The medical scheme industry is financially healthy despite the low growth in membership (0.4%), according to Professor Yosuf Veriava, chair of the Council for Medical Schemes (CMS).<\/p>\n
In his chairperson’s report released at the announcement of the CMS’ annual results on Tuesday, Veriava said the average age of beneficiaries – 32.1 years – has remained almost unchanged in the last three years.<\/p>\n
He believes, however, that membership growth in the younger age groups would contribute to keeping costs down.<\/p>\n
The average cost of total benefits utilised by beneficiaries has increased by 10% and the amount for legislated prescribed minimum benefits (PMBs) by 13.4%.<\/p>\n
Total hospital expenditure by medical schemes \u2013 which includes ward fees, theatre fees, consumables, medicines and per diem arrangements \u2013 consumed R46.6bn or 37.6% of the R124.1bn that medical schemes paid to all healthcare providers in 2014.<\/p>\n
Total medical scheme expenditure on private hospitals increased by 11.6% to R46.4bn from R41.6bn in 2013. In-patient admissions constituted 88% of the R46.4bn paid to private hospitals in 2014 (same-day in-patient admissions constituted 12%).<\/p>\n
Medical scheme payments for medicines dispensed by pharmacists and providers other than hospitals amounted to R20.5bn or 16.6% of total healthcare benefits paid. This was an increase of 8.9% compared to 2013.<\/p>\n
The most significant increase \u2013 14.5% to R9.4bn \u2013 in benefits paid in 2014 was in respect of supplementary and allied health professionals.<\/p>\n
Expenditure on general practitioners (GPs) amounted to R8.2bn or 6.6% of healthcare benefits paid, representing an increase of 7.6% on the 2013 figure of R7.6bn. Only 10.9% of the R8.2bn paid to GPs in 2014 was paid to those operating in hospitals.<\/p>\n
Payments to medical specialists also amounted to R8.2bn, with about 54% of this paid to those operating in hospitals. Expenditure on pathology amounted to R6.6bn or 5.3% of healthcare benefits paid while expenditure on surgical specialists and radiology services amounted to R6.4bn and R5.3bn respectively.<\/p>\n
The report indicates that the distribution of out-of-pocket expenditure across disciplines has not changed from 2013 to 2014. Medicines and specialists still account for the bulk of out-of-pocket expenditure. In absolute terms, out-of-pocket expenditure increased by 11.9% from R18.5bn in 2013 to R20.7bn in 2014.<\/p>\n
The CMS pointed out that these figures are an understatement of the true extent of out-of-pocket expenditure as beneficiaries do not claim for all out-of-pocket spending on healthcare.<\/p>\n
It also highlighted the fact that out-of-pocket expenditure of South African medical scheme members was at least 18% of the total healthcare cost \u2013 well above the WHO guideline of 15%.<\/p>\n
The CMS analysis found that the level of out-of-pocket expenditure is influenced by benefit design. Beneficiaries do not claim when they realise their schemes will not be paying for their claim.<\/p>\n
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