New amendments to PMBs leave patients exposed

© Aleksandar Radovanovic – 123RF.com

The South African Society of Anaesthesiologists (SASA) notes with concern that this may result in loss of patient benefits and multiply additional burdens placed on medical practitioners.

SASA believes that the gazetted proposed amendments to Regulation 8 leave patients exposed to potentially higher co-payments, with medical schemes being afforded the ability to pay far less for PMBs in terms of their cover of their members. This leaves the question of who is liable for the gap between what medical practitioners charge and what medical schemes will be determined to pay.

PMBs must currently be funded in full and at the doctor's or the provider's 'usual tariff' by all medical schemes on behalf of their members, regardless of which plan they subscribe to. A PMB refers to close to 300 listed conditions - all of which in some way affect quality of life or longevity. These conditions include many cancers, congenital (from birth) conditions, fractures, burns, high blood pressure, diabetes and complications thereof, among many others.

SASA has a responsibility, as a representative association of providers of medical services, to try to unpack the amendments from the perspective of the beneficiary (the patient) and to add its voice to ensure that consumers are aware of the consequences to them of the proposed changes. SASA wants to ensure that not only does it understand the implications for the medical practitioner but also that the public understands the full potential implication of the proposed amendments.

In its opinion, the proposed amendments effectively nullify the intent of the PMB regulations from the Medical Schemes Act, making any scheme member presenting for treatment for a PMB condition more at risk for non-payment of benefits.

In addition to this, and less publicly reported, is the proposed amendment of Regulation 5. This proposed change also adds additional administrative burdens on medical practitioners and hospitals, without ensuring that the infrastructure to receive and process the required discharge summaries, as submitted to medical schemes, is in place within the medical schemes. As this is a condition for payment to be made, extensive delays in payment are expected. In effect, there could now be pre-authorisation and post-intervention authorisation needed from schemes.

Six key notes

Here are six things to note about the new draft amendments:

1. The new proposed legislation potentially has significant adverse implications for consumers. As the proposed PMB regulation change reads, medical schemes are entitled to pay less for prescribed minimum benefits than what medical services currently cost and will potentially be permitted to pay less for PMB conditions that what the members' chosen plan would cover for non-PMB conditions.

2. In SASA and its legal adviser's interpretation, the proposed PMB regulation change does not prescribe that medical practitioners must charge less for services, but speaks only to the requirement for payment by the medical schemes. Others however have interpreted the change to mean it may force payment at a rate (national reference price list rate) that will result in a compromise to service delivery and access to skills for emergency treatments.

3. Requiring medical practitioners to charge a set rate would be in violation of the regulations of the Health Professions Council of South Africa and the Constitution and would amount to price-fixing by the government. While SASA does not oppose price benchmarking exercises, such prices must be based on fact and relate to the actual cost of service. The more recent iterations of the National Reference Price List (which were based on the 2006 price list proposed in this legislation) were rejected by the courts as not meeting those criteria and being, essentially, an unsubstantiated guess.

4. This gap between what medical schemes would be liable to pay and medical practitioners' costs means that patients will potentially be liable for higher co-payments. This goes directly against why the PMBs' Regulation 8 was instituted.

5. Under the proposed new regulations, medical schemes may also be allowed to pay out less than their own benefit schedules. This may violate the contractual terms and conditions between medical schemes and patients. In the instance that consumers have increased co-payments, this will place an additional financial burden on them that they may not be able to afford, thus defaulting on payments to their medical practitioners. SASA would like to highlight that such a scenario would burden medical practitioners financially and is one that creates a disincentive for medical practitioners to avail themselves to provide medical services or continuously train and develop themselves in their field of specialty.

6. Regulation 5, while less publicly reported, has also been proposed for amendment. This regulation requires attending doctors to provide a discharge summary to medical schemes for all conditions, including PMB conditions, for hospital and doctors (potentially all medical) bills. While medical bills may be submitted at present using multiple digital platforms, these summaries are not catered for in current medical scheme systems. There is every possibility and likelihood, therefore, that schemes will simply not reimburse medical practitioners for months or years pending finalisation of such reports. These reports may also contain patient confidential information requiring specific consent for sharing such confidential information.
   

Adding to patients' burdens

As currently interpreted by SASA, the proposed reporting and PMB changes will burden patients with higher co-payment costs and all patients need to ensure they understand whether they are sufficiently covered for all potential healthcare needs.

The macro level impact of the proposed changes to Regulation 8 and Regulation 5 is that it will ultimately cost the country through a potentially shrinking medical skills base. The country already faces a significant specialist skills shortage and struggles to retain the existing skilled medical practitioners.

SASA has always engaged constructively with the healthcare role-players and has consistently been able to resolve many issues through this manner of constructive engagement. SASA shall approach this concern in the same proactive manner and has every expectation that a positive outcome can be achieved.