Wednesday, February 2, 2011

How prescribed minimum benefits help you manage diabetes

What is diabetes mellitus?

When we eat, the food is broken down into materials that our bodies need to function properly. One of the substances into which food is broken down is the simple sugar glucose. Sugar is absorbed into the bloodstream and stimulates the pancreas to produce insulin. Insulin allows sugar to move from the blood into the cells where it is converted into energy.

Diabetes is a chronic disease where your blood sugar levels (blood glucose) are too high because the normal control mechanisms of your body fail.

There are two types of diabetes, namely type I and type II. The two types are actually two completely different diseases.

Diabetes type I occurs when your body does not produce adequate quantities of insulin. It typically starts in early childhood.

Diabetes type II occurs when your body does not make enough insulin or, even if adequate amounts of insulin are produced, the body fails to transport the glucose from the bloodstream into the body cells. Type II usually starts later in life.

The result of both is that the glucose stays in your blood and cannot be used as an energy source for normal cell functions.

Diabetes leads to serious complications and could even jeopardise your life. It may cause heart disease and strokes and damage the eyes, kidneys and nervous system. Blood sugar levels that are too high or too low can also cause you to fall into a coma.

Diabetes cannot be cured but it can be successfully managed.

Treating diabetes

The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially diet and exercise, but most sufferers also use medicine management at some point.

People with diabetes mellitus type I almost always need insulin therapy but lifestyle management is still important. People with diabetes mellitus type II may be able to manage their disease with lifestyle changes but if blood sugar levels cannot be controlled this way, oral anti-hyperglycaemic drugs and even insulin therapy may be required. Treatment of other risk factors such as blood pressure and high cholesterol is extremely important.

PMB entitlement

Diabetes mellitus type I and type II are included on the prescribed minimum benefit (PMB) Chronic Diseases List. This means that your medical scheme must fund the diagnosis, treatment and care of your condition and it must do so from its risk pool and in full.

Your condition must be treated according to the algorithm in the PMB regulations. These algorithms are also available on the Council for Medical Schemes (CMS) website at the following links:

The disease management interventions that must be funded by the scheme include:

• Consultations with your treating provider (GP or specialist – if authorised by your scheme)
• Lifestyle modification interventions such as dietary and disease education
• Annual eye examination for retinopathy
• Annual comprehensive foot examination
• Pathology tests at 3-6 monthly intervals
• Disease identification card or disc
• Home glucose monitoring

It is important to remember that the scheme may still use managed care protocols which for instance allow only a specific number of consultations with your treating provider per year. These protocols must be supplied to you on request.

If there is a clinical reason or need for more benefits than those specified in the protocol the medical scheme may not refuse to fund these.

The Communications Unit would like to thank Ronelle Smit, Dr Nkuli Mlaba, Dr Selaelo Mametja and Dr Boshoff Steenekamp for making this edition of CMScript possible.

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