Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast and Cervical Cancer

Abstract

Breast and cervical cancers are among the top five worldwide. Over half of untreated breast cancer patients die, compared to nearly 90% of cervical cancer patients. Early breast and cervical cancer screening can reduce mortality risk. This study examined breast and cervical cancer rates among South African medical scheme members. The study’s secondary goal was to analyse how medical schemes funded these two cancers, including patient and/or out of pocket payments, to identify funding gaps. The study was a cross-sectional retrospective review of medical scheme claims data for oncology benefits, especially for breast and cervical cancers. The study used a multivariate logistic regression model to assess cancer rates. The results showed that the relative proportion of beneficiaries with breast cancer was higher in open schemes than restricted, in large schemes than medium and small schemes, in comprehensive plans, Efficiency Discount Options (EDOs), and hospital plans than in partial cover plans, and in age bands older than 55 in an out of hospital settings than in in-hospital settings. The paper advises examining the funding mechanism of oncology benefits to reduce Out of Pocket Payments (OOPs) for cancer patients, revising network arrangements, and using DSP as a barrier to access against uneven oncology provider distribution.

Eye care services and benefits paid by medical schemes in South Africa

“…25 From a recent study on funding health care benefits by medical schemes, approximately 511 ophthalmologists claim from medical schemes. 26 The latter provide further credence to the statistic indicating that the private sector employs 85% of active ophthalmologists (again, distribution is skewed to the private sector).…”

“…Similarly, with ophthalmology, a study by Majola 20 confirmed that more than 593 ophthalmologists registered, while Willie found 511 claiming ophthalmologists from medical schemes. 26 The analysis showed that the geographic distribution of claiming optometrists was relative to the distribution of members other than Mpumalanga and KwaZulu-Natal provinces. Provinces such as the Gauteng and North West had an undersupply of optometrists relative to the covered population.…”

“…Non-health care spending varies per administrator based on member profile, the number of benefit options and scheme type. 19,26,29,53 The effect of network arrangements on funding eye care services was also investigated in this study.…”

“…This is because medical schemes typically only cover fundamental vision requirements, such as eye exams, lenses and a basic frame, which restricts the coverage available to members. 26,30,31…”

“…28,29 There is also evidence that most of them have emigrated, and of the nine registered orthoptists (five orthoptists in Gauteng, three in the Western Cape and one in KwaZulu-Natal as of 2020), only a few are claiming from medical schemes. 26,28,29 In comparison, approximately 100 orthoptists are registered to practise and are employed in the UK. 45 Another aspect contributing to this situation is that there are currently no training facilities in South Africa for the discipline.…”