Transcript Prescribed_Minimum_Benefit__PMB`s-2008

Prescribed Minimum Benefits
&
Chronic Medication
COUNCIL FOR MEDICAL
SCHEMES
Prescribed Minimum Benefits (PMB’s)
• All medical schemes have to provide a basic set
of benefits known as Prescribed minimum
benefits- “270 treatment pairs”
• Schemes to pay the full cost of diagnosis,
treatment and care thereof.
• Each option offered by a medical scheme must
make provision for the PMB’s.
Objectives of the Prescribed
Minimum Benefits
• Protects consumers from invisible limits to
necessary benefits
• Prevent unfair discrimination on selected benefits
• Protect cover for necessary and high cost services
• Prevent dumping on the public health system
• Promote more appropriate behavior in benefit
design, costing and management of cost
Preamble to Regulations
• “The objective of specifying a set of Prescribed
Minimum Benefits within these regulations is two
fold:
1. To avoid incidents where individuals lose their
medical scheme cover in the event of serious illness
and the consequent risk of unfunded utilization of
public hospitals.
2. To encourage improved efficiency in the allocation of
Private and Public health care resources”
The 15 PMB categories
PMB Category
Example
Brain and nervous system
Eye
Ear, nose, mouth and throat
Respiratory system
Heat and vasculature (blood vessels)
Gastro-intestinal system
Liver, pancreas and spleen
Musculoskeletal system (muscles and bones);
Trauma NOS
Skin and breast
Endocrine, metabolic and nutritional
Urinary and male genital system
Female reproductive system
Pregnancy and childbirth
Stroke
Glaucoma
Cancer of oral cavity, pharynx, nose, ear, and larynx
Pneumonia
Heart attacks
Appendicitis
Gallstones with cholecystitis
Fracture of the hip
Haematological, infectious and miscellaneous
systemic conditions
Mental illness
Chronic conditions
Treatable breast cancer
Disorders of the parathyroid gland
End stage kidney disease
Cancer of the cervix, ovaries and uterus
Antenatal and obstetric care requiring hospitalisation,
including delivery
HIV/Aids and TB
Shizophrenia
Asthma, diabetes, epilepsy, hypothyroidism,
schizophrenia, glaucoma, hypertension
HIV/AIDS PMB
• Diagnosis: HIV infection
• Treatment:
– HIV voluntary counseling and testing
– Co-trimoxazole as preventive therapy
– Screening and preventive therapy for TB
– Diagnosis and treatment of STIs
– Pain management in palliative care
– Treatment of opportunistic infections
– Prevention of mother-to-child transmission of HIV
– Post-exposure prophylaxis following occupational
exposure or sexual assault
• Care : ARV’s
Applications
•
Regulation 8 (1 January 2004) specifies:
(1)
Subject to the provisions of this
regulation, any benefit option that is
offered by a medical scheme must pay
in full, without a co-payment or the
use of deductibles, the diagnosis,
treatment and care costs of the
prescribed minimum benefit conditions
Chronic diseases
• 25 chronic diseases are included in the 270
PMB conditions
• Treatment algorithms were developed:
– to manage risk
– to ensure appropriate treatment standards
– treatment covered by schemes may not be
inferior to the algorithms
• Consultations & tests are also covered
• Protocols, formularies & designated service
providers may be used to manage risk
Chronic Disease List
 Addison’s Disease
 Asthma
 Bipolar Mood Disorder
 Bronchiectasis
 Cardiac Failure
 Cardiomyopathy
 Chronic Renal Disease
 Chronic Obstructive
Pulmonary Disease
 Coronary Artery Disease
 Crohn’s Disease
 Diabetes Insipidus
 Diabetes Mellitus Type 1 & 2
Dysrythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus
Erythematosus
 Ulcerative Colitis












CDL:
What members need to know
• Schemes can demand pre-authorisation or
the joining of a benefit management
programme
• Schemes may decide for which medicines
it will pay, as long as they are at least on
par with the published treatment standards
• Chronic medicine limits can still be set, but
if limits are exhausted, schemes have to
continue paying for chronic medication
obtained from DSPs
Can my scheme refuse to cover my
medication if I need, or want a brand
other than that which the scheme
says it will pay for?
The scheme may refuse to cover all the
expenses.
When a formulary drug is clinically appropriate
and effective; and the beneficiary knowingly
declines; and ops to use another drug instead,
the scheme may impose a co-payment
Can schemes still set a
chronic medicine limit?
Yes, your scheme can set a limit for chronic medication,
however if you exhaust the set limit for chronic medicine
your scheme will have to continue paying for any chronic
medication you obtain from its designated service
provider for a PMB condition.
Legal Framework
•
Regulation 8 (1 January 2004) specifies:
(1) Subject to the provisions of this regulation,
any benefit option that is offered by a
medical scheme must pay in full, without
a co-payment or the use of deductibles,
the diagnosis, treatment and care costs of
the prescribed minimum benefit conditions
Legal Framework
Managed Care Interventions
(4) Medical schemes may employ….
appropriate interventions such as ….
pre-authorisation, treatment protocols,
formularies, etc.
Formularies
(5) When a formulary drug is clinically
appropriate and effective; and the
beneficiary knowingly declines; and ops
to use another drug instead, the scheme
may impose a co-payment
Legal Framework
15 H Protocols and 15 I Formularies:
(a) … must be developed on the basis of evidencebased
medicine,
taking
into
account
considerations
of
cost-effectiveness
and
affordability…
(b) ….must provide such protocol / formulary to
health care providers, beneficiaries and members
of the public, upon request,…
(c) Provision must be made for appropriate
exceptions / substitution…has been ineffective
of causes or would cause harm to a beneficiary,
without penalty to that beneficiary.
Co-payments
• Co-payments can be levied if members
choose to use non-formulary medication
and/or non-designated service providers
• Co-payments must be approved in rules
• Quantum to relate to difference between
actual costs and preferred provider /
reference price of formulary drug
• Co-payments may not be recovered out of
savings accounts
What is a designated service
provider?
It is a healthcare provider/s (doctor, pharmacist,
hospital etc) which is chosen by your medical
scheme to be utilised as a preferred provider to its
members when they need diagnosis, treatment or
care for a PMB condition.
The role of Designated Service
Providers (DSPs)
• DSP = medical scheme’s 1st choice provider
for PMB condition treatment
• May be state facilities, but not necessarily
• Scheme responsibilities:
– ensure accessibility
– ensure DSPs can deliver required services
• Non-DSP services are covered when:
– DSPs are not accessible
– DSPs cannot deliver
– Emergency treatment is required
DSPs: Prevailing practices
•
•
•
•
•
Schemes designate the public sector as
DSP without ensuring reasonable
availability & accessibility of services
PMB service provision not arranged with
public sector
Responsibility to secure a bed in the
public sector is shifted to beneficiaries
Promoting unfunded utilisation of services
in the public sector
Members not fully informed about their
DSP setting, particularly when it is the
public sector
Proposed model for
reimbursement of Prescribed
Minimum Benefits
Obtained from a
designated
(contracted)
service provider
(public/private)?
YES
NO co-payment
Voluntary
Co-payments
NO
Involuntary
No co-payments
The message to your
constituents
1.
2.
3.
4.
5.
Confirm with your scheme that your condition is a
PMB
Obtain the applicable rules from your scheme,
i.e. protocols, formularies, DSPs, co-payments
Make sure your GP/specialist manage your
treatment in terms of PMB rules & provisions
Adhere to your medical scheme’s rules
applicable to your condition
Be an active consumer: ask questions, obtain 2nd
opinions, follow the complaints procedure
You could appeal
• If formulary medication is not effective
beneficiaries can appeal to their schemes to
approve alternative treatment
• Doctor needs to provide clinical history
• If successful, scheme will cover non-formulary
treatment in full
• NOTE: personal preference is not grounds for
appeal
THANK YOU!