National Health Insurance
Multiple Chronic Disease and Disease Management Programmes
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It is not only the numbers with chronic disease that are important, but the complexity and severity of disease that can be expected. Figure 1 showed the strong shape by age of the rate of multiple chronic disease. The data from the REF Study 2005 enables a detailed picture of the patterns of multiple disease to be extracted. The graphs below include all 25 CDL disease combinations but exclude anyone with HIV (as this is the subject of a separate policy brief).
Figure 5: Proportion of Multiple CDL Diseases by Age and Gender in Medical Schemes
The graph above shows that at older ages, nearly half the beneficiaries on medical schemes with chronic disease have more than one chronic disease. While the graph shows that there are very few lives with five or more simultaneous CDL diseases, the data showed people being diagnosed for up to eleven simultaneous conditions and treated for up to nine simultaneous conditions. The most common combinations of conditions in the REF Study 2005 are shown in Figure 6 below.
There is a very distinctive pattern by age and gender of the chronic conditions and combinations shown in Figure 6. When combined with the medical scheme population expected in 2009, the most common chronic disease for those under age 20 is asthma. While the rate of chronic disease rises very strongly with age, as shown in Figure 1 , there are fewer people at older ages in medical schemes and thus the greatest number of people with chronic disease are in the age group 50-64 for both females and males, as shown in Figure 7 .
Figure 6 : Most Common Combinations of Chronic Conditions in Medical Schemes
Figure 7 : Numbers Expected with Combinations of Multiple Chronic Conditions in Medical Schemes in 2009
Many medical schemes in South Africa introduced disease management programmes during the 1990s. These have been described as programmes that “involve active management by the scheme
administrators of the prevention, diagnosis and treatment of specific conditions such as asthma, diabetes or pregnancy. Such programmes represent one of the more comprehensive mechanisms for managing costs. Typically they allow better collection of data on the beneficiary’s medical condition,
and dissemination of best practice information to providers caring for the patient. They also provide the basis for interventions directed by the administrators (such as preventive action)”.
The Old Mutual Healthcare Surveys used to report on the extent to which various managed care practices were used by medical schemes. The last report to do so, that in 2003, showed that 59% of medical schemes had disease management programmes in place, up from 38% in 1999. Questions about pharmacy management programmes were no longer asked after 2001 as these were found in nearly all schemes.
The first chronic disease management programmes tended to be for asthma and diabetes, as these were tractable to intervention. Cardiac conditions, including hypertension, were more prevalent but programmes were less frequently seen. However these single disease programmes proved to be problematic for people with multiple diseases and the evidence above shows some of the complexity of the combinations. Some leading administrators and managed care companies have moved to programmes dealing with high-cost individuals who typically have multiple chronic conditions. The focus has rightfully become the person rather than the sum of the diseases.
Typically including pre-authorisation of chronic medicines and consideration of drug interactions. May include advising on the use of formulary medicines which have been assessed for price and efficacy and which the medical scheme is willing to reimburse in full.
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