Lynne Carlisle: Business Day,

WIDESPREAD changes to SA's present range of prescribed medical benefits (PMBs), formally under review, have been proposed to the government by the medical schemes sector to make private healthcare affordable to more South Africans and extend cover to members.

Heidi Kruger, head of corporate communications at the Board of Healthcare Funders (BHF), says the concept of a standard, basic set of health services provided by every medical scheme for the protection of its members is laudable.

However, she says the current set of PMBs set out in the Medical Schemes Act of 1998, which consist of 271 referred-based conditions and 25 chronic conditions, have had many unintended consequences, including:

• Lack of primary care benefits included in the package;
• Lack of clarity in interpreting the PMBs; and,
• Absence of a regulatory framework for arriving at prices for the set of benefits.

"These, coupled with other problems such as those related to designated service provider arrangements and those relating to the responsible implementation of new technology for PMBs, have prompted a review of the package by the CMS and the Health Department."

Kruger says that in law the PMBs must be reviewed every two years to address:

• Inconsistencies or flaws in the present regulation;
• The cost-effectiveness of health technologies and interventions;
• Consistency with developments in health policy; and,
• The impact on medical scheme viability and its affordability

"The BHF has proposed an essential healthcare package to the government to replace the current PMB package. The proposed package is guided by the principle of coverage for all and not coverage of everything, with the primary care component being service-based rather than disease based.

It departs from the current PMB package since it includes primary and preventative care components.

"The introduction of a mandated primary care benefit could be effectively structured to help to reduce healthcare costs, generate better user satisfaction and population health outcomes, and improve access, equity and continuity of care.

"The BHF proposal stresses that if this it to be achieved there must be a functional referral system in the private healthcare sector and between the public and private sectors."

Kruger says primary healthcare is the level where people first contact the health system.