Statistics from Fedhealth’s data warehouse over the last 3 years show that of all their deliveries in South Africa, 76% are performed via C-section. This is across both public and private facilities. Although this percentage is much lower in Europe and the United States, globally C-section statistics are on the rise with the United States, United Kingdom and Germany all having reported an increase in c-section procedures over the last three years.
C-section procedures and the resultant hospitalisation cost, is significantly more than a natural delivery. Peter Jordaan, Acting Principal Officer of Fedhealth says on average C-sections cost a scheme around R28 500 with hospital costs making up approximately 70% of the total cost. Natural deliveries, on the other hand, are significantly less, costing a scheme approximately R16 500.
“From a health funding perspective, at some stage consideration needs to be given to the additional costs associated with medically unnecessary C-sections,” notes Jordaan, “and although there is currently no price differential between elective and non elective C-sections, this may not always be the case. Typically a scheme will cover hospital confinement at the scheme rate and allow three nights’ hospital confinement for a C-section delivery and two nights for a natural delivery.”
How to keep co-payments to a minimum
While pregnancy is an exciting time for expectant parents, it can indeed be a costly exercise if not planned correctly and co-payments are something that few members will escape completely during a pregnancy. With 14 – 18 February being Pregnancy Week, Jordaan offers couples advice on how to keep co-payments to a minimum.
“First and foremost I would suggest that members register their pregnancy with their scheme and obtain authorisation for the birth. Emergencies during a pregnancy will also require authorisation.”
Next Jordaan urges members to ensure that their chosen specialist, typically a gynaecologist/ obstetrician, assisting them with their pregnancy and birth is covered by their medical scheme option. “Many women choose to go by word of mouth when selecting a specialist but depending on what scheme or option they are on, it is not always guaranteed that consultations with the member’s preferred specialist will automatically be covered,” adds Jordaan.
“Members ideally should make use of a network specialist or GP to ensure that consultations will be covered. Many schemes provide unlimited visits on most of their plan options provided a network specialist or GP is consulted. The same applies to the facility or hospital that members will be making use of. In many cases only network hospitals or facilities are covered, or members may have to pay in 40% of the total cost depending on what option they are on,” he advises.
This also applies to attending specialists during the birth. To avoid co-payments members must ensure that the delivery by a general practitioner or medical specialist and the services of the attending paediatrician and or anaethetist fall within the scheme’s specialist network. Members should also check whether the global obstetric fee covers post-natal care by a general practitioner and medical specialist up to and including the six-week post natal consultation.
Jordaan says that co-payments can also be reduced by making use of Designated Service Providers when it comes to purchasing of medication. Again, this will depend on the various scheme options. “Members should stick to using medication that is within the formulary. This will decrease potential co-payments and will make sure that benefits last longer,” he says.
He explains that pre- and post-natal medications covered by various schemes are subject to scheme rules for the particular option as well as scheme specific clinical policies and protocols. “Reimbursement of anti-coagulants post-surgery or during pregnancy is subject to the relevant scheme option.”
Scheme rules and clinical policies will also apply to routine procedures and blood work in pregnancy. “Generally specified pregnancy-related tests and procedures will be covered and two 2D scans will be reimbursed per pregnancy subject to Out of Hospital Expense Benefits (OHEB) and savings. In most cases postpartum doctor’s visits are also funded from the OHEB and savings. Bear in mind that scheme rules change per option. Make sure that you are on an appropriate option,” he concludes.
(Press release, Fedhealth, February 2012)