Discovery Wellth Fund pays out more than R600-million in less than ...

In less than 18 months, Discovery Health Medical scheme’s Wellth Fund has been used by 485,000 beneficiaries and paid out more than R600-million to providers and members.

The once-off benefit, which comes to an end in December this year has predominantly been used to access dentists, GPs, physiotherapists, optometrists, obstetricians and gynaecologists.

The Wellth fund was introduced in January 2023 and was funded with excess solvency reserves. One of the key motivating factors was the sharp increase in cancer claims in 2022, following two years during Covid when many members did not have their regular health screenings. Discovery Health Medical Scheme (DHMS) claims data shows that during January to December 2020, the first year of the Covid-19 pandemic, annual health checks carried out by members dropped by 52%, compared to the same time period in 2019.

Martin Rimmer, chief executive of Sirago (which offers gap cover), says a late diagnosis could ultimately mean more complex health interventions with more invasive, aggressive, costly, and lengthy treatment and recovery time. “We’re seeing evidence of this with a sharp uptick in ‘mega’ gap claims related to cancer — these are internally classified as claims of R50,000 and above for shortfalls or co-payments not paid by medical schemes,” he says.

Although medical schemes do cover the cost of Prescribed Minimum Benefits (PMBs) cancer treatments at cost, this does not mean that all diagnosed cancers are automatically a PMB benefit. Rimmer says each scheme has its own rules and protocols for diagnosing and managing PMBs and if the cancer detected does not form part of the PMB basket, members will most certainly be exposed to some out-of-pocket expenses during their treatment. Certain medical schemes might also only fund certain treatments partially like biologicals, if at all.  “Many core plans also do not fund any of the diagnostic tests such as MRI and PET scans,” Rimmer warns. An MRI scan at a hospital in South Africa costs around R3,000, while a CT scan will cost between R1,500 and R2,200.

Having an annual health check can alert members to warning signs early on, so that cancer and even chronic health conditions can be appropriately treated as soon as possible.

Increase in chronic disease prevalence

The increasing prevalence of chronic disease in South Africa is impacting the clinical outcomes for members across medical schemes. From 2018 to 2023, the prevalence (the number of people who have a condition at a specific point in time) of diabetes increased by 29%, hypertension increased by 22% and hypercholesterolaemia increased by 35%.

Read more in Daily Maverick: Diabetes is South Africa’s second-biggest killer disease: hiking the sugar tax would help

“Many chronic illnesses have no symptoms — people typically don’t feel unwell until the chronic disease is well-advanced. For instance, diabetes will often only be detected for the first time following a heart attack, a non-healing foot sore, diminished eyesight. Similarly, hypertension is often only detected for the first time following an acute cardiac event such as a stroke or heart attack,” explains Dr Ron Whelan, CEO of Discovery Health. He adds that with the introduction of the Wellth Fund, the health checks rate has not only returned to pre-Covid levels but exceeded expectations, with a 47% increase in health checks compared to 2022.

“If members keep up with their annual health check — which typically takes 15 to 20 minutes to complete — they have a regular update on their blood pressure, blood glucose, cholesterol, and waist-adjusted Body Mass Index (BMI), enabling effective management of their health and early-detection of the main health risks impacting lifespan and health span,” says Dr Whelan.

How does the Wellth Fund work?

The Wellth Fund is activated once all beneficiaries on a medical aid plan have completed their health checks. For adults, this is the annual health check (funded from the existing Discovery Health medical scheme screening and prevention benefit), and for children (two years and older), the annual online Kids Health Review.

The Health check available to DHMS adult members involves tests for blood pressure, blood glucose, cholesterol, and waist-adjusted Body Mass Index (BMI). The assessment also includes a voluntary non-smoker’s declaration and HIV screening.

Health checks can be completed in person at a Discovery Store, an accredited pharmacy, a GP’s rooms in the Discovery Health Wellness Network or at an employer’s Wellness Day.

Once the Wellth Fund is activated, each adult beneficiary is allocated R2,500 and children between the ages of two and 18 years of age are allocated R1,250 each — up to a limit of R10,000 per family. Children under the age of two have full access to the fund once a primary member has activated the benefit, without first having to complete any health check.

The Wellth Fund gives members access to:

General health screenings, including screenings for visual, hearing, dental and skin conditions; Physical health screening at a dietician, chiropractor, biokineticist and/or physiotherapist; Mental health wellness check-ups; Women and men’s specific health screening such as gynaecological, prostate and/or heart consultations with a doctor and bone density checks. Children’s specific health screening in the form of a child wellness visit which includes growth and developmental milestone assessments with an occupational therapist, speech therapist and/or physiotherapist; and Medical monitoring devices for personal monitoring of key health metrics including blood pressure, cholesterol, blood sugar management and respiratory. DM