Michael Mncedisi Willie*
Policy Research and Monitoring, Council for Medical Schemes, Pretoria, South AfricaFulltext PDF
Background: Optometry services generally form part of the preventative benefits package in the health sector delivery. Studies have also shown that early access to such services prevents or even reduce eyesight loss in the long term. Funding these services remains a key challenge in medical schemes, and this benefit remains one of the underfunded benefits. The Council for Medical Schemes annual report depicts that optometrists' benefits account for less than two percent of all benefits paid. This may be because medical schemes only contribute to basic visual needs such as eye tests, lenses, and frames. The complexity of product design, benefit limits, networks short or co-payments makes it even more difficult for members to understand the funding model of these benefits. Objectives: The primary objective of this study was to assess the distribution of optometrists claiming from medical schemes. The study's secondary objective was to conduct multivariate analysis to determine factors that affect optometrist expenditure in medical schemes. Setting: The study was conducted in the medical schemes sector, mainly for optometrist's benefits paid by medical schemes for services rendered in South Africa. Methods: The study entailed a retrospective comparative analysis of medical schemes' claims data associated with benefits paid for optometry services. The review period was 2016-2020 data sourced the CMS annual report at aggregated scheme level than at benefit option level. The analysis included claims data from 61 medical schemes. Fifteen were open schemes, and forty-six were closed schemes. Results: The analyzed schemes accounted for 8.1 million lives of 2020 beneficiaries, accounting for 91% of all beneficiaries over the same period. Of these, 1.1 million utilized optometrist benefits, which accounted for 13% of beneficiaries included in the study. The average expenditure per utilizing beneficiary per annum was higher in closed schemes than open schemes, R2 987 (SD=1039) and R2 317 (SD=708), respectively. A Generalized Linear Model employed showed the effect of the sector (p-value =0.0334) and size–small schemes vs. large schemes (p-value =0.2373) for and small schemes vs. medium schemes (p-value =0030). The range of benefits paid was wider in small schemes than large and medium schemes R1 302 to R5 532 compared to R1 275 to R4 4473 vs. and R938 to R3 900, respectively. However, the operating model was not statistically significant to benefits paid for optometrist services (p-value =0.2377). The co-payment level paid by members was 18%, higher in open schemes vs. closed schemes, 23% vs. 13%, respectively. Conclusion: The study found a disparity in the optic benefits funding model employed by medical schemes; open schemes mainly fund this benefit from saving benefits while closed schemes seem to be funding these from risk benefits. Open scheme members were subjected to higher co-payment levels than closed schemes, thus depicting better funding of these benefits. The study also revealed the size factor as one of the deterministic factors of optometry benefits, where small schemes paid higher benefits than medium and large schemes. The study recommends the capping of copayments, in particular in open schemes. The study recommends reviewing the funding model in restricted schemes that fully fund optometry benefits from the risk pool.
Optometry; Benefits paid; Risk; Personal medical savings account; Medical schemes; South Africa
Willie MM. Benefits Paid to Optometrists by Medical Schemes, South Africa. Ann Clin Med Res. 2022; 3(1): 1058.