National Health Insurance
Cancer in Medical Schemes in South Africa

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The first comprehensive study of the diagnosis-treatment pairs (DTP) in Prescribed Minimum Benefits (PMBs) in medical schemes was done using 2001 data. ICD-10 coding practice has improved substantially since then but there has been no further study of the PMBs by this level of detail, at least in the public domain. The data used for the 2001 PMB-DTP study was provided to the CARe Consortium by Medscheme. The data covers the cost of DTP events in hospitals for the 2001 calendar year and was fully run-off at the time of extraction in July 2002. The data set covered 90 options in 31 schemes, providing 18.071 million beneficiary months of data. The average exposure was 1.506 million beneficiaries over that year which was some 25% of medical scheme beneficiaries in that year, making this a very substantial data set.

5.412 per 1,000 beneficiaries were hospitalised for neoplasms in 20019. 40.2% of these tumours were diagnosed as malignant while a further 19.8% were either growths in situ or not classifiable. Thus 60.0% of all neoplasm admissions were either diagnosed with cancer or could not have the diagnosis of cancer ruled out. Note that malignancy is not a clear-cut indication of the health risk that a tumour represents. For example, the author quotes Youngson that benign brain tumours can pose a greater health risk and require more expensive treatment than some malignant skin cancers, for example.

Treatment of neoplasms accounted for 5.9% of the cost of the PMB package and 5.2% of total claim costs. In total R98.821 million was paid in respect of claims for neoplasms during 2001. The average cost was R15,793 for neoplasm DTPs that were found to be PMBs and R7,538 for those not meeting the PMB definition at that time. Overall, the average cost for all neoplasms was R12,125 in 2001 Rand terms. One serious constraint of this data was that it covered essentially in-patient admissions and costs and the costs of chemotherapy were not available. It was necessary to estimate out-patient costs and these were not done separately for neoplasms.

There has for some years been discussions within the Risk Equalisation Technical Advisory Panel (RETAP) as to whether cancer should be treated as a separate risk factor in risk adjustment. The intention was to gather further data on this and to consider the issue on the next occasion when Risk Equalisation Fund risk factors are evaluated. One concern with adding cancer treatment might be that that it would increase the retrospective nature of payments whereas the current formula for risk adjustment attempts to be largely prospective. The need in recent years to have a means to verify chronic disease10 has introduced more retrospective assessment of treatment than was originally envisaged.

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