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Purely Medical Business...

01 October 2008 Linza van Aswegen, (FIA)

PMBs are a SOS for medical scheme members, but schemes need to exercise due care in their delivery to ensure that they remain sustainable for the future.

Prescribed Minimum Benefits (PMBs) have three pillars. The first is a list of 270 medical conditions, the second pillar consists of 25 listed chronic conditions and the third one addresses any unexpected medical emergency condition that requires immediate treatment or an operation.

Medical schemes are liable for the cost related to the diagnosis, treatment and care of these specified conditions. This includes doctor's consultation fees, tests and medicine related to PMBs. The regulations of the Medical Schemes Act 131 of 1998 contain a set of minimum treatment standards or protocols for each and every PMB.

Coding quagmire

All PMBs have specific ICD-10 codes and will be identified by those codes of which the specific protocol should be adhered to by all medical schemes. The ICD-10 coding system is an international coding system developed by the World Health Organisation (WHO) and contains the written description of medical and health information into standard codes.

Although 271 PMB conditions have been identified, the application of the ICD-10 coding has resulted in thousands of ICD-10 codes being relevant to the main PMB conditions.

Implications

Many critics have voiced numerous concerns regarding PMBs introducing unlimited benefits within Designated Service Providers (DSPs). These benefits have escalated the cost of medical cover, despite the fact that cover is provided within a contracted provider, and costs will have been negotiated with the DSP to limit exposure to the scheme as much as possible.

The scheme could also be exposed due to different opinions and interpretations of the emergency list, as well as the revision of the protocols on some conditions from time to time, as is often the case, thanks to the continuing development of medical technology.

There are also concerns over the right to patient confidentiality in terms of applying the ICD-10 coding system that might lead to a breach in the doctor and patient confidentiality code.

Work in progress

The "2008 PMB Review Consultation Document" contains proposed reviews by various task teams who have taken heed of comments from various role players in the healthcare industry on the future development and implementation of PMBs.

This consultation process will hopefully ensure less criticism and provide some solutions by experts on how to implement and provide a most important and crucial medical scheme benefit. The expansion and implementation of the PMB benefits need to be decided, taking into consideration the impact of the cost and the additional administration required to manage such a package.

Cost effectiveness remains essential

Cost effectiveness in terms of provider tariffs, drug pricing and over servicing continue to have a significant impact on medical schemes.

Clearly defined guidelines rules, protocols, verification criteria, appropriate formularies and algorithms must be applied. This will have an effect on the liability of medical schemes towards their members that should be stipulated as clearly as possible to ensure protection of all medical scheme members.

The proposed review of PMBs aims to provide the medical scheme members with a quality healthcare service and to avoid cases where medical scheme beneficiaries do not have access to continuous healthcare to improve general wellness regardless of age, or medical scheme option.

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