Steep medical scheme increases coming

140
446

Medical scheme members should brace themselves for steeper-than-usual increases next year, because the two largest medical schemes in the country have reported an unexpected increase in claims.

In separate presentations at a conference in Cape Town this week, the chief executive of the administrator of the largest open medical scheme in South Africa and the principal officer of the country’s largest restricted scheme revealed that their schemes are facing higher-than-usual claims, particularly hospital claims.

Health care contribution

They attributed this to increases in hospital bed capacity and higher-than-normal anti-selection (people joining schemes only when they are facing high medical costs), and fraud and abuse.

Dr Jonathan Broomberg, the chief executive of Discovery Health, which administers Discovery Health Medical Scheme (DHMS), and Dr Guni Goolab, the principal officer of the Government Employees Medical Scheme (Gems), addressed delegates from schemes, administrators, managed-care entities and private healthcare providers at the Board of Healthcare Funders conference.

Their presentations focused on the increase in scheme members’ use of medical services and the increase in chronic diseases, both of which often result in above-inflation increases in contributions each year.

Recently, both schemes have experienced an unexpected increase in claims, and Broomberg said that, “as far as we are aware, most medical schemes in the country are experiencing similar trends”.

Hospital admission spike

Broomberg and Goolab said DHMS and Gems have seen a spike in hospital and hospital-related claims since the second half of last year. The increase seems due, in part, to the opening of several new private hospitals. Broomberg said 25 new hospitals with 2 653 beds have opened over the past eight years.

In 12 out of 18 regional case studies conducted by Discovery Health, it was found that new hospitals resulted in a significant increase in hospital admissions among scheme members, although the prevalence of disease had not increased. The increase in admissions cost the scheme R1.1 billion.

The administrator’s analysis of costs in Durban showed that the admission rate was 14 percent higher than the national average in 2010. In 2011, after a new hospital opened in Hillcrest, it was 19.8 percent higher, and in 2014, after a new hospital opened in Umhlanga, it was 29.7 percent higher.

Goolab presented evidence of an increase in hospital admissions among Gems members late last year and early this year. This showed how admissions in Polokwane and Pietermaritzburg had increased from less than three percent a year to more than 12 percent after hospitals opened in those areas.

Goolab said the increase in admissions was of particular concern, because hospital and related costs – for example, pathology and radiology – account for 62 percent of all the scheme’s claims.

He said that, over the past five years, there had been an almost 20-percent increase in hospital bed capacity, while medical scheme beneficiaries had increased by only six percent, yet private hospitals continue to report high occupancies.

Fraud on the rise

Broomberg and Goolab highlighted how a fair proportion of members’ contributions was wasted on fraud and unco-ordinated and unnecessary health care.

Goolab said the tough economic climate and the record level of unemployment had led to an increase in fraud and abuse, which results in all members paying more than they need to in contributions.

Since 2010, Gems had investigated 5 000 cases of fraud, he said.

The national average for psychologist consultations for patients admitted to hospital is eight percent, but at one hospital the utilisation of psychologists was found to be nearly five times the national average, indicating that fraudulent claims were being submitted, Goolab said.

The scheme’s data also uncovered a family practitioner who claimed to have treated 311 Gems members or beneficiaries in a day, which means that if the doctor had worked for 24 hours, he would had to have seen one patient every four minutes.

The scheme has been able to detect ambulance claims that do not correspond with hospital admissions in areas where fraud syndicates are known to be operating.

Another trend is the abuse of hospital cash-back plans offered by life assurers and short-term insurers. Medical scheme members are admitted to hospital, but no pathology tests are conducted during the members’ stay in hospital, which is highly unusual, Goolab said.

It is suspected that members are admitted under false pretences, often after being approached by a fraud syndicate. The scheme pays the hospital bill, and the member collects the cash payout from the insurance policy, which is shared with the syndicate.

Broomberg said Discovery had recovered R1.04 billion in fraudulent claims between 2013 and 2015. In 2013, the scheme recovered R288 million, and by 2015 this had increased 21 percent to R394 million.

Broomberg said international studies estimate that fraud accounts for between three and 15 percent of healthcare funders’ costs.

Anti-selection

Goolab and Broomberg presented evidence of anti-selection, which is accelerating the cost of claims.

Anti-selection is when someone joins a scheme only when he or she is ill and needs to claim. It is possible to do this, because open medical schemes must admit anyone who applies to join and may impose only limited waiting periods, during which new members cannot claim certain benefits. Restricted schemes are obliged to admit anyone who is eligible for membership and typically do not apply any waiting periods.

Broomberg said DHMS statistics show that, over the eight years to the end of 2015, the average age of its members increased by 6.9 percent, from 31.51 years to 33.68 years. This indicates that young people are waiting until they are older and sicker before joining a medical scheme.

Over the same period, the scheme had a 59-percent increase in the prevalence of chronic illnesses. In 2008, 13.9 percent of beneficiaries had chronic illnesses; by 2015, this had increased to 22.1 percent.

Broomberg said that, on average, a member with a chronic illness claims four times more than a member who does not have one.

In addition, the scheme relies on members who do not claim anything in a year to fund a surplus that carries the costs of those who do claim.

Broomberg said, that over the eight years to 2015, the percentage of DHMS members who did not claim anything in a year decreased from 60 percent to 50 percent.

Another indication of anti-selection is the increase in the number of members claiming for rare diseases, such as multiple sclerosis and rheumatoid arthritis. Broomberg said the incidence of people who claim for these illnesses should be random, but the scheme has noticed a large increase in the number of people who claim for these illnesses in the first year of membership. This indicates that they were advised to join a scheme at any cost, because their claims were likely to be high.

On average, the claims of a member with multiple sclerosis exceed his or her annual contributions by four to five times. In other words, a scheme needs five healthy families to cover the costs of that one person, he said.

Goolab said anti-selection was not confined to open medical schemes. Restricted schemes, such as Gems, had found that principal members enrolled family members as beneficiaries only when they needed to claim.

Gems’s statistics show that in the first year – in particular, within the first three months – of members joining the scheme, hospital admissions are 53.4 percent higher than in subsequent periods.

Broomberg says these statistics provide an indication of the uphill battle that medical schemes are waging in trying to keep contribution increases in line with increases in salaries and wages.

140 COMMENTS

  1. 879371 995921Hello. I wanted to ask 1 thingis this a wordpress internet internet site as we are preparing to be shifting more than to WP. Furthermore did you make this template yourself? Thanks. 734541

  2. 699134 252340Hey this is kinda of off topic but I was wanting to know if blogs use WYSIWYG editors or in the event you have to manually code with HTML. Im starting a blog soon but have no coding experience so I wanted to get advice from someone with experience. Any assist would be greatly appreciated! 474210

  3. I simply want to mention I am newbie to weblog and really enjoyed you’re page. Very likely I’m want to bookmark your website . You really come with excellent articles and reviews. Appreciate it for sharing your blog.

  4. 762040 568557Hello there, just became alert to your weblog by way of Google, and identified that it is genuinely informative. Im gonna watch out for brussels. Ill be grateful in case you continue this in future. A lot of men and women is going to be benefited from your writing. Cheers! 7157

  5. That is the appropriate blog for anyone who desires to search out out about this topic. You realize a lot its virtually hard to argue with you (not that I really would want…HaHa). You undoubtedly put a brand new spin on a subject thats been written about for years. Great stuff, just great!

  6. Cool post. I see anything more difficult on different websites regularly. It will probably continually be stimulating to read content from other article writers and exercise a little things from their unique shop. I?d would rather use some together with the contents on my weblog whether you don?t head. Natually I?ll supply a hyperlink on your web website. Many thanks for posting.

  7. 439540 756135Aw, this was a truly nice post. In concept I wish to put in writing like this moreover – taking time and actual effort to make an outstanding article nevertheless what can I say I procrastinate alot and not at all appear to get something done. 937681

  8. Simply wish to say your article is as surprising. The clarity for your submit is just great and that i could assume you’re a professional on this subject. Well with your permission let me to clutch your RSS feed to stay up to date with coming near near post. Thanks 1,000,000 and please keep up the enjoyable work.

  9. We’re a group of volunteers and opening a new scheme in our community. Your website provided us with valuable information to work on. You’ve done an impressive job and our entire community will be thankful to you.

  10. I do agree with all the concepts you’ve presented for your post. They’re really convincing and can definitely work. Still, the posts are too brief for novices. May just you please prolong them a bit from next time? Thanks for the post.

  11. I loved as much as you will receive carried out right here. The sketch is tasteful, your authored subject matter stylish. nonetheless, you command get bought an shakiness over that you wish be delivering the following. unwell unquestionably come further formerly again since exactly the same nearly a lot often inside case you shield this hike.

  12. I loved as much as you will receive carried out right here. The sketch is tasteful, your authored subject matter stylish. nonetheless, you command get bought an impatience over that you wish be delivering the following. unwell unquestionably come more formerly again since exactly the same nearly very often inside case you shield this increase.

  13. Unquestionably believe that that you said. Your favourite reason seemed to be at the internet the simplest factor to consider of. I say to you, I certainly get irked while folks think about issues that they just don’t realize about. You controlled to hit the nail upon the top and also defined out the entire thing with no need side effect , other folks could take a signal. Will likely be again to get more. Thank you

  14. Woah! I’mreally loving the template/theme of this site.
    It’s simple, yet effective. A lot of times it’s tough to get
    that “perfect balance” betgween user friendlinees and visual
    appearance. I must say that you’ve done a superb job with this.
    Also, the blog loads extremely quick for me on Chrome.
    Exceptional Blog!

  15. I loved as much as you’ll receive carried out right here. The sketch is attractive, your authored subject matter stylish. nonetheless, you command get bought an shakiness over that you wish be delivering the following. unwell unquestionably come more formerly again since exactly the same nearly a lot often inside case you shield this increase.

  16. Very good site you have here but I was curious if you knew of any message boards that cover the same topics talked about here? I’d really like to be a part of community where I can get feedback from other knowledgeable individuals that share the same interest. If you have any recommendations, please let me know. Thanks!

  17. Excellent blog you have here but I was wondering if you knew of any community forums that cover the same topics discussed here? I’d really like to be a part of community where I can get suggestions from other experienced individuals that share the same interest. If you have any recommendations, please let me know. Cheers!

  18. Can I simply say what a reduction to find someone who really knows what theyre talking about on the internet. You definitely know how to bring a difficulty to mild and make it important. More folks have to learn this and understand this side of the story. I cant believe youre no more popular since you positively have the gift.

  19. Its like you read my mind! You seem to know so much about this, like you wrote the book in it or something. I think that you can do with some pics to drive the message home a little bit, but other than that, this is great blog. A great read. I’ll certainly be back.

  20. Hey just wanted to give you a brief heads up and let you know a few of the pictures aren’t loading correctly. I’m not sure why but I think its a linking issue. I’ve tried it in two different web browsers and both show the same outcome.

  21. I’m really enjoying the theme/design of your weblog. Do you ever run into any web browser compatibility issues? A handful of my blog audience have complained about my website not working correctly in Explorer but looks great in Firefox. Do you have any recommendations to help fix this issue?

  22. I don’t even know the way I ended up right here, but I believed this submit used to be great. I don’t understand who you are but definitely you are going to a well-known blogger should you are not already 😉 Cheers!

  23. The very next time we study a blog, I hope me as much as this one that it doesnt disappoint. After all, it is known by me ended up being my alternatives to see, but I really thought youd bring something interesting to state. All we listen to is a lot of whining about some thing that you might fix any time you werent also hectic wanting attention.

  24. Thanks for another magnificent article. Where else could anybody get that kind of information in such a perfect way of writing? I have a presentation next week, and I am on the look for such information.

  25. What’s Happening i’m new to this, I stumbled upon this I’ve found It absolutely useful and it has helped me out loads. I hope to contribute & help other users like its aided me. Great job.

  26. I have not been around your internet site for very long. I recollect browsing it a whilst back, but that had been a lengthy time ago so I forgot the scenery lol. I’m happy that I’m returning to this wonderful write-up! Greatest of all I really like the items you stated within the conclusion! I believe everyone will undoubtedly be very best off just performing them. There all of the successful company need to have.

  27. I’m curious how creative writing instructors at colleges and universities handle students who write about really disturbing things and who seem potentially dangerous to themselves and others? Are instructors privy to students’ mental health records? Do they let such students get away with violent or disturbing writing in an effort NOT to stir too much trouble? Do you become proactive in trying to help these students? Do you undergo training to deal with problem students? As a creative writing student at a university, I often see disturbing stuff brought into workshops. I’m wondering what the profs think of all this. Thanks to any answers!.

  28. Cool blog! Is your theme custom made or did you download it from somewhere?

    A design like yours with a few simple tweeks would really
    make my blog stand out. Please llet me know where you got
    your design. Thank you

  29. I like the helpful info you provide on your articles. I’ll bookmark your weblog and check again here regularly. I am somewhat sure I will be informed many new stuff proper right here! Best of luck for the following!

  30. Someone essentially help to make seriously articles I would state. This is the first time I frequented your website page and thus far? I amazed with the research you made to create this particular publish extraordinary. Excellent job!

  31. Hello! This post couldn’t be written any better! Reading this post reminds me of my good old room mate! He always kept talking about this. I will forward this write-up to him. Fairly certain he will have a good read. Many thanks for sharing!

  32. I will right away grasp your rss feed as I can’t in finding your email subscription link or e-newsletter service. Do you’ve any? Kindly permit me recognise so that I may just subscribe. Thanks.

  33. Hmm is anyone else experiencing troubles with the images on this weblog loading? I’m trying to uncover out if its a dilemma on my finish or if it is the blog. Any feed-back would be greatly appreciated.

  34. A person essentially help to make seriously posts I would state. This is the first time I frequented your website page and thus far? I surprised with the research you made to make this particular publish amazing. Excellent job!

  35. Hey very nice web site!! Man .. Excellent .. Amazing .. I’ll bookmark your blog and take the feeds also…I am happy to find so many useful info here in the post, we need develop more techniques in this regard, thanks for sharing. . . . . .

  36. I know this if off topic but I’m looking into starting my own weblog and was wondering what all is required to get setup? I’m assuming having a blog like yours would cost a pretty penny? I’m not very web savvy so I’m not 100 sure. Any recommendations or advice would be greatly appreciated. Many thanks

  37. Normally I do not read post on blogs, but I would like to say that this write-up very forced me to try and do so! Your writing style has been amazed me. Thank you, very nice post.

  38. Once I initially commented I clicked the -Notify me when new feedback are added- checkbox and now every time a remark is added I get 4 emails with the same comment. Is there any means you’ll be able to take away me from that service? Thanks!

  39. Youre so cool! I dont suppose Ive read anything like this before. So nice to find somebody with some original thoughts on this subject. realy thank you for starting this up. this website is something that is needed on the web, someone with a little originality. useful job for bringing something new to the internet!

  40. Wonderful blog! Do you have any tips and hints for aspiring writers? I’m planning to start my own blog soon but I’m a little lost on everything. Would you advise starting with a free platform like WordPress or go for a paid option? There are so many options out there that I’m totally confused .. Any ideas? Thank you!

  41. I wanted to start my own blog and I was looking for your suggestions for which sites you think are the best to start one with. . I want to be able to post pictures, text, and music (maybe).. I only want to use a free blog host..

  42. I?d need to consult you right here. That is not at all something it’s my job to would! I love checking out a post that can cause people to thought. Additionally, thank you for enabling us to review!

  43. This design is spectacular! You definitely know how to keep a reader entertained. Between your wit and your videos, I was almost moved to start my own blog (well, almost…HaHa!) Wonderful job. I really loved what you had to say, and more than that, how you presented it. Too cool!

  44. Glorious weblog! I actually really like how it is simple on my eyes in addition to the details are properly written. I’m wondering how I might be notified every time a brand new post has been made. I’ve subscribed to your rss feed which must do the trick! Have a good day! ????

  45. Thank you a lot for sharing this with all people you actually realize what you are talking approximately! Bookmarked. Please also talk over with my site =). We will have a hyperlink alternate agreement among us!

  46. What i don’t understood is actually how you’re not actually much more well-liked than you may be now. You’re very intelligent. You realize therefore considerably relating to this subject, made me personally consider it from a lot of varied angles. Its like men and women aren’t fascinated unless it’s one thing to accomplish with Lady gaga! Your own stuffs excellent. Always maintain it up!

  47. I really like your blog.. very nice colors & theme. Did you make this website yourself or did you hire someone to do it for you? Plz respond as I’m looking to construct my own blog and would like to find out where u got this from. cheers

  48. Hey! Someone in my Myspace group shared this website with us so I came to look it over. I’m definitely enjoying the information. I’m book-marking and will be tweeting this to my followers! Excellent blog and excellent design and style.

  49. I’m looking joomla template to design site for one hindu temple.? Any suggestion for template and components for Joomla ?. Mainly looking for event details , picture gallery and blogs..

  50. of course like your web site however you need to take a look at the spelling on several of your posts. A number of them are rife with spelling problems and I to find it very troublesome to inform the reality then again I will certainly come back again.

  51. Lo mejor es llamar a nuestro servicio tecnico Bosch de profesionales, que le atenderan gustosamente y con en la mayor brevedad tendrá la averia servicio restablecido reparado, siempre a su servicio. Es esencial un correcto diagnóstico del problema antes de tocar nada y ante la duda, lo mejor que puede hacer es llamar al Servicio Tecnico de Calderas Junkers para evitar averías serias que dañen la caldera. Nuestro equipo de técnicos le garantiza seriedad en la reparación así como una explicación detallada de la avería, su reparación y el porqué de la misma.

  52. I enjoy you because of your entire work on this site. My daughter enjoys engaging in research and it’s really easy to see why. I learn all regarding the dynamic manner you make effective techniques via your blog and therefore welcome contribution from people about this content plus our own princess is really studying so much. Enjoy the remaining portion of the year. You’re doing a useful job.

  53. I’ve been browsing on-line more than three hours today, yet I never discovered any fascinating article like yours. It is beautiful price enough for me. Personally, if all site owners and bloggers made good content material as you probably did, the net will probably be a lot more helpful than ever before. “Perfection of moral virtue does not wholly take away the passions, but regulates them.” by Saint Thomas Aquinas.

  54. Pretty section of content. I just stumbled upon your site and in accession capital to assert that I acquire in fact enjoyed account your blog posts. Anyway I’ll be subscribing to your feeds and even I achievement you access consistently rapidly.

  55. We’re a group of volunteers and starting a new scheme in our community. Your site provided us with valuable information to work on. You’ve done a formidable job and our whole community will be thankful to you.

LEAVE A REPLY