hiv/aids benefits in medical schemes in 2002

Centre for Actuarial Research

HIV/AIDS Benefits in Medical Schemes

in 2002

Centre forActuarial Research

Prescribed Minimum Benefits


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.


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.


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.


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.


Survey


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


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


Survey Coverage of Options

8% 11%

36%

64%52%

30%

46%

67%

109%

58%

0%

20%

40%

60%

80%

100%

120%


Open

Restricted

221 options 54% of options


Survey Coverage of Beneficiaries

2%

18%

35%

78% 75%

36% 41%

76%

122%

94%

0%

20%

40%

60%

80%

100%

120%

140%


Open

Restricted

5,290,030 beneficiaries 80% of beneficiaries


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.


HIV/AIDS Benefit Management


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


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


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


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


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%


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.


Coverage of Current PMBs


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


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


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.


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


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


Coverage of Proposed PMBs


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


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


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


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%.


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


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.


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


Coverage of Anti-Retroviral

Therapy


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


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


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


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


Conclusions


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


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.


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.

hiv/aids benefits in medical schemes in 2002

Documents

small schemes

medical schemes

surgical management

schemes7 schemes

medical management of

hivaids benefits

medium open schemes

hivassociated disease