1. CDL Disease Prevalence: Diagnosis and Treated 8 June 2009 Additional material supplied with IMSA NHI Policy Brief 3 National Health Insurance Policy Brief 3

2. REF Study 2005 Tables derived from data in REF Study 2005: Four administrators: Discovery Health, Medscheme, MHG and Old Mutual Healthcare. 63.4% of beneficiaries in industry. Data on prevalence and PMB expenditure for calendar 2005. REF Entry and Verification Criteria v2, in force from 1 January 2007 for determining diagnosis and treatment. Graphs show final tables published with REFCT2007: Revised Prevalence: after application of multiple disease rules. Final REFCT2007 used for order of diseases for multiple rules. Diagnosed Cases Prevalence originally published as “CASES” Treated Patient Prevalence originally published as “TREATED”. The tables of CDL disease were originally developed for 2007 but remain valid for later calendar years. Source: REF Study 2005

3. Diagnosed Cases and Treated Patient Diagnosed Cases requires Diagnosis-related information i.e. ICD-10 code and perhaps tests. Treated Patient requires Proof of Treatment i.e. evidence of payment of relevant drugs from risk pool (not savings accounts).

4. Respiratory Disease

5. Asthma Diagnosis and Treated Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3 Asthma has a very different shape to other chronic diseases with high prevalence in childhood years. Most frequent chronic disease in childhood.

6. Bronchiectasis Diagnosis and Treated Diagnosis data has overlap to both asthma (at younger ages) and COPD at older ages. At older ages BCE reduces as COP > BCE. Respiratory rule for multiple disease: use highest of COP+AST+BCE Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

7. Chronic Obstructive Pulmonary Disease: Diagnosis and Treated Much higher prevalence in males. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

8. Diabetes

9. Diabetes Insipidus Diagnosis and Treated “Treated patient” very low compared to diagnosis. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

10. Diabetes Mellitus Type 1 Diagnosis and Treated Only about half meet “treated patient” criteria. Possibly due to overlap with DM2 while ICD-10 coding was becoming compulsory in 2005. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

11. Diabetes Mellitus Type 2 Diagnosis and Treated About two-thirds meet “treated patient” criteria. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

12. Cardiac and Renal Disease

13. Cardiomyopathy and Cardiac Failure: Diagnosis and Treated Originally collected separately, now combined as one disease. Unlike many other chronic diseases, does not decline at oldest ages. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

14. Dysrhythmias Diagnosis and Treated Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3 Has different shape at oldest ages compared to cardiomyopathy. Higher prevalence in males.

15. Hyperlipidaemia Diagnosis and Treated Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3 Shows substantial decline at oldest ages. Much higher prevalence in males.

16. Coronary Artery Disease Diagnosis and Treated Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3 Shows decline at oldest ages. Much larger gap between diagnosed cases and treated patients in males.

17. Hypertension Diagnosis and Treated Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3 Shows decline at oldest ages. Much higher prevalence in females.

18. Chronic Renal Disease Diagnosis and Treated Very large numbers not verified as “treated patients” as definition essentially requires dialysis. Unlikely to be significant movement to becoming “treated”. Not verified due to “treated patient” definition Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

19. Gastro-intestinal Disease

20. Crohn’s Disease Diagnosis and Treated Higher rate of diagnosis amongst females but similar rates of “treated patient”. Not enough data for smooth curves. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

21. Ulcerative Colitis Diagnosis and Treated Large numbers not meeting “treated patient” criteria. Curves not smooth at older ages. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

22. Skeletal Disease

23. Rheumatoid Arthritis Diagnosis and Treated Much higher prevalence amongst females. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

24. Systemic Lupus Erythematosus Diagnosis and Treated Very low prevalence for males. Rate of female prevalence peaks at age 50-54. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

25. Neurological Disease

26. Bipolar Mood Disorder Diagnosis and Treated Very large difference between diagnosed and “treated patient”, particularly for females. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

27. Epilepsy Diagnosis and Treated Has significant prevalence in childhood years. Note drop at age 25 which suggests some anti-selection – bringing children onto medical schemes if they have a chronic disease. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

28. Multiple Sclerosis Diagnosis and Treated Much higher prevalence for females. Not enough data for smooth curves at older ages. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

29. Schizophrenia Diagnosis and Treated Unusual increase at age 85+. Very little data at oldest ages. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

30. Parkinson’s Disease Diagnosis and Treated Similar shapes for females and males with higher prevalence for males. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

31. Other Disease

32. Addison’s Disease Diagnosis and Treated Insufficient data for smooth curves for this rare disease. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

33. Haemophilia Diagnosis and Treated Very few cases hence data is very “lumpy”. Predominantly a male disease but some treatment of females. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

34. Glaucoma Diagnosis and Treated Seems to have small reduction in oldest males but not females. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

35. Hypothyroidism Diagnosis and Treated Very much higher prevalence amongst women. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

36. Multiple Disease

37. Two Simultaneous Conditions Diagnosis and Treated About the same prevalence in females and males. As women survive longer, there will be more elderly women than men with multiple chronic disease in the population. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

38. Three Simultaneous Conditions Diagnosis and Treated Very similar rates of prevalence for females and males. Greater gap between diagnosed and treated than for two simultaneous conditions. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

39. Four+ Simultaneous Conditions Diagnosis and Treated Much greater gap between diagnosed and treated than for three simultaneous conditions. Original source of data: REF Study 2005 for REFCT2007 Source: Additional material supplied with IMSA NHI Policy Brief 3

40. Summary In some diseases there is a very large number of patients who have been diagnosed with the disease but are not meeting the “treated patient” criteria. This means they are not receiving medication from the risk pool in the medical scheme according to the REF Verification Criteria: for most diseases this is two months of every three. The gap between diagnosed and treated should be of concern to funders. Untreated chronic disease may result in larger expenditures in hospital. If more people become compliant with treatment then the immediate price of PMBs will increase as more is paid on PMB medicines but this could lead to reductions in hospital costs in the future. The non-PMB component may also reduce as more expenditure comes under PMBs.

41. Innovative Medicines South Africa (IMSA) is a pharmaceutical industry association promoting the value of medicine innovation in healthcare. IMSA and its member companies are working towards the development of a National Health Insurance system with universal coverage and sustainable access to innovative research-based healthcare. Contact details: Val Beaumont (Executive Director) Tel: +2711 880 4644 Fax: +2711 880 5987 Innovative Medicines SA (IMSA) Cell: 082 828 3256 PO Box 2008, Houghton, 2041. South Africa val@imsa.org.za www.imsa.org.za

42. Material produced for IMSA by Professor Heather McLeod hmcleod@iafrica.com www.hmcleod.moonfruit.com