Cape Town - Uncertainty hangs over proposed amendments related to prescribed minimum benefits (PMBs) covering a range of chronic conditions amid fears medical aid scheme members, currently fully covered for these, will be left to pick up the tab.
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 health-care providers and medical aid schemes while banning any patient co-payments.
Medical schemes are compelled by law to pay for PMBs in full.
Currently 25 PMBs – including diabetes, asthma, schizophrenia, high blood pressure, HIV, some heart conditions and epilepsy – must be paid for in full, regardless of charges, by medical aid schemes.
Also covered are a range of 270 treatments, including emergency medical and some cancer treatment.
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.
Critics of the proposed amendments say they are worried the proposed amendments could restrict access to health care – effectively dumping medical aid scheme members in an already overburdened public health-care system – or place 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 health-care providers has also been met with scepticism.
It is understood the Health Department wanted “to balance the scales” in the current scenario, likened to ordering from an unpriced menu in a restaurant where the waiter says the prices would be revealed at the end of the meal.
However, its intervention comes amid a Competition Commission inquiry into the cost of private health care, 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 remains pending.
While medical aid schemes members have been hit by consecutive above-inflation premium hikes, administrators have long complained the PMBs created an open-ended liability as providers charge what they like, knowing there is an obligation for full coverage.
Health deputy director-general, Dr Anban Pillay, said the intention was for “reasonable pricing” in health care, not one that was exploitative.
The aim was for medical aids and health providers to negotiate, without the costs being passed on the medical aid members. The department was aware of the risks, and may yet go back to the drawing board, Pillay added: “There’s maybe an alternative… providers can share with us what is the reasonable cost.”
Patient rights stem from section 27 of the constitution which stipulates everyone has the right to access health-care services and no one may be refused emergency medical treatment.
In law, financial hardship was prevented by making PMBs fully covered.
Although only 15% of South Africans belong to medical aid schemes, this represents about nine million citizens who through monthly premiums access private medical care.
Section27, a civil society organisation, said the proposed amendments effectively introduced payments for PMB – and must be withdrawn because they were tantamount to “a whittling down of government measures to protect the right to access health-care services”.
The proposals could “place an additional burden on patients to cover the costs of PMB conditions”, said Section27 attorney, Umunyana Rugege, adding the proposals failed to explain their rationale.
Patient rights advocacy groups like the Treatment Action Campaign, People Living With Cancer and South African Depression and Anxiety Group (Sadag), according to Section27, were concerned the proposed amendment “has the potential to take away access to health care for patients”.
Linda Greeff, a director at People Living With Cancer, said: “Many cancer treatments will simply be out of reach for anyone without the guarantee of payment for PMB conditions related to cancer.”
Sadag operations director, Cassey Chambers, said: “Many patients with mental health conditions will not be able to afford to pay or co-pay for the medicine they need and will land up in hospital with even more serious conditions.”
Private Practitioners’ Forum chief executive officer, Dr Chris Archer, said the proposed amendment effectively turned a minimum benefit into a maximum benefit and went against the legislative intention to protect patients.
“Patients with cancer, diabetes, heart conditions… won’t have the full cost of their care met by the scheme. They will either be bankrupted or dumped on the state.”
The NHRPL was not based in fact, but “a thumbsuck made in 2006, not on the basis of any study of costs”, he added.
The possibility of negotiations was also downplayed as Archer pointed out medical aid schemes used designated scheme provider contracts, presented with a take-it-or-leave-it attitude even if with the sweetener of higher fees.
Labour federation, Cosatu, last week reiterated a previous concern that the law failed to specify the minimum tariff for PMB, “creating a wonderful money-spinning opportunity for some health-care providers, particularly private hospitals and specialists”.
Cosatu social development policy co-ordinator, Khwezi Mabasa, said the proposal to negotiate an alternative tariff without defining this did not correct the legislative oversight, while it ignored “unequal bargaining power”.
Politicial Bureau