BACKGROUND: In South Africa, private hospitals absorb a high proportion of the total health expenditure on private health care. Between 2008-2010 private hospital expenditure which includes ward fees, theatre fees, consumables, medicines and per diem arrangements consumed between 40.5% and 40.9% of the total benefits paid by medical schemes from the risk pool, whilst in-hospital managed care fees ranged between 1.8% and 2.8% for the equivalent years. OBJECTIVE: The aim of this paper is to highlight key factors contributing to utilisation of hospital services within the medical schemes population and to recommend "appropriate" and cost effective strategies on hospital utilisation management. METHODS: A cross sectional survey informed by retrospective analysis of quantitative data was used. Researchers also triangulated quantitative data with systematic review of literature. RESULTS: The results show that demographic indicators such as age profile, dependency ratio, pensioner ratio and prevalence of chronic conditions are not the only key factors influencing hospital admissions, but rather the effectiveness of each medical scheme in containing hospital admissions is also influenced by available technical capacity on utilisation review and audit as well as the managed care methodology including the philosophy underpinning benefit option design. CONCLUSION: This study highlights the importance of "value based" managed care programs linked to benefit option design in health care utilisation management. The choice of one managed care program over the other often leads to tradeoffs whereby unintended consequences emanate. Medical schemes are therefore encouraged to continuously review their managed care programs to ensure value for money as well as better access and health outcomes. Keywords ORIGINAL RESEARCHFarmeconomia. Health economics and therapeutic pathways 2012; 13(2): 83-96
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.
Background: South Africa has a dual healthcare system comprised of private and public sectors covering 16% and 84% of the population, respectively. Medical schemes are the primary source of health insurance in the private sector. The aim of this study was to assess the perceived knowledge and satisfaction of open medical schemes members. Methods: A cross-sectional survey was conducted using a stratified systematic sample of members from 22 open medical schemes. Nine hundred and sixty members were requested to complete an online semi-structured questionnaire to determine their perceived knowledge and satisfaction with their schemes. We tested to see if variables such as age, gender, years of membership, education, income or having a chronic disease were associated with better-perceived knowledge or satisfaction. We calculated a composite perceived knowledge and satisfaction score, for which a score above 60th percentile for perceived knowledge and 60th for perceived satisfaction were considered good perceived knowledge and good perceived satisfaction with their schemes.Results: Respondents, generally perceived themselves to have good knowledge and were satisfied with their schemes except for accessibility to doctors under the designated service providers arrangement. Overall, members were satisfied, especially with the quality of service from their designated service providers (DSPs) and their schemes. However, only 9% were satisfied with accessibility to doctors under their DSP arrangement, 25% were satisfied with the cost of scheme membership and only 46% were satisfied with the prescribed minimum benefit package. The test for association showed that years of medical schemes membership, perceived knowledge of the prescribed minimum benefits, better income and laying a complaint were associated with better-perceived knowledge. Conclusion: Medical schemes remain a key element of private healthcare in South Africa. The analysis shows that medical schemes, should put more effort into the accessibility of general practitioner under their designated service providers. Furthermore, the PMBS should be reviewed to provide a comprehensive benefits basket without co-payment for members as recommended by the Medical Schemes Act Amendment Bill of 2018.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.