Childhood cancers in a section of the South African private health sector: Analysis of medicines claims data

Background: Although childhood cancers are rare, increases in incidence have been observed in recent times. There is a paucity of data on the current incidence of childhood cancers in South Africa.Aim: This study described the epidemiology of childhood cancers in a section of the private health sector of South Africa, using medicines claims data.Setting: This study was designed on a nationally representative medicine claims database. Method: A longitudinal open-cohort study employing children younger than 19 years and diagnosed with cancers between 2008 and 2017 was conducted using medicine claims data from a South African Pharmaceutical Benefit Management company. Cases were identified using International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes C00 to C97, together with a medicine claim reimbursed from oncology benefits. Crude incidence rates were calculated per million persons younger than 19 years on the database and standardised using the Segi 1960 world population. Temporal trends in incidence rates, analysed using the joinpoint regression, were reported as annual percentage changes (APCs). Results: Overall, 173 new cases of childhood cancers were identified in the database, translating into an age-standardised incidence rate (ASR) of 82.3 per million. Annual incidence of cancer decreased from 76.7 per million in 2008 to 58.2 per million in 2017. More incident cases were identified in males (68.8%). The highest proportion of incident cases was recorded for leukaemias (39.9%), the 5­9 year age group (34.1%) and the Gauteng Province (49.7%).Conclusion: The incidence of childhood cancers decreased over time in the section of the private health sector studied. Leukaemias were the major drivers of childhood cancer incidence

Understanding the types of fraud in claims to South African medical schemes

Background. Medical schemes play a significant role in funding private healthcare in South Africa (SA). However, the sector is negatively affected by the high rate of fraudulent claims.Objectives. To identify the types of fraudulent activities committed in SA medical scheme claims.Methods. A cross-sectional qualitative study was conducted, adopting a case study strategy. A sample of 15 employees was purposively selected from a single medical scheme administration company in SA. Semi-structured interviews were conducted to collect data from study participants. A thematic analysis of the data was done using ATLAS.ti software (ATLAS.ti Scientific Software Development, Germany).Results. The study population comprised the 17 companies that administer medical schemes in SA. Data were collected from 15 study participants, who were selected from the medical scheme administrator chosen as a case study. The study found that medical schemes were defrauded in numerous ways. The perpetrators of this type of fraud include healthcare service providers, medical scheme members, employees, brokers and syndicates. Medical schemes are mostly defrauded by the submission of false claims by service providers and syndicates. Fraud committed by medical scheme members encompasses the sharing of medical scheme benefits with non-members (card farming) and non-disclosure of pre-existing conditions at the application stage.Conclusions. The study concluded that perpetrators of fraud have found several ways of defrauding SA medical schemes regarding claims. Understanding and identifying the types of fraud events facing medical schemes is the initial step towards establishing methods to mitigate this risk. Future studies should examine strategies to manage fraudulent medical scheme claims

Fate of Outstanding COIDA Occupational Disease Claims Following Closure of the Western Cape Provincial Medical Advisory Panel in 2008 : An audit

Background and objectives: The Western Cape Provincial Medical Advisory Panel (PMAP) was established in 2004 in terms of Section 70(1) of COIDA. A primary function was to improve the efficiency of medical assessment of occupational disease claims. The PMAP was closed by the Compensation Commissioner in 2008. This audit aimed to determine the fate of claims outstanding at the time of closure. Methods: A total of 68 claims outstanding in April 2008 were followed up by telephone; email and/or internet to determine what proportion had progressed or; if accepted; had resulted in a permanent disablement compensation payment. Results: Of the 68 claims; 31 (44) were confirmed as having progressed. Of these; payment of permanent disablement awards could be confirmed in only 15 claims (22). The remaining 56 either showed no progress or no longer had a record in the COIDA system. Those stages of the claims process that had previously been aided by PMAP functioning had deteriorated in efficiency. Conclusions: Overall; the low proportion of outstanding claims finalised and awarded is consistent with inefficiency in claims handling of occupational disease; a finding echoed by recent complaints about general Compensation Fund performance from both healthcare providers and parliamentary investigation