We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byAshanti Tanney
Modified over 2 years ago
© Benguela Health (Pty) Ltd Regulatory Protection for Medical Scheme Beneficiaries FPI 3 August 2010 Durban By Esmé Prins-van den Berg Director Benguela Health (Pty) Ltd
Agenda Medical scheme trends PMBs ICD10 coding Waiting periods Tariffs Medicine pricing Generic substitution Dispensing fees Issues to consider when advising clients © Benguela Health (Pty) Ltd
3 Medical Scheme Trends
Medical Scheme Coverage 2008 Principal members: (2009: ) Beneficiaries: (2009: ) Population Coverage –2008: 48.7m…16% medical scheme coverage –Best estimate 2009: 49.32m…16.4% medical scheme coverage 4 © Benguela Health (Pty) Ltd OPEN SCHEMESRESTRICTED SCHEMESTOTAL Principal members Dependants Beneficiaries
Trends: Medical Schemes Consolidation trend… –2008: 119 schemes –Jan 2009:110 schemes –Dec 2009: 112 schemes –Will be further reduced due to amalgamations and liquidations…. Bestmed & Telemed; Momentum Health & Ingwe; Oxygen & Medshield; GEMS & Medcor; Liberty Health & Medicover; Discovery Health & Umed… –Administrator consolidation: Medscheme & Old Mutual; Eternity Health & Sanlam; Momentum Health & Metropolitan 5 © Benguela Health (Pty) Ltd 2010
6 Benefit Pay-out: © Benguela Health (Pty) Ltd 2010 Increases in expenditure: FFS (over-servicing) Imbalance between schemes and providers (e.g. hospital groups)
7 Non-Health Care Expenditure: (2008: R9.7b) Increase: 8.1% Under CPIX © Benguela Health (Pty) Ltd 2010
Medical Schemes: Financial Health Gross contribution income –2008: R74b (R pabpm) –2009: R84.9b (R pabpm) Operating Results Average solvency –2008: 36.6% –2009: 32.6% 8 © Benguela Health (Pty) Ltd Deficit before investment & other income R929.4mR2.8b Surplus after investment & other income R2.4bR655.4m
© Benguela Health (Pty) Ltd Prescribed Minimum Benefits (PMBs)
PMBs Annexure A: –Diagnosis and Treatment Pairs – DTPs –270 conditions 2003 –Emergencies –Statutory definition 2004 –Chronic Disease List – CDL –26 conditions 10 © Benguela Health (Pty) Ltd 2010
PMBs 270 Diagnosis and Treatment Pairs (DTPs) –Code 155E Diagnosis: Myocarditis; cardiomyopathy; transposition of great vessels; hypoplastic left heart syndrome Treatment: Medical and surgical management; cardiac transplant –Code 903D Diagnosis: Bacterial, viral, fungal pneumonia Treatment: Medical management, ventilation 11 © Benguela Health (Pty) Ltd 2010
PMBs –Code 168S Diagnosis: HIV Infection Treatment: –HIV Voluntary counseling and testing –Co-trimoxazole as preventive therapy –Screening and preventive therapy for TB –Diagnosis and treatment of sexually transmitted infections –Pain management in palliative care –Treatment of opportunistic infections –Prevention of mother to child transmission of HIV –Post-exposure prophylaxis following occupational exposure or sexual assault –Medical management and medication, including the provision of anti-retroviral therapy, and ongoing monitoring for medicine effectiveness and safety, to the extent provided for in the national guidelines applicable in the public sector 12 © Benguela Health (Pty) Ltd 2010
Medical and Surgical Management Medical management or surgical management, describes standard of treatment required, namely prevailing hospital- based medical or surgical diagnostic and treatment practice for specified condition Significant differences between public and private sector practices follow public sector practice (national/provincial protocols) No public sector protocol Consultation with provincial authorities to ascertain practice It does not restrict setting to a hospital where relevant care should be provided It does not prevent delivery of any PMB on outpatient basis or in another setting Treatment and care to be rendered where it is clinically most appropriate 13 © Benguela Health (Pty) Ltd 2010
PMBs Emergencies –Sudden and at the time an unexpected onset of a health condition –Requiring immediate medical or surgical treatment, –Failure of which Will result in serious impairment to bodily functions or Will result in serious dysfunction of bodily organ or part or Would place the persons life in serious jeopardy Conditions on Chronic Disease List (CDL) –Statutory algorithms/treatment paths 14 © Benguela Health (Pty) Ltd 2010
Chronic Disease List (CDL) Addisons disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy Disease Chronic Renal Disease Coronary Artery Disease Crohns Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2 Chronic Obstructive Pulmonary Disorder Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinsons Disease Rheumatoid Arthritis Systemic Lupus Erythromatosis Schizophrenia Ulcerative colitis 15 © Benguela Health (Pty) Ltd 2010
PMBs 2004: –DSPs (Designated Service Providers)…preferred providers / preferred provider networks Funding –Full and unlimited funding of diagnosis, treatment and care costs –Diagnosis-based (ICD10 codes) What are ICD10 codes? –International Statistical Classification of Diseases and Related Health Problems (ICD10) –Consists of +/ diagnostic codes –Listed alpha-numerically –Used to index health care data –Confidentiality Why are they important? –Correct benefit pool –Full funding –Different rules for PMBs, co-pays, etc. 17 © Benguela Health (Pty) Ltd 2010
PMBs –Co-pays for Voluntary use of non-DSPs Clinically appropriate and effective drug on formulary – beneficiary chooses alternative drug knowingly Medicines: Reference price lists –Full and unlimited funding for involuntary use of non-DSPs –Involuntary use Emergencies No DSP within reasonable proximity of work or residence of beneficiary Service unavailable or unreasonable delays –Benefit limits? –Biological drugs / Biosimilars? –PET CT scans? 18 © Benguela Health (Pty) Ltd 2010
PMBs Interpretation of full costs –CMS: Appeal Committee Decisions –Industry: Opposing Legal Opinions Many schemes and administrators pay benefits in accordance with scheme rules CMS: Must enforce compliance with own legislation Industry Task Team –CMS/DoH –Funders –Providers –Consumers Code of Conduct: 30 July 2010 Change in legislation? 19 © Benguela Health (Pty) Ltd 2010
Managed Care PMBs may be subject to managed care interventions –Protocols –Disease management programmes –Formularies –Networks –Pre-authorisation Not for emergencies Therefore –Access to benefits may be subject to compliance with such interventions –E.g. registration on medicine benefit programme could be conditional prior to being able to access benefit © Benguela Health (Pty) Ltd
Formularies & Protocols Regulations 15H (Protocols) & I (Formularies) Evidence-based medicine, cost-effectiveness and affordability –Evidence-based medicine = Conscientious, explicit and judicious use of current best evidence in making decisions about care of beneficiaries whereby individual clinical experience is integrated with best available external clinical evidence from systematic research Provide to providers, beneficiaries, public on request Appropriate substitution where ineffective or (would) cause adverse reaction without penalty to beneficiary –Motivations by doctors –Cannot for example impose higher co-payment 21 © Benguela Health (Pty) Ltd 2010
Waiting Periods S 29A, Regulation 12 Condition-specific –Max period: 12 months no benefits in respect of condition –Condition for which medical advice, diagnosis, care or treatment recommended/received in 12 months prior to application for membership of medical scheme –Medical report may be required by scheme … must pay costs of any medical tests or examinations required by scheme for purposes of compilation of report General –Max period: 3 months no benefits Change benefit options: Only unexpired periods of waiting periods, no new periods Child dependant born during period of membership: No waiting periods © Benguela Health (Pty) Ltd 2010
Waiting Periods Category 1 –First time joiners –Applies for membership > 90 days after previous membership –Waiting periods General and Condition-specific Apply to PMBs © Benguela Health (Pty) Ltd 2010
Waiting Periods Category 2 –= 24 months continuous medical scheme benefits Previously beneficiary of medical scheme for continuous period of 24 months Termination < 90 days prior to application –Waiting periods Condition-specific –Not to PMBs Unexpired portion of general or condition-specific imposed by previous scheme © Benguela Health (Pty) Ltd 2010
Waiting Periods Category 3 –> 24 months continuous medical scheme benefits Previously beneficiary of medical scheme for continuous period of > 24 months Terminated < 90 days prior to application –Waiting periods General –Not to PMBs Unexpired portion of general or condition-specific ? © Benguela Health (Pty) Ltd 2010
Waiting Periods Category 4 –Changes for reasons of employment Previously beneficiary of medical scheme Terminated < 90 days prior to application Because of change in employment or Employer changes/terminates medical scheme cover of employees: Change at beginning of financial year or reasonable notice given for transfer at beginning of financial year –Waiting periods No waiting periods Only unexpired portions or previously imposed waiting periods –General –Condition-specific © Benguela Health (Pty) Ltd 2010
27 WAITING PERIODS Category 3 Month General 12 Month Condition-Specific Applicable to PMBs New applicants/persons not members for preceding 90 days Yes Applicants who were members for 2 years NoYesNo Applicants who were members for more than 2 years YesNo Change of benefitsNo N/A Child dependant born during period of membership No N/A Involuntary transfer - change in employment or employer change scheme No N/A Source: CMS © Benguela Health (Pty) Ltd 2010
Beneficiaries Rights Entitled to full and unlimited funding for PMBs….exceptions (DSPs)….schemes apply differently….often providers charge more for PMBs Payment may not occur from savings accounts No benefit limits Must submit accurate ICD codes Access to protocols and formularies Challenge evidence basis of formulary and/or protocols Ineffective/adverse reactions - protocols and formularies - need support of treating practitioner to enforce change at scheme level © Benguela Health (Pty) Ltd 2010
Disputes Medical/ Clinical Advisor Medical/ Clinical Governance Committee Principal Officer Board of Trustees Disputes Committee / CMS Courts © Benguela Health (Pty) Ltd Ex Gratia
In the Pipeline: Review of PMB Package (2008) Revised PMB Package In-Hospital Care DTPsCDL Out-of- Hospital Care DTPs/CDL Primary and Preventative Care Basic Dentistry Basic Optometry Medicine Lists Negative List (Exclusions) Potentially Above Threshold Out-of- Hospital Benefits 30 © Benguela Health (Pty) Ltd 2010
Procedural Coding and Tariffs RAMS: Statutory tariff ( Contracted in vs Contracted out) (Until 1993) BHF (scale of benefits) & SAMA (Private Tariffs) Competition Commission: 2004…anti-competitive CMS (NHRPL) DoH (RPL) (2007) –National Health Act (Regulations) RPLs Benchmark tariffs –Doctors can determine own tariffs –Schemes have specified reimbursement rates Court Case February 2010 –RPL and Regulations declared null and void retroactively until © Benguela Health (Pty) Ltd 2010
Procedural Coding and Tariffs HPCSA (Ethical Price List) –Scrapped –RPL should be benchmark –Only charges above RPL with informed consent Central negotiations again in future? –Draft legislation –Independent Commission Where does this leave the beneficiary? Over-charging? –HPCSA 33 © Benguela Health (Pty) Ltd 2010
Medicine Pricing Medicine pricing –Single Exit Price (2004) –Formula –Annual increases authorised by DG of Health –International Benchmarking 35 © Benguela Health (Pty) Ltd 2010
Generic Substitution Obligation on pharmacists (and dispensing doctors)…Medicines Act No substitution if –Forbidden by patient –Prescriber wrote in own hand next to item no substitution –Retail price of generic is higher –MCC declares product not substitutable MCC Guidelines (April 2010) –Only biosomilars non-substitutable –Previously also With narrow therapeutic range Shown erratic intra and inter patient responses Dosage forms can result in clinically significant bio-availability problems Intended for the critically ill, geriatric and paediatric patients Reasonable steps to inform of substitution Generally no/lesser co-payment 36 © Benguela Health (Pty) Ltd 2010
Licensed Dispensers: Dispensing Fees 37 Dispensing Fees S INGLE E XIT P RICE (P ROPOSED N EW F EES ) D ISPENSING F EE (M AX ; E XCL VAT) < R65 ( R75)30% of SEP (30% of SEP) R65 (> R75)R20 (R22.50) © Benguela Health (Pty) Ltd 2010
Pharmacists: Proposed Fees 38 Dispensing Fees S INGLE E XIT P RICE D ISPENSING F EE (M AX ; E XCL VAT) < R75R6 + 46% of SEP R75 < R200R % of SEP R200 < R700R % of SEP R700R % of SEP © Benguela Health (Pty) Ltd 2010 Retail pharmacists to annually disclose certain information to Director-General of Health Display dispensing fee structure in pharmacy Provide detailed invoices
© Benguela Health (Pty) Ltd Issues to be Considered
Advice to Clients Complex environment Expensive Financially healthy medical scheme…will scheme be around in the future? Good governance Benefits –Benefits when in need –Costly treatments covered Hospitalisation Cancer Good administration Compliant with legislation Business ethic Impact of NHI Affordability 40 © Benguela Health (Pty) Ltd 2010
© Benguela Health (Pty) Ltd Questions? Thank You
Prescribed Minimum Benefits & Chronic Medication COUNCIL FOR MEDICAL SCHEMES.
Centre for Actuarial Research HIV/AIDS Benefits in Medical Schemes in 2002.
CDL Disease Prevalence: Diagnosis and Treated 8 June 2009 Additional material supplied with IMSA NHI Policy Brief 3 National Health Insurance Policy Brief.
Health Market Inquiry presented by Charlene Sunkel.
Presentation on Bonitas Medical Fund to The Health Portfolio Committee June 2010 Prepared by: Gerhard van Emmenis: Acting Principal Officer.
22 August 2012 Parliamentary Portfolio Committee on Health.
Pharmaceutical Society of South Africa The community pharmacy environment HMI Public Hearing Set 1 Hearing 2 Pharmaceutical Society of South Africa.
1 Isolation and Quarantine Protocol Public Health Seattle and King County 2004.
Commonwealth Connector Pharmacy Benefits July 12, 2007.
HR Essentials: Employment Contracts Presented by Kristin Ramsey Associate Director.
Commonwealth Connector Minimum Pharmacy Standards October 11, 2007.
Briefing to the Health Portfolio Committee: Operational Activities and Budgets KP Matshidze Acting CEO and Registrar Council for Medical Schemes XX August.
What is commissioning? Paul McManus Pharmacist Advisor Yorkshire and the Humber Office North of England Specialised Commissioning Group North of England.
Healthcare Cover with Lifestage Modelling The Impact of Best Advice on the Medical Schemes Industry Anthea Towert Technical and Actuarial Consulting Solutions.
Road Accident Fund Amendment Bill, 2004 Comments by the South African Medical Association (SAMA) Presented by: Dr J. Van Zyl.
Time for a BREAK! You have 45 Minutes. Time Left 44.
Connecticuts Value Based Insurance Design The Health Enhancement Program for Connecticut State Employees (Covers Active State Employees and Retirees After.
1 CREATING AN ADMINISTRATIVE DRAW REQUEST (OCC) Complete a Checklist for Administrative Draw Requests (Form 16.08). Draw Requests amount must agree with.
BMU - E I 1 Development of renewable energy sources in Germany in
1 ITU Interconnection Workshop 17 August 2001 Role of the Regulator K S Wong Office of the Telecommunications Authority Hong Kong, China.
Scaling up HIV services for women and children achievements and challenges e-lluminate session e-lluminate session Yves Souteyrand 2 March 2010.
7/16/08 1 New Mexico’s Indicator-based Information System for Public Health Data (NM-IBIS) Community Health Assessment Training July 16, 2008.
Review of the Medical Schemes Environment and the Private Health Industry: Alex van den Heever Advisor Council for Medical Schemes.
1 Design of Dose Response Clinical Trials Boston Chapter of ASA April 10, 2006 Naitee Ting, Pfizer Global R&D.
Latest in Health Law…. SAPRAA June Key pieces of legislation Health Charter & BB BEE Medicines & Related Substance Act, regulations & Code Medical.
Gerard Toohey Director, Student Administration Monash University VSU Roundtable discussion - Who's doing what with VSU? ATEM Victorian.
1 CREATING AN ADMINISTRATIVE DRAW REQUEST (HBA) Complete a Checklist for Administrative Draw Requests (Form 16.08). Draw Requests amount must agree with.
Overview of Risk management: A EU perspective Lincoln Tsang May 2008.
2007 Annual Meeting ● Assemblée annuelle 2007 Vancouver 2007 Annual Meeting ● Assemblée annuelle 2007 Vancouver Canadian Institute of Actuaries Canadian.
C Copyright © 2005, Oracle. All rights reserved. Practice Solutions.
Engagement in Human Research & Multi-Site Studies K. Lynn Cates, M.D. Assistant Chief Research & Development Officer Director, PRIDE May 30, 2012.
A Brief History of Private Tariffs Dr Chris Archer SAPPF.
Easy to get appointments I can choose my doctor I’m part of the decision free to focus on my patients test results online excellent prenatal care great.
Human Capital Investment Programme Disability Activation Project (DACT) WELCOME Support Workshop Thursday 7 th February
BMU – KI III 1 Development of renewable energy sources in Germany in
Copyright © 2009 Pearson Prentice Hall. All rights reserved. Chapter 8 Capital Budgeting Cash Flows.
IPA Foundation presentation to IPAs Bankmed GP Provider Network & PHA.
PP Test Review Sections 6-1 to 6-6 Mrs. Rivas 1. 2.
Rwanda Social Security Board (RSSB) Medical Insurance Scheme May 2013.
1 January 5, 2014 ©Copyright 2010 Jacqueline Madrigal Benefits Manager.
Board of Early Education and Care Retreat June 30,
Council for Medical Schemes: An overview Prof Yosuf Veriava Chairperson: Council for Medical Schemes.
Cost of HIV/AIDS Adult and Pediatric Clinical Care and Treatment in Ghana Felix Asante, Jim Rosen, Futures Group/HPI August 4, 2010 Accra.
Copyright © 2003 Pearson Education, Inc. Slide 1 Computer Systems Organization & Architecture Chapters 8-12 John D. Carpinelli.
1 Impact Assessment. 2 Demographics 3 Sex and Age.
Regional Policy Management and control systems Franck Sébert, DG Regional and Urban Policy, Head of Unit C1 FOURTEENTH MEETING OF THE EXPERT.
Update on Recent Health Reform Activities in Minnesota.
1 © 2000 American College of Radiology Physicians Employment Contracts How to Survive Your First Contract Thomas R. Hoffman Associate General Counsel American.
© 2017 SlidePlayer.com Inc. All rights reserved.