Contribution inflation in Medical Schemes 10 August 2016 by Charlton Murove 10 August 2016 1
Overview I. Inflation & medical inflation as measure by Statistics South Africa (Stats SA) II. Contribution inflation in medical schemes III. Drivers of contribution inflation IV. Utilisation in 2014 & 2013 V. Contribution inflation measurement (prospective) VI. Questions 2
Inflation - Stats SA CPI general increases in prices of goods and services Rebased after carrying out Income and Expenditure surveys (IES) every five years (may be reduced to 3 years) Medical inflation from Stats SA Also includes medical inflation basket targeting healthcare goods and services Stats SA measures how the general prices of medical services increase from year to year This is regardless of how much if these services are consumed from year to year 3
Medical inflation - Stats SA Medical inflation measures how prices change over time The price measured is not affected by how much health services are consumed Just calculate the increase in the price of one egg. This does not measure how many eggs are consumed over time For medical schemes, its important how much health services are consumed 4
Medical inflation or contribution inflation Contributions are used to finance both Medical services & goods and non health-care expenditure It is important to measure how much cost of services change over time and how much of the services are consumed over time for Medical Schemes Even when the price of eggs do not change you would need more cash 5
Contribution inflation Contribution increases of medical schemes respond to a number of factors such as: I. General increase in price levels of medical goods and services II. Increase in use of the medical goods and services (utilisation) III. General increase in non-healthcare expenditure (NHE) IV. Reserving requirements Industry technical advisory panel (ITAP) formula & work Medical inflation = tariff increase + utilisation increase Medical inflation = tariff increase + (demand side component + residual supply side effect) Medical inflation = tariff increase + (plan-mix effect + residual demographic effect) + residual supply side effect ITAP led to the review of data collected by CMS so as to measure medical inflation more accurately 6
No of beneficiaries Contribution inflation Effect of demographic profile on cost of PMBs 900 000 Changes in demographic profile from 2005 to 2014 800 000 700 000 600 000 500 000 400 000 300 000 200 000 100 000 - < 1 Year 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 7
Proportion of beneficiaries Contribution inflation Effect of demographic profile on cost of PMBs 10% Beneferciary profile changes from 2005 to 2014 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% < 1 Year 1-4 5-9 10-1415-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + 2005 2014 There were significant change with a higher proportion of beneficiaries in the older ages and an increasing proportion of beneficiaries in younger ages 8
Contribution inflation < 1 Year Effect of demographic profile on cost of PMBs 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + 2014 Cost of PMBs pbpm 1 947 153 79 89 171 286 446 464 481 519 606 735 940 1 242 1 613 1 951 2 156 2 289 2 061 All Beneficiaries in 2014 270 626 640 610 773 740 672 734 636 933 469 327 638 615 736 123 704 826 689 077 615 338 554 042 447 887 318 886 241 759 173 879 116 995 68 834 44 227 Cost of PMBs pbpm in 2014 582,96 * All Beneficiaries in 2005 127 763 420 470 575 877 615 955 600 673 440 336 436 872 569 258 596 517 582 196 508 188 386 104 316 477 222 694 162 136 115 329 81 920 48 340 28 516 Cost of PMBs pbpm in 2005 The change in beneficiary profile translates to an increase of 8% in the cost of PMBs from 2005 to 2014 539,48 *The 2014 PMB cost pbpm is different from previous publication as a sample was beneficiaries was used in those publications 9
% change Contribution inflation Effect of demographic profile on cost of PMBs 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Change in PMB cost over time (by changes in risk profiles) 2006 2007 2008 2009 2010 2011 2012 2013 2014 Annual Change (%) Cumulative Change (%) Cost of PMBs pbpm for 2014 was used to calculate the cost of PMBs using the beneficiary profiles of the previous years If the profile had not changed from 2005, the cost of PMBs would be 8% lower In 2014 the effect of change in demographic profile was 0,94% 10
% change Contribution inflation Effect of demographic profile on cost of PMBs 16% 14% 12% 10% 8% 6% 4% 2% 0% -2% -4% -6% Change in PMB cost over time (by scheme type) 2006 2007 2008 2009 2010 2011 2012 2013 2014 Open Cumulative Change (%) Ristricted Cumulative Change (%) The impact of change in membership profile was mostly on open schemes If the profile had not changed from 2005, the cost of PMBs would be 14% lower on open schemes In 2014 the effect of change in demographic profile was 0,91% for Open schemes and 0,87% for restricted schemes. 11
Contribution inflation < 1 Year Effect of disease burden on cost of CDLs 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + 2014 Cost of CDLs per CDL meeting Entry and Verification Criteria 167 869 7 890 6 089 7 381 11 534 12 754 8 923 6 271 5 574 5 518 5 464 5 309 5 229 5 101 4 896 4 783 4 702 4 464 4 326 All Beneficiaries in 2014 270 626 640 610 773 740 672 734 636 933 469 327 638 615 736 123 704 826 689 077 615 338 554 042 447 887 318 886 241 759 173 879 116 995 68 834 44 227 CDLs meeting Entry and Verification Criteria as a percentage of beneficiaries in 2014 0,1% 1,7% 2,3% 2,4% 2,3% 3,0% 4,5% 8,8% 15,2% 23,1% 32,8% 45,3% 59,6% 79,5% 99,7% 115,4% 127,1% 132,0% 121,0% Cost of CDLs per CDL meeting Entry and Verification Criteria in 2014 6 477 CDLs meeting Entry and Verification Criteria as a percentage of beneficiaries in 2008 0,1% 1,7% 2,0% 1,8% 1,8% 2,1% 3,0% 5,7% 10,0% 15,6% 25,6% 36,9% 52,6% 73,8% 93,0% 109,4% 119,2% 117,2% 104,1% Cost of CDLs per CDL meeting Entry and Verification Criteria in 2008 using 2014 CDL costs and beneficiary profile 5 266 The change in disease burden translates to an increase of 19% from 2008 This calculation is based on the cost of CDLs only The calculation excluded the less than 1 year old beneficiaries This calculation includes beneficiaries with multiple chronic conditions 12
% change Contribution inflation Effect of disease burden on cost of CDLs Change in CDL cost over time (by chronicity) 25% 20% 15% 10% 5% 0% -5% 2009 2010 2011 2012 2013 2014 Annual Change (%) Cumulative Change (%) Cost of CDLs pbpy for 2014 was used to calculate the cost of CDLs using the chronicity of beneficiaries in the previous years adjusted for changes in beneficiaries overtime If the chronicity had not changed from 2008, the cost of CDLs would be 19% lower In 2014 the effect of change in disease burden was 2,67% for all schemes 13
% change Contribution inflation Effect of disease burden on cost of CDLs Change in CDL cost over time (by scheme type) 35% 30% 25% 20% 15% 10% 5% 0% 2009 2010 2011 2012 2013 2014 Open Cumulative Change (%) Ristricted Cumulative Change (%) The impact of changes disease burden was higher on restricted schemes If the disease burden had not changed from 2008, the cost of CDLs would be 12% lower on open schemes and 27% lower on restricted schemes In 2014 the effect of change in disease burden was 0,64% for open schemes and 5,24% for restricted schemes 14
Utilisation Providers Data Collected Data Table Fields collected Option level for financial years 2013 & 2014 Adjustments / Quality of data A2 No of beneficiaries at the end of each month in the financial years 2013 and 2014. None / good quality B1 No of visits to the various providers and the total cost of such visits None / good quality Consultation code was used to identify each visit Providers included GPs, Specialists Supplementary& Allied providers Table B1 data was collected by discipline code 15
Utilisation Providers Category Average Cost Tariff per event Utilisation pabpm Sub-category Providers (43,7% of total benefits paid) Each visit paid for by the schemes No of visits In-Hospital & Out-of-Hospital This calculation included benefits paid from Risk and the member savings accounts (MSA) 16
Utilisation Providers 2013 2014 % change pabpm Providers Number of visits 68 824 388 71 435 900 2.7% In-hospital 17 340 663 18 428 527 5.2% Out-of-hospital 51 483 725 53 007 373 1.9% Average cost per visit (R) 689.13 744.05 8.0% In-hospital (R) 1 103.59 1 184.16 7.3% Out-of-hospital (R) 549.53 591.04 7.6% Utilisation of providers increased more for in-hospital visits 17
Utilisation A hospital GP visit costs more than double an out-ofhospital visit. The assumed increase in GPs tariffs was 6,6% 18
Utilisation There is a very significant increase in utilisation of medical technology especially in-hospital. The average cost per event is also much higher in-hospital 19
Utilisation Medicines Data Collected Data Table A2 Fields collected Option level for financial years 2013 & 2014 No of beneficiaries at the end of each month in the financial years 2013 and 2014. Adjustments / Quality of data None / good quality B2 Total amount spend on medicines and consumables outside hospital and the no of items dispensed None / good quality NAPPI code was used to identify medicines and consumable (first digit of the NAPPI code is less or equal to 7, product is classified as medicine and the remaining products were classified as Consumables) Was also collected by discipline code of the provider dispensing medicines 20
Utilisation Medicines Category Average Cost Tariff per event Utilisation pabpm Sub-category Medicines (16,6% of total benefits paid) Each item dispensed and paid for by the schemes No of items dispensed Consumables & Medicines This calculation included benefits paid from Risk and the MSA 21
Utilisation Medicines 2013 2014 % change pabpm Medicines Number of items dispensed 212 366 520 223 161 203 4.2% Consumables 14 752 285 15 063 860 1.0% Medicine 197 614 235 208 097 343 4.2% Average cost per item dispensed (R) 88.69 92.18 3.9% Consumables (R) 66.38 72.25 8.8% Medicine (R) 90.36 93.62 3.6% The increase in average cost per item dispensed for medicines was lower compared to consumables 22
Utilisation Hospitalisation Data Collected Data Table A2 B3 Fields collected Option level for financial years 2013 & 2014 No of beneficiaries at the end of each month in the financial years 2013 and 2014. Hospital admission data for beneficiaries: no of admissions, admission type and no of days spent in hospital Adjustments / Quality of data None / good quality Adjustments to length of Stay for some options / reasonable quality B6 Hospital admission data for beneficiaries: no of admissions, admission type & category and no of days spent in hospital None / reasonable quality 23
Utilisation Hospitalisation Category Average Cost Tariff per event Utilisation pabpm Sub-category Hospitalisation (37,6% of total benefits paid) Each hospital admission paid for by the schemes Each day spent in-hospital paid for by the schemes No of admissions No of in-patient days per admission and is not calculated pabpm In patient days <24hrs Short stay & In patient days >24hrs Long stay 24
Utilisation Hospitalisation 2013 2014 % change pabpm Hospitalisation Number of admissions 2 506 398 2 540 535 0.3% Day case 756 185 769 764 0.7% Long stay 1 750 213 1 770 771 0.1% Average cost per admission (R) 16 606.88 18 331.34 10.4% Day case (R) 6 545.34 7 213.98 10.2% Long stay (R) 20 953.99 23 164.12 10.5% Number of inpatient days 7 494 131 7 904 851 4.1% Day case 756 185 769 764 0.0% Long stay 6 737 946 7 135 087 4.7% Average cost per day (R) 5 554.14 5 891.50 6.1% Day case (R) 6 545.34 7 213.98 10.2% Long stay (R) 5 442.90 5 748.82 5.6% 25
Hospital admissions per 1 000 beneficiaries Utilisation Hospitalisation - No of admissions per 1 000 beneficiaries (all admissions) 1 200 1 000 800 600 400 200 0 Less than one year 1-4 years 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 years years years years years years years years years years years years years years years 2013 Males 2014 Males 2013 Females 2014 Females 80-84 years 85 years+ 26
Average length of stay per admission Utilisation Hospitalisation Average Length of Stay per admission (In patient > 24 hours) 5,0 4,5 4,0 3,5 3,0 2,5 2,0 1,5 1,0 0,5 0,0 Less than one year 1-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50-54 years 55-59 years 60-64 years 65-69 years 70-74 years 75-79 years 80-84 years 85 years+ 2013 Males 2014 Males 2013 Females 2014 Females 27
Utilisation major take-away I. no of admissions increased marginally while length of stay increased at 4% I. (it would be more helpful to unpack utilisation in hospital more) II. utilisation of providers increased most in-hospital 5,2% compared to 1,9% out-ofhospital III. average cost per event is higher in hospital for a number of disciplines IV. the increase in average cost of medicines was 3,6% - probably due to single exit price and use of generics 28
Contribution increase measurement Contribution allocation in Medical schemes Non Healthcare Expenditure Medicines Providers & Hospitalisation Need to determine: What proportion of contributions goes towards NHE & HC costs? How does NHE & HCE increase over time? How does the utilisation of HC change over time? 29
Contribution inflation measurement Assumptions / objectives 1. By analysing the industry wide revenue account of medical schemes one has in actual fact considered all drivers of contribution increases (tariff +utilisation) 2. Understanding and measuring utilisation does not require us to determine how much each individual component of utilisation contributes over time with more data this maybe possible The following method is a mirror of contribution assumptions methodology; it does not specify how each individual component of utilisation contributes to total contribution inflation 30
Contribution inflation measurement Actual expenditure is used true reflection of how contributions are spent Basket of items is rebalanced every year Utilisation trends would be easily calculated from the data For years 2014 and 2015, total healthcare expenditure can be analysed by age we can accurately determine the demographic component
Health-Care Expenditure Non Health-Care Expenditure Actual increase in contributions Weight in Index All Schemes Tariff (cost per event) Utilisation (no of events pabpm) 2013 2 013 2 014 % Change 2013 2014 % Change Overall Increase Administration Expenditure 7,84% 12 932,55 13 810,05 6,79% - - - 6,79% Managed Care 2,68% 4 412,06 4 711,41 6,78% - - - 6,78% Brokerage 1,33% 2 186,76 2 347,33 7,34% - - - 7,34% Other Expenditure -2,78% -4 588,60-4 757,50 3,68% - - - 3,68% Sub-Total 9,06% 7,82% - - - 7,82% Day Admission 4,17% 6 545,54 7 214,21 10,22% 1,051 1,057 0,60% 10,87% Long Stay Admission 30,92% 5 437,57 5 741,91 5,60% 9,373 9,811 4,67% 10,53% Medicines 15,05% 90,44 93,63 3,53% 274,422 285,736 4,12% 7,80% Consumables / Medicines 0,82% 66,40 72,26 8,82% 20,481 20,684 0,99% 9,90% Providers In-Hospital 16,13% 1 103,91 1 184,19 7,27% 24,089 25,306 5,05% 12,69% Providers Out-of-Hospital 23,84% 549,34 590,93 7,57% 71,545 72,803 1,76% 9,46% Sub-Total 90,94% 6,31% 3,66% 10,19% Grand Total 100,00% 6,45% 3,33% 9,98% NHE was assumed to increase at 6,1% in 2014 Assumed Utilisation increase was 2,3% & overall increase was 9,2% SEP was 5,8% for 2014 32
Actual increase in contributions Contribution increase including NHE In 2014 tariff increase = 6,45% In 2014 utilisation increase = 3,33% All Schemes summary Increases in Healthcare Expenditure (excluding NHE) In 2014 tariff increase = 6,31% In 2014 utilisation increase = 3,66% Effect of demographic change (2014) = 0,94% Effect on increasing disease burden (2014) = 2,67% Unexplained utilisation (2014) = 0,05% This assumes the effect of demographic & disease burden for total healthcare is similar to PMB experience
Health-Care Expenditure Non Health-Care Expenditure Actual increase in contributions Open Schemes Weight in Index Open Schemes Tariff (cost per event) Utilisation (no of events pabpm) 2013 2 013 2 014 % Change 2013 2014 % Change Overall Increase Administration Expenditure 9,25% 16 262,19 17 135,61 5,37% - - - 5,37% Managed Care 2,74% 4 812,26 5 075,67 5,47% - - - 5,47% Brokerage 2,17% 3 809,99 4 066,59 6,73% - - - 6,73% Other Expenditure -2,28% -4 001,83-4 676,49 16,86% - - - 16,86% Sub-Total 11,87% 3,44% - 3,44% Day Admission 4,41% 6 443,88 7 281,14 12,99% 1,204 1,214 0,82% 13,92% Long Stay Admission 30,71% 5 967,22 6 177,69 3,53% 9,052 9,567 5,69% 9,42% Medicines 13,75% 115,59 111,55-3,50% 209,183 232,647 11,22% 7,33% Consumables / Medicines 0,76% 81,89 81,71-0,21% 16,227 17,054 5,09% 4,87% Providers In-Hospital 16,33% 1 181,96 1 268,39 7,31% 24,301 25,583 5,28% 12,98% Providers Out-of-Hospital 22,17% 569,68 609,98 7,07% 68,426 69,533 1,62% 8,81% Sub-Total 88,13% 4,47% 5,20% 9,78% Grand Total 100,00% 4,34% 4,58% 9,03% 34
Actual increase in contributions Contribution increase including NHE In 2014 tariff increase = 4,34% In 2014 utilisation increase = 4,58% Open Schemes summary Increases in Healthcare Expenditure (excluding NHE) In 2014 tariff increase = 4,47% In 2014 utilisation increase = 5,20% Effect of demographic change (2014) = 0,91% Effect on increasing disease burden (2014) = 0,64% Unexplained utilisation (2014) = 3,65% This assumes the effect of demographic & disease burden for total healthcare is similar to PMB experience
Health-Care Expenditure Non Health-Care Expenditure Actual Increase in Contributions Restricted Schemes Weight in Index Restricted Schemes Tariff (cost per event) Utilisation (no of events pabpm) 2013 2 013 2 014 % Change 2013 2014 % Change Overall Increase Administration Expenditure 5,84% 8 831,59 9 667,33 9,46% - - - 9,46% Managed Care 2,59% 3 919,15 4 257,63 8,64% - - - 8,64% Brokerage 0,12% 187,50 205,60 9,65% - - - 9,65% Other Expenditure -3,51% -5 311,30-4 858,42-8,53% - - - -8,53% Sub-Total 5,04% 21,57% - 21,57% Day Admission 3,83% 6 720,30 7 096,86 5,60% 0,862 0,862-0,03% 5,57% Long Stay Admission 31,20% 4 833,09 5 228,47 8,18% 9,769 10,115 3,55% 12,02% Medicines 16,92% 72,18 78,88 9,28% 354,774 351,871-0,82% 8,39% Consumables / Medicines 0,92% 54,37 64,29 18,26% 25,721 25,206-2,00% 15,89% Providers In-Hospital 15,84% 1 005,88 1 076,68 7,04% 23,829 24,960 4,75% 12,12% Providers Out-of-Hospital 26,24% 526,60 569,46 8,14% 75,387 76,877 1,98% 10,28% Sub-Total 94,96% 8,17% 2,34% 10,68% Grand Total 100,00% 8,84% 2,22% 11,23% 36
Actual increase in contributions Contribution increase including NHE In 2014 tariff increase = 8,84% In 2014 utilisation increase = 2,22% Restricted Schemes summary Increases in Healthcare Expenditure (excluding NHE) In 2014 tariff increase = 8,17% In 2014 utilisation increase = 2,34% Effect of demographic change (2014) = 0,87% Effect on increasing disease burden (2014) = 5,24% Unexplained utilisation (2014) = -3,77% This assumes the effect of demographic & disease burden for total healthcare is similar to PMB experience
Conclusion The objective is to have a way of understanding and measuring proponents of contribution increases Its important that this is measured for all schemes and is based on data that is readily available The proposed method may be improved to in cooperate other details /indicators and we would be keen to work with stakeholders on this Contribution inflation and what drives it has been very topical and there are many views of what is driving it let's work towards telling one story based on global evidence and what is measurable 38
Questions 39
Thank You 40