Interpreting the PMB Level of Care, Prof van den Heever raised concerns of widespread non-compliance as schemes continue to regard PMBs as a discretionary benefit.
Prescribed minimum benefits (PMBs) have been around as part of revised regulatory framework since 2000. However, to a large extent there are still problems with compliance from the perspective of universal health coverage (UHC) that we require in the SA context.
“The question that sits before the industry as a whole, is what role does it want to play in providing universal coverage?” said Prof Alex van den
Heever. “And is it short-changing everybody by not complying with such a fundamental requirement?”
Speaking during a webinar hosted by the IHRM (Institute of Health Risk Managers) on Interpreting the PMB Level of Care, Prof van den Heever raised concerns of widespread non-compliance as schemes continue to regard PMBs as a discretionary benefit. Believing medical schemes play a critical part in SA’s UHC system, Van den Heever stressed that ensuring that medical schemes fulfil this role requires that they not discriminate against vulnerable groups and that they cover essential healthcare.
“Where private services form part of the UHC framework, access to care depends on access to insurance,” he said. “Medical schemes must effectively protect people's coverage and provide them with a comprehensive support framework from cradle to grave in a single system.
“A large portion of the expenditure on PMB conditions involves out of pocket expenditure, medical savings account expenditure, and risk pool expenditure. The risk pool expenditure is expected, but why is all of it not in the risk pool expenditure. If it's a PMB condition and what that suggests, and it's difficult to differentiate, but somebody might be arguing that maybe yes, it was a PMB condition, but for some or other technical reason, it didn't comply with PMB requirements in the regulation, so it wasn't treated as a PMB,” Prof Van den Heever explained. “But the expenditure distributions are so widespread, so broad that it suggests that in fact very small amounts, very limited level of expenditure is on what could be classified as a PMB benefit. One that complies with all the conditions of requiring no co-payments, no balanced billing, and no purchases from the medical savings account.
“It suggests that most PMB conditions are treated as general benefits unless medical scheme members complain and there is ultimately a regulatory decision in the appeal processes through the Council for Medical Schemes,” Prof Van den
“Expecting any part of the population to purchase high-cost healthcare services on an out-of-pocket basis effectively amounts to a denial of access to care. Financial risk protection therefore emphasises catastrophic health expenses. However, most of the medical scheme systems appear to have automated all systems to treating PMBs as general benefits, unless there is some kind of reaction from members. This puts members in a very vulnerable position as most cannot navigate the medical scheme system and just accept the word of the scheme.
“This is how schemes save money and compete with other medical schemes. But what’s happening is that members have been short-changed and there’s an aspect of breach of the legal framework that happens,” explained Prof Van den Heever.
“It also means there's a breach of the social contract, that people are short-changed for commercial reasons, and it's done wilfully. There's systemic noncompliance with PMBs because it would create a competitive disadvantage to treat PMBs conditions as PMB benefits.” There appears to be a failure of the industry to see the importance of its role in performing a major function as part of the universal coverage model in SA and that medical schemes have a long-term permanent role to play in that.