Discovery Health and Discovery Health Medical Scheme (DHMS) have released medical aid claims data showing claims trends that drive healthcare costs in SA. CEO of Discovery Health, Dr Jonathan Broomberg, discusses these trends and the costs associated with the prevalence of chronic conditions.

The data show claims trends in terms of in-hospital admissions and treatments, chronic conditions, day-to-day treatment, screening and prevention, maternity and cancer.

“Annual medical scheme claims expenditure rose on average by 11.3% a year over the past decade – roughly 5% above CPI. We are very aware that consumers are under increasing financial pressure on multiple fronts, and we therefore work very hard to ensure the best access to care for all Scheme members, at affordable, sustainable contributions,” said Dr Broomberg.

“During the past year, Discovery Health Medical Scheme covered just over 670,000 hospital admissions. The highest claim covered by the Scheme was R6.8 million towards 199 days of treatment for a 58-year old for a cardio-vascular related condition. This single claim would require 205 years’ worth of contributions by the member to cover the claim,” continued Dr Broomberg.

The Scheme paid a total of R26.3 billion for hospital claims and R2.9 billion towards the care of 642,410 members with a chronic condition. Maternity claims cost R1.4 billion, with caesarean births representing the greatest total hospital cost to the Scheme (28,329 admissions) and 9,750 natural births covered on the Scheme.

Chronic diseases of lifestyle on the rise

South Africa is very much part of the global challenge of chronic diseases of lifestyle, and Discovery Health Medical Scheme’s claims data reflect the trend of escalating chronic disease. In 2008, just over 300,000 members registered on the Chronic Illness Benefit, with this figure more than doubling by 2017 (642,410 members registered for a chronic illness).

“We know that chronic diseases of lifestyle are on the rise. But what our claims trends are telling us now is that increasingly, members are presenting with more than one chronic disease and some are experiencing up to five chronic diseases,” said Dr Broomberg.

According to Discovery Health, on-going medicine treatment remains a significant cost component to manage for the Scheme. On average, for every R100 paid by the Scheme for a claim relating to a chronic condition, R78.60 is spent on medicines. Essential hypertension afflicts the majority of members with an average monthly cost per chronic member, at R387, followed by hypercholesterolemia, asthma and diabetes and other chronic conditions. Hypothyroidism has seen the greatest increase in enrolled members, up 11% from the previous year. The most costly chronic condition is diabetes mellitus with an average monthly cost of R650 per enrolled member.

Cancer prevalence

The Scheme’s claims experience also reflects the global trend in increasing cancer prevalence.

“The number of members receiving oncology treatment has increased over the past 10 years due to the higher prevalence of cancer in South Africa and globally,” said Dr Broomberg.

Scheme data show 33, 985 members actively claiming for oncology-related treatment at a total cost of R3 billion over 2017. The top three cancers are breast (14,435 members), followed by prostate (12,122 members) and colorectal cancer (3,970 members). Soft tissue and thyroid cancer have seen the greatest increase in claimants, up 8.2% each from the previous period. The most expensive cancer to treat is lung cancer at an average monthly cost of R16,417.

The highest oncology claim paid out was for multiple myeloma at R1.5 million.

“There have been significant advances in treatment regimens that include new cancer drugs, resulting in potentially life-saving options for patients. These treatments, however, come at a far higher cost than the older treatments they replace, which is a challenge for medical schemes to manage. Our responsibility as Discovery Health is to provide access to clinically relevant and appropriate care, and to ensure that this is done in a manner that is fair to all members of the Scheme,” said Dr Broomberg.

Curbing the impact of chronic diseases of lifestyle

DHMS members have access to Discovery’s Vitality wellness programme – offered through its administrator, Discovery Health, separate to the medical scheme. “Discovery Health offers members of Discovery Health Medical Scheme access to Vitality, one of the leading evidence-based wellness programmes globally. This is a critical strategy for us to help reduce claims costs for Discovery Health Medical Scheme,” said Dr Broomberg.

Effective population-based screening is critical for the early detection of, and intervention in, chronic diseases of lifestyle. The Scheme’s data shows a direct correlation between screening outcomes and mortality and morbidity experience. According to Discovery, members who are highly engaged in Vitality have better health outcomes than members who do not participate in the programme. These members, on average, have 10% lower hospital admissions, 25% shorter hospital stays and 14% lower overall claims costs.

“Vitality’s impact reduces the Scheme’s claims costs by around 3% each year – generating total savings of approximately R11.6 billion since 2008. This allows the Scheme to provide richer benefits to its members at contributions that are, on average, around 16% lower than other competitor open-schemes, on a like-for-like basis,” explained Dr Broomberg.

Supporting this approach is Discovery Health’s strategy to offer the Scheme clinical programmes that help manage chronic disease more effectively.

“We have done significant work for the Scheme in developing clinical programmes that improve collaboration between the doctor, the patient and us, as the funder; all with the aim of improving quality of care and patient outcomes at a sustainable cost to the Scheme,” added Dr Broomberg.

One such programme is the DiabetesCare programme that offers members clinically appropriate benefits and improved care. At the same time, actively engaged doctors are paid higher fees when they achieve defined quality-of-care measures. The early results of this programme are positive, with significant increases in the percentage of diabetes patients having critical monitoring tests performed, and with clear evidence of improved outcomes as well.

“We have seen similarly excellent results in our dialysis and other clinical programmes, with all parties benefiting significantly; patients through improved quality of care, doctors through enhanced remuneration, and the medical scheme through lower claims,” concluded Dr Broomberg.

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