Chapters authored
Telephone Consultations by Medical Scheme Patients Consulting General Medical Practitioners, South Africa
Background: The COVID-19 climate has seen a shift in the manner that patients seek care. Lockdown measures and COVID-19 regulations, and the fear of contracting the virus at a health care facility has also changed health seeing behaviour among patients. The COVID-19 climate has seen a significant increase in the utilisation of virtual platforms to consult with providers. Objectives: The objective of this chapter was to conduct the descriptive analysis of telephonic consultations by members of medical schemes who consulted general medical practitioners. Methods: The study entailed a descriptive analysis of medical scheme claims data for the 2020 review period. The inclusion criteria were all National Pharmaceutical Product Interface (NAPPI) codes associated with a telephonic consultation consulting general medical practitioners. The ICD-10 code primary diagnosis was used to describe the diagnosis. The study mainly focused on outpatient patients with service dates between March and December 2020. Results: The analysis covered claims data from a total of 12 medical schemes. The schemes analysed accounted for 1,6 million lives. The total number of telephonic consultations was 17 237. The mean (SD) claimed amount for telephone consultation for a general medical practice consult was R2821 (SD = 20). This was slightly lower than the scheme tariff of R2872 (SD = 19). The study found that most telephonic consults were for Acute bronchitis, unspecified; Acute upper respiratory; Emergency use of U07.1 (Confirmed diagnosis); Emergency use of U07.2 (Suspected Diagnosis); Follow-up examination; Special screening. Conclusion: The study found evidence of patients utilising telephonic consultations for general medical practitioner services. The effect of COVID-19 in this respect was seen in the three main primary diagnoses that were associated with the consult, Acute upper respiratory, Emergency use of U07.1 (confirmed diagnosis) and Emergency use of U07.2 (suspected diagnosis). Even though the average telephonic consult was claimed at just under R3003, few general medical practitioners claimed between R4004 and R5005 which were higher than the industry average. There is a need to develop telephone consult guidelines at industry level, these should also address reimbursement rate differentials.
Part of the book: Primary Health Care
Funding of Oncology Benefits by Medical Schemes, South Africa: A Focus on Breast and Cervical Cancer
Breast and cervical cancers are among the top five worldwide. The mortality rate for breast cancer is over 50%, when compared to cervical cancer, which is nearly 90%. 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), hospital plans than in partial cover plans, in age groups older than 55, in an out-of-hospital setting than in in-hospital setting. 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 designated service provider (DSP) as a barrier to access against uneven oncology provider distribution.
Part of the book: Healthcare Access