PMB change: ‘Specialists over-charging medical schemes’

A Stellenbosch University team (pictured) performed the world's first penis transplant in March.
Dr Anban Pillay, Deputy Director-General of Health
Dr Anban Pillay, Deputy Director-General of Health

This is why the health department has proposed an amendment to the Medical Schemes Act that recommends set tariffs for these benefits, according to Dr Anban Pillay, Deputy Director General of Health.

The PMBs cover medical emergencies and almost 300 other conditions including diabetes, heart attacks and HIV, and until now medical schemes have had to pay in full for these to be treated.

But Pillay said government was concerned that the PMBs gave service providers “a blank cheque” as they knew that medical schemes had to cover costs.

Addressing the Board of Healthcare Funders conference yesterday (29 July), Pillay showed slides of how anaesthetists’ and other specialists’ costs increased when they were working on conditions covered by PMBs in comparison to conditions not covered.

Massive increase in bi-polar

“In 2012/13, there was a massive increase in bipolar disorder [covered by PMBs] and a huge decrease in major depression [not covered],” added Pillay.

The BHF has hailed government’s proposal for a uniform tariff to be set for PMBs – called Regulation 8 – but patient lobby groups have expressed fears that patients will have to cough up the difference should specialists feel short-changed by the medical schemes.

The Treatment Action Campaign (TAC), South African Depression & Anxiety Group (SADAG) and People Living With Cancer (PLWC) this week expressed concern about the proposed amendment.

[quote float = right]There is evidence to show that patients face financial ruin when forced to pay or co-pay for PMBs”

“We acknowledge that there are legitimate concerns about the high cost of private health care in South Africa, but limiting medical scheme coverage for PMBs is not a sensible solution to this problem,” said the three organisations in a joint statement.

“We have not seen any definitive evidence on which to base such a far-reaching change in the law, which has the potential to take away access to health care for patients.

“However, there is evidence to show that patients face financial ruin when forced to pay or co-pay for PMBs,” they said. “One family with a child suffering from Crone’s Disease – a PMB – fought Genesis [medical scheme] for years to pay for their child’s treatment.  This has exhausted all their finances and the parents have had to tap into their pension fund and sell their home to pay for their child’s treatment.”

But Pillay said the new regulation “was not cast in stone”, and government was open to ideas about how to solve the problem of the rising cost of private healthcare.

He said the department would like to convene a workshop to get all stakeholders together.

However, in a reference to the National Health Insurance (NHI) scheme, Pillay said “we are about to introduce massive change in how medical insurance is rolled out and don’t want to make piece-meal changes”. – Health-e News.

 

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