in 2015.
Hospitalisation increased slightly from 7.5% in 2014 to 7.6% in 2015 for in-patient hospital admissions where patients stayed for longer than 24 hours. While, the in-patient hospital admissions for patients staying shorter than 24 hours decreased by 0.7% from 18.5% in 2014 to 17.8% in 2015.
Editor’s Thoughts:
These statistics has a significant bearing on life insurers. An increase in CDL care could translate into a decrease in claim levels among life insurers. If anything, there will be a change in trends. Please comment below, interact with us on Twitter at @fanews_online or email me your thoughts jonathan@fanews.co.za.
Comments
Added by Andre Kruger, 17 Nov 2016Me think they are dodging the bullet Report Abuse