hiv/aids benefits in medical schemes in 2002
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Centre for Actuarial Research
HIV/AIDS Benefits in Medical Schemes
in 2002
Centre forActuarial Research
Prescribed Minimum Benefits
Centre forActuarial Research
Existing PMB Definition
Code: 168s Diagnosis: # HIV-associated disease - first admission or
subsequent admissions Treatment: # medical and surgical management for
opportunistic infections / localised malignancies
6) Specified categories shall take precedence over others present. Such“overriding” categories are preceded by “#” .
Suffering from pneumonia and HIV: 168S is an overriding category, thus the entitlements guaranteed by the ‘pneumonia’ category (903D) are overridden.
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Review of PMBs
1999 Regulations: A review shall be conducted at least every two years by
the Department that will involve the Council for Medical Schemes, stakeholders, Provincial health departments and consumer representatives.
In addition, the review will focus specifically on development of protocols for the medical management of HIV/AIDS.
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Proposed PMB Definition Code: 168S Diagnosis: #HIV-infection Treatment: 1
HIV voluntary counselling and testingCo-trimoxazole as preventive therapyScreening and preventive therapy for TBDiagnosis and treatment of sexually transmitted
infectionsPain management in palliative careTreatment of common opportunistic infectionsPrevention of mother-to-child transmission of HIVPost-exposure prophylaxis following sexual assault.
Centre forActuarial Research
Proposed PMB Definition
1 Note: comment is requested on this formulation of the benefit for HIV, in addition to other possible formulations, such as the wording of the existing benefit; and a treatment making provision for the provision of anti-retroviral therapy when clinically indicated.
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Survey
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Comparison to Previous Research at UCT
First research conducted in 2001 Looked at HIV/AIDS benefits by scheme No direct input from schemes
This survey conducted in 2002 Benefits by scheme, option and beneficiary Information provided by schemes
Centre forActuarial Research
Survey Coverage of Schemes
20% 20%
40%
70%
51%
39%47%
87% 83%
55%
0%
20%
40%
60%
80%
100%
Ultra Small Small Medium Large Total
Open
Restricted
77 schemes 53% of schemes
Centre forActuarial Research
Survey Coverage of Options
8% 11%
36%
64%52%
30%
46%
67%
109%
58%
0%
20%
40%
60%
80%
100%
120%
Ultra Small Small Medium Large Total
Open
Restricted
221 options 54% of options
Centre forActuarial Research
Survey Coverage of Beneficiaries
2%
18%
35%
78% 75%
36% 41%
76%
122%
94%
0%
20%
40%
60%
80%
100%
120%
140%
Ultra Small Small Medium Large Total
Open
Restricted
5,290,030 beneficiaries 80% of beneficiaries
Centre forActuarial Research
Validity of Survey
The survey covers 5,290,030 beneficiaries. This is estimated to be some 80% of all beneficiaries
75% of open scheme beneficiaries 94% of restricted scheme beneficiaries.
Small restricted schemes under-represented. Poor coverage of small and medium open schemes.
Expect benefits to be worse in schemes that did not reply.
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HIV/AIDS Benefit Management
Centre forActuarial Research
Categories of Benefits (by schemes)
7 schemes offer only Prescribed Minimum Benefits
9.1%
13.0%
41.6%
36.3%No additional benefit
Non-managed scheme
Aid for Aids
Other DMP
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Categories of Benefits (by beneficiaries)
Fewer beneficiaries affected – thus small schemes that are not offering PMBs
2.5%7.7%
36.2%53.6%
No additional benefit
Non-managed scheme
Aid for Aids
Other DMP
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Disease Management Programme(by schemes)
78% of schemes use aDisease Management Programme
42%
5%
3%
4%
3%
3%
18%
1%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Aid for Aids
Calibre
Discovery
Lifesense
MX Health
New med
Ow n
Qualsa
Centre forActuarial Research
Disease Management Programme(by beneficiaries)
89% of beneficiaries covered by a Disease Management Programme
36%
1%
20%
8%
6%
7%
9%
2%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Aid for Aids
Calibre
Discovery
Lifesense
MX Health
New med
Ow n
Qualsa
Centre forActuarial Research
Options that Require Registration
86 % of options use a Disease Management Programme
88%
100%
100%
75%
100%
93%
66%
100%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Aid for Aids
Calibre
Discovery
Lifesense
MX Health
Newmed
Own
Qualsa
100%
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0.15%
0.21%
0.16%
0.30%
0.00%
0.05%
0.10%
0.15%
0.20%
0.25%
0.30%
0.35%
Open excl. Aid-for-AIDS
Restricted excl.Aid-for-AIDS
Total excluding Aid-for-AIDS
Total including Aid-for-AIDS
Beneficiary Participation on Disease Management Programmes
Grave concern about low take-up of benefits on offer to beneficiaries.
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Coverage of Current PMBs
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Cover Only for Prescribed Minimum Benefits
15% of options cover only PMBs, but only 3% of families affected. These tend to be larger families.
3.9%3.0%
14.9%
0%
2%
4%
6%
8%
10%
12%
14%
16%
% Beneficiaries % Families % Options
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Opportunistic Infections(by option)
71% 70% 71%
59% 58% 58%60%
51%56%
9% 9% 9%15%
5%11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Open Restricted Total
% o
pti
on
s
Normal Hospital
ChronicMedicationHIV Cover
Savings
Other
20 options are using members’ savings accounts for part or full cover of PMBs
Centre forActuarial Research
Proposed Regulations 2002
REGULATION 10: PERSONAL MEDICAL SAVINGS ACCOUNTS
(6) The funds in a member’s medical savings account shall not be used to pay for the costs of a prescribed minimum benefit.
Centre forActuarial Research
Savings Used for Opportunistic Infections
Trustees should review use of savings accounts in benefit design
0%
33%
5%
14%9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Aid for Aids No additionalBenefit
Non-managedscheme
Other DMP Total
% o
pti
on
s
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Hospitalisation Limits(by option)
6%3%
2%
45%
38%
4%
0.5%
0.5%No Benefit
Full Savings
Limit with partial savings
Monetary Limit
Event
No Limit
State
Network
Trustees should review use of savings accounts in benefit design
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Coverage of Proposed PMBs
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Support Services (by beneficiaries)
91%
76%
91%
76%85%
90%86%
79%
91%
0%10%20%30%40%50%60%70%80%90%
100%
HIV Counselling HIV Testing Education &Information
Open
Restricted
Total
Medical schemes have embraced support services
Centre forActuarial Research
13%
87% 84%
64%
0%
20%
40%
60%
80%
100%
No Benefits 1 or more benefits 2 or more benefits All benefits
Support Services (by option)
29 options from 13 schemes provide no support services
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HIV-Related Conditions (by beneficiary)
Good coverage but needs to be 100%.
84% 84% 87% 88%
0%10%20%30%40%50%60%70%80%90%
100%
TB Screening PreventativeTherapy for TB
PreventativeTherapy for PCP
STD Treatment
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HIV-Related Conditions (by beneficiary)
92%
68%
83%79%
100%94%
100%94%
82%76%
82%76%
83% 85% 87% 89%84% 84% 87% 88%
0%10%20%30%40%50%60%70%80%90%
100%
TB Screening PreventativeTherapy for TB
PreventativeTherapy for PCP
STD Treatment
UltrasmallSmallMediumLargeTotal
Good coverage but needs to be 100%.
Centre forActuarial Research
41%
56% 55%
84%
47%
77%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AZT only AZT and 3TC Nevirapine Caesareansection
Formulafeeding
MTCTCounselling
Mother-To-Child Transmission (by beneficiary)
92% of beneficiaries have access to some form of ART for MTCT
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Mother-To-Child Transmission (by options)
13%
87%76% 73%
64%
25%
9%
0%10%20%30%40%50%60%70%80%90%
100%
NoBenefits
1 or morebenefits
2 or morebenefits
3 or morebenefits
4 or morebenefits
5 or morebenefits
All benefits
13% of options (7% of beneficiaries) have no MTCT benefits.
Centre forActuarial Research
Post-Exposure Prophylaxis
96% 94%
79%87%
81%
68%
0%10%
20%30%40%50%
60%70%
80%90%
100%
Sexual assault Occupation injury Other sexual exposure
% beneficiaries
% options
96% of beneficiaries have access to ART in the event of sexual assault
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Coverage of Anti-Retroviral
Therapy
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Anti-Retroviral Therapy (by options)
27%20%
58%
71%
0%10%20%30%40%50%60%70%80%90%
100%
No Anti-retroviralTherapy
Mono-therapy Dual-therapy Triple-therapy
27% of options provide no access to ART
Centre forActuarial Research
Anti-Retroviral Therapy (by beneficiaries)
8%
21%
73%
90%
0%10%20%30%40%50%60%70%80%90%
100%
No Anti-retroviralTherapy
Mono-therapy Dual-therapy Triple-therapy
90% of beneficiaries have access to Triple-therapy
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Anti-Retroviral Therapy Support (by beneficiaries)
90% 94%
76% 76%85% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Surveillance of Drug Effectiveness Counselling for people on drugtreatment
Open
Restricted
Total
Note : may also be for rape or MTCT
90% 94%
76% 76%85% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Surveillance of Drug Effectiveness Counselling for people on drugtreatment
Open
Restricted
Total
Centre forActuarial Research
Anti-Retroviral Therapy Support (by options)
Needed for effective ART programme
15%
85% 81%
0%
20%
40%
60%
80%
100%
No Benefits 1 or more benefits All benefits
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Conclusions
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Key Findings
Only 4% of beneficiaries have no access to benefits other than PMBs.
89% of beneficiaries covered by a Disease Management Programme.
92% of beneficiaries have access to some form of ART to prevent Mother-to-Child Transmission.
96% of beneficiaries have access to ART after sexual assault.
90% of beneficiaries already have access to triple therapy. Trustees have provided comprehensive access to
benefits for HIV/AIDS
Centre forActuarial Research
Benefit Design Issues
Although survey covers only 53% of schemes, it covers some 80% of beneficiaries.
Little knowledge of designs used by small restricted schemes or small and medium open schemes.
Expect non-reporting schemes to have worse coverage. “Swiss-cheese” benefit design as a means of risk-rating :
PMB extension thus levels the playing field. Concern : 20 options report using members’ savings
accounts for part or full cover of PMBs. Micro detail of benefit designs needs further attention to
ensure adequate benefits : nature and size of limits.
Centre forActuarial Research
Implications for Proposed PMBs
It appears that coverage of beneficiaries for the proposed HIV/AIDS Prescribed Minimum Benefits is already high.
Great concern about low take-up of benefits : only 0.30% of beneficiaries reported registered on programmes.
Schemes may not yet be experiencing the full costs of benefit structures.
Crucial need to model future impact of HIV/AIDS in medical schemes.
Responsible extension of PMBs requires that coverage must be adequate and sustainable.
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