The Medical Schemes Act, No. 131 of 1998 provides legal protection for medical schemes members [7, 11]. This study provides evidence on perceived knowledge of open scheme members and their satisfaction with their medical schemes.
The overall results showed that approximately 71% of participants felt that they had good knowledge of their medical scheme, compared to 54% who scored above 61% for satisfaction. This finding is consistent with the Health Market Inquiry (HMI) report which showed a strong correlation between good perceived knowledge and good satisfaction . Seventy-five percent of the participants also understood the benefits and cost involved before they joined their scheme. The top four chronic diseases in participants were asthma, cardiac failure, hypertension, and thyroid conditions, consistent with the Council for Medical Schemes (CMS) data and with other studies conducted in South Africa on the burden of non-communicable disease [7, 13, 14]. The increased incidence of non-communicable diseases in South Africa is a public health concern and has consequences for medical scheme membership costs.
Thirty-eight percent of the respondents earned a monthly income of R30 000 (2 160 US$) or above. This raises the issue of affordability of medical schemes in South Africa which has a GDP/ capita of 6 281 USD and a high GINI coefficient. Kaplan highlighted the same concern in his findings . McLeod and Ramjee pointed out that affordability constituted a major barrier to medical aid access in South Africa and was the greatest obstacle to the growth of the medical schemes industry . Furthermore, the cost of entry-level medical schemes options remains mostly unaffordable . Very few members (14%) were on a high-level option as members selected their option not based on their income or health needs, but on paying less, except when faced with a chronic disease.
The Healthcare consumer survey conducted in South Africa in 2016 found that 92% of participants who used brokers felt that they received satisfactory information . This finding is higher than ours where only 62% of respondents perceived their brokers to be knowledgeable about medical schemes. Additionally, our study found that there was no relationship between good perceived knowledge and joining a medical scheme through brokers.
The finding of an association between perceived knowledge and income is consistent with Adewole’s study in Nigeria . This may imply that members with better income are more able to access various sources of information that could improve their knowledge. Inconsistent with Adewole’s study , we found that the level of perceived knowledge and satisfaction was not associated with gender or suffering from a chronic disease. This dissimilarity may be due to a different study population and study setting. Adewole study’s population comprised mostly of farmers, artisans, and traders in a rural area, whereas South African open scheme members live mostly in urban areas. Ackah and Owusu in Ghana showed that older individuals were more knowledgeable in health insurance .
The PMBs are critical aspects of medical schemes regulation in South Africa, introduced after exclusions and high costs resulting from cream skimming and risk rating by the industry. Though almost half of the respondents indicated that they had made out of pocket payments for services, they were still satisfied with their medical schemes. Our study is limited, as it does not determine the amount of money spent out of pocket. We also did not know if the members were reimbursed or not or if the OOPs were the result of the use of non-Designated Service Provider GP or drugs not covered under the PMBs. The question of OOPs and satisfaction regarding PMBs needs further exploration. According to Mohammed, Sambo, and Dong, Odeyemi and Nixon, out of pocket payments (OOPs) had a negative impact on consumers as it delayed health access and promoted the use of alternative treatment [9, 16]. They suggested that OOPs were related to patient dissatisfaction [9, 16].
Some respondents expressed the desire to tackle waste and fraud in the medical scheme’s environment and the need for more transparency with regards to the DSP contract. The prevalence of health care fraud in South Africa is estimated at 5% to 15% of the total health care expenditure . In South Africa, fraud waste and abuse adds approximately R22 billion (US$1,584 million) to the annual cost of private health care  in addition to other cost drivers .
The respondents also indicated their wish to have access to a comprehensive benefits package at an affordable rate without co-payment. These desires are echoed in the new Medical Schemes Amendment Bill, which suggested a comprehensive benefits package fully covered by the schemes and the abolition of the PMBs .
The Medical Schemes Act promotes DSP arrangements between medical schemes and healthcare providers to ensure proper service delivery of the PMBs [4, 7, 11]. To reduce the cost of health care services, many medical schemes have contracted with DSPs. Although anecdotal evidence shows that consumers do not like DSPs, this study showed that 81% of participants were satisfied with the quality of care received from the DSPs. However, the proportion of participants who had a good perceived knowledge of DSPs was only 55%. Eighty-one percent of participants did not have access to DSPs hospitals where they lived, while 9% were satisfied with access to a designated GP. This could be because of the location of the hospitals and GP or the cap on the number of consultations allowed. However, other unknown reasons may explain this limited access. In 2010, another healthcare survey found that 60% of medical schemes members had a negative attitude towards DSPs. In contrast to ours, this study did not evaluate the quality of service received from the DSPs, but rather, participants’ freedom of choice as they wanted to choose their own doctors as they found DSPs to be inconvenient .
Regarding complaints against medical schemes, the results showed that there was a statistically significant relationship between perceived knowledge and complaints. This emphasises the responsibility of the schemes to ensure that principal members have the necessary knowledge to get the most value out of their benefit option. Few participants made appeals against their medical schemes and the CMS. This is consistent with the study of Rodwin that showed that most schemes members chose not to appeal, even when they had a reasonable cause . Respondents were quite satisfied when they appealed to their schemes, but dissatisfied with CMS outcome.
The main limitation of this study was that to maintain confidentiality, the research team was not in direct contact with the interviewees and relied on the schemes to distribute the letters that linked to the URL of the questionnaire. Therefore, the researchers could not contact individuals who did not respond and had to rely on general reminders to the entire sample.
This study also used a cross-sectional survey. Our analysis could therefore not determine any underlying issues or infer a causal relationship. Recall bias could also be an issue for respondents who had a poor experience with their service providers or those who had not used their medical scheme recently.