Windhoek
After a number of Namibia Medical Care (NMC) members expressed dissatisfaction with their medical aid benefits thus far this year, with many claiming their self-medication benefits were already exhausted during the first quarter of the year, the fund has hit back claiming that many of its members previously abused the self-medication option.
According to NMC’s principal officer, Alison Begley, an analysis of claims for 2014 picked up that the expenditure on self-medication when paid from the Benefit Booster was increasing in excess of 50 percent per year.
A similar increase, she said, was seen in previous years, the impact of which is two-fold for NMC.
“Firstly, these members were using their Benefit Booster for self-medication only and were not able to access this benefit for the other service disciplines and secondly, the high (and increasing) expenditure on this one benefit would have resulted in additional increases to the contributions, such as higher increases than were eventually implemented. The specific claims experience was analysed in full detail. Many individual cases were identified that strongly suggested that members might have abused this benefit,” explained Begley.
She said the Benefit Booster is available on four of NMC’s options, with the purpose of providing members an additional benefit once they reach their benefit limits.
For example, if a single member on NMC’s Ruby option depletes their benefit limit for general practitioners and specialists of N$6 250 per year, then this member will have an additional benefit to the value of N$1 950 through the Benefit Booster. Begley noted that the Benefit Booster can be used in the same way for acute medicine, dentistry and auxiliary services (physiotherapists, psychologists, etc.).
However NMC members are up in arms as in 2014 they were able to use the Benefit Booster once their self-medication limit was reached.
“NMC’s day-to-day self medication saw me paying a large portion of the bill with the N$120 that was provided by NMC. The self-medication ran out by May and at this rate what happens for the rest of the year, whilst I still pay thousands throughout the year. I am afraid to get sick half of the year,” said an NMC member on the Ruby option, preferring anonymity.
“I had a baby earlier this year but two months down the line the daily self-medication benefits were used up. I did not use it for anything out of the ordinary but it’s already used up. I can’t keep going to the doctor for basic medication. NMC is robbing people! This is the time I need medical aid the most,” lamented another NMC member.
These members argue that they need NMC’s Benefit Booster more for self-medication as this option often eliminates doctor visits and expensive prescription medication.
Meanwhile, NMC’s Begley noted that the fund’s trustees decided to remove the self-medication benefit from the Benefit Booster.
“This was done to ensure that the Benefit Booster is available for the other, very important, service disciplines, to keep the increase in contributions as low as possible and to avoid a situation where the majority of members are paying for a small minority of members who are abusing the benefits. In recognition of the impact that this might have, the stand-alone self-medication benefit was increased by 20 percent,” mentioned Begley.
NMC and other medical aids review the benefits of all their options on an annual basis to ensure that the benefits remain relevant and competitive. Begley noted that the change in the value of benefits provided by each option is driven by three main factors, namely, annual tariff adjustments (to compensate the medical service providers for the impact of inflation, also known as medical inflation), the increase in utilisation (members tend to use the services more often and this includes the impact of newer and more expensive treatments and medicines) and then the increase due to benefit changes.
According to Begley, NMC is under severe pressure to keep annual increases as low as possible, but on the other hand, its purpose is to provide its members with the greatest possible benefits.
“Within this equation, medical aid funds have to deal with very high medical inflation (the numbers above show clearly that this is by far the biggest contributor to the annual increases), constantly increasing utilisation by members and in many cases, abuse of the fund benefits. The decision therefore on how to balance benefit increases with contribution increases is very difficult, especially considering the very diverse needs of the approximately 28 000 families that are members of NMC. The decision is made through constructive engagements with members, service providers and also by thorough analysis of data and claims trends,” said Begley.