A bitter pill to swallow
SUFFERERS of chronic illnesses such as diabetes, asthma and heart disease as well as the aged, who are more prone to afflictions such as pneumonia, will be in serious trouble if changes are made to the prescribed minimum benefits (PMBs) offered by medical aids.
The Department of Health is seeking to change the extent to which medical schemes are financially liable for PMBs. These, according to the Council for Medical Schemes, are a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the option they have chosen.
There are 270 medical conditions and 25 chronic conditions for which every scheme has to cover the diagnosis, treatment and care, whether someone is on a lowcost hospital plan, or high-cost medical scheme.
At present medical schemes are compelled by law to pay for PMBs in full. The guidelines according to which these minimum benefits are granted to members are set out in Regulation 8 of the Medical Schemes Act.While this clearly outlines which illnesses are covered and their applicable treatment protocols, its provisions for how medical aid schemes should pay for costs associated with these illnesses is not defined explicitly.
The provision for payment in full is proving a dilemma for many medical schemes, even threatening their sustainability, owing to the fact that the Act does not define payment tariffs for PMBs.
The proposed amendments, if accepted in their current form, will limit medical schemes’ liabilities to the rates set out in a 2006 tariff guide, called the National Health Reference Price List, adjusted for consumer price inflation.
The proposed amendments say medical schemes can negotiate higher tariffs with healthcare providers to protect members from co-payments if they wish, but they are not legally obliged to.
In effect, the draft regulations reduce some of the financial risk medical schemes face for prescribed minimum benefits and shift the burden on to consumers, who have virtually no power to negotiate with healthcare providers.
The proposed changes to the legislation could mean that medical aid scheme members currently fully covered for certain illnesses will be left to pick up the tab.
With a falling economy and cash-strapped households, changes to the regulations governing PMBs could spell more physical hardship, even death, for those suffering from chronic conditions.
There are also fears that changes to PMBs could restrict access to health care, forcing medical aid members to seek care from an already overburdened public health-care system.
The proposed amendments are ill-conceived as they are at odds with Section 27 of the Constitution, which states everyone has the right to have access to healthcare services.