The large number of sickness claims related to Covid-19 in the past financial year indicates that the long-term effects of the coronavirus, in the form of long Covid, are starting to show in numbers and that the physical impacts of the pandemic will be felt for years to come, some medical insurance companies say.
The warning from PPS and Liberty may be an indication that Covid is still very much with us, notes MedicalBrief, and coincides with the results of a large-scale analysis of how the pandemic and lockdowns affected other healthcare services which shows a concerning drop, notably in cancer screenings and care.
In their analysis, published in the South African Medical Journal, researchers said although some reductions in cancer screenings and care were not statistically significant, these decreases alongside significant reductions in medical and surgical hospital admissions and doctor visits may result in patients presenting with more severe illnesses in the future. More long-term research will be needed to confirm or disprove this hypothesis, they said.
Elective surgeries, as well as regular and routine healthcare services, including cancer screening, antenatal care and HIV and TB testing, dropped dramatically when South Africa implemented strategies to slow the spread of the epidemic, including lockdowns of varying severity.
Although essential medical services continued during the lockdowns, the pandemic led to the re-organisation of the healthcare system. Elective surgeries, considered less urgent, were paused to create capacity to manage Covid cases, particularly during peaks in transmission. Certain high-volume hospitals, meanwhile, closed due to facility outbreaks.
To investigate the epidemic’s impact on private healthcare services, a comparison was done of anonymised claims data from all Discovery Health Medical Scheme (DHMS) members between April and December in each of the following years: 2019, 2020 and 2021.
DHMS is the country’s largest open medical scheme with about 2.8m members.
The analysis tracked four areas: emergency room visits, hospital admissions, out-of-hospital doctor visits for patients with chronic conditions, as well as cancer screenings and registrations for Discovery Health Medical Scheme’s Oncology Care Programme.
Visits to the Emergency Room (ER) are generally an indication of immediate care sought to relieve an acute condition or to manage a clinical emergency.
Hospital admissions included admissions to private hospitals, day clinics, rehabilitation centres and psychiatric hospitals. These admissions were categorised based on whether they were medical or surgical in nature as well as how severe cases were based on a case mix index.
A case mix is a measure of the average severity of hospital admissions, considering both the mix of admissions (e.g. a heart transplant versus a pneumonia admission) and the complexity of the admission (e.g. a pneumonia admission for a patient with HIV versus a pneumonia patient without HIV). Case mix indices are lower for people with fewer concurrent health problems and for people with admissions that require less complicated care.
Doctor visits to GPs were limited to those among patients living with chronic conditions as identified by their status on Discovery's Chronic Illness Benefit: this covers the 27 chronic conditions that qualify for Prescribed Minimum Benefits as well as an additional 22 conditions for some members, depending on their plan. Doctor visits included both in-person and virtual consultations.
Finally, cancer screenings were limited to mammograms and Pap smears as colon cancer screening was only introduced in 2019.
Covid contributed to huge reductions in most areas
Our analysis reveals that Covid led to significant reductions in emergency room visits, hospital admissions, in-person doctor visits and Pap smears particularly during the initial and strictest lockdown. The number of virtual doctors' consultations, however, rose.
We also discovered that although hospital visits decreased during the first two years of Covid-19, patients who were being admitted were on average sicker than those admitted before the pandemic.
This was true whether patients were admitted for Covid related care or other illnesses.
Fewer patients were admitted during Covid-19 but those who were, were also sicker. Emergency room visits fell significantly by almost a third (31.9%) between April and December 2020 compared with the same period in 2019. In 2021, emergency room utilisation rebounded in the last four months of the year but overall, for the period analysed was still 16.6% less than in 2019.
The greatest reduction in emergency room visits was observed during the strictest lockdown level in April 2020.
Total hospital admissions similarly decreased the most (62%) during the strictest lockdown in April 2020. In this month, the medical admission rate fell by 58.2% compared to April 2019 while surgical admissions fell even further (73.2%).
At the same time, patients who were admitted into hospitals both with Covid-19 as well as other illnesses were much sicker in 2020 and even more so in 2021 compared with 2019, the case mix index showed. The average case mix index of 1.32 for April to December 2020 was 12.6% higher than the corresponding period in 2019, and this elevated case mix level persisted into 2021 with an even bigger differential of 13.5%.
Telemedicine helped plug the gap
GP visits also fell among chronic disease patients in 2020 (14.5% per 1 000 chronic lives) against 2019 rates before rebounding in 2021 to nearly pre-pandemic levels. In 2021, the rate of doctor visits among people living with chronic conditions was still 4.3% less than those seen in 2019 but this was not statistically significant.
The reduction in consultations also extended to specialists, including gynaecologists and psychiatrists. Peaks in virtual visits coincided with the surge in infections during the various waves but not enough to offset the reduction in face-to-face visits.
GPs accounted for the highest number of virtual consults followed by radiotherapists and general physicians.
Cancer screenings, already low, dropped further
Registrations on to DHMS’ cancer treatment programme dipped in 2020 (18.2%). As in the case of emergency room visits and hospital admissions, cancer registrations fell the sharpest during April 2020’s hard lockdown.
The rate of registrations increased in early 2021 after the second wave of infections but declined once again at the onset of the third wave and remains low, compared with previous years.
Similarly, the rate of mammograms per 1 000 female lives to detect breast cancer also decreased by nearly a quarter in 2020 (24.9%) before recovering to remain slightly lower (5.2%) than pre-Covid levels in 2021. Neither dip in breast cancer screenings was statistically significant however.
A statistically significant decrease (23.4%) was observed in Pap smear visits per 1 000 female lives in 2020 when compared to 2019. This trend persisted into 2021 although the reduction (10.8%) in 2021 in relation to 2019 was not statistically significant.
DHMS introduced colorectal cancer screenings in 2019, however, registrations for DHMS’s Oncology Programme for this cancer fell during the pandemic in 2020 (16.5%) and continued in 2021 (12.1%). As with declines in mammography, reductions in colorectal cancer were not statistically significant.
In summary, our analysis found declines in cancer screenings and registrations in DHMS’s Oncology Programme during the first two years of the epidemic. In 2021, however, there appears to be an improvement approaching pre-pandemic levels for breast cancer and cervical cancer screening.
Although only reductions in 2020 Pap smears were found to be statistically significant, the decreased utilisation of cancer screenings and care is concerning, given South Africa’s already low rates of cancer screening. Therefore, any decrease in cancer screening is coming off an already low base.
Risk of more serious illness in the future
Our research adds to a growing body of evidence that shows Covid-19 reduced the uptake of other health services, namely in this study emergency room visits, hospital admissions, doctor visits and cancer screenings.
Our study is the first in the South African private sector to evaluate this using a large claims-based dataset.
Scaling up decentralised health services could solve problems
Previous studies have suggested that fear of being exposed to Covid-19 in healthcare settings played a key role in driving reductions in primary healthcare.
These findings may inform current pandemic preparedness discussions about how to best safeguard essential health services during outbreaks, for instance by scaling up digital or home-based care.
However, our data suggest that some changes in healthcare utilisation patterns seen during Covid-19 present opportunities by helping to decentralise care, initially by providing a catalyst for the adoption and scale of digital health services. Second, shifts in the uptake of hospital services may provide the private health sector with a chance to remedy long-standing patterns of hospital over-use by shifting care to outpatient settings, including the home.
A continued shift towards decentralised care like this will drive down healthcare costs while possibly improving care.
Meanwhile, 2022 figures from PPS show that although its total gross claims paid declined by 18% to R5bn, thanks to a drastic decline in Covid-19-related death claims, Covid sickness claims rose.
The insurer paid R263m in Covid-19-related claims, with R213m going towards sickness claims and only R39m for death claims, reports News24.
In 2021, PPS recorded more than 10 000 Covid-19-related sickness claims. In 2022, the number came down but still stood at 7 700.
The insurer is concerned that this is still “significant”.
“Covid reduced but not that much on the sickness side…. There are still many, many Covid sickness claims,” said PPS CEO Izak Smit.
Last year, PPS recorded its first Covid-19 critical illness claim – which differs from sickness claims that the insurer pays when someone cannot work for a few days or weeks because of the virus.
Critical illness claims are for a more severe illness that impedes the person’s ability to function as they used to or prevents them from working for more extended periods.
PPS believes this may hint that the long-term effects of the virus, in the form of long Covid, are starting to show in numbers and that the impact of the physical impacts of the pandemic will be felt for years to come.
At Liberty, managing executive for retail risk solutions David Jewell said the group is happy about the substantial reduction in life cover and funeral claims directly attributed to the virus in 2022 compared with the previous two years, but it was clear there are “second-order effects” in the form of rising critical illness and disability claims.
“These have not had an equivalent drop-off and have actually increased … they may in some instances be related to not only long Covid but also other lifestyle diseases such as cancer,” he said.
Other insurers differ, with Sanlam Individual Life's product actuary, Petrie Marx, saying Covid-19-related claims are not a concern for them anymore.
Marx said that although Sanlam experienced unexplained additional claims in 2022, they were not classified as Covid-19-related.
For most of 2022, Sanlam recorded low double-digit Covid-19-related death and sickness claims. It had only six Covid-19 death claims this March and 22 sickness claims.
In contrast, it recorded a monthly average of around 200 Covid-19-related claims for these benefits between July 2020 and December 2021.
Momentum Life head Stephen van Niekerk believes there are some signs of long Covid, given the increase in cardiac conditions among its clients and presenting mostly in critical illness claims.
“But we are not seeing a direct impact from Covid… obviously, we are keeping an eye on but at the moment, I wouldn’t say (long Covid) is material at all,” he added.
Study details
Understanding the impact of the COVID-19 pandemic on healthcare services for adults during three waves of COVID-19 infections: A South African private sector experience
N Nematswerani, L Steenkamp, S Haneef, R M Naidoo, S Fonn.
Published in the SA Medical Journal in April 2023-05-02
Background
Since the onset of the COVID‑19 pandemic, healthcare resources have been repurposed to focus on COVID‑19. Resource reallocation and restrictions to movement that affected general access to care may have inadvertently resulted in undue disruptions in the continuum of care for patients requiring non‑COVID‑19 healthcare services.
Objectives
To describe the change in pattern of health service use in the South African (SA) private sector.
Methods
We conducted a retrospective study of a nationwide cohort of privately insured individuals. An analysis of claims data was performed for non‑Covid‑19 related healthcare services provided from April 2020 to December 2020 (year 1 of Covid‑19) and April 2021 to December 2021 (year 2 of Covid‑19) relative to the same period in 2019 prior to the COVID‑19 pandemic in SA. Over and above plotting the monthly trends, we tested for statistical significance of the changes using a Wilcoxon test given the non‑normality of all the outcomes.
Results
Between April and December 2020, relative to the same period in 2021, and also relative to the same period in 2019, we found a 31.9% (p<0.01) and a 16.6% (p<0.01) reduction in emergency room visits, respectively; a 35.9% (p<0.01) and 20.5% (p<0.01) reduction in medical hospital admissions; a 27.4% (p=0.01) and 13.0% (p=0.03) reduction in surgical hospital admissions; a 14.5% (p<0.01) and 4.1% (p=0.16) reduction in face‑to‑face general practitioner consultations for chronic members; a 24.9% (p=0.06) and 5.2% (p=0.54) reduction in mammography for female members; a 23.4% (p=0.03) and 10.8% (p=0.09) reduction in Pap smear screenings for female members; a 16.5% (p=0.08) and 12.1% (p=0.27) reduction in colorectal cancer registrations and an 18.2% (p=0.08) and 8.9% (p=0.07) decrease in all oncology diagnoses. Uptake of telehealth services throughout the healthcare delivery system increased by 5 708% in 2020 compared with 2019, and 36.1% for 2021 compared with 2020.
Conclusion
A significant reduction in emergency room visits, hospital admissions and utilisation of primary care services was observed since the start of the pandemic. Further research is required to understand if there are long‑term consequences of delayed care. An increase in the use of digital consultations was observed. Research on their acceptability and effectiveness may open new modalities of care, which may have cost‑ and time‑saving benefits.
News24 article – Some insurers are picking up worrying long-term effects of Covid-19 in their claims
See more from MedicalBrief archives:
A worrying drop in antenatal and follow-up visits during lockdown
Telemedicine: The end of the physical examination can mean losing touch
One million cancer diagnoses likely missed in Europe because of COVID pandemic
Lockdown’s terrible damage to South African healthcare
Lockdown must go or else non-coronavirus mortality will outstrip COVID-19 deaths