1
15 YEARS ON THE PULSE
DR ANTON DE VILLIERS
GENERAL MANAGER: RESEARCH AND MONITORING
SEPTEMBER 2015
2
Membership and Utilisation
15 YEARS ON THE PULSE
Membership and Number of Schemes1.
Utilisation data2.
The cost of the PMB’s3.
Managed Care4.
Resources and Membership5.
Conclusions6.
3
Outline
15 YEARS ON THE PULSE 4
Consolidation: Small-sized restricted schemes
144 Schemes in 2000
4741 41 37 33
27 26 25 24 23
84 83 81 8277 73 71 68
63 60
131124 122 119
110100 97 93
87 83
0
20
40
60
80
100
120
140
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Nu
mb
er o
f sc
hem
es
Open schemes Restricted schemes All
Trend in the number of schemes
15 YEARS ON THE PULSE 5
Growth: 0.4% (8.78 million to 8.81 million)
Negative growth in the restricted schemes
4.91 5.05 4.95 4.89 4.82 4.80 4.76 4.76 4.85 4.90
1.93 2.082.53
2.993.25
3.523.77 3.92 3.93 3.91
6.847.13
7.487.87 8.07
8.32 8.53 8.68 8.78 8.81
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Nu
mb
er o
f b
enef
icia
ries
(M
illio
ns)
Open schemes Restricted schemes Consolidated
Trend in membership
15 YEARS ON THE PULSE
• Since 2010 industry growing at a decreasing rate
• Growth is almost flat
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Consolidated 2.6% 4.3% 4.9% 5.3% 2.5% 3.1% 2.5% 1.8% 1.1% 0.4%
Restricted schemes 1.2% 7.6% 21.7% 18.2% 9.0% 8.1% 7.1% 4.1% 0.2% -0.4%
Open schemes 3.2% 3.0% -2.0% -1.3% -1.5% -0.3% -0.8% 0.0% 1.8% 1.1%
-5.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Trends in the industry
6
Percentage growth in membership: 2005 - 2014
15 YEARS ON THE PULSE
-22.2%
-21.7%
-13.5%
-12.8%
-11.4%
-9.8%
-9.7%
-7.8%
-5.9%
-5.4%
-2.6%
-2.1%
-1.5%
-0.8%
-0.5%
0.9%
1.0%
1.1%
2.4%
2.7%
3.0%
3.0%
3.3%
4.3%
4.6%
6.6%
8.7%
8.9%
13.6%
20.1%
47.4%
57.9%
-30% -20% -10% 0% 10% 20% 30% 40% 50% 60%
QUANTUM MEDICAL AID SOCIETY
RESOLUTION HEALTH MEDICAL SCHEME
TRANSMED MEDICAL FUND
COMMUNITY MEDICAL AID SCHEME (COMMED)
SIZWE MEDICAL FUND
AECI MEDICAL AID SOCIETY
SPECTRAMED
SISONKE HEALTH MEDICAL SCHEME
MEDSHIELD MEDICAL SCHEME
MOTOHEALTH CARE
KEYHEALTH
HOSMED MEDICAL AID SCHEME
LIBERTY MEDICAL SCHEME
GOVERNMENT EMPLOYEES MEDICAL SCHEME (GEMS)
SOUTH AFRICAN POLICE SERVICE MEDICAL SCHEME (POLMED)
BONITAS MEDICAL FUND
BANKMED
MEDIHELP
PROFMED
DISCOVERY HEALTH MEDICAL SCHEME
SAMWUMED
REMEDI MEDICAL AID SCHEME
BESTMED MEDICAL SCHEME
UMVUZO HEALTH MEDICAL SCHEME
GLENCORE MEDICAL SCHEME
MOMENTUM HEALTH
LA-HEALTH MEDICAL SCHEME
MEDIPOS MEDICAL SCHEME
PLATINUM HEALTH
COMPCARE WELLNESS MEDICAL SCHEME
TOPMED MEDICAL SCHEME
MASSMART HEALTH PLAN
Annual % change
7
Winners and losers
15 YEARS ON THE PULSE 8
Average age: 32.1 years
PMB/Healthcare cost can increase without an increase in the average age
34.734.8 34.6
31.2 31.1 31.0
32.031.5
31.932.6
32.9 33.1 33.333.8
33.5 33.632.9
31.831.5
29.8 29.6 29.4 29.529.9 30.0 30.2
31.7 31.6 31.3 31.5 31.6 31.5 31.632.0 31.9 32.1
24.0
26.0
28.0
30.0
32.0
34.0
36.0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Ave
rag
e ag
e (y
ears
)
Open schemes (excluding DHMS) Restricted schemes (excluding GEMS)
Open schemes Restricted schemes
Consolidated
Trends in Age
15 YEARS ON THE PULSE 9
• Most common type of option offered by the schemes is the traditional option with DSP arrangements.
• The second most popular was the new savings option with DSP arrangements.
• Average number of options per scheme: Open = 6; Restricted = 2.3; Consolidated = 3.3
Benefit option type
Number of benefit options
Proportion of
BeneficiariesOpen Schemes
Restricted
Schemes All schemes
Traditional + PMBs & other Chronic @ DSP 34 59 93 35.2%
Hybrid (EDO + primary) 19- 19 20.7%
Savings + PMBs & other Chronic 12 1 13 12.9%
Savings+ PMBs & other Chronic @ DSP 38 40 78 12.8%
Traditional + PMBs & other Chronic 1 5 6 6.0%
Traditional & PMBS Only @ DSPs 7 10 17 5.8%
PMBs & other Chronic 23 9 32 5.4%
PMB Exempt - 9 9 0.8%
PMBS Only 3 2 5 0.4%
Total 137 135 272 100.0%
Classification of Benefit options
15 YEARS ON THE PULSE 10
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
PMB Exempt
PMBS Only
PMBs & other Chronic
Tradition & PMBS Only @ DSPs
Savings + PMBs & other Chronic @DSP
Tradition + PMBs & other Chronic @DSP
Savings+ PMBs & other Chronic
Tradition + PMBs & other Chronic
Hybrid (EDO + primary)
Loss of membership: < 35 years
Hybrid (EDO + primary): Primary option and efficiency discount option
Proportion of beneficiaries exiting by benefit option type
15 YEARS ON THE PULSE 11
Old system
Poor quality data submitted by medical schemes:
Manual data entry (prone to data entry errors)
Labour intensive
Weak validation rules and vague indicator definitions
Expansion of the utilisation section limited by current technology
Limited indicator set
New system (DDDR, Project Lion)
Insight Actuaries and Consultants was appointed to assist CMS with the development of the new utilisation specification
Industry workshops
The new/retained indicators:
• Appropriate
• Relevant
• Properly and unambiguously defined
• Consistently available in good quality in most/all South Africa medical scheme administration platforms
Avoid big bang approach
Utilisation
15 YEARS ON THE PULSE 12
Total Healthcare benefits paid
R124.1 billion R111.7 billion in 2013 11.1% increase
R14 185 pabpa R12 892 pabpa in 2013 10% increase
Healthcare benefits paid from risk pool
R111.8 billion R100.7 billion in 2013 11.1% increase
R12 783 pabpa R11 616 pabpa in 2013 10.1% increase
Benefits paid from savings
R12.3 billion
Healthcare benefits paid
15 YEARS ON THE PULSE 13
37.6%
16.6%7.6%
6.6%
6.6%
5.3%5.2%
4.3%2.8% 2.5% 2.1% 2.0%
0.7%
0.0% 0.0%
Hospitals Medicines Dispensed
Supplementary and Allied Health Professionals General Practitioners
Medical Specialists Pathology
Surgical Specialists Radiology
Other Health Services Dentists
Anaesthetists Total out-of-hospital managed care arrangements
Dental Specialists Ex-gratia payments
Medical Technology
All Specialists: 23.5% (5 categories)
Total Benefits paid per discipline
15 YEARS ON THE PULSE 14
All Specialists: 23.5%
• Anaesthetists: 2.07%
• Pathology : 5.32%
• Radiology: 4.31%
• Medical Specialists : 6.61%
• Surgical Specialists: 5.2%
Total Benefits paid to Specialists
15 YEARS ON THE PULSE 15
Increase in prevalence rates for the industry. Is it a concern?
Top 5: Hypertension, Hyperlipidaemia, DM2, Asthma and HIV
0
20
40
60
80
100
120
140
2014 Prevalance 2013 Prevalance
Prevalence of Chronic Conditions
(per 1 000 beneficiaries)
15 YEARS ON THE PULSE 16
6.2%
6.6%
7.9%
8.6%
10.5%
10.6%
10.9%
11.0%
11.1%
12.1%
13.4%
16.9%
23.6%
40.9%
Dentists
General Practitioners
Medicines Dispensed
Dental Specialists
Radiology
Hospitals
Pathology
Medical Specialists
Surgical Specialists
Anaesthetists
Supplementary and Allied Health Professionals
Other Health Services
Ex-gratia payments
Medical Technology
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%
Percentage increase per average beneficiary per annum
Percentage increase per average beneficiary per annum per discipline
15 YEARS ON THE PULSE 17
R 328.70
R 651.37
R 691.41
R 668.13
R 879.62
R 888.14
R1 166.94
R1 470.51
R1 720.81
R2 506.42
R0 R500 R1 000 R1 500 R2 000 R2 500 R3 000
General Practitioners
Medical Technology
Supplementary and Allied Health Professionals
Pathology
Dentists
Medical Specialists
Dental Specialists
Radiology
Surgical Specialists
Anaesthetists
2014 2013
Total Benefits paid per visit
15 YEARS ON THE PULSE
Per 1 000 beneficiaries:
• Number of beneficiaries visiting GPs at least once a year: 763.1
• Number of beneficiaries visiting Dentists at least once a year: 213
• Number of beneficiaries receiving MRI: 20.3
• Number of beneficiaries receiving CT scans: 26.6
Average GP visits: 3.7
Average Dentist visits: 1.4
Average number of inpatient days per beneficiary: 4.3 days
Average number of inpatient days for maternity admissions: 3 days
Caesarean sections per 1 000 pregnant females: 707.7 (slight increase)
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Utilisation of services
15 YEARS ON THE PULSE
• Inaccurate data from 19 schemes
• Estimated cost: R552 per beneficiary per month
(PMB Costing Study 2009)
• Actual cost for 2014
– R567 per beneficiary per month
• Proportionally 52,5% of all risk benefits paid out are
for the PMB’s (flat for the last two years)
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Cost of PMB’s for 2014
15 YEARS ON THE PULSE 20
• The cost will fall if we can have an increase in membership in the age bands 1 to 40
• Membership > 40 years; increase of 68 100 beneficiaries
• Membership < 40 years; slight increase of 1 300 beneficiaries
• Haemophilia the most expensive CDL to treat: R31 900 per patient per month
• CMS will continue to collect the Scheme Risk Measurement (old REF) data, but only through the Annual Statutory Returns
-
100 000
200 000
300 000
400 000
500 000
600 000
700 000
800 000
-
500
1 000
1 500
2 000
2 500
< 1Year
1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +
Nu
mb
er
of
Be
ne
fic
iari
es
Co
st
pe
r b
en
efi
cia
ry p
er
mo
nth
Age
Beneficiaries 2014 Beneficiaries 2013 PMBs 2014 PMBs 2013 Average 2014 Average 2013
Cost of the PMB’s (Sample data)
15 YEARS ON THE PULSE 21
Membership 2013 versus 2014(Population)
(2 927)(3 422)
14 318
6 667
(6 792)
(9 097)
(12 891)
13 723
(1 190)
6 365
3 348
7 507
11 176 10 356 8 629 7 859 7 395
2 438 3 047
(15 000)
(10 000)
(5 000)
-
5 000
10 000
15 000
20 000
-
100 000
200 000
300 000
400 000
500 000
600 000
700 000
800 000
< 1Year
1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 +
Ch
ang
e in
Ben
efic
iari
es
No
of
Ben
fici
arie
s
Beneficiaries 2014 Beneficiaries 2013 change in Beneficiaries
15 YEARS ON THE PULSE
• CMS and ITAP are involved in a process of
identifying minimum standards of care for CDL
conditions
• So far 9 conditions have been discussed
• Process and outcome indicators were identified for
each of these conditions
• Of the 9 conditions – indicators of 7 of them have
been collected from the schemes through ASR
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What is the Quality of Care Beneficiaries
received?
15 YEARS ON THE PULSE
Process indicators (What should be done)i. What any good disease management program should demonstrate is quality care
given to patients
ii. These are minimum and universal interventions that a care provider should do and apply to all patients being treated for specific conditions
iii. The indicators identified are cost effective
iv. The indicators identified are also measurable
Outcome indicators (Result of interventions)i. These indicators assist to in concluding if patient has been well looked after or not
ii. They are also disease specific
iii. Pragmatism is important – All cause mortality and hospital admission are examples
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Process & outcome indicators
15 YEARS ON THE PULSE 24
Indicators for a few CDLsDiabetes Mellitus (1 and 2) Hypertension HIV
Process indicators
at least one (1) Fundus Exam test at least one (1) electrocardiogram test at leat one ART treatment claim
at least two (2) HBA1c tests at least one (1) Creatinine / eGFR test for whom CD4 count was taken
at least one (1) LDL / lipogram test at least one (1) total cholesterol test for whom Viral Load was taken
at least one (1) Creatinine/ Albumin test
beneficiaries receiving Statins
Outcome Indicators
Hospital Admissions (All cause) Ischemic Heart Disease Hospital Admissions (All cause)
Mortality (All Cause) Chronic Renal Failure Mortality (All Cause)
Renal Dialysis Hospital Admissions (for Stroke) 3rd line treatment Regimen
Retinopathy
Amputations
Neuropathy
15 YEARS ON THE PULSE 25
Electrocardiogram test: Find out whether your high blood pressure has caused any damage to your heart or blood vessels; cholesterol clogging
up your heart’s blood supply; a heart attack in the past, enlargement of one side of the heart, abnormal heart rhythms
Creatinine / eGFR test: Detect early nephropathy; Glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney.
Creatinine will not be raised above the normal range until 60% of total kidney function is lost.
Total cholesterol test: High cholesterol is one of the most important risk factors for cardiovascular disease.
Fundus Exam test: Retinopathy screening; Preventing blindness
HBA1c tests: Glucose control; In diabetes mellitus, higher amounts of glycated hemoglobin, indicating poorer control of blood glucose levels,
have been associated with cardiovascular disease, nephropathy and retinopathy. How well your diabetes is being controlled?
LDL / lipogram test: Aim for a lower LDL (‘bad’ cholesterol) and higher HDL (‘good’ cholesterol) levels
Creatinine/ Albumin test: Elevated levels of urinary albumin in people with diabetes or hypertension are associated with increased risk of
developing cardiovascular disease; Evaluate renal function status
Statins: Are used primarily for lowering blood cholesterol and for prevention of events associated with cardiovascular disease and chronic kidney
disease.
Viral load: Is the term used to describe the amount of HIV in a body fluid; Should be non-detectable
Short description of a few process indicators
15 YEARS ON THE PULSE 26
2014 2013
No of Patients in sample 404 161 382 153
Process indicators - Unique beneficiaries 2014 2013
at least one (1) electrocardiogram test 33.8% 34.6%
at least one (1) Creatinine / eGFR test 43.3% 43.7%
at least one (1) total cholesterol test 61.1% 60.7%
Outcome indicators - Unique beneficiaries
Hospital Admissions - Day 19.3% 19.3%
Hospital Admissions - More than a day 35.3% 34.7%
Co-morbidities Diabetes Mellitus 22.7% 23.7%
Hypertension
Coverage: Hypertension
15 YEARS ON THE PULSE 27
No of Patients in sample 44 608 45 355
Process indicators - Unique beneficiaries 2014 2013
at least one (1) Fundus Exam test 6.6% 6.2%
at least two (2) HBA1c tests 22.5% 21.8%
at least one (1) LDL / lipogram test 21.7% 20.5%
at least one (1) Creatinine/ Albumin test 39.7% 39.3%
on Statins 10.4% 10.2%
Outcome indicators - Unique beneficiaries
Hospital Admissions - Day 12.7% 12.5%
Hospital Admissions - More than a day 31.5% 32.6%
Co-morbidities -Renal Dialysis 1.0% 1.0%
Diabetes Mellitus 1
Third party data issues?
Coverage: Diabetes Mellitus 1
15 YEARS ON THE PULSE 28
No of Patients in sample 323 878 304 369
Process indicators - Unique beneficiaries 2014 2013
at least one (1) Fundus Exam test 4.4% 4.1%
at least two (2) HBA1c tests 18.8% 18.3%
at least one (1) LDL / lipogram test 23.0% 21.3%
at least one (1) Creatinine/ Albumin test 38.3% 36.8%
on Statins 6.3% 6.2%
Outcome indicators - Unique beneficiaries
Hospital Admissions - Day 9.9% 10.3%
Hospital Admissions - More than a day 22.5% 21.6%
Co-morbidities -Renal Dialysis 0.4% 0.4%
Diabetes Mellitus 2
Third party data issues?
Coverage: Diabetes Mellitus 2
15 YEARS ON THE PULSE 29
No of Patients in sample 220 093 180 570
Process indicators - Unique beneficiaries 2014 2013
for whom CD4 count was taken 71% 76%
for whom Viral Load was taken 71% 75%
Outcome indicators - Unique beneficiaries
Hospital Admissions - Day 4.6% 5.2%
Hospital Admissions - More than a day 19.5% 20.3%
HIV
Coverage: HIV
15 YEARS ON THE PULSE
• Continue with the process of identifying indicators
• We will expand data collection to include conditions as they are
discussed through ITAP
• We will engage with schemes to help improve quality of data
submissions
• Value = Quality/Cost
• We will continue to report actively on the quality
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Managed Care – the way forward
15 YEARS ON THE PULSE 31
Eastern Cape Free State GautengKwa-Zulu-
NatalLimpopo Mpumalanga
NorthernCape
North WestWestern
Cape
Medical Specialists 5.4 4.9 43.0 14.7 1.8 1.7 0.6 2.6 25.4
% Membership 7.9 4.6 33.8 14.8 5.0 6.7 2.2 6.0 14.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Per
cen
tag
e (%
)
Resources versus Membership
15 YEARS ON THE PULSE 32
Eastern Cape Free State GautengKwa-Zulu-
NatalLimpopo Mpumalanga
NorthernCape
North WestWestern
Cape
Surgical Specialists 6.2 4.3 41.1 15.5 2.0 1.9 1.1 2.5 25.4
% Membership 7.9 4.6 33.8 14.8 5.0 6.7 2.2 6.0 14.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Per
cen
tag
e (%
)
Resources versus Membership
15 YEARS ON THE PULSE 33
• Growth in membership a concern – LCBO
• Decrease in the number of medical schemes (Risk Based
Solvency)
• Medical Scheme Inflation is a concern
• Still a significant proportion of risk benefits offered by
schemes on top of the PMBs
• Measuring the value of managed care is a priority for CMS
• Improvement in utilisation data – Please challenge your
Data Officers!
Conclusions
15 YEARS ON THE PULSE
Thank you!
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