Discovery has seen a big jump in these types of medical claims over the last year

Discovery Health Medical Scheme (DHMS) has released its latest healthcare claims report showing that it paid over R58.4 billion in claims for the period between October 2017 and September 2018.

The bulk of that sum was paid to hospital claims (49%), with 671,016 admissions at an average cost of R43,057 per admission at 3.5 days per visit.

Discovery has 2.8 million members, which represents 31% of the total medical scheme population and 56% of the open scheme population.

The majority of members reside in metropolitan areas such as Cape Town, Durban, Johannesburg and Pretoria, Discovery said.

Chronic conditions

The most common chronic condition for the period was essential hypertension (high blood pressure) with 376,341 members enrolled.

Hypothyroidism has seen the greatest increase in enrolled members (12.1%) compared to the previous period.

Other notable jumps include Hypercholesterolaemia aka high cholesterol (9.9%) and Bipolar mood disorder (9.1%).

The most costly chronic condition, based on average cost per chronic member, is Ischaemic heart disease with an average cost of R665 per chronic member per month, excluding hospital claims.

“On average, for every R100 paid by DHMS for the treatment of a chronic condition, R77.70 is spent on medicines,” Discovery said.

“Of the members with a registered chronic condition, 46% have multiple chronic conditions.

The most common combination of chronic conditions is hypercholesterolemia and essential hypertension which is the case for 37,835 members, Discovery said.

Claims

DHMS said that it paid nearly R60 billion in claims over a year period.

These include:

• R28.9 billion paid for hospital claims;
• R21.4 billion paid for day-to-day claims;
• R3.2 billion for claims relating to chronic conditions;
• R3.4 billion for oncology treatment;
• R1.5 billion paid for births.

On average for every R100 paid by DHMS for a claim relating to a hospital admission, R62.70 is paid to the hospital and R17.80 to specialists, Discovery said.

“Over the period, 835 members experienced hospital claims greater than R1 million and 11,798 members experienced hospital claims greater than R250,000.”

DHMS  said that members can be admitted to hospital for a number of reasons.

The graph below illustrates that some admissions are less frequent, but very costly, while others may cost relatively less, but can occur much more frequently.

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