Proposed PMB changes trigger cost fears

UNCERTAINTY hangs over proposed amendments related to prescribed minimum benefits (PMBs) covering a range of chronic conditions amid fears that medical aid scheme members, who are currently fully covered for these, will be left to pick up the tab.

The Star, 27 July 2015

Public comment can be made over the next two-and-a-half months, before a decision on amending the regulations is finalised by the Health Department. A two-paragraph proposed amendment to regulation 8 of the Medical Schemes Act set the cat among the pigeons earlier this month: one paragraph limits coverage to the 2006 national health reference price list (NHRPL), as adjusted annually for inflation; the other allows negotiations for higher tariffs between healthcare providers and medical aid schemes while banning any patient co-payments.

Critics say they are worried the proposed amendments could restrict access to healthcare - by dumping medical aid scheme members in an already overburdened public healthcare system - or placing unsustainable financial burdens on patients, who are left to pick up the difference between what is charged and the NHRPL, or a negotiated tariff.

The NHRPL has long been dismissed as inadequate and not reflective of true costs. The option of negotiating prices between medical aid schemes and healthcare providers has been met with scepticism.

It is understood that the Health Department wanted "to balance the scales" in the present scenario likened to ordering from an unpriced menu in a restaurant where the waiter says the prices would be revealed after the meal. However, its intervention comes amid a Competition Commission inquiry into the cost of private healthcare, and a court case against PMBs by a Cape Town-based medical aid scheme, which the Health Department has not opposed. A ruling on whether patient rights groups could join proceedings to oppose the application is still pending. While medical aid scheme members have been hit by consecutive above-inflation premium hikes, administrators have long complained that the PMBs created an open-ended liability as providers charge what they like, knowing that there is an obligation for full coverage.

Health deputy director-general Anban Pillay said the intention was for "reasonable pricing" in healthcare, not one that was exploitative. The aim was for medical aids and health providers to negotiate, without the costs being passed on to the medical aid members. The department was aware of the risks, and might go back to the drawing board. Patient rights stem from section 27 of the Constitution, which stipulates that everyone has the right to access healthcare services and no one may be refused emergency medical treatment. By law, financial hardship was prevented by making PMBs fully covered.

Although only 15 percent of South Africans belong to medical aid schemes, this represents about 9-million citizens who access private medical care through monthly premiums. Section27, a civil-society organisation, said the proposed amendments effectively introduced payments for PMBs - and must be withdrawn as they were tantamount to "a whittling down of government measures to protect the right to access healthcare services".