HIV/AIDS Benefits in Medical Schemes in 2002

1. HIV/AIDS Benefits in Medical Schemes in 2002

2. Prescribed Minimum Benefits

3. Existing PMB Definition • Code: 168s • Diagnosis: # HIV-associated disease - first admission or subsequent admissions • Treatment: # medical and surgical management for opportunistic infections / localised malignancies • 6)Specified categories shall take precedenceover others present. Such“overriding” categories are preceded by “#” . • Suffering from pneumonia and HIV: 168S is an overriding category, thus the entitlements guaranteed by the ‘pneumonia’ category (903D) are overridden.

4. Review of PMBs • 1999 Regulations: • A review shall be conducted at least every two years by the Department that will involve the Council for Medical Schemes, stakeholders, Provincial health departments and consumer representatives. • In addition, the review will focus specifically on development of protocols for the medical management of HIV/AIDS.

5. Proposed PMB Definition • Code:168S • Diagnosis: #HIV-infection • Treatment: 1 • HIV voluntary counselling and testing • Co-trimoxazole as preventive therapy • Screening and preventive therapy for TB • Diagnosis and treatment of sexually transmitted infections • Pain management in palliative care • Treatment of common opportunistic infections • Prevention of mother-to-child transmission of HIV • Post-exposure prophylaxis following sexual assault.

6. Proposed PMB Definition • 1 Note: comment is requested on this formulation of the benefit for HIV, in addition to other possible formulations, such as the wording of the existing benefit; and a treatment making provision for the provision of anti-retroviral therapy when clinically indicated.

7. Survey

8. Comparison to Previous Research at UCT • First research conducted in 2001 • Looked at HIV/AIDS benefits by scheme • No direct input from schemes • This survey conducted in 2002 • Benefits by scheme, option and beneficiary • Information provided by schemes

9. Survey Coverage of Schemes 77 schemes 53% of schemes

10. Survey Coverage of Options 221 options 54% of options

11. Survey Coverage of Beneficiaries 5,290,030 beneficiaries 80% of beneficiaries

12. Validity of Survey • The survey covers 5,290,030 beneficiaries. • This is estimated to be some 80% of all beneficiaries • 75% of open scheme beneficiaries • 94% of restricted scheme beneficiaries. • Small restricted schemes under-represented. • Poor coverage of small and medium open schemes. • Expect benefits to be worse in schemes that did not reply.

13. HIV/AIDS Benefit Management

14. Categories of Benefits (by schemes) 7 schemes offer only Prescribed Minimum Benefits

15. Categories of Benefits (by beneficiaries) Fewer beneficiaries affected – thus small schemes that are not offering PMBs

16. Disease Management Programme(by schemes) 78% of schemes use a Disease Management Programme

17. Disease Management Programme(by beneficiaries) 89% of beneficiaries covered by a Disease Management Programme

18. 88% Aid for Aids 100% 100% Calibre Discovery 100% Lifesense 75% 100% MX Health 93% Newmed Own 66% Qualsa 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Options that Require Registration 86 % of options use a Disease Management Programme

19. Beneficiary Participation on Disease Management Programmes Grave concern about low take-up of benefits on offer to beneficiaries.

20. Coverage of Current PMBs

21. Cover Only for Prescribed Minimum Benefits 15% of options cover only PMBs, but only 3% of families affected. These tend to be larger families.

22. Opportunistic Infections(by option) 20 options are using members’ savings accounts for part or full cover of PMBs

23. Proposed Regulations 2002 • REGULATION 10: PERSONAL MEDICAL SAVINGS ACCOUNTS • (6) The funds in a member’s medical savings account shall not be used to pay for the costs of a prescribed minimum benefit.

24. 50% 45% 40% 33% 35% 30% % options 25% 20% 14% 15% 9% 10% 5% 5% 0% 0% Aid for Aids No additional Non-managed Other DMP Total Benefit scheme Savings Used for Opportunistic Infections Trustees should review use of savings accounts in benefit design

25. Hospitalisation Limits(by option) Trustees should review use of savings accounts in benefit design

26. Coverage of Proposed PMBs

27. Support Services (by beneficiaries) Medical schemes have embraced support services

28. Support Services (by option) 29 options from 13 schemes provide no support services

29. 100% 88% 84% 87% 84% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% TB Screening Preventative Preventative STD Treatment Therapy for TB Therapy for PCP HIV-Related Conditions (by beneficiary) Good coverage but needs to be 100%.

30. HIV-Related Conditions (by beneficiary) Good coverage but needs to be 100%.

31. 100% 84% 90% 77% 80% 70% 56% 55% 60% 47% 50% 41% 40% 30% 20% 10% 0% AZT only AZT and 3TC Nevirapine Caesarean Formula MTCT section feeding Counselling Mother-To-Child Transmission (by beneficiary) 92% of beneficiaries have access to some form of ART for MTCT

32. Mother-To-Child Transmission (by options) 13% of options (7% of beneficiaries) have no MTCT benefits.

33. 96% 94% 100% 87% 90% 81% 79% 80% 68% 70% 60% % beneficiaries 50% % options 40% 30% 20% 10% 0% Sexual assault Occupation injury Other sexual exposure Post-Exposure Prophylaxis 96% of beneficiaries have access to ART in the event of sexual assault

34. Coverage of Anti-Retroviral Therapy

35. 100% 90% 80% 71% 70% 58% 60% 50% 40% 27% 30% 20% 20% 10% 0% No Anti-retroviral Mono-therapy Dual-therapy Triple-therapy Therapy Anti-Retroviral Therapy (by options) 27% of options provide no access to ART

36. 100% 90% 90% 73% 80% 70% 60% 50% 40% 30% 21% 20% 8% 10% 0% No Anti-retroviral Mono-therapy Dual-therapy Triple-therapy Therapy Anti-Retroviral Therapy (by beneficiaries) 90% of beneficiaries have access to Triple-therapy

37. 100% 94% 90% 88% 85% 90% 76% 76% 80% 70% 60% Open 50% 40% Restricted 30% Total 20% 10% 0% Surveillance of Drug Effectiveness Counselling for people on drug treatment Anti-Retroviral Therapy Support (by beneficiaries) Note : may also be for rape or MTCT

38. 100% 85% 81% 80% 60% 40% 15% 20% 0% No Benefits 1 or more benefits All benefits Anti-Retroviral Therapy Support (by options) Needed for effective ART programme

39. Conclusions

40. Key Findings • Only 4% of beneficiaries have no access to benefits other than PMBs. • 89% of beneficiaries covered by a Disease Management Programme. • 92% of beneficiaries have access to some form of ART to prevent Mother-to-Child Transmission. • 96% of beneficiaries have access to ART after sexual assault. • 90% of beneficiaries already have access to triple therapy. • Trustees have provided comprehensive access to benefits for HIV/AIDS

41. Benefit Design Issues • Although survey covers only 53% of schemes, it covers some 80% of beneficiaries. • Little knowledge of designs used by small restricted schemes or small and medium open schemes. • Expect non-reporting schemes to have worse coverage. • “Swiss-cheese” benefit design as a means of risk-rating : PMB extension thus levels the playing field. • Concern : 20 options report using members’ savings accounts for part or full cover of PMBs. • Micro detail of benefit designs needs further attention to ensure adequate benefits : nature and size of limits.

42. Implications for Proposed PMBs • It appears that coverage of beneficiaries for the proposed HIV/AIDS Prescribed Minimum Benefits is already high. • Great concern about low take-up of benefits : only 0.30% of beneficiaries reported registered on programmes. • Schemes may not yet be experiencing the full costs of benefit structures. • Crucial need to model future impact of HIV/AIDS in medical schemes. • Responsible extension of PMBs requires that coverage must be adequate and sustainable.