17 July 2019: South Africa: The prescribed minimum benefits (PMB) in the healthcare sector needs to be revised as the current regime is discriminatory and not conducive for the health and human development of the population, says Dr Rajesh Patel, Head of Benefit and Risk at BHF, speaking ahead of the upcoming 20th annual Board of Healthcare Funders (BHF)of Southern Africa Conference to be held in Cape Town from 21 – 24 July 2019.
PMBs refer to the set of diagnosis-based benefits that all medical scheme members have access to, regardless of the benefit option they have selected. There are approximately 270 Diagnosis and Treatment Pairs (DTPs) or PMB conditions, and 26 chronic conditions.
The BHF estimates that the total cost of PMBs for medical schemes is closer to R75 billion.
“Our biggest challenge is that prescribed minimum benefits are not aligned to good health policies, public health priorities, the National Health Act, and the constitution; the current cost makes them unsustainable,” says Dr Patel.
“Regulation has been approached in a knee-jerk fashion. Benefits are not clearly defined and thus subject to interpretation.
Another challenge is that PMBs are diagnosis based and are therefore by its nature discriminatory. For example, rheumatoid arthritis is included in the PMB regulations, however there are four or five conditions in the same class that are not – for example, polymyositis. The medication for RA is the same as that used to treat the other non-listed conditions. This raises the question; how can an essential medication be given to some patients and not to others? The PMBs are also predominantly hospi-centric. So in many ways, the current PMBs are discriminatory and not conducive for the health and human development of the population,” says Dr Patel.
He advocates for a regime that is fairer and more transparent, one that moves away from the current diagnosis based to an essential services-based benefit package.
“We need a new set of PMBs, that are primary healthcare based, where all citizens are guaranteed essential health services.” says Dr Patel.
Dr Patel says it is crucial that all stakeholders in the healthcare sector participate in the formulation of new PMBs to ensure that South Africans can access their constitutional right to quality and affordable healthcare services.
Efforts are being made by various stakeholders to begin to reframe future PMBs and the discussion on the desired future PMBs will be further unpacked at the 20th Annual BHF Conference to be held in Cape Town, from 21 – 24 July 2019.
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