SA Medical Schemes Working Towards Quality and Affordable Health Care Services

The Council for Medical Schemes (CMS) is in consultation with medical schemes to establish the best standard of health care at an affordable price. Read further for more on quality and affordable health care services.

The CMS has expressed concern that expenditure by medical schemes for conditions on the Chronic Disease List (CDL) is much lower than estimated costs.

It says the CMS, could be a reflection of poor quality care being received by medical scheme beneficiaries.

CDL conditions

  • Hypertension remains the most prevalent CDL condition and represents the most expensive health care issue paid for by medical schemes over the last year.
  • Diabetes 2 recorded a significant increase of 19% over the same period.
  • Although chronic renal diseases are relatively low, expenditure was comparable to that of Diabetes 2.



Statistics reveal that the registration of hypertensive patients on the CDL management programme is more concerned with providing access to drugs rather than to a holistic approach regarding patients’ health.


Diabetes 2

Quality and Affordable Health Care ServicesThe increase in the prevalence of Diabetes 2 is more moderate, also with the proportion of patients claiming for chronic disease medication pegged at 28.8% compared with 27.3% the previous year.



HIV is the best managed CDL condition in the medical scheme industry.

So the proportion of HIV beneficiaries receiving Antiretroviral Therapy is 67.4%, up from 61.9% the previous year.

HIV monitoring tests have also increased significantly from 53% to 59% over the last year.


CDL costs per patient per month

  • Haemophilia – R18 666
  • Multiple Sclerosis – R3 797
  • Renal Diseases – R2 938


Disease Treatment Pairs (DTPs) – largely hospital based

Pregnancy remains the most expensive DTP, while default emergency conditions and major affective disorders were the most expensive out-patient treatments.

So in total, DTPs accounted for R20 655 billion payments to medical scheme beneficiaries.


Top 10 DTP conditions

  • Pregnancy – R3 964 billion
  • Default Emergencies – R2 719 billion
  • Bacterial, viral, fungal pneumonia – R2 552 billion
  • Major affective disorders, including unipolar and bipolar depression – R2 457 billion
  • Acute and subacute ischemic heart disease, including myocardial infarction and unstable angina – R2 107 billion
  • Closed fractures, dislocated limbs (excluding fingers and toes) – R1 593 billion
  • Cataracts, aphakia – R1 527 billion
  • Respiratory conditions in newborn babies – R1 480 billion
  • Treatable breast cancer – R1 143 billion
  • Treatable types of cancer – oral, pharynx, nose, ear and larynx – R1 113 billion


So to date, the CMS has collected date on nine of the 26 listed CDL conditions.


Conclusion on Quality and Affordable Health Care Services

The medical scheme industry, together with the Council for Medical Schemes, is continually working to improve the level of quality and affordable health care services.

All info was correct at time of publishing