Thursday, October 7, 2010

Clarity on PMB's

Carte Blanche on MNET had a slot last Sunday on Prescribed Minimum Benefits which might have caused some confusion.

Just to get more clarity on the PMBs as introduced into the Medical Schemes Act

· PMB’s was introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment.

· These PMBs cover a wide range of close to 300 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.

· Terminology

In order to understand the impact of the legislation changes, a clear understanding of the terminology is required:

Designated service provider (DSP)

This refers to health care provider/s that have been "selected by the scheme to provide its members diagnosis, treatment and care in respect of one or more of the PMB conditions".

Emergency medical condition

This is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment. Failure to provide this treatment would result in impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy.

Prescribed Minimum Benefits (PMB's)

PMB's are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:

· any emergency medical condition
· a range of conditions as specified in Annexure A of the Regulations to the Medical Schemes Act (No 131 of 1998), subject to limitations specified in Annexure A. Included in this list of conditions is the list of chronic conditions

So this means that a long list of conditions identified as Prescribed Minimum Benefits was issued. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.

The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.

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