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CMS: Regulator invites industry to help cost PMBs

19 April 2010 The Council for Medical Schemes (CMS)

PMB costing study 2010: request for data

The Risk Equalisation Fund Technical Advisory Panel (RETAP) meeting held on 19 February 2010 agreed that the cost estimates from the REF Study 2005 are outdated and that it has become necessary to calculate new estimates for current prescribed minimum benefits (PMBs).

Schemes and administrators are requested to provide the Council for Medical Schemes (CMS) with data at a detailed level to be used in this costing exercise. Annexure A below contains the detailed specifications of the data set that is required. Detailed personal information – such as the RSA identification number, name, surname, and address – is not required. Prior to the CMS receiving any data from administrators, Principal Officers are kindly requested to confirm the willingness of their schemes to participate in the exercise and to share their data with the CMS.

To protect the confidentiality of the data, the CMS will work with each administrator on the data cleaning and costing process. The CMS will then combine all the data to calculate the estimates for the industry. The industry estimates will be discussed at RETAP before publication.

One of the proposed analytical approaches is to use historical claims and group them into episodes that measure

care across inpatient and outpatient settings to account for the entire episode of care related to a given condition. It is not the intention of the CMS to prescribe the grouper for managed care purposes; this analytical tool will only be used for costing the PMB package. The CMS will also apply other techniques to cost the package and the results from utilisation of the various techniques will be compared and feedback given to all participating schemes.

Other interested stakeholders who do not represent schemes or administrators are also invited to contribute data and expertise. A number of administrators, medical schemes, and individuals have already indicated that they would like to participate. Participation is very important to ensure that the estimates reflect the medical scheme population.

The CMS invites each entity to nominate before 30 April 2010 a maximum of two people to serve on the PMB Costing Study Technical Committee.

Confidentiality of the data is very important and confidentiality agreements will be entered into where necessary.

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