LIMS Household Survey

1
LIMS Household Survey

• For the Consultative Investigation into Low
  Income Medical Scheme Coverage, established by
  the Council for Medical Schemes and Ministerial
  Task Team on SHI

Health and Development Africa Gill Schierhout,
Saul Johnson, Duane Blaauw with fieldwork support
from Social Surveys
2
Aims of the LIMS Household Survey

• To document current health insurance cover and
  reasons for this
• To elicit willingness to pay for health insurance
• To elicit preference for various packages of
  health insurance
• To document current utilisation and expenditure
  on health care (including private and public
  health care, pharmaceuticals, traditional
  medicine etc)

In accordance with LIMS target market, the study
population is urban (non-rural) households with a
Gross Household Income less than R6000 per month
with sub-groups R0-R2500 R2501-R6000
3
Urban communities grouped into 7 community
clusters based on agreed upon variables including
household income and access to infrastructure
SA urban communities clustered into groups of
similar communities community
clusters/community types
5 communities sampled from each cluster

• E.g. Informal urban communities
• Low income
• High unemployment
• 98 of communities with average monthly household
  income below R6000
• Poor access to infrastructure

• E.g. Township communities
• Metropolitan
• High levels of infrastructure
• Formal dwellings
• Low to middle income with 50 of communities with
  average household income below R6000

100 households sampled at random from each
community interviewing households with below
R6000 monthly household income
3500 households sampled to provide national sample
Application of this methodology allowed for
weighting back of sample results to the SA
population in urban communities earning an
average monthly income of below R6000 weighting
back per community type also possible
4
Methods of Data Collection

• Head of household or spouse interviewed by
  trained interviewer proxy respondent
• Household roster completed, with demographics,
  health events, health insurance data elicited for
  each household member
• Includes recently deceased
• Attitudinal questions were asked directly from
  the respondent
• Information on remittances received and sent from
  the household

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Size and Characteristics of the Target Market

• Overall 50 of households some formal sector
  employment
• Remittances fairly common (14)
• Disproportionate to household income and medical
  aid status
• Over ½ of remitters were significant others
  that is people who were involved in decision
  making
• Less than 1 in 5 remitters were members of
  medical aid schemes

LIMS Household Survey data here includes only
the R2501-R6000 Gross Household Income band
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What are the levels of and barriers to current
health insurance cover in the target population?
7
Characteristics of Individuals with Medical Aid
Coverage (1)

• Overall 12 of individuals living in households
  with gross income R2501-R6000 were members of
  schemes.
• For households with income R4501-R6000, coverage
  was 20
• Medical aid coverage of individuals drops steeply
  for ages 20-29 years and after age 50 years.
• Scheme membership increased with increasing
  education, within household income bands

8
Households with Medical Aid Coverage

• Around 1 in 5 households have one or more members
  covered
• fully covered every household member a scheme
  member
• partially covered some, not all household
  members are scheme members
• Medical scheme coverage increases with household
  income
• Of households with 1 or more formal sector
  employees, 13 have full coverage, 11 have
  partial coverage
• Larger households (gt4 members) account for around
  80 of partially covered households

Households with Gross Income of R2501-R6000
per month
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Characteristics of Individuals with Medical Aid
Coverage (2)
Individuals in Poor or Very Poor Health

• Health status
• No marked differences in health status between
  members non members overall
• In lower income groups, deceased household
  members accounted for a greater proportion of
  individuals in the medical aid subpopulation (6)
  than in the non-medical aid subpopulation (1.5)
• Prior membership of schemes
• Amongst those who were not covered, 6 overall
  and 13 of those in households with gross income
  R4501-6000 pm, had previously been members of
  medical aid, but were no longer

Individuals Deceased in Past 12 Months
10
Characteristics of Individuals with Medical Aid
Coverage (3) Households with some members
covered but not all

• Insured individuals in the partially covered
  households appear to be higher service users than
  expected
• Individuals in poor or very poor health are 1.5
  times more likely to have medical cover than
  those who are in good health
• Older (above 64 years) and young adults (20-29
  years) are significantly less likely to be
  covered than those aged 30-64 years

Annualised Per Capita Visits to Various Health
Care Providers
11
Lack of employment was the most commonly cited
barrier to medical aid membership (amongst those
not covered)
I am no longer working for the company that
offered us medical aid. They took it when my
husband retired It was cancelled on
retirement Medical Aid is only for those who
work full time responses to why are some
members of the household are not on medical aid?

• Mentioned more in households with no members
  formally employed (75 of reasons)
• Where the household had one or more members
  formally employed, the most common reason for not
  being covered related to expense (16)

12
Other commonly cited barriers to medical aid
membership
Employer does not offer it (16 - higher for the
informally employed) Their parents do casual
work and are not offered medical aid We are
self employed, dont work for government I
cant have medical aid because I am a domestic
worker Expense and value for money (11 -
higher for those formally employed) There is no
Medical Aid for low income earners. I do not
qualify for Medical Aid with the salary Im
getting We were members, now it is too much to
pay ?Conceptual barriers (3 of reasons) Im
willing to pay only when Im sick I am not a
person who just gets sick, so I do not think
paying every month is fair I do not want to
keep paying money that I might end up not using
for years It took cash from us It is a
luxury. We cannot afford it
13
Are Respondents Willing to Pay for Health
Insurance?
14
In principle Willingness to Pay for Health
Insurance
Respondents Prepared to Pay a Small Amount
Each Month towards Health Insurance
Respondents Prepared to Pay the Same as Others
Even if Others Claim More

• Across all income groups, high levels of interest
  in health insurance
• Expressed willingness to risk pool by over 60
  of all household income groups but low proportion
  of respondents strongly agreed with these and
  other statements

I would like a medical aid where I pay a small
amount each month responses to why are some
members of the household are not on medical aid?
15
Proportion of Respondents Prepared to Pay Various
Amounts for Insurance for Private Doctor Visits
16
Proportion of Respondents Prepared to Pay Various
Amounts for Insurance for Private Sector Hospital
Cover
17
Proportion of Respondents Prepared to Pay Various
Amounts for Insurance for Comprehensive Cover
18
Proportion of Respondents Prepared to Pay Various
Amounts for Insurance for Improved Care at Public
Hospitals
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What Components of Packages Do Respondents Value?
- DCE Willingness to Pay

• Willingness to pay
• Economic approach to valuation
• Stated preferences vs revealed preferences
• Discrete choice experiment
• Type of conjoint analysis
• Choices determined by particular combination of
  package characteristics
• Allows measurement of relative importance of
  package components

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What Components of Packages Do Respondents Value?
- DCE Willingness to Pay Total Sample
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What Components of Packages Do Respondents Value?
- DCE Willingness to Pay Segmentation Analysis
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What Health Care Do Households Currently Use and
How Much Do They Pay?
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Satisfaction with and use of health care services
most recent visit
N13 310
N971

?
Public hospital and clinic is always full and
you have to wake up early in the morning I
borrowed somebody elses medical aid!
responses to why did you use a private doctor,
not go to a public sector clinic?
Private doctor is too expensive There is no
private doctor close to where I live I only
had flu nothing serious responses to why
did you use a public clinic, not go to a private
doctor?
Out patient visits within the past 4 weeks
?Hospital admissions within the past year
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Distribution of Visits to Health Care Providers
in Past 4 Weeks
Households with Gross Income of R2501-R6000
per month
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Households Use a Mix of Public and Private
Services, Despite Medical Cover
Percentage of Households Where One or More
Members are Receiving Chronic Medication from the
Public and the Private Sectors
Percentage of Households Where One or More
Members Visited Private Doctors and Visited
Public Out Patient Facilities
Households with Gross Income of R2501-R6000
per month
27
Selection of Respondents Views on the Public
Sector
I do not see any need for a medical insurance
I was born in hospital and growing up going to
the public hospital so I am very confident about
public hospitals As long as there is free
treatment from government or public hospital, I
am satisfied. I dont need to pay for a medical
aid. There is no care at the public clinics.
They say they are on tea breaks, so medical aid
is very important Medical aid money will
sometimes be finished. We will still go to public
institutions.. Maybe if we had medical aid we
would have taken our mother to a private hospital
and she would not have died..
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Contribution of Out of Pocket Cost Components to
Overall Costs of Out Patient Visits

• .

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Out of Pocket Payment for Transport
Expenditure data on transport were available for
1740 visits (86 of all recent visits) On
average, those on medical aid schemes incurred
lower transport costs than those not on schemes
?socio-economic status likely to live work in
better resourced areas
Average Cost for Transport Per Visit

• Those not on medical aid
• R29 to get to and from government clinics
• R60 to get to and from private doctors

• Medical aid members
• R7 to get to and from government clinics
• R30 to get to and from private doctors

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Out of Pocket Payment for Fees
Expenditure data on fees were available for 1765
visits (87 of all recent visits) 84 of those on
a medical aid who visited private doctors did not
incur costs for fees 78 of those on medical aid
and 87 of those not on medical aid and visited
public clinics did not incur costs of fees for
these visits
Average Cost for Fees Per Visit

• Those not on medical aid
• R5.76 for government clinics
• R111.66 for private doctors
• R115.40 for dentists

• Medical aid members
• R11.89 for government clinics
• R24.44 for private doctors
• R0 for dentists

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Out of Pocket Payment for Medicines
Expenditure data on medicines were available for
1708 visits (85 of all recent visits) Some 82
of those on a medical aid and 27 of those not on
a medical aid who visited private doctors did not
incur costs for medicines
Average Cost for Medicines Per Visit

• Those not on medical aid
• R1.83 following visits to government clinics
• R34 following visits to private doctors

• Medical aid members
• R1.34 following visits to government clinics
• R13.35 following visits to private doctors

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Out of Pocket Payment for Tests Investigations
Expenditure data on tests investigations were
available for 1754 visits (86 of all recent
visits) Some 94 of those on a medical aid and
68 of those not on a medical aid who visited
private doctors did not incur costs for tests
investigations
Average Cost for Tests Per Visit

• Those not on medical aid
• R0.91 following visits to government clinics
• R6.85 following visits to private doctors

• Medical aid members
• R0.11 following visits to government clinics
• R1.79 following visits to private doctors

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What Health Care Do Households Currently Use and
How Much Do They Pay? (1) Note on methods to
obtain costs to the household

• Out patient Health Care
• Data from /- 2100 health care visits across
  /-740 households
• 1 month recall
• Average cost for each type of visit was
  calculated for the household
• Costs incurred by the household for each type of
  service extrapolated by mulitpyling number of
  visits of each type (average over 3 months) by
  the cost to the household for that type of visit
• In the households where there was service use but
  was no cost data for a particular provider (no
  use lt1 month, but use in past 3 months), average
  cost by medical aid status was assigned.

• In-hospital Health Care
• Data from /- 622 hospitalisations across /-580
  households
• Cost based on admissions in the past year (every
  person in household)
• Average cost calculated for the household for
  each type of admission (private/public)
• Costs incurred by the household in past year
  summed by type of admission to get total cost in
  past year.

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What Health Care Do Households Currently Use and
How Much Do They Pay? (2) Households with no
medical aid (R2501-R6000)

• 12 of Households used Private Doctors (General
  Practioners)
• Spent on average R105 on GP services per month
• Approx 2.9 of gross income
• 28 of Households used Public Sector Clinics
• Spent on average R16
• Approx 0.4 of gross income

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What Health Care Do Households Currently Use and
How Much Do They Pay? (3) Hospital Admissions
full sample

• 16 of all households reported one or more
  hospitalisations in the past year (n580).
• 1.5 of households reported one or more
  admissions to private hospitals. (59 households)
• 85 of which were in households with medical aid
  coverage 15 (16 households) had no medical
  cover. For these households, reasons for using
  private rather than public facilities
  predominantly related to trust and perceived
  better quality care in the private sector (8
  households) 3 of these admissions were emergency
  admissions.
• Costs related to private admissions for
  individuals not on medical aid, ranged from R250
  to R3000, with one outlier of R35000. Average
  cost for a single admission was R1816
• Individuals on medical aid paid on average R75
  per admission to a private hospital
• 14 of households reported public sector hospital
  admissions.
• Of these, 58 reported some out of pocket
  expenditure. Individuals not covered by medical
  aid paid on average R52 per admission and
  individuals who were medical scheme members paid
  on average R106 per admission.

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Maternity and childbirth

• Women currently without medical aid used public
  sector clinics/hospitals almost exclusively for
  childbirth (97)
• Women currently with medical aid used private
  hospitals (66) and public sector
  clinics/hospitals (25)

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Can households afford the health care that they
are using? (1)
Proportion of Households that Took a Loan in the
Past Three Months to Pay for Medical Expenses

• Just over 1 in 10 households without medical aid
  and 9 of households earning ltR2500 pm took a
  loan in the past 3 months to pay for medical
  expenses
• For hospital admissions (lt1 year) 14 of those
  without medical aid, and 3 of those with medical
  aid, had not yet paid their hospital debts
• 3 of hospitalisations amongst those not on
  medical aid had caused households to draw on
  savings to pay

By Household Medical Aid Status
I cant join if I buy my family a steak of meat
each Sunday
By Household Income
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Can households afford the health care that they
are using? (2)
Proportion of Households that Did not Visit a
Doctor When They Felt It was Needed

• 12 of households not on medical aid and 15 of
  the lowest income band had not visited a doctor
  when needed because they could not afford it

By Household Medical Aid Status
By Household Medical Aid Status

• A further 3 of households said they had not
  followed a doctors advice, because of cost
  factors (higher for lower income earners for
  those not on medical aid)

By Household Income
By Household Income
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HIV and AIDS seemed to be top of mind for some
respondents when considering medical insurance
Im desperately wanting to have a medical aid
since Im diagnosed with this killer disease.i
dont know if I will qualify since I earn so
less Why is medical aid excluding HIV
infected people? I think they discriminate
people because of their status because the HIV
positives are the ones who need medical and
health insurance
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Summary and Key Themes (1)

• There are substantial numbers of individuals in
  the target market without health insurance these
  include
• Age groups 20-29 year olds and the old (over 50
  years)
• Uninsured members of households where other
  members are insured for every household where
  all members are scheme members, there is another
  household where some are left off current
  schemes- those left off of current schemes
  include the healthy and those living in large
  households.
• There is still considerable scope within formal
  sector employment for increasing cover ¾ of
  households with one or more formal sector
  employed members had no health insurance
• Amongst the uninsured, health insurance is
  largely seen as the domain of the higher earning
  full-time wage earner - perceived barriers to
  obtaining health insurance stress
  in-affordability of available packages, but also
  incorporate perceptions and issues relating to
  rules only for those who work full-time
  conceptual barriers (risk pooling) were cited but
  not a predominant feature (3).

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Summary and Key Themes (2)

• Respondents expressed attitudes consistent with
  receptiveness to purchasing health insurance
  should lower cost products become available
  (/-2/3 of target group) Expressed WTP for
  combined packages were
• Full cover R151 per member per month
• LIMS (GPdentaloptometryemergency) R110 per
  member per month
• Attitudinal questions suggested that premiums of
  over R100 per member per month become
  unaffordable for many in the target market
• Around 1 in 4 respondents in higher earning
  groups and 1 in 10-20 for the lower income
  groups, said that they would be prepared to pay
  R100-R150 per member per month for comprehensive
  cover

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Summary and Key Themes (3)

• Another way of looking at affordability is what
  people currently do pay for health care
• Transport is the biggest cost component related
  to outpatient health visits for poor households
  slightly less so for medical aid members
• Around 1 in 10 households already borrow or use
  savings to service medical costs others do
  without health care, when they feel they need it
• For many, the motivation to insure is not about
  future risk, but present reality
• Amongst uninsured, perception that public sector
  clinics are sufficient for minor illnesses and
  routine care, but for really serious conditions,
  private doctors/private hospitals are needed.

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WHY DONT YOU INTRODUCE MEDICAL AID WHICH WILL
INCLUDE WILL INCLUDE BURIAL BENEFIT BECAUSE MOST
POOR PEOPLE INTERESTED IN BURIAL OF DEATH . . I
WOULD LIKE TO KNOW MORE ABOUT MEDICAL AID ITS SO
IMPORTANT TO ME AS MY WIFE IS SICK PERSON SHE CAN
GO TO PRIVATE DOCTORS IF HAVE MEDICAL AID. . I
WOULD LOVE TO HAVE A MEDICAL AID ,I THINK
EVERYBODY NEED IT. . THE MEDICAL AID IS
GOOD THING BECAUSE IN THE MIDDLE OF THE MONTH YOU
CAN GO TO THE DOCTOR USING THE CARD. PEOPLE
ALWAYS COMPLAINING ABOUT MEDICAL AID BECUASE THEY
DEDUCT TO MUCH FROM THIER SALARIES SO I WOULD
NOT HAVE ONE ,THERE IS LOT OF CHEATING IN
MEDICAL AID.

• .

Discussion and Comment
CANT SAY ANYTHING ABOUT MEDICAL AID PEOPLE
AROUND HERE ARE DRINKING TOO MUCH DRINK ALL THIER
INCOME MEDICAL AID NOT FOR ME WE RECIEVE FREE
SERVICE IN OUR LOCAL CLINIC.HEARING ABOUT IT, I
FIND IT INTERESTING, BUT I DONT HAVE THE MONEY
THIS MEDICAL AID SOUNDS RIGHT BUT THEY SHOULD NOT
TELL YOU OR GIVE YOU THE NUMBER OF DOCTORS YOU
CAN VISIT IN A MONTH. ONE SHOULD GO AS THEY
PLEASE. SINCE WE HAVE PEOPLE WHO NEED MEDICAL
CARE WE WILL LIKE TO HAVE A MEDICAL AID THE
MEDICAL AID SCHEME IS A RISK BUSINESS BECAUSE
SOMETIMES PEOPLE WHO WORK WITH MONEY EVERY MONTH
AND THEY END UP NOT TAKING THE MONEY YOU AGREED
ABOUT,THEY TAKE MORE.WE WOULD LIKE TO HAVE IT