New PMB regulations – ICON rises above the chaos

The Health Minister’s proposed amendments to the Medical Scheme Act have rocked the healthcare industry in South Africa. Among the confusion and uncertainty, ICON has emerged as a voice of reason, with solutions that offer a win-win for all.

Health Minister, Aaron Motsoaledi’s announcement in July of proposed amendments to the Medical Schemes Act has been met with criticism, shock and confusion by the South African public. Experts have offered widely differing views and interpretations of the amendment, with some warning of an added financial burden for consumers and others denying that patients will have to pay extra at all.

At the opening ceremony of the Board of Healthcare Funders’ (BHF) 16th annual conference in Cape Town on 26 July 2015, delegates heard that the minister was worried about the reaction to his intention to change the medical aid scheme act and in particular, the amendment of regulation eight of the act, which currently specifies that medical aids have to pay in full for prescribed minimum benefits (PMBs). Under the proposed amendment, medical aid schemes will only have to pay providers according to the 2006 tariffs set by the Council for Medical Schemes, where rates are considerably lower than what many healthcare providers are currently charging.

At present, PMBs cover all emergency medical conditions and a list of 271 conditions and 26 chronic conditions and include most treatable cancers. But over the years, abuse of the current legislation has led to some healthcare providers charging exorbitant fees for PMBs, resulting in a substantial financial burden for medical aid schemes and members.

The proposed amendment aims to rectify this by reducing the amount medical aid schemes have to pay providers. Organisations like Samwumed, the restricted scheme for municipal workers, have hailed the amendment as a victory. But others, like Professor Alex van den Heever, the Chair of Social Security at the Wits School of Governance explained in a recent radio interview that if passed, the amendment could result in South Africans finding out that they aren’t covered by medical aids for conditions they thought they were covered for – possibly resulting in patients having to pay in extra.

There is also concern that if passed in its present state, the amendment will increase bad debt, with consumers unable to pay providers and add to the burden of the already-struggling public health system.

But BHF managing director Dr Humphrey Zokufa said things had to change. “There has been reckless spending of medical aid money. The current trend is not enabling an environment where healthcare services are accessible and affordable. Healthcare in the private sector is getting more expensive and less accessible.”

In the midst of this confusion and uncertainty, Dr Ernst Marais, Executive Operations Manager for the Independent Clinical Oncology Network (ICON), is a voice of reason.

“In the current debate, most people are missing the point,” he says. “No-one has to lose. It is possible to design a healthcare system where everyone wins and more importantly, where the industry as a whole is strengthened – but there has to be some give and take.”

Since ICON’s inception almost 10 years ago, it has actively worked to implement innovative strategies to reduce the rising cost of cancer care primarily by standardising treatment protocols and negotiating prescribed fees in collaboration with oncologists and medical aids, resulting in a reduction of costs for cancer treatments as well the prices of some generic medicines.

These achievements earned ICON a commendation from the World Innovation Summit for Health (WISH) earlier in 2015, marking it out among a handful of global innovators that are making an impact on the rising costs of healthcare.

“ICON’s standard protocols take all of this noise out of the system and we ensure all the PMB diagnoses and treatments are covered by medical aids, no questions asked,” says Dr Marais. “In the realm of cancer care, patients will not be disadvantaged by any amendments to the act. We have already made provision for cost-effective, quality-focused treatment protocols that cover all PMB conditions and that are not a financial risk to medical aids. We have even made provision for some conditions that are not PMB, like more advanced cancer cases, for which there is also effective treatments in our models.”

Understanding the act and its proposed amendment is complicated, even for health experts, admits Dr Marais. “PMB for cancer is very complex,” he says. “But ICON has created a solution that works for all parties where quality and cost are addressed jointly – but most importantly, where the wellbeing of patients is put back at the centre of healthcare, where it was always meant to be.”