Eye care services and benefits paid by medical schemes in South Africa

African Vision and Eye Health

Field Value
Title Eye care services and benefits paid by medical schemes in South Africa
Creator Willie, Michael M.
Subject primary care; optometry, ophthalmology; vision science eye care; medical schemes; optometry; ophthalmologists; visual impairment; benefits
Description Background: Vision impairment (VI) affects people worldwide, and demographic factors like age are significantly linked to VI. Routine eye exams and other eye care treatments can detect and prevent common eye illnesses. However, many lack access to these services.Aim: This study’s major objective was to analyse the distribution and funding of eye care services by medical schemes in South Africa.Setting: The study was conducted in the private sector in South Africa for benefits paid by medical schemes to optometrists, ophthalmologists and orthoptists.Methods: A retrospective, longitudinal study of eye care services claim data from the Council for Medical Schemes (CMS) annual reports. The review period was 2020, and scheme-level data were gathered and analysed at the aggregated rather than benefit option level.Results: In 2020, eye care benefits comprised 3.1% of total benefits paid; this proportion remained at the same levels throughout the review period. Closed schemes spent more per beneficiary per year than open schemes for optometrists, orthoptists and ophthalmologists. Self-administered schemes had 11% copayment for ophthalmology services, whereas outsourced schemes had less than 10%.Conclusion: Optometrists had higher copayments than ophthalmologists and orthoptists. Medical schemes with capitated models had a lower average expenditure than other types of models, and the operating model affected expenditure; self-administered schemes spent less on optometry benefits when adjusted for beneficiaries. The study suggests reviewing eye care benefit funding models (risk vs savings), administration activities and managed care models for cost savings and health quality.Contribution: This research contributes to the discussion and implementation of universal health insurance coverage through national health insurance in South Africa. The research shows that there are not enough eye care services in the public sector and that there are different funding gaps in the private sector. 
Publisher AOSIS
Contributor None
Date 2023-07-31
Type info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion — quantitative research
Format text/html application/epub+zip text/xml application/pdf
Identifier 10.4102/aveh.v82i1.756
Source African Vision and Eye Health; Vol 82, No 1 (2023); 9 pages 2410-1516 2413-3183
Language eng
The following web links (URLs) may trigger a file download or direct you to an alternative webpage to gain access to a publication file format of the published article:

https://avehjournal.org/index.php/aveh/article/view/756/2167 https://avehjournal.org/index.php/aveh/article/view/756/2168 https://avehjournal.org/index.php/aveh/article/view/756/2169 https://avehjournal.org/index.php/aveh/article/view/756/2170
Coverage South Africa 2016-2020 Age, Sector
Rights Copyright (c) 2023 Michael M. Willie https://creativecommons.org/licenses/by/4.0