THE Minister of Health, Dr Aaron Motsoaledi, does not believe that PMBs for medical schemes should be treated as a blank cheque for healthcare providers. Moremi Nkosi, the director of health insurance at the Health Department, told the workshop on PMBs that if the law relating to the PMBs was a problem, then the new PMB task team should discuss this and how to address it. The Board of Healthcare Funders (BHF) has already made a suggestion on how the law should be amended, its managing director, Humphrey Zokufa, told the PMB workshop. Zokufa said schemes were so worried about the impact of having to pay for the PMBs at whatever rate providers charged that they wanted to seek a court order on whether this was the correct interpretation of the regulations. But, Zokufa says, Motsoaledi did not want a court to decide the matter, and said medical scheme stakeholders should rather agree on a way forward. At the Minister's suggestion, the BHF drew up draft regulations and proposed these to the Council for Medical Schemes. The council has also submitted its own draft regulations and issued three consultation documents to the Minister following past meetings with interested stakeholders held to review the PMBs. Zokufa said the council was probably considering the BHF's proposed regulations and, as a result, the BHF did not want the task team appointed to deal with this issue, but rather other issues, such as the problems of ICD-10 codes for the PMBs.

Laura du Preez: Personal Finance, 15 May 2010

A 16-MEMBER task team has been established by the Council for Medical Schemes (CMS), together with other roleplayers in the health industry, to tackle issues concerning compliance with prescribed minimum benefits (PMBs) legislation following a workshop held in Johannesburg this week. The team will also have to come up with a code of conduct for the health sector that will provide more clarity and detail on how and why PMBs must be implemented. The code will be binding on all industry roleplayers. The CMS has previously said almost all the medical aid schemes and administrators were not complying fully with the Medical Schemes Act as far as payment for PMBs was concerned. However, having the task team in place does not mean that the CMS will back down on its decision taken last year to penalise schemes and administrators for non-compliance. The penalties announced by the regulator included a threat to deregister culprits. Aleksandra Serwa, a spokeswoman for the CMS, said that full compliance with the Medical Schemes Act was non-negotiable. She said the process of establishing a PMB task team and drafting a more detailed code of conduct did not change anything. It would not change the current legislation, it would not change what was required or expected of the industry, and it would not change the council's statutory mandate as a regulator, Serwa said. The task team will have delegations from four groups: the regulators, which will include representatives from the Department of Health, the CMS and the Health Professions Council of SA; the schemes and administrators; healthcare providers; and consumer groups or beneficiary trustees. Each group will consist of four members mandated to represent the interests of that particular group on the task team. The names of the members will be finalised this week. Serwa said the cause of non-compliance appeared to be commercial in nature. She said that that non-compliance had little to do with protecting the sustainability of schemes as there was no indication that schemes faced differential pricing of PMBs by providers. She added that there was little evidence of schemes taking considered action to manage the PMB-related liabilities separately from their other benefits. The Board of Healthcare Funders (BHF) has approached the Minister of Health because it wants regulation 8 of the Medical Schemes Act, which governs the payment of PMBs, to be rewritten because it feels this gives too much power to the service providers at the moment.

Slindile Khanyile: Business Report, 13 May 2010

THE Council for Medical Schemes is to convene a high-stakes meeting today to try to resolve a row with the industry over the extent to which schemes are liable for members' claims for prescribed minimum benefits. The Medical Schemes Act says all medical schemes must provide all their members with cover for prescribed minimum benefits, a basic basket of care that includes emergency medical conditions, 270 diseases and 25 chronic conditions. In December last year, the council issued a strongly worded circular to the industry, saying many medical schemes were failing to comply with the Medical Schemes Act by refusing to pay for such benefits in full. Several schemes responded by saying they could not afford the open-ended liability punted by the council, and in the interests of all their members had to cap the level at which they would pay for such benefits. Most schemes set their threshold at a multiple of the controversial national health reference price list, leaving members to pay the difference if their doctor or service provider charged more than the rates set out in these guidelines. Many doctors and specialists charge above the reference price list rates because, they say, the recommended tariffs do not reflect the actual costs of running a practice. Today's meeting in Pretoria is expected to establish a task team that will work with the industry to draw up a binding code of conduct for handling prescribed minimum benefits claims. The stakes are high, as the council has threatened to deregister schemes or administrators that do not comply with the regulations on prescribed minimum benefits. At issue is how to interpret the regulations to the Medical Schemes Act that spell out medical schemes' duties regarding such benefits. Regulation 8 says all benefit options "must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions". The council says this means schemes are obliged to foot the bill for such benefits in their entirety, while many industry players say "in full" simply means to the maximum allowed by their own scheme rules. The industry also needs to figure out how to deal with a small minority of healthcare providers that abuse the loopholes in the system to charge very high rates, according to Boshoff Steenekamp from the council's strategic projects unit. He said that contrary to schemes' assertions that doctors routinely inflated their fees for prescribed minimum benefit conditions, the council had found no evidence that this was a widespread industry practice. Samwumed, which covers municipal workers, said the Medical Schemes Act's prescribed minimum benefit provisions should not be interpreted as a blank cheque. Samwumed principal officer Neil Nair said his scheme had been at the forefront of the battle for the past four years, challenging the council on the term "payment in full". He said it could never imply that a service provider could charge what he liked. Nair added that only about 10% of specialists were not adhering to scheme tariffs, but the fear was that this figure would increase in the future.

Tamar Kahn: Business Day, 11 May 2010

BAXTER Healthcare, which is planning to buy a unit of Adcock Ingram, has completed its due diligence of Adcock Ingram's Critical Care (AICC) division. The two companies are now in the process of finalising the shareholders' agreement. They have also begun discussions regarding the basis for determining the fair market value of AICC as set out in the option agreement. Baxter, a Swiss firm, notified Adcock of its intention to exercise a call option to acquire 51 percent of AICC last year.

Slindile Khanyile: Business Report, 10 May 2010

MEDI-Clinic expects its basic earnings a share and basic headline earnings a share for the year to March to be between 60 percent and 70 percent higher than a year earlier. The listed hospital group said these results included one-off items that would be elaborated on when it released its full results later this month. Excluding the one-off items, both measures of earnings were expected to increase by between 30 percent and 40 percent when compared with the year ended March 2009.

Slindile Khanyile: Business Report,

THE medical aid industry remains divided as attempts to reconcile differences between Discovery Health and the Board of Healthcare Funders (BHF) have failed. Five other schemes left the BHF together with the country's biggest medical aid scheme about two years ago because they did not see eye to eye with the industry body on a number of issues. One of those issues is said to be the BHF's position on the proposed national health insurance. Discovery deputy chief executive Jonathan Broomberg said that unfortunately, despite several meetings and intensive efforts to resolve these issues, the task team was not able to agree on mutually acceptable solutions to the various problems that led several schemes and administrators to leave the BHF in the first place. For this reason, he said, Discovery and, as far as he knew, all other schemes that left the BHF, were not intending to rejoin the BHF at this stage. BHF spokeswoman Heidi Kruger said one of the issues in contention, that the organisation's articles of association did not allow for administrators to become members, had since been resolved. She said that members of the BHF decided that, in the interest of pursuing the ideal of one industry body, the articles of association should be amended to allow for administrator organisations to be full members of the BHF. This process was completed and several administrators had now joined the BHF. Kruger said the five other schemes that had quit the BHF were Quantum, Altron, Anglovaal, Tsogo Sun and AECI, which are all administered by Discovery Health. She said, however, that they did not specifically cite the Discovery resignation as their reason for leaving. There were one or two other schemes that resigned due to mergers and financial reasons. Kruger said the BHF had embarked on an aggressive membership outreach drive in order to encourage these schemes back into the fold. A spokesperson for AECI Medical Aid Society said at the time that it resigned from the BHF that it was because the trustees believed there was no value added for the members' benefit. The society has not ruled out rejoining the BHF. Broomberg said that when Discovery left the BHF, a working group was set up to represent schemes and administrators that were dissatisfied with the BHF. Not formally constituted, it was loosely termed the Private Funders Forum. He said that at this stage, there was no formal organisation as the Private Funders Forum. However, a large number of schemes and administrators remain dissatisfied with the approach taken by the BHF to several key policy issues, and these organisations continued to meet.

Slindile Khanyile: Business Report, 10 May 2010

THE national health minister has mooted setting up a pricing commission, possibly along the lines of the National Energy Regulator of SA (Nersa), for all relevant healthcare tariffs to be discussed.

Heidi Kruger, head of corporate communications for the Board of Healthcare Funders of Southern Africa (BHF), the industry body for medical schemes and administrators, says: "Hopefully this will bring some certainty to the market with regard to tariffs. We regard this as a constructive development."

She says that the lack of transparency in what constitutes the drawing up of private hospital tariff structures is an ongoing concern. This, added to the fact that there has not been much movement on this issue over the past few years - apart from the proposed pricing commission - presents a challenge for medical schemes, Kruger says.

Another contentious issue is the absence of a regulatory framework for the governance of healthcare institutions, which is not confined to private hospitals and clinics alone but covers a range of institutional healthcare facilities.

"As we move towards a national health insurance (NHI) scheme, these issues should be resolved over time, but the establishment of the NHI could take some time to bed down."

She says that one of the main concerns for medical schemes remains the prescribed minimum benefits package - the basket of basic benefits that medical schemes are obliged to cover in full. There is evidence to show that for those particular procedures the tariff costs are much higher than for others, which in itself is problematic for medical schemes, says Kruger.

David Jackson: Business Day, 7 May 2010

THE Department of Health has urged private sector doctors to refer patients who are at high risk of dangerous complications from flu to state facilities to ensure they get vaccinated ahead of this year's flu season. The department's head of communicable diseases, Frew Benson, said public facilities could not turn anyone away. SA has not been able to secure sufficient stock to immunise the entire population ahead of the winter flu season. In the private sector, the 400 000 doses supplied by Solvay were sold out within weeks on a first come, first served basis, while the government has rationed the limited stock it has obtained, prioritising people at greatest risk from flu. Most people will recover without complications but some patients with chronic diseases or a suppressed immune system are more vulnerable. The high-risk groups include pregnant women, people with chronic lung diseases, diabetes, chronic heart disease, HIV or other diseases that suppress the immune system, and people over the age of 65. SA's flu season usually starts towards the end of May, peaks in June and tails off by the end of August. The peak coincides with the five-week Soccer World Cup. Three strains are expected to circulate this winter - pandemic A(H1N1) or swine flu is likely to dominate, but people may also be infected with seasonal strains A(H3N2) and influenza B, according to the National Institute of Communicable Diseases (NICD). The department bought 1,3-million doses of a trivalent vaccine that offers protection against all three strains from Sanofi Aventis. So far only 300 000 doses had been supplied to government hospitals and clinics, due to delays in clearing the stock with authorities in Bloemfontein, said Benson. The bottleneck should be cleared early next week, he said. The first batch of government vaccine was earmarked for frontline workers at ports and in healthcare facilities, and HIV-positive children under the age of 15 on antiretroviral therapy. The next phase will target the elderly, people with chronic diseases and pregnant women, he said. SA had no budget for procuring unused H1N1 vaccine from European governments, Benson said, but it had secured a donation of 3,5-million doses from the World Health Organisation (WHO). He said 40 000 of these shots had been earmarked for private hospitals for vaccinating their frontline staff. The WHO shipment had arrived in SA, and was expected to be cleared by authorities by the end of next week, Benson said. Most World Cup visitors are likely to have been vaccinated against swine flu and the likelihood of transmission in open-air stadiums is low, but the NICD said earlier this month flu outbreaks can occur at outdoor mass gatherings. Since most South Africans will not be immunised, the NICD said people should observe "cough etiquette", wash their hands, and stay at home if mildly ill until 24 hours after symptoms disappear.
Fifa said earlier this week that the biggest demand for tickets had come from the US, the UK and Australia, which have all run mass flu vaccination programmes.

Tamar Kahn: Business Day, 6 May 2010

THE Board of Healthcare Funders (BHF) wants regulation 8 of the Medical Schemes Act to be rewritten. The organisation, which met with the Minister of Health three months ago, said the regulation, which governs the payment of prescribed minimum benefits (PMBs), negatively affected medical scheme contributions. BHF spokeswoman Heidi Kruger said Regulation 8 had had unintended consequences in that it had allowed an open-ended liability for schemes, adding that the Council for Medical Schemes' (CMS's) interpretation of this regulation was that schemes must pay for PMBs in full irrespective of the amount charged. Kruger said that as the regulation was written and interpreted by the CMS at the moment, the balance of power rested entirely with the provider of service as he or she not only decided on the diagnosis and how to treat the condition, but also was able to decide on the quantum. The CMS said it had, together with the Health Department, made proposals to the Minister to revise PMB regulations in a way that dealt with the concerns raised by the BHF. According to the CMS the process had been inclusive and included the full range of affected parties. The PMB basket includes any emergency medical condition, 270 diseases and 25 chronic conditions. A workshop will be held next week to discuss the issue of non-compliance with PMB cover and to set up a task team to ensure compliance. While doctors say they also have some concerns with the PMBs, they are unimpressed with the BHF's move and have accused the organisation of not consulting with practitioners. The SA Medical Association (Sama) said any manipulation of tariffs should be a joint engagement among stakeholders. The association said it would always cause anxiety if the BHF wanted to make changes itself and added that it was also unhappy about certain aspects of PMBs because there were essential conditions not covered. Sama chairman Norman Mabasa said that primary healthcare conditions were not particularly well covered and that was why benefits got exhausted so quickly. Lex Visser, the chief executive of the Alliance of SA Independent Practitioners' Associations said that if there should be changes, all parties should sit down and come up with a solution that protected everyone. He added that no-one had ever done research on what doctors charged for PMBs. The Hospital Association of SA declined to comment as it had not seen the proposal. Kruger said everyone would be able to comment on the amendment once the regulation had been rewritten. A report in the MEDICAL CHRONICLE said the Department of Health was looking at setting up an independent commission that would be responsible for setting tariffs in the industry. The Health Department did not respond to request for comment, but the BHF and Sama welcomed the idea.

Slindile Khanyile: Business Report, 6 May 2010

BUSINESS Leadership South Africa (BLSA) wants a meeting with the Minister of Health as it seeks to contribute to the policy that will pave the way for the national health insurance (NHI) legislation, according to Mark Cutifani, the chief executive of gold mining firm AngloGold Ashanti. He said last week that the NHI legislation was one of four key laws on energy and healthcare that the lobby group, which represents top 80 companies, expected to directly affect big business. The organisation would put out a position paper on the NHI as soon as it had concluded consultations with the Minister and other roleplayers in the healthcare industry. As a guest speaker at the Hospital Association of SA conference, he said business agreed that the health system had to be reviewed. Cutifani said that where there were concerns with the NHI was if it were implemented as a narrow policy perspective, adding that there were other healthcare issues like prevention, clean water, good sanitation and service delivery. He said South Africa was unique and it had to find solutions that were suitable for its profile and that would match its income levels. He concluded by saying that South Africa did have a system that worked, but the question was how to leverage it to change the outcomes for average South Africans. Fidel Hadebe, the spokesman for the Department of Health, said any engagement with any interested party on the NHI would be welcome as it was an open process.

Slindile Khanyile: Business Report, 3 May 2010