Visit to general practitioners as a proxy for accessing chronic benefits by members of medical schemes, South Africa

Mncedisi M Willie,Monwabisi Gantsho

doi:10.4102/phcfm.v4i1.419

Abstract

BackgroundPrescribed Minimum Benefits is a list of conditions that all medical schemes need to cover in full, and includes a select of chronic conditions. Chronic conditions affect people's lifestyles and require ongoing management over a period of years for long-term survival.ObjectivesThis study examined the association between prevalence of selected chronic diseases and health service use, in particular visits to general practitioners (GPs) by medical scheme members.MethodThis was a retrospective study on medical schemes data. The median imputation method was employed to deal with missing and unreported chronic diseases prevalence. Multivariate logistic regression analysis was employed to assess effects of chronic disease prevalence, age stratum and scheme size on GP visits per annum.ResultsThe study showed that prevalence of asthma was significantly associated with more than three GP visits (OR = 1.081; 95% CI = 1.008–1.159), as was prevalence of type 2 diabetes (OR = 1.087; 95% CI = 1.027–1.152), whilst prevalence of hyperlipidaemia (OR = 0.92; 95% CI = 0.875–0.97) was more likely to be associated with less than three GP visits. Prevalence of hypertension was associated with more than three GP visits per year (OR = 1.132; 95% CI = 1.017–1.26).ConclusionThis study shows that scheme size, prevalence of chronic diseases such as asthma, type 2 diabetes, hyperlipidaemia and hypertension are related to GP visits. GPs and managed care programmes employed by schemes should give special attention to certain disease states with high prevalence rates in an effort to better manage them.

Highlights

General practitioners’ (GPs) services have been shown to be a significant determinant of population health, effective cost-containment and promotion of equity objectives.[1]
The prevalence of select chronic diseases per 1000 beneficiaries for the medical schemes considered in the current study
Our study showed that the prevalence of asthma was significantly associated with more than the average of three annual visits to a GP (OR = 1.081; 95% confidence intervals (CIs) = 1.008–1.159; p = 0.0291)

Summary

Introduction

General practitioners’ (GPs) services have been shown to be a significant determinant of population health, effective cost-containment and promotion of equity objectives.[1]. Medical scheme members are entitled to certain benefits that the schemes have to cover in full These are called Prescribed Minimum Benefits (PMBs), and the PMB Chronic Disease List is a list of conditions which all medical schemes need to cover on all the plans they offer to their members. This cover includes funding for diagnosis, treatment and ongoing care for the listed conditions.[5] from a member’s perspective there is still a lack of understanding of what these benefits entail. Other studies have shown that delivering optimal health care for chronic illnesses requires health systems to move from a reactive approach to a proactive one.[12]

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Discussion

Conclusion