Prescribed Minimum Benefits claims are cost drivers

01 August 2011 Dr Tumi Seane, Sechaba Medical Solutions

There has been much industry debate about the issue of Prescribed Minimum Benefits (PMBs), but claiming patterns over the last few months have revealed that PMB claims are definite cost drivers.

While hospital costs are still the main cost drivers in the medical schemes industry, they are worsened and complicated by the PMB regulations.

Sense of entitlement

While the intentions of the regulations are noble, important and unintended consequences could present a sense of entitlement and financial expectations among both beneficiaries and service providers, including hospitals and doctors.

Anecdotal evidence suggests that service providers expect full payment for services and treatment rendered in respect of PMB conditions and other related conditions. While it is difficult to tell at this stage whether this trend is indicative of coding issues with service providers or a true reflection of the situation, the trend is apparent and administrators and schemes are feeling the effects.

Driving up costs

PMBs are the most common chronic conditions with hypertension currently at the top of the list for having the highest number of scheme members registered. This is followed closely by diabetes, HIV, oncology and heart disease. Claims relating to these chronic conditions are definitely driving up costs and Sechaba has seen an increase in these claims.

The reasons for the increase are unclear, but especially with HIV, increased awareness is playing a role. Sechaba’s wellness campaigns are reaching larger numbers of people, who see the benefits of joining a scheme with an HIV programme and are also feeling less ostracised. This could definitely result in an increase in claims for HIV PMBs, for example.

Containing costs

A combination of a decrease in treatment costs and encouraging healthy lifestyles will assist in driving down PMB claims and costs. The minimum entitlement also needs to be clarified for the industry in order for healthcare to be accessible and affordable for all. Limitations will not only benefit the current health funding model, but the proposed National Health Insurance (NHI) scheme as well.

The Managed Care solution

Managed Care advocates cost-effective care, with better clinical outcomes. Members are encouraged to engage with service providers and explore cost-effective solutions, as not every patient needs to be in ICU, or High Care, or even in hospital.

Managed Care is a major focus for Sechaba Medical Solutions, and an important tool in continuing to educate and assist members on how to manage their own conditions. In combination with various other interventions, Managed Care has been one of the key drivers to lowering contribution increases for members. Managed Care assists schemes drive down costs by decreasing their claiming patterns, even among members with chronic conditions, and improving their general health.

Advancements in Managed Care technologies are also continuously being evaluated by experts to ensure members are offered the best care and quality without compromising their health outcomes.

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