SAHR 2007 - Health Systems Trust

Medical Schemes 4
Medical schemes and risk-pooling
The size of risk pools
The number of medical schemes has been in a long decline
since 1974 since the Registrar began record keeping. There
were 252 registered schemes and a further 53 exempt
schemes for a total of 305 schemes in 1974. The number
of registered schemes has fallen from 170 in 1994 to 124
at the end of December 2006. Since 1974, the number of
beneficiaries in medical schemes has roughly doubled from
3.5 million to 7 million. This is excellent news for risk-pooling
as it means that risk pools are becoming larger.
Of the 146 schemes registered in 2000, only 117 (80.1%)
were still registered at the end of 2005. Twelve of these
schemes had liquidated and 17 had amalgamated with
other schemes, with the majority of the activity occurring
within the restricted scheme market. Consolidation activity
in the market is likely to increase in the next year given that
schemes losing a large proportion of their members to
GEMS will be left with smaller risk pools and higher claiming
profiles.
The larger the risk pool the more stable and predictable
the results and the lower the risk of insolvency. The average
registered scheme size was under 10 000 beneficiaries in
1974, growing to some 31 000 by 1994 and 52 000 by
2005. However, average figures are very misleading as
there are substantial differences in sizes of schemes. Figure 3
shows scheme size at the end of 2005 and shows that open
medical schemes are generally much larger than restricted
schemes.
One open scheme, Discovery Health Medical Scheme, now
dominates the market having grown from its inception in
1993 to 1.855 million beneficiaries by September 2006. 12
This scheme is more than three times the size of its nearest
competitor and alone accounts for over 35% of the open
scheme market and 25% of all medical scheme beneficiaries.
Optimum health risk pool size has not yet been studied in
South Africa but in the United States of America the minimum
size to accept full health care risk is considered to be 20 000
beneficiaries. 27 At the end of 2005 only 23% of restricted
schemes exceeded 20 000 beneficiaries while 67% of open
schemes did so.
Figure 3: Size of medical schemes and number of options, 2005
35
14
Number of schemes
30
25
20
15
10
9
Risk pools smaller
than minimum to
accept full health care
risk
10
19
26
Sufficiently large risk pools to
accept full health care risk
6
7
3 2
13
12
11
10
9
8
7
6
5
4
3
Weighted number of options
5
0
2
5
3
5 4
8 7
8
1
3
1
2
1
0
Below 2 500
2 500 to under
5 000
5 000 to under
10 000
10 000 to under
20 000
20 000 to under
30 000
30 000 to under
50 000
50 000 to under
100 000
100 000 to under
200 000
200 000 to under
500 000
500 000 to under 1
000 000
1 000 000 to under
1 500 000
Over 1 500 000
Number of beneficiaries in scheme
Restricted schemes
Open schemes
Number of options
restricted schemes
Number of options
open schemes
Source: CMS, 2007. 12 57