GPs Share of Medical Schemes Expenditure Shrinking

September 18, 2008

Acting registrar of medical schemes, Patrick Matshidze, told The Star that this could be attributed to some beneficiaries going directly to specialists without GP referrals. There is also a possibility that some members choose to be hospitalised to ensure that schemes pay in full for their treatment. Matshidze said the council was concerned that the way benefits were presented could be promoting in-hospital over out-of-hospital treatment.

Expenditure on hospitals and specialists rose again with schemes spending R19.9bn on private hospitals, up from R18.9bn in the previous year. Benefits paid to specialists, including pathologists, anaesthetists and radiologists recorded an 11% increase, representing 21.7% of schemes? total spend. Of the R12.2bn (up from R10.9bn in the previous year) paid to specialists, close to R2.5bn went to pathologists and R2.3bn to radiologists up from R2bn and R2.1bn in 2006 respectively. Anaesthetists got just over R1bn up from R968m in the previous year. Of the other specialities, gynaecologists and physicians were the top earners at R884m and R662m respectively. Spending on medicine showed an 8% increase to R9.4bn.

The schemes spent R8,9bn on non-healthcare costs, including administration and broker fees, up by 7,3%, although this rate of increase was nearly halved after membership and inflation increases were factored in. Restricted schemes spent about R50 per beneficiary per month on administration costs and open schemes on average about R80.

The general health of medical schemes showed an improvement with the industry recording a total loss of less than a billion rand in comparison to R2bn in 2006. However, when investment income was added, schemes showed a total surplus of R2.4bn.

According to the report, there was a 12.3% increase in members? contributions from R57.5bn in 2006 to R64.7bn last year of which schemes paid out R56.3bn in claims up from R51.3bn in 2006. However, the average ratio of claims to contributions declined from 88% to 86.4% with open schemes showing an average claims ratio of 83.5% and restricted schemes 92.7%.

The total number of beneficiaries rose by 4.9% and now stands at close to 7.5 million members. There was a decrease in the number of beneficiaries in open schemes from 5.1 million to 5 million while the number of beneficiaries in restricted schemes increased from 2.1 million to 2.5 million. The growth in membership of restricted schemes can be mainly attributed to the Government Employees Medical Schemes (GEMS), which showed a 300% increase in membership. But the rapid increase in membership caused a significant drop in GEMS? solvency level to 8.3% down from 36.6% in 2006, which is well below the required 22%. The average solvency level for the whole industry was almost unchanged at close to 38%.

Thanks to Health and Chronicle – the publishers of the Medical Chronicle

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