Dilemma for medical aids

Medical schemes challenging the government regulator of the industry in court on the scope of the set of compulsory benefits may find themselves in an uncomfortable position should they happen to win.

Known as prescribed minimum benefits (PMBs), these are a set of conditions that schemes have got to pay for in full, according to the Medical Schemes Act. But the Board of Healthcare Funders, and several schemes individually, have challenged the interpretation of the Medical Schemes Council on a section of the Act which if successful could see a cornerstone of medical scheme members' rights disappear.

They may, however, in that eventuality, be faced with "thousands more PMBs", according to Dr Monwabisi Gantsho, the registrar of the council. Asked to explain this, he said if a court found against the council and PMBs, the whole NHI (National Health Insurance) plan would have to be brought forward hastily to ensure people could rely on getting the healthcare they needed. He added that there were many more conditions the NHI would have to cover than PMBs. Gantsho implied too, that should the council win, schemes may find themselves in any event faced with more PMBs. The dispute on PMBs has risen in tandem with and related to the rising costs of healthcare in private health. The disputed regulation states PMBs must be paid in full, at cost and cannot be paid from savings accounts in benefits and must be paid from the major risk pool. All emergency procedures fall under the PMB umbrella as well as those conditions specified in the Act and its regulations. In the registrar's report within the Council for Medical Schemes' latest Annual Report, Gantsho stated that the council had submitted draft amendments to PMB regulations to the Health Minister, which would soon be published for comment.

A code of conduct for schemes in dealing with PMBs had been published - but this, in the case of some, appeared to have been breached. In the section of the report dealing with complaints, issues around PMBs had pride of place at the top of the list of types of complaints the council dealt with from members (1 749 complaints for the year), followed by non-payment of accounts (1 230 complaints). These two accounted for around half the complaints in the year that the council received.

Gantsho was less forthcoming, however, about the fate of medical schemes in general in the light of the impending NHI plans. Asked what would happen, he said the green paper had stated that schemes would continue to exist, but they might be in a different form. This was also stated in the council's annual report. He preferred not to be drawn on what form this might take. The council has set up a task team to deal with the issues and has a place on the Health Minister's advisory committee dealing with the NHI. Pressed for more detail,

Gantsho pointed again to the green paper, saying top-up schemes, supplementary and complementary services were available among other options internationally and this could be the case in South Africa. He said it was not possible to tell now how it would evolve over time and South Africa was not using the "big bang" approach that had been used, for instance in the UK, to introduce the National Health Service.

Pat Sidley: The Citizen, 7 September 2011