ABSTRACT
The primary objective of this study was to assess the characteristics of patients admitted for COVID-19, 'J18.9 Pneumonia, unspecified organism' and other types of diagnoses. The aim was to assess as to what extent do COVID-19 related admissions changed to pneumonia, and as to what extent do 'J18.9 Pneumonia, unspecified organism' related admissions that changed to COVID-19 diagnosis at discharge stage. The secondary objective of the study was to assess' predictors of readmissions in private hospitals. The review period was private hospital claims received by the scheme between January and August 2020. The inclusion criteria for COVID-19 admissions were patients that had a laboratory-confirmed (RT ? PCR assay) COVID-19. Predictors of readmissions were modelled using logistic regression. The study found that restricted scheme patients admitted for a COVID-19 diagnosis changed to a 'J18.9 Pneumonia, unspecified organism' diagnosis. The converse was found to be true in that some patients that were admitted as J18.9 Pneumonia, unspecified organism' diagnosis changed to a COVID-19 diagnosis. This study showed underlying factors associated with hospital admissions and predictors of readmissions in private hospitals.
Subject(s)
Patient Admission , Pneumonia , Risk Factors , Diagnosis , COVID-19ABSTRACT
General Practitioners (GPs) serve a gatekeeper function in many healthcare systems. Cost containment strategies in the health care ecosystem usually focus on the role of GPs as the point of entry. The healthcare expenditure as the proportion of total healthcare spent on medi-cal schemes in South Africa has been declining over time. This could be attributed to a shift in benefit design and product development employed by schemes. The aim of this study was to investigate GP health spending by medical schemes, the average spent per GP visit, the level of co-payment that members are subjected to and the GP to member ratio in South Africa. The study design was a cross-sectional study which was performed by linking annual statutory returns data, claims data and provider distribution data collected on an annual basis by the Council for Medical Schemes. The data was further mirrored to the Practice code numbering data received from the Board of Healthcare Funders (BHF). A total of 79 medical schemes claims data was included in the analysis. The average number of visits per beneficiaries was 3. The distribution of GPs claiming from medical schemes follow the distribution of beneficiary by province. The ratio of claiming GPs per 1000 beneficiaries was 2. These results further revealed a shift in benefit design and that medical scheme members bypass GPs directly to specialist services which is a secondary level of care, thus undermining the role of GPs as gatekeepers. It is concerning that GP consultation is attracting a co-payment of as high as 39%. Repriori-tisation and emphasis on the role of a GP as gatekeepers as a function of the benefit design process is key to improving quality of care.