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Research Note 1/2022: Funding of healthcare services by medical schemes

This study presents the various funding models medical schemes employ for various healthcare services. It outlines the unique count of claiming providers and quantify the PMB expenditure paid by members who have PMSA on their benefit option.


Data was sourced from the Annual Statutory Returns (ASR) data submitted by medical schemes to the Council for Medical Schemes for the 2020 review period.


A recent analysis showed that medical scheme members are exposed to co-payments across all disciplines that offer relevant healthcare services. The study shows the average number of visits per discipline, the average amount paid per visit and the unique count of beneficiaries visiting a medical service provider. The experience can be higher or lower than the average numbers depicted in this research note, or differ subject to the following factors:

  • Scheme type/Scheme size/Scheme operation model (Insourced vs Outsourced)
  • Setting (In/Out of hospital)
  • Geographic distribution of providers
  • Network arrangements
  • Demographics, age, and chronicity
  • Tariff rate between the scheme and a provider
  • Benefit option enrichment
  • Funding model
  • Average time spent per service or consult
  • Information asymmetry/ members not understanding what they are covered for

The research note provides a summary of claiming providers and quantifies the average amount paid per medical service provider and PMB expenditure paid from Personal Medical Savings (PMSA) which is in contravention of  the Medical Schemes Act.

Out-of-pocket (OOP) payment is computed as the difference between what was charged by the provider and what was eventually paid by the scheme. OOP is depicted both in percentage and rand value. The review period is the 2020 claims experience.

Download the Research Note here

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