Presentation to Global Campaign for Microbicides Consultation:

Insurance Funds as options to operationalise access to ART

19 – 20 June 2008

Elaine McKay

Head: HIV Strategy

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Agenda

1. Introducing Medical Schemes and Discovery1. Introducing Medical Schemes and Discovery

2. HIV and AIDS in Discovery Health2. HIV and AIDS in Discovery Health

3. The HIV Partnership Fund and others3. The HIV Partnership Fund and others

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What is a “medical scheme” (South Africa)

• A medical scheme helps you to pay for your healthcare needs, such as nursing,

surgery, dental work, medicine and hospital costs.

• It can be described as “insurance” you are taking out to cover your health costs.

You (and in certain cases your employer) pay regular contributions to the scheme.

• A medical scheme is a non-profit organisation and should be registered at the

Registrar of Medical Schemes. A board of trustees who are elected by the

schemes’ members manages a medical scheme. They are responsible to manage

the scheme to the benefit of its members.

• The Medical Schemes Act (No 131 of 1998) came into effect on 1 January 2001.

• Offers a compulsory minimum package of benefits and exclusion of risk rating, and

the discrimination on the basis of health, age, race, gender of medical history

(important in the context of what would be termed “anti-selection” for trial

participants

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What are the advantages of belonging to a medical scheme

• You have the security of knowing your medical needs will be looked after

• A portion of your contribution can be deducted from your taxable income

• You can budget for your medical expenses

• You can get the best medical care available in facilities with state of the art

equipment and infrastructure

• You can undergo medical surgery when you need it most and not be put on a waiting

list for available doctors to perform the surgery or availability as in the case of state

hospitals

• You will be treated immediately in the case of an emergency without any worries

regarding funds available

• You can benefit on a personal level with different wellness and vitality options

available

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What should a medical scheme pay for?

• In 2004 the Medical Schemes Act of 131 of 1998 introduced Prescribed Minimum

Benefits (PMB).

• It is a set of defined benefits to ensure that all medical scheme members have

access to certain minimum health services, regardless of the benefit option they

have selected.

• The aim is to provide people with continuous care to improve their health and to

make healthcare more affordable.

PMBs determine that medical schemes have to cover the costs related to the certain

diagnosis, treatment and care of medical conditions. Important since HIV and AIDS

are covered under PMBs

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The Discovery Group

2 million lives 1.2 million lives250,000 lives

172,053 policies59,262 lives 89,220 lives

Driven by a central mission Statement: To make people healthier and enhance and protect their lives

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Growth in lives under management

2 million lives

0

500,000

1,000,000

1,500,000

2,000,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Feb2007

Liv

es

ad

min

iste

red

• Established in 1992

• Covering 1 open scheme and 11 Restricted schemes

• R19 billion in premium income per annum

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Unique position in market

Source: 2006 Global Credit Rating reports and scheme financial results

Cha

nge

in m

embe

rshi

p ('0

00)

Membership level end 2005 ('000)

-40

-20

20

40

60

80

100

100 200 300 400 500 600 700 800

Oxygen

Spectramed

FedHealth

MedicoverHosmed

ResolutionBestMe LibertyMunimedProSano

SizweMedshield

MediHelp

Momentum

Bonitas

Next top 15 open Next top 15 open schemes in SAschemes in SA

Discovery

Discovery is positioned at the centre of the healthcare system

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Integrated scalable systems provide world class support to Discovery

• 120,000 claims per day

• 96% claims within 3 days

• R 7,000,000 paid per hour

• 85% paid directly to health professionals

Claims

• 1 patient hospitalised every 56 seconds

• 35,000 calls answered per day

• Answer 90% within 20 seconds

• 92% of calls resolved on first contact

• R19bn billed annually

Service to members

• Process 1,000 – 1,500 new lives daily

• 80% processed in less than 2 days

New business

• 14,588 GP consultations paid per day

• 4,383 Specialist consultations paid every day

Interaction with health professionals

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HIV and AIDS in Discovery Health Medical Scheme

Number of members registered on disease management versus estimated prevalence

3,9406,181

8,937 12,560

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

2004 2005 2006 2008 (To date)

80,000

Estimated

prevalence

Me

mb

ers

70% of enrollees require ART at registration

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HIV Strategy in the Workplace

VCT for all Employees

HIV (+ve) HIV (-ve)

PreventionDHMS or other medical

scheme membersUninsured

Enroll on HIV disease management programme

Identify funding source

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Funding Options for HIV+ uninsured employees and their family members

HIV Insurance Models

Direct corporate funding (AngloAmerican, SAB Miller etc)

NGO/Bilateral donor funded programmes such as Right to Care, BroadReach

Public facilities

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Insurance for Health Service Delivery in the context of HIV

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Important issues to consider

• Reciprocity vs justice

• Anti-selection (few who seroconvert) vs equity (all participants)

• ART for few or better health care for all (responsibility to community)

• Don’t have to do it alone

Vaccine Initiative

PharmAccess and Health Insurance Fund

Civil Society

donors

• Opportunity to be innovative and demonstrate impact in a complex trial

environment

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Options for Trial Participants

a) Registration of/with a Fund (preferably in country) which:

are based on risk pooling and thus realise solidarity : offer subsidised

contributions from donors

protect against unexpected financial shocks due to illness

generate budgets for investments in efficient health care, and

empower members to insist on high quality health care.

Funds would cover the costs of case management, of out-of-hospital

treatment, including ARV medication (basket of services) where clinically

indicated, monitoring tests (CD4/VL) etc.

Supports the development of better health care facilities where these do not

exist (clinic improvement initiatives, better training of doctors and nurses

etc.) – leverage current “health systems strengthening agenda

Could be joint IAVI/IPM Fund with other partners (e.g. donors)

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Other Options

b) Work with an existing medical insurer to design a product for trial participants

i. Efficiency and effectiveness would be determined by number of beneficiaries

(closed scheme) – issue of who is the employer?

ii. Expensive option since risk pool would have to be funded upfront

iii. Simpler to manage since administrator would take responsibility for payment

of claims etc. (outsource arrangement)

c) Purchase disability cover for participants (scope for misuse of funds since money

is paid to beneficiary not service provider)

Recommendations:

Push current boundaries and limitations; explore new and innovative partnerships.