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Chairperson: Prof. Y Veriava Chief Executive & Registrar: Dr M Gantsho
Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157 Tel: 012 431 0500 Fax: 012 430 7644 Customer Care: 0861 123 267
[email protected] www.medicalschemes.com
Prevalence of chronic diseases in the
population covered by medical aid schemes in
South Africa Research and Monitoring Unit
June 2014
Chairperson: Prof. Y Veriava Chief Executive & Registrar: Dr M Gantsho
Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157 Tel: 012 431 0500 Fax: 012 430 7644 Customer Care: 0861 123 267
[email protected] www.medicalschemes.com
Contents
Acknowledgements.................................................................................................................................. 1
Executive Summary ................................................................................................................................. 2
1 Introduction ...................................................................................................................................... 5
2 Research approach ......................................................................................................................... 8
2.1 Purpose ................................................................................................................................... 8
2.2 Data source ............................................................................................................................. 8
2.3 Analytical approach ................................................................................................................. 8
3 Results ........................................................................................................................................... 10
3.1 Scheme demographics .......................................................................................................... 10
3.2 CDL prevalence ..................................................................................................................... 11
3.2.1 Hypertension...................................................................................................................... 12
3.2.2 Hyperlipidaemia ................................................................................................................. 13
3.2.3 Diabetes mellitus type 2 ..................................................................................................... 14
3.2.4 Asthma .............................................................................................................................. 15
3.2.5 Hypothyroidism .................................................................................................................. 16
3.2.6 HIV/AIDS ........................................................................................................................... 17
3.2.7 Ischaemic heart disease .................................................................................................... 18
3.2.8 Epilepsy ............................................................................................................................. 19
3.2.9 Cardiomyopathy ................................................................................................................. 20
3.2.10 Dysrhythmias ................................................................................................................. 21
3.2.11 Other CDL conditions .................................................................................................... 22
3.2.12 Top 10 CDL conditions: 2007 - 2012 ............................................................................. 22
3.2.13 Multiple CDL conditions: 2007 - 2012 ............................................................................ 23
3.2.14 Top 10 CDL conditions by scheme size: 2007 – 2012 ................................................... 23
4 Discussion ..................................................................................................................................... 25
5 References .................................................................................................................................... 26
1
Acknowledgements
The research team responsible for this work was led by Mr. Mondi Govuzela and Mrs. Carrie-Anne
Cairncross, researchers of the Research and Monitoring Unit, at the Council for Medical Schemes
(CMS). We also acknowledge the contributions made to the development of these ideas by Mr. Michael
Willie, and Dr. Anton de Villiers.
2
Executive Summary
The 2014 retrospective study of the CMS’s Scheme Risk Measurement Database was undertaken to
establish changes in the frequency of chronic diseases among beneficiaries of medical schemes
between 2011 and 2012. The study compared trends for open and restricted schemes, schemes of
various sizes, and a range of benefit options. The main finding was that there has been a sustained
upward trend in diagnosis and treatment of many conditions on the chronic disease list (CDL). While
the study could not isolate specific reasons for this increase in chronic diseases, the trend could be
generally attributed to improved data management systems of medical schemes and administrators,
the deteriorating disease profile and higher average age of beneficiaries, increased beneficiary
awareness of entitlements and changes in care-seeking behaviour. The findings of the 2014 prevalence
study are summarised in Table 1 below.
Table 1: Prevalence of chronic conditions (Cases/1 000 beneficiaries), 2011 and 2012
Condition Type 2011 2012 Trends
Hypertension (HYP)
Total 82.56 86.16 Overall increase of approximately 4% between
2011 and 2012, with increase more marked in
restricted schemes (8%) than open schemes (2%)
Open 85.53 86.92
Restricted 79.10 85.30
Hyperlipidaemia (HYL)
Total 34.43 35.58 Moderate increase across all schemes, with higher
prevalence in open schemes Open 39.21 40.50
Restricted 28.79 30.03
Diabetes mellitus type 2 (DM2)
Total 23.30 25.66 Overall increase of almost 10% across all
schemes. Both prevalence and rate of increase
were slightly higher in restricted schemes
Open 21.25 23.01
Restricted 25.73 28.65
Asthma (AST) Total 15.36 15.77 Moderate increase across all schemes and similar
prevalence rates in open and restricted schemes Open 15.49 15.78
Restricted 15.20 15.77
Hyperthyroidism (TDH)
Total 14.28 14.70 Overall increase of 3% across all schemes. In
restricted schemes the increase was 7% while
open schemes showed no significant increase
Open 15.26 15.23
Restricted 13.13 14.09
HIV/AIDS (Receiving ARVs)
Total 9.38 14.57 Largest increase of any condition, with 55% rise in
prevalence across all schemes. Prevalence and
rate of increase were higher in restricted schemes
Open 6.00 8.53
Restricted 13.37 21.39
Ischaemic heart disease (IHD)
Total 7.30 7.30 Prevalence across the total number of schemes
remained steady with higher prevalence in open
schemes and a minor rise in restricted schemes
Open 8.60 8.35
Restricted 5.71 6.11
Epilepsy (EPL)
Total 4.13 4.24 No significant increase and prevalence rate of
about 4 per 1 000 beneficiaries remained steady Open 4.38 4.44
3
Restricted 3.84 4.01 across all types of schemes
Cardiomyopathy (CMY & CHF)
Total 4.14 4.17 Minor increases appear insignificant and similar
prevalence occurs in all categories of schemes Open 4.32 4.03
Restricted 3.92 4.34
Dysrhythmias (DYS)
Total 3.43 3.59 Overall increase of 5% between 2011 and 2012
across all schemes, with higher prevalence in open
schemes
Open 4.50 4.48
Restricted 2.18 2.59
Figure 1 below depicts the trends in the top 10 common conditions between 2007 and 2012. The order
of these conditions has remained mostly unchanged for the period under review. Hypertension,
hyperlipidaemia and diabetes mellitus type 2 have shown the fastest increase amongst the top 10
common diagnosed and treated CDL conditions. Other conditions, though increasing, have remained at
rates below twenty per thousand beneficiaries.
Figure 1: Top 10 diagnosed and treated CDL conditions: 2007 - 2012
Figure below shows the pace of increase in the diagnosis and treatment of some of the chronic
conditions. The number of beneficiaries on ARV/HAART treatment has increased by 195% between
2007 and 2012. This may be attributable to reducing stigma related to HIV and AIDS. The number of
beneficiaries treated for bipolar mood disorder increased by 173% in the period under review. CDL
conditions that may be attributable to lifestyle choices such as diabetes mellitus type 2 (78%),
4
cardiomyopathy (58%) and hypertension (41%), have also shown a strong and sustained increase for
period between 2007 and 2012.
Figure 2: Top 10 fastest increasing treated conditions: 2007 - 2012
5
1 Introduction
The Medical Schemes Act of 1998 makes it mandatory for medical schemes to cover costs for the
diagnosis, treatment or care of a defined set of benefits or Prescribed Minimum Benefits (PMBs),
regardless of the benefit option they have selected. PMBs include any medical condition which meets
the definition of an emergency, a limited set of 270 medical conditions and 25 chronic conditions
defined in the Chronic Disease Listing (CDL). CDL specifies medication and treatment for the chronic
conditions that are covered as PMBs. This law ensures that beneficiaries with chronic conditions are
not risk-rated and forced to pay higher amounts for their cover. Various factors were taken into account
when identifying the chronic diseases that would be covered, such as; the nature of the disease and
how that disease would affect the quality of life of the individual, the prevalence of the conditions the
affordability of the treatment, and the financial impact to medical schemes.
The 2013 retrospective study of the Scheme Risk Measurement database of the Council for Medical
Schemes for the period 2006 – 2011 found that there had been a sustained upward trend in diagnosis
and treatment of many chronic conditions on the CDL. These increases were thought to be as a result
to improved data management systems of medical schemes and administrators, the worsening age and
disease profile of beneficiaries, the increased beneficiary awareness of entitlements, and behavioural
change. Unfortunately, the study could not isolate the different components that contribute to the
observed trends. The study found that the top ten conditions that showed the most rapid increase in the
period 2006 – 2011, in order of their prevalence from highest to lowest in 2011 were hypertension,
hyperlipidaemia, diabetes mellitus type 2, hypothyroidism, glaucoma, rheumatoid arthritis, bipolar mood
disorder, Parkinson’s disease, chronic renal disease, and systemic lupus erythematosus.
The prevalence of hypertension grew by 36.8% between 2006 and 2011, from 57.6 to 78.8 per 1 000
beneficiaries, making it the fastest increasing cardiovascular disease among medical scheme
beneficiaries and the most prevalent chronic disease on the PMB Chronic Disease List (CDL).
Hyperlipidaemia’s prevalence among beneficiaries grew by 37.7% from 23.9 in 1 000 beneficiaries in
2006 to 32.9 in 1 000 beneficiaries in 2011. This is most likely due to lifestyle changes.
The 84.2% increase in the prevalence of diabetes mellitus type 2 between 2006 and 2011 (from 12.0 to
22.1 per 1000) again points to the importance of leading a healthy lifestyle.
6
Six times more females were treated for hypothyroidism between 2006 and 2011 than male
beneficiaries. The overall prevalence of the disease increased from 9.7 to 13.7 per 1 000 beneficiaries
in that period. The prevalence in female beneficiaries increased by 37.5%, from 16.5 per 1 000 in 2006
to 22.6 per 1 000 in 2011. The prevalence of hypothyroidism among male beneficiaries increased at a
faster rate, from 2.3 per 1 000 in 2006 to 3.8 per 1 000 in 2011, an increase of 63.2%.
The prevalence of glaucoma increased from 1.8 per 1 000 beneficiaries in 2006 to 2.7 per 1 000 in
2011. The study found that there was no significant gender-related difference in prevalence.
Rheumatoid arthritis prevalence increased from 2.0 per 1 000 beneficiaries in 2006 to 2.6 per 1 000
beneficiaries in 2011, an increase of 31.7%. More female beneficiaries were treated for the disease
during that period than male. The prevalence of rheumatoid arthritis amongst female beneficiaries
increased from 2.8 to 3.8 per 1 000 in 200 – 2011, compared to a change from 1.1 to 1.4 per 1 000 in
male beneficiaries during the same period.
The prevalence of bipolar mood disorder (BMD) among medical schemes beneficiaries more than
doubled between 2006 and 2011. The psychiatric condition showed an increase of a staggering
250.0% during the period covered by the study. Very few beneficiaries under the age of 14 years were
treated for BMD, but the prevalence of BMD among female beneficiaries 15 – 39 years increased from
1.0 per 1 000 in 2006 to 2.9 per 1 000 in 2011. Similar trends were observed in the older age groups
(above 40 years).
Parkinson’s disease prevalence increased by 47.2% between 2006 and 2011, from 0.5 to 0.8 per 1 000
beneficiaries. Prevalence of the disease among beneficiaries between the ages of 60 and 79 years
increased from 3.9 to 4.4 per 1 000 in the same period; the prevalence was higher in beneficiaries older
than 80 years, increasing from 11.0 per 1 000 in 2006 to 12.2 per 1000 in 2011.
The prevalence of chronic renal disease increased from 0.2 per 1 000 in 2006 to 0.3 per 1 000
beneficiaries in 2011, an increase of 47.6%. More male than female beneficiaries were treated for the
disease, in 2011, its prevalence was 0.4 per 1 000 male and 0.3 per 1 000 female beneficiaries.
The prevalence of systemic lupus erythematosus (SLE) increased from 0.16 per 1 000 beneficiaries in
2006 to 0.22 per 1 000 beneficiaries in 2011. The prevalence of SLE was higher in women than in men.
There were seven times more women than men treated for SLE in 2011.
7
Chronic diseases remain a serious concern in South Africa. It is reported that 37% of deaths that
occurred during 2000 in South Africa were due to chronic diseases. The WHO estimates that deaths
from chronic diseases will increase by 77% by 2020, and that most of these deaths will occur in the
developing regions of the world (WHO, 2011).
The 2014 prevalence report presents the results of the retrospective review of the trends in the
prevalence of chronic diseases in the medical schemes industry from 2007 to 2012, a follow-up to the
2013 prevalence report (CMS, 2013).
8
2 Research approach
2.1 Purpose
This study evaluated trends in the frequency of chronic diseases (CDLs) in the medical schemes
beneficiaries between 2007 and 2012. HIV/AIDS will also be included in the analysis because on the
chronic nature of HAART treated HIV/AIDS. People infected with HIV/AIDS now have the same
requirements as those of patients with traditional chronic diseases such as hypertension and asthma.
The study compared these trends between open and restricted schemes, as well as on the size of the
medical schemes. This study is a follow-up to the 2013 report on the retrospective review of the trends
in the prevalence of chronic diseases in the medical schemes industry from 2006 to 2011.
2.2 Data source
This study relied on the data that is submitted by medical schemes for the purposes of Scheme Risk
Measurement project (SRM). The SRM database contains aggregate prevalence data for more than
99% of all medical schemes beneficiaries. Medical schemes use the rules set out in the “Guidelines for
the Identification of Beneficiaries with Risk Factors in Accordance with the Entry and Verification
Criteria” (CMS, 2014) to identify each chronic disease case. The purpose of this guideline is to define
criteria that must be met in the identification of beneficiaries with the all the CDL conditions, HIV and
maternity events. These criteria have been developed with the emphasis on the verifiability of cases
and are used to ensure that there is uniformity in the way that medical schemes identify SRM risk
factors. These guidelines provide specific clinical codes that serve to identify patients who were treated
for CDL conditions.
2.3 Analytical approach
The data was extracted into Windows Excel spreadsheet format and imported to STATA statistical
software package for management and analysis. The output was then transcribed to Excel for
tabulating summary statistics and constructing graphical representation of the results. The average
annual prevalence and number of lives for each age band were calculated for each medical scheme or
chosen strata (scheme type or size). The 2014 study will report on the annual average prevalence
based on the average annual beneficiaries. Prevalence for the month of June was reported in the 2013
report. The difference between these two approaches is not significant, but caution should be exercised
when comparing the findings of the two reports. Only data that was deemed to be of acceptable quality
9
through the SRM data quality evaluation process was included in the analysis. The proportion of
beneficiaries for whom fair data was submitted ranged from 75.0% to 84.0% during 2011 and 2012.
Descriptive statistics were calculated to produce summary statistics of key variables. CDL’s included in
the analysis are listed in Table 2.
Table 2: Chronic diseases in the Chronic Disease List
Chronic Disease Code Full Description
ADS Addison’s Disease
AST Asthma
BCE Bronchiectasis
BMD Bipolar Mood Disorder
CHF Cardiac failure1
CMY Cardiomyopathy
COPD Chronic Obs. Pulmonary Disease
CRF Chronic Renal Disease
CSD Crohn’s Disease
DBI Diabetes Insipidus
DM1 Diabetes Mellitus 1
DM2 Diabetes Mellitus 2
DYS Dysrhythmias
EPL Epilepsy
GLC Glaucoma
HAE Haemophilia
HYL Hyperlipidaemia
HYP Hypertension
IBD Ulcerative Colitis
IHD Coronary Artery Disease
MSS Multiple Sclerosis
PAR Parkinson’s Disease
RHA Rheumatoid Arthritis
SCZ Schizophrenia
SLE Systemic Lupus Erythematosus
TDH Hypothyroidism
HIV/AIDS HIV/AIDS
1 CHF was combined with CMY in the prevalence tables.
10
3 Results
3.1 Scheme demographics
Demographics of beneficiaries of medical schemes are shown in Table 3. The number of beneficiaries
in all schemes increased by 1.8%, the average age increase from 31.6 to 32.0 and the pensioner ratio
increased from 6.6% to 7.1% between 2011 and 2012.
The number beneficiaries in restricted schemes grew by 4.1%. The average age and pensioner ratio
increased by 1.4% and 11.8%, respectively.
No significant change was observed in the number of beneficiaries in open medical schemes. The
average age and pensioner ratio for open schemes increased by 1.5% and 5.1%, respectively.
Table 3: Medical schemes demographics (all beneficiaries)
Attribute
Restricted Open Total
2011 2012 % change
2011 2012 % change
2011 2012 % change
Lives 3 766 295 3 919 479 4.10 4 760 114 4 759 994 0.00 8 526 409 8 679 473 1.8
Average age 29.5 29.9 1.4 33.3 33.8 1.5 31.6 32.0 1.3
Pensioner ratio (%) 5.1 5.7 11.8 7.8 8.2 5.1 6.6 7.1 7.6
11
3.2 CDL prevalence
The 2011 and 2012 average prevalence per 1 000 beneficiaries for the 26 CDL conditions in open and
restricted schemes is shown in Table 4 below. Cardiomyopathy (CMY) and cardiac heart failure (CHF)
are reported together as per SRM Entry and Verification criteria.
Table 4: Average prevalence per 1 000 beneficiaries for the 26 CDL conditions
Chronic
Disease
Code
2012 industry rank
(2011)
Restricted Open Total
2011 2012 %
change
2011 2012 %
change
2011 2012 %
change
ADS 24 (23) 0.04 0.04 -7% 0.07 0.07 3% 0.05 0.05 -1%
AST 4 (4) 15.20 15.77 4% 15.49 15.78 2% 15.36 15.77 3%
BCE 23 (23) 0.04 0.05 20% 0.06 0.06 6% 0.05 0.06 11%
BMD 13 (14) 1.87 2.19 17% 2.82 3.27 16% 2.38 2.76 16%
CMY & CHF 9 (8) 3.92 4.34 11% 4.32 4.03 -7% 4.14 4.17 1%
COP 15 (15) 0.96 0.89 -7% 1.66 1.63 -2% 1.34 1.29 -4%
CRF 18 (18) 0.24 0.31 30% 0.42 0.50 19% 0.34 0.41 22%
CSD 21 (21) 0.10 0.10 6% 0.20 0.23 16% 0.15 0.17 12%
DBI 25 (25) 0.01 0.01 -1% 0.02 0.02 6% 0.02 0.02 3%
DM1 14 (13) 2.30 2.22 -4% 2.89 2.77 -4% 2.62 2.51 -4%
DM2 3 (3) 25.73 28.65 11% 21.25 23.01 8% 23.30 25.66 10%
DYS 10 (10) 2.18 2.59 19% 4.50 4.48 -1% 3.43 3.59 5%
EPL 8 (9) 3.84 4.01 4% 4.38 4.44 1% 4.13 4.24 3%
GLC 12 (11) 2.32 2.55 10% 3.20 3.22 1% 2.80 2.91 4%
HAE 25 (25) 0.00 0.00 -14% 0.03 0.03 21% 0.02 0.02 15%
HYL 2 (2) 28.79 30.03 4% 39.21 40.50 3% 34.43 35.58 3%
HYP 1 (1) 79.10 85.30 8% 85.53 86.92 2% 82.58 86.16 4%
IBD 19 (19) 0.22 0.23 3% 0.39 0.42 8% 0.31 0.33 6%
IHD 7 (7) 5.71 6.11 7% 8.60 8.35 -3% 7.27 7.30 0%
MSS 22 (22) 0.07 0.07 -4% 0.17 0.18 5% 0.13 0.13 2%
PAR 16 (16) 0.64 0.70 10% 0.94 0.90 -4% 0.80 0.81 1%
RHA 11 (12) 2.70 3.03 12% 2.74 2.84 4% 2.72 2.93 8%
SCZ 17 (17) 0.40 0.42 7% 0.46 0.47 1% 0.43 0.45 3%
SLE 20 (20) 0.20 0.22 9% 0.27 0.30 11% 0.24 0.26 10%
TDH 5 (5) 13.13 14.09 7% 15.26 15.23 0% 14.28 14.70 3%
HIV 6 (6) 13.37 21.39 60% 6.00 8.53 42% 9.38 14.57 55%
12
The prevalence rank of many CDL conditions has remained unchanged between 2011 and 2012. The
prevalence of rare CDL conditions such as addison’s disease, bronchiectasis, crohn’s disease,
haemophilia, ulcerative colitis, multiple sclerosis, schizophrenia and systemic lupus erythematosus has
shown very little change in the period under review. The large changes in prevalence were seen mostly
in CDL conditions that are associated with lifestyle choices. These include diabetes mellitus type 2,
hyperlipidaemia and hypertension. Asthma and HIV/AIDS make a significant contribution to the burden
of disease in the medical schemes. Significant changes in CDL conditions are discussed in more detail
in the next section.
3.2.1 Hypertension
Hypertension (HYP) was the most diagnosed and treated condition in both 2011 and 2012. The
prevalence of hypertension increased by 4% between 2011 and 2012 from 82.56 to 86.16 per thousand
beneficiaries in all medical schemes. In 2011, the prevalence of hypertension was higher in open
schemes than in restricted schemes. The prevalence in restricted schemes was 75.21 while open
schemes recorded a prevalence of 82.86 per thousand beneficiaries. In 2012, the prevalence of
hypertension in restricted schemes increased by 8% to 85.30 per thousand beneficiaries. Prevalence in
open schemes showed a moderate increase of 2% to 86.92 per thousand beneficiaries in 2012.
Figure 3 below shows HYP grew by 41.3% from 60.98 per thousand beneficiaries in 2007 to 86.16 per
thousand beneficiaries in 2012.
Figure 3: Average prevalence of hypertension between 2007 and 2012
50.00
55.00
60.00
65.00
70.00
75.00
80.00
85.00
90.00
2007
2008
2009
2010
2011
2012
Prev
alenc
e ra
te p
er 1
000 b
enef
iciar
ies
Year
Hypertension
13
3.2.2 Hyperlipidaemia
Hyperlipidaemia (HYL) remained the second most prevalent condition in 2012. The average number of
beneficiaries in the industry who were treated for hyperlipidaemia increased by 3%, from 34.43 in 2011
to 35.58 per thousand beneficiaries in 2012. Similar to hypertension, the prevalence of hyperlipidaemia
was higher in open schemes than in restricted schemes. The prevalence in restricted schemes was
28.79 while open schemes recorded a prevalence of 39.21 per thousand beneficiaries in 2011. In 2012,
the prevalence of hyperlipidaemia increased to 30.03 and 40.50 per thousand beneficiaries in restricted
and open schemes.
A steady increase in the overall prevalence of treated HYL was noted between 2007 and 2012 as
shown in Figure 4. HYL increased from 30.22 per thousand in 2007 to 35.58 per thousand beneficiaries
in 2012, an increase of 17.7%.
Figure 4: Average prevalence of hyperlipidaemia between 2007 and 2012
20.00
25.00
30.00
35.00
40.00
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er
1 0
00
be
ne
fici
arie
s
Year
Hyperlipidaemia
14
3.2.3 Diabetes mellitus type 2
Diabetes mellitus type 2 (DM2) was the third most prevalent CDL condition in 2011 and 2012. Across
all medical schemes, the prevalence of DM2 increased by 10% from 23.30 in 2011 to 25.66 per
thousand beneficiaries in 2012. More beneficiaries in restricted schemes were diagnosed and treated
for DM2. In restricted schemes, the prevalence of DM2 increased by 11% from 25.73 in 2011 to 28.65
per thousand beneficiaries in 2012. In open schemes, prevalence increased by 8% from 23.30 to 25.66
per thousand beneficiaries for the period under review.
Figure 5 shows that overall prevalence of DM2 has increased from 14.40 per thousand in 2007, to
25.66 per thousand in 2012. This represents an increase of 78% for the period of the study.
Figure 5: Average prevalence of diabetes mellitus type 2 between 2007 and 2012
10.00
15.00
20.00
25.00
30.00
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er
1 0
00
be
ne
fici
arie
s
Year
Diabetes Mellitus 2
15
3.2.4 Asthma
Asthma (AST) was ranked as the fourth most diagnosed CDL condition in 2011 and 2012. The
prevalence of asthma increased moderately from 15.36 to 15.77 per thousand beneficiaries in all
medical schemes. In 2012, the average prevalence of asthma was similar in both open (15.77 per
thousand beneficiaries) and restricted (15.78 per thousand beneficiaries) schemes.
The increase in the prevalence of asthma was more significant when observed over a longer period. As
shown in Figure 6, the overall prevalence of asthma in the medical aid population increased by 22%
between 2007 and 2012, from 13.04 to 15.77 per thousand beneficiaries.
Figure 6: Average prevalence of asthma between 2007 and 2012
10.00
12.00
14.00
16.00
18.00
2007
2008
2009
2010
2011
2012
Prev
alen
ce r
ate
per 1
000
ben
efic
iari
es
Year
Asthma
16
3.2.5 Hypothyroidism
Hypothyroidism (TDH) was the fifth most prevalent condition in the period under review. The prevalence
of hyperthyroidism increased by 3% from 14.28 to 14.70 per 1 000 beneficiaries in all medical schemes.
Hyperthyroidism was more prevalent in open schemes than restricted schemes. In restricted schemes,
prevalence increased by 7% from 13.13 to 14.09 per thousand beneficiaries. For open schemes, the
increase in the number of beneficiaries treated for hyperthyroidism did not show a significant increase
between 2011 (15.23 per thousand beneficiaries) and 2012 (15.26 per thousand beneficiaries).
The average prevalence of TDH increased from 10.99 to 14.77 per thousand beneficiaries for the
period between 2007 and 2012, as shown in Figure 7.
Figure 7: Average prevalence of hypothyroidism between 2007 and 2012
10.00
12.00
14.00
16.00
2007
2008
2009
2010
2011
2012
Prev
alen
ce r
ate
per 1
000
ben
efic
iari
es
Year
Hypothyroidism
17
3.2.6 HIV/AIDS
The largest increase in prevalence of any condition was observed in HIV/AIDS. The average number of
beneficiaries on ARV’s increased by 55% from 9.38 in 2011 to 14.57 per thousand beneficiaries. The
prevalence of HIV/AIDS was higher in restricted schemes than in open schemes. In restricted schemes,
prevalence increased from by 60% 13.37 to 21.39 per thousand beneficiaries, whilst the prevalence
increased by 42% from 6.00 to 8.53 per thousand beneficiaries for open medical schemes as depicted
in Table 4.
Between 2007 and 2012, that average prevalence of HIV/AIDS increased by 195%, from 4.94 to 14.57
per thousand beneficiaries as depicted in Figure 8.
Figure 8: Average prevalence of HIV/AIDS between 2007 and 2012
-
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
2007
2008
2009
2010
2011
2012
Prev
alen
ce r
ate
per 1
000
ben
efic
iari
es
Year
HIV/AIDS
18
3.2.7 Ischaemic heart disease
Ischaemic heart disease (IHD) was the seventh most prevalent condition in the period under review.
The prevalence of ischaemic heart disease has remained steady at 7.30 per thousand beneficiaries in
2011 and 2012 for all medical schemes. The prevalence of this cardiovascular condition was higher in
open schemes than in restricted schemes, even though a minor increase was observed in restricted
schemes. In 2012, prevalence was 6.11 and 8.35 per thousand beneficiaries in restricted and open
schemes, respectively.
The average prevalence rate of IHD was 7.30 per thousand beneficiaries in 2012 compared to 6.44 per
thousand beneficiaries in 2007 as depicted in Figure 9. The 2009 spike in the prevalence of IHD is
likely to be attributable to the quality of submitted data.
Figure 9: Average prevalence of ischaemic heart disease between 2007 and 2012
6.00
6.50
7.00
7.50
8.00
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er
1 0
00
be
ne
fici
arie
s
Year
Coronary Artery Disease
19
3.2.8 Epilepsy
Epilepsy (EPL) became the 8th most prevalent CDL condition in 2012, from position 9 in 2011. About
four for every thousand beneficiaries across all schemes, irrespective of scheme type, were diagnosed
and treated for epilepsy in 2011 and 2012. The prevalence of treated EPL increased by 22% from 3.48
per thousand beneficiaries in 2007, to 4.24 per thousand beneficiaries in 2012 as shown in Figure 10.
Figure 10: Average prevalence of epilepsy between 2007 and 2012
3.00
3.25
3.50
3.75
4.00
4.25
4.50
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er
1 0
00
be
ne
fici
arie
s
Year
Epilepsy
20
3.2.9 Cardiomyopathy
About four in every thousand beneficiaries across all schemes, irrespective of scheme type, were
diagnosed and treated for cardiomyopathy and cardiac heart failure (CMY & CHF) in 2011 and 2012.
The observed increases in the prevalence do not seem to be significant.
As shown in Figure 11, the prevalence of diagnosis and treatment of CMY paid for by medical aid
schemes increased from 2.65 per 1000 in 2007, to 4.17 per 1000 in 2012. The 2009 spike in the
prevalence of IHD is likely to be attributable to the quality of submitted data.
Figure 11: Average prevalence of cardiomyopathy between 2007 and 2012
2.00
2.50
3.00
3.50
4.00
4.50
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er 1
00
0 b
en
efi
ciar
ies
Year
Cardiomyopathy
21
3.2.10 Dysrhythmias
Dysrhythmias (DYS) completes the list of top ten most prevalent conditions in 2012. The average
number of beneficiaries diagnosed with DYS increased by 5% from 3.43 in 2011 to 3.59 per thousand
beneficiaries. The prevalence was higher in open than in restricted schemes. In 2012, the prevalence of
DYS was 2.59 and 4.48 per thousand beneficiaries in restricted and open schemes, respectively.
The overall prevalence of DYS increased by 28%, from 2.82 in 2007 to 3.59 per thousand in 2012 as
depicted in Figure 12.
Figure 12: Average prevalence of dysrhythmias between 2007 and 2012
2.00
2.50
3.00
3.50
4.00
20
07
20
08
20
09
20
10
20
11
20
12
Pre
vale
nce
rat
e p
er
1 0
00
be
ne
fici
arie
s
Year
Dysrhythmias
22
3.2.11 Other CDL conditions
CDL conditions outside the top ten most prevalent conditions had a prevalence of between 0.02 and
2.93 per thousand beneficiaries in 2012. Haemophilia (HAE) was the least prevalent condition in 2011
and 2012.
Bipolar mood disorder (BMD) was one of the fastest increasing CDL conditions, increasing by 16%
between 2011 (2.38 per 1 000) and 2012 (2.76 per 1000) across all schemes. BMD prevalence was
higher in open than in restricted schemes. In 2012, prevalence was 2.19 and 3.27 per thousand
beneficiaries in restricted and open schemes, respectively.
3.2.12 Top 10 CDL conditions: 2007 - 2012
Figure 13 below depicts the trends in the top 10 common conditions between 2007 and 2012. The
order of these conditions has remained mostly unchanged for the period under review. Hypertension,
hyperlipidaemia and diabetes mellitus type 2 have shown the fastest increase. Other conditions, though
increasing, have remained at rates below twenty per thousand beneficiaries.
Figure 13: Top 10 CDL conditions: 2007 - 2012
23
3.2.13 Multiple CDL conditions: 2007 - 2012
A number of beneficiaries of medical schemes were diagnosed and treated for multiple CDL conditions.
Beneficiaries diagnosed with two CDL conditions increased by 31.2% from 28.2 in 2007 to 37.0 per
1000 beneficiaries in 2012. The prevalence of three simultaneous CDL conditions in beneficiaries on
medical schemes also increased by 59.0% from 8.3 to 13.2 per thousand beneficiaries between 2007
and 2012. A number of beneficiaries with four or more CDL conditions increased by 63% from 1.5 in
2007 to 2.5 per thousand beneficiaries in 2012. Figure 14 depicts the trends in the prevalence of
multiple conditions for the period between 2007 and 2012.
Figure 14: Multiple CDL conditions: 2007 - 2012
3.2.14 Top 10 CDL conditions by scheme size: 2007 – 2012
The 2011 and 2012 average prevalence per 1 000 beneficiaries for the 26 CDL conditions in small,
medium and large size schemes is shown in
28.2 29.0 30.8
32.1
35.3 37.0
8.3 8.8 9.7 10.4
12.1 13.2
1.5 1.4 1.6 1.8 2.2 2.5
-
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
2007 2008 2009 2010 2011 2012
Mu
ltip
le C
DL
rate
pe
r 1
00
0 b
en
efi
ciar
ies
Two simultaneous CDLs Three simultaneous CDLs Four or more simultaneous CDLs
24
Table 5 below. The prevalence of CDL conditions was highest in schemes with less than 6000
beneficiaries as shown below. This trend was reversed in the case of HIV, where the prevalence was
higher in large schemes compared to medium and small schemes.
25
Table 5: Prevalence of chronic diseases: size
CDL Small Medium Large
2011 2012 % change 2011 2012 % change 2011 2012 % change
ADS 0.12 0.13 11% 0.07 0.08 2% 0.05 0.05 -1%
AST 19.58 19.24 -2% 17.39 17.39 0% 15.15 15.64 3%
BCE 0.10 0.13 36% 0.07 0.07 11% 0.05 0.06 12%
BMD 2.56 2.88 13% 2.00 2.18 9% 2.42 2.80 16%
CMY & CHF 4.59 5.91 29% 4.63 4.54 -2% 4.09 4.14 1%
COP 2.09 2.27 8% 2.45 2.35 -4% 1.24 1.20 -3%
CRF 0.29 0.35 17% 0.32 0.42 33% 0.34 0.41 21%
CSD 0.18 0.15 -17% 0.19 0.20 6% 0.15 0.17 13%
DBI 0.06 0.08 35% 0.02 0.02 1% 0.02 0.02 3%
DM1 2.47 2.17 -12% 3.32 3.25 -2% 2.56 2.46 -4%
DM2 28.89 31.01 7% 26.37 28.60 8% 22.99 25.41 11%
DYS 4.62 5.85 27% 4.43 4.85 9% 3.34 3.49 4%
EPL 5.45 5.72 5% 4.75 4.74 0% 4.06 4.19 3%
GLC 5.00 5.24 5% 4.02 4.09 2% 2.67 2.81 5%
HAE 0.02 - -100% 0.01 0.01 18% 0.02 0.02 15%
HYL 54.90 63.42 16% 48.31 49.08 2% 33.07 34.44 4%
HYP 106.97 121.22 13% 103.31 105.54 2% 80.60 84.56 5%
IBD 0.37 0.41 9% 0.45 0.45 0% 0.30 0.32 7%
IHD 7.88 9.28 18% 8.57 8.87 4% 7.16 7.17 0%
MSS 0.15 0.21 38% 0.14 0.12 -8% 0.12 0.13 2%
PAR 1.21 1.61 33% 1.20 1.19 -1% 0.77 0.78 1%
RHA 3.50 4.18 20% 3.52 3.74 6% 2.65 2.86 8%
SCZ 0.43 0.55 28% 0.53 0.53 -2% 0.42 0.44 4%
SLE 0.29 0.36 24% 0.27 0.29 5% 0.23 0.26 10%
TDH 22.85 25.79 13% 20.75 21.39 3% 13.66 14.15 4%
HIV 5.30 5.56 5% 7.13 8.85 24% 9.61 15.03 56%
CC2 49.38 54.74 11% 45.41 46.03 1% 34.31 36.30 6%
CC3 18.09 21.50 19% 16.81 17.90 7% 11.63 12.78 10%
CC4 3.60 4.27 19% 3.29 3.63 10% 2.07 2.38 15%
26
4 Discussion
There has been a sustained upward trend in diagnosis and treatment of many chronic conditions on the
Chronic Disease List. These increases may be due to improved data management systems of medical
schemes and administrators, the worsening age and disease profile of beneficiaries, and increased
beneficiary entitlement awareness. Behavioural change of members and providers can also explain the
observed trends.
The observed increase in the prevalence of CDL conditions far outstrips the 1.8% increase in the
number of beneficiaries between 2011 and 2012. Changes in age and pensioner ratio may explain
some of the observed changes in prevalence. Changes in risk profiles of schemes are as a result of
beneficiary aging, scheme mergers and movement of beneficiaries or group of beneficiaries between
open and restricted schemes. The upward trend in the prevalence of chronic disease is likely to
continue as the risk profiles of schemes worsen. This is mostly true for small medical schemes. Small
schemes, faced with an ever increasing burden of disease, will be left without a choice but to seek
mergers with large medical schemes. This scenario is unfortunate because the reduction in the number
of schemes is undesirable for competition and choice available to the public and beneficiaries of
medical schemes. Large risk pools are in a better position to absorb the effects of increasing
prevalence.
The implications of more medical schemes beneficiaries with chronic diseases is an increase in GP and
specialists visits, an increase in the use of medicines, and an increase in hospital events. Without
aggressive intervention into the root causes of these chronic diseases and their costs, these trends are
expected to continue to worsen.
27
5 References
Council for Medical Schemes (2014). Gudelines for the Idenitification of Beneficiaries with Risk Factors in Accordance with the Entry and Verification Criteria: Version 7.1. 2014 [cited 2014 25 March]; [Available from: www.medicalschemes.com/Publications.aspx.
Council for Medical Schemes (2013). Research Brief 3 of 2013: Trends in chronic disease prevalence in the S.A. medical aid schemes: 2006 – 2011 [cited 2014 25 March]; [Available from: www.medicalschemes.com/Publications.aspx.
World Health Organization (2011). Global status report on noncommunicable diseases 2010. Geneva : World Health Organization. 2011.
