National Health Insurance
Disease Management in the Private Sector

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Dr Leon Regensberg, the Senior Medical Advisor of Aid for AIDS, has long shown that the major cost driver in managing HIV/AIDS is hospitalisation for AIDS-related conditions. Antiretroviral therapy is effective and reduces the need for hospitalisation. Aid for AIDS is the longest running disease management programme in the private sector and is described in a case study in the South African Health Review of 2007.

Aid for AIDS has found from experience that “Treatment costs are high at entry into the programme because hospitalisation typically coincides with diagnosis or registration.” “Treatment costs have been shown to stabilise once a patient has enrolled and been stabilised on HAART.” This is shown below in terms of time from registration on the confidential disease management programme.

Figure 6: Components of treatment Costs relative to Enrolment on Aid for AIDS Disease Management Programme, January 2007 [Source: Michael Hislop, Aid for Aids]

Aid for AIDS researchers “have always suspected that there is a degree of ‘coincidence’ in the cost spike at AfA entry. In other words, patients enrol on AfA as a consequence of admission most likely either because they are diagnosed HIV+ for the first time or know about their status but only finally decide to do something about it after the admission experience”. Patients in a later stage of disease, in terms of a CD4 count, “have a significantly higher spike and higher average post registration treatment costs than patients who enter at an early stage”. Significant hospital costs might therefore be avoided through earlier diagnosis and registration on disease management programmes. A commitment to destigmatising the disease remains essential.

Disease management programmes to manage HIV/AIDS benefits were already found to have become standard by 2003. A survey found that these programmes could potentially be accessed on a confidential basis by 90% of medical scheme beneficiaries before treatment became mandatory in medical schemes. By mid-2006 it was found that there were seventeen companies offering HIV/AIDS disease management, covering 55,900 patients. A further 11,600 were treated on community treatment programmes so that the total number of individuals receiving HAART in the private sector was estimated to be at least 67,600. Roughly 181 000 people had started HAART in the public health sector by June 2006. No attempt was made to estimate the number of individuals paying for their own treatment and not belonging to disease management programmes, community treatment programmes or public sector programmes.

Aid for AIDS has, since inception in 1998, made clinical guidance on the management and treatment of HIV/AIDS freely available. The clinical guidelines are currently in their seventh edition. Aid for AIDS would be an excellent source for costs of treatment according to the stage of HIV infection.
A concern expressed by Aid for AIDS is that disease management programmes “do not offer integrated programmes traversing the areas of TB, STIs and HIV and AIDS, and therefore the overall health care needs of individuals are not managed holistically”.

Personal communication, Michael Hislop, Aid-for-AIDS, 2 July 2009.

Aid for AIDS clinical guidelines:
http://www.aidforaids.co.za/ex_MEDSCHEME_VS07/MedschemeHealthRisk/

HealthRiskManagement/AidForAids/ClinicalPublications.aspx

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