Why PMBs are hurting health care
Ipaf head says the prescribed minimum benefits policy needs to be looked at again
Poorly designed and unamended prescribed minimum benefits (PMBs), while well intended, have ballooned out of control, costing funders billions and ramping up medical inflation, according to Prof Morgan Chetty, the head of the Independent Practitioners Association Foundation (Ipaf). He also accused some doctors of colluding with patients to claim in a skewed “sick care” environment.
Chetty, who is a member of the KwaZulu-Natal Doctors’ Healthcare Coalition, was responding to comments by the Board of Healthcare Funders, executives, a Discovery Health clinical excellence chief, and Unben Pillay, the CEO of the Alliance of South African Independent Private Practitioners Association.
All agree that the lack of proper government regulation of private health care and poor, uncorrected legislation contribute to rampant medical inflation, a hospital-centric/ curative approach and the marginalisation of family practitioners.
Chetty says busy doctors have a duty to educate their patients to be the central players in holistic and cost-efficient health care. “For example, you give a diabetic patient a lab form which has 10 tick boxes and send him off for bloods. He
has no idea what the ticks are for, nor that you may be depleting his medical aid savings or incurring a co-payment. The patient is naive and passive,” he says.
He cites a US campaign that improved health care significantly. “Know Your Numbers” aimed to educate patients on optimum levels for blood pressure, haemoglobin, cholesterol and body mass index, among others. Chetty says this allows a patient to engage with doctors.
He says family practitioners live in a highly competitive environment and face an “onslaught” from hospitals and pharmacies and often give in to patient demands on PMBs and other benefits. There are more than 200 PMB conditions, including a chronic disease list (CDL).
Noluthando Nematswerani, the chief clinical officer at Discovery Health, says lifestyle diseases affect younger populations and grow quickly while the cost of expensive but effective new drugs adds to the funding burden.
Chetty says the list of PMBs is “formidable”. The CDL, while relatively small, has tens of thousands more people on it. He says there is insufficient interrogation of PMBs, the policy needs re-regulation and the Council for Medical Schemes (CMS) has been remiss.
“That’s the reason there’s no progress. We’re legislating our way into a crisis and there are too many groups working in silos,” he says. “PMBs were well intended but badly constructed and are not being probed to make them more manageable. They’re hurting health care. The legislators didn’t grasp the complexities of co-morbidities, multiple morbidities and more and more people entering this space.” He says the solution is for all to work together as they did when threatened by Covid and customise and modify PMBs, while allowing medical aids to offer low-cost benefit options —“or we will have an issue of super [medical] inflation”.
“These insurance funding options preclude them from long-term care, so patients get dumped back into the public sector as soon as they need more complex management. I agree with the principles of universal health care, but the NHI [National Health Insurance] scheme must be implemented in an iterative way with the programme corrected or adjusted as issues arise.” His sentiments reflect closely those of the government’s leading man in NHI, Nicholas Crisp.
Chetty says patients too often regard medical aid or insurance in terms of what it costs them and are not educated into making the right decisions.
Doctors should complement brokers, who too often give insufficient information to enable weighing up the benefits versus the disadvantages of lower-cost options.
“It’s strange how many patients are forced to change from one plan to another because a broker navigates it for them.”
He says they need to ask the principal member whether their or their dependants’ health profiles are matched to the right scheme. “We need to turn patients into activists rather than passive recipients of care.”
CMS registrar Sipho Kabane says it has reviewed PMBs “using the best scientific evidence, cost-effectiveness, protecting members and the financial health of schemes, while probing rare, high-cost diseases that threaten to collapse schemes”.
The confidential CMS findings on PMBs, low-cost benefit options, the lack of consultant tariff ceilings and other recommendations made by the health market inquiry are with health minister Joe Phaahla.
He tells the FM “they’re tied up in legalities right now. I’ll pronounce within months.”