PMB Review

Stakeholder Submissions (Circular 6)

Olurotimi ModupeCouncil FOR MEDICAL SCHEMES

Framework for revised PMB packageA draft PMB benefit package framework was drafted and published for stakeholder comments. The recommended

framework proposed a departure from the current package which is disease/condition based, to a service based

package. The proposed benefits will serve as a minimum package that must be available in a primary care setting,

and a hospital setting. Several submissions were received on the proposed framework. The submissions will be

submitted to the priority setting committee. These categories will be expanded further to incorporate the specific

service that should be covered, including the level of setting where the services should be accessed

Initial proposed package Stakeholder submissions(PMG, Johnson & Johnson, OTASA, PASA, NVF, Rare

diseases SA, SASCI, SAOA, SAMA, PsychMG, CPF, OSSA)(Numbers indicates different stakeholders)

4.1: Maternal and Neonatal services4.1.1 Antenatal services (not included in the current PMB Regulations)

Diagnosis of pregnancy

Information on nutrition and maintenance of a

healthy diet throughout pregnancy

Education and counselling on preparation for

childbirth, newborn and child care, breast

feeding, and emergency preparedness

Pre-natal supplementation

Immunization for vaccine-preventable diseases

Laboratory antenatal tests including screening for

fetal abnormalities

Radiology services including 2D pregnancy

ultrasounds

PMTCT

4.1.2Delivery (included in PMB) Diagnosis and monitoring progress of labour and

fetal well-being

Delivery of uncomplicated and complicated

pregnancies (including breech delivery and

1.Recommendation for separation of Maternal and neonatal services. Reference should be made to guidelines for maternity care in South Africa 2016.Maternity in accordance with Management of pregnancy

Basic antenatal care and specialised antenatal care for high risk patients

Intrapartum and post-partum careDelivery services

This is all part of Maternity services

Management in accordance with National Maternity Guidelines (2016)

Neonatal services

Neonatal Care Guidelines 2008 are outdated and there are new more innovative guidelines: Paediatric Standard Treatment guidelines 2017

Essential Neonatal Care: is the care required by all new-borns in the first 28 days of life, if they are healthy, or if they are sick or small. It includes the care they require to prevent illness in the new born period and later in life. This care takes place at home, in clinics, and in hospitals. Some new-borns require

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vaginal delivery after previous Caesarean

section)

Management of obstetric emergencies such as

eclampsia, multiple pregnancies, cord prolapse

etc.

Caesarean section for high risk or complicated

pregnancies (including breech delivery and

vaginal delivery after previous Caesarean

section, eclampsia, multiple pregnancies, cord

prolapse etc.).

Management of post-partum complications

Immediate care of neonate and initiation of

breastfeeding

4.1.3 Post-natal services Nutrition counselling and advice

Breast and perineal care

Continuation of education and counselling on

newborn and child care

Initiation or continuation of antiretroviral therapy

for HIV

Management of maternal complications

4.1.4 Other services (included in the current PMB Regulations)

Termination of pregnancy and post abortion care

Medical management of high risk pregnancies

such as Diabetes Mellitus, Hypertension, Heart

Failure Preeclampsia, etc.

Medical management of mild to moderate

pregnancy complications such as urinary

infection, mild to moderate anaemia, vaginal

infections

Care post abortion and family planning

4.1.5 Neonatal services Management of neonates with complications

including respiratory distress

Examination, Screening and Management of

intensive or specialised care. Management of sick neonates such as apnoea,

hypoglycaemia, convulsions, airway management including intubation, jaundice etc. The specialists and Provincial National Department can provide guidelines for this

Neonatal Resuscitation, management of abnormal birth weight.

Examination, screening and management of congenital disorders including congenital infections such as HIV and Syphilis.

2. Stakeholder feels encouraged by the inclusion of “immunisation against vaccine preventable diseases according to the National Department of Health (NDoH) guidelines” in this section. They highlighted that neonates born to mothers with

hepatitis B who are HBsAg positive have a 90% risk of becoming chronically infected carriers of hepatitis B virus if not vaccinated at birth. This puts them at a high risk of liver cirrhosis and hepatocellular carcinoma.

They then recommend that vaccinating hepatitis B virus-exposed neonates at birth should be part of the PMB service.

Stakeholder stated that by vaccinating the pregnant mother, neonates are protected from pertussis, influenza and all-cause pneumonia. They therefore propose that vaccinating pregnant women for their benefit as well as benefitting their babies be part of a PMB service.

3. Add Psychiatric care to ensure the mental health of both mother and child in antenatal services

Add psychiatric care to ensure mother and baby mental health in post-natal services.

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congenital disorders

Immunization against vaccine preventable diseases according to NDoH guidelines

4.2: Child Health Services

Advice, information and assistance of mothers on

breast feeding, weaning and active feeding

Management and care of high risk babies and

referral where necessary

Immunisation against vaccine preventable

diseases according to NDoH guidelines

Oral rehydration therapy for diarrhoea

Screening for common genetic disorders

Screening for genetic metabolic and childhood

cancers

Screening for symptoms of child abuse and

neglect

Screening for eye diseases, vision and speech

problems, and other abnormalities

Growth monitoring and nutritional support

(multivitamins) where indicated

Oral health checks and health advice

Deworming

Provision of ARTs in children infected with HIV

Treatment of opportunistic diseases

Referral for further treatment where appropriate

1. Recommendation for Integrated management of Childhood disorders and management of other childhood disorders.

Immunisation against vaccine preventable diseases according to NDoH guidelines including Vitamin a supplementation

Oral rehydration therapy for diarrhoea (Part of childhood illnesses management)

Screening for symptoms of child abuse and neglect and mental health

Integrated management of Childhood disorders as per National Department of Health

Chronic diseases of Childhood Growth Developmental assessment Optometry and audiology screening Oral health: routine preventative oral services

cleaning, fluoride and sealants. Dental emergencies (toothache, inflammation, infection)

Specialised health care: Dentistry has many areas of specialised care. For more inputs contact SADA

Hospitalisation

2. Recommendation that the inclusion of oral rehydration therapy under Child Health Services along with screening for metabolic conditions suggests that there is little clear direction in this section. It was proposed that the CMS invites or allows them to appoint a Paediatrician to join the panel.

3. Stakeholder is pleased by the inclusion of “immunisation against vaccine preventable diseases according to the National Department of Health (NDoH) guidelines” in this section. They mentioned that there are vaccines against

communicable diseases such as rubella, mumps, hepatitis A, chickenpox and meningococcus, that are not included in the EPI schedule; and there are also implementable immunisation strategies that are not

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part of the EPI. They suggest the consideration of communicable

diseases not covered in the EPI as part of the PMB package since they have high morbidity and mortality.

Stakeholder highlighted that vaccines currently used in South Africa do not offer life-long protection, with the protective immunity waning off after 5 years. School aged and adolescent immunisation guidelines for SA are currently being finalised. They recommend that these should be a PMB service.

They further went on to suggest that international and local recommendations on immunisation of diseases such as rubella and a booster dose for acellular pertussis should be considered as part of the PMB package.

4. Add Screening of intellectual abilities and neurodevelopmental disorders and management of acute and chronic child psychiatric disorders

4.3: Preventative services Information on the prevention of communicable

and non-communicable diseases

Information on early treatment seeking behaviour

Screening for non-communicable diseases e.g.

hypertension, hyperlipidaemia, diabetes, breast

cancer

Screening for communicable diseases e.g.

tuberculosis, HIV

Weight monitoring / screening (obesity and

underweight)

Nutritional advice and support

Chemo-prophylaxis for selected diseases

Family planning, advice and provision of

contraceptives

1. Screening for n diseases risk factors e.g. hypertension, hyperlipidaemia, diabetes, breast, cervical, prostate and colon cancer. Need to define criteria for Cancer screening.

2. Strongly recommend that immunising high-risk communities be included as a PMB service since they are at greatest risk of infection. They suggested infections that they should be immunised against include invasive pneumococcal disease, meningococcal disease, influenza, hepatitis A and B, and herpes zoster.

3. Stakeholder concluded that optometrists, as primary care givers can make contributions to preventive care and public health through specified screening methods to facilitate early diagnosis, linkage to care, treatment options and sustainable managed care.

Recommendation that the following needs to be

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included in PMB package: Immunisation and vaccines as per NDoH Guidelines for children and adults, Counselling and advice

Family planning advice and contraception, Information and education, on diseases but also

on assisting patients in seeking healthcare Supplements and nutrition, as well as nutritional

advice (other than as it would be associated with a medical condition under the current PMBs)

Screening for genetic disorders, cancer, abuse, eye and speech problems

Weight monitoring Prophylactic chemotherapy Screening for all non-communicable disease risk-

factors and co morbidities Screening for complications

4.Add early screening for neurodevelopmental disorders, psychiatric disorders, substance abuse and neurocognitive disorders

Add Psychiatric care for those who are victims of gender violence and all forms of abuse

4.4: Communicable and Non-communicable diseasesScreening and assessment of risk factors and co-

morbidities

Initiation of early treatment

Screening and management of complications

Follow up and monitoring of treatment adherence

Interpretation of common laboratory and radiological

results

Specialised geriatric care – including foot care

Referral to higher level of care when required

Neurological conditions/ neurology

Ophthalmology

Ear, Nose and Throat (ENT)

1. Recommendation that all services include specialist care and necessary support services such as occupational therapists, physiotherapist, biokinecists, dietician, podiatrists, and a whole range of others as registered by the HPCSA.

Specialised dentistry Primary Geriatric Care Internal medicine Infections Immunology Neonatology Paediatrics Family medicine

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Respiratory

Cardiovascular

Gastro-intestinal

Musculoskeletal

Dermatological

Endocrinology

Renal/Nephrology

Urology

Gynaecology

Oncology

Haematology

General surgery and Reconstruction surgery

Maxillo-Facial and Oral surgery should be added to the above services. Reason: The management of a variety of other facial PMB conditions are also the domain of Maxillo-facial and oral surgery, e.g. facial sepsis, cleft lip and palate, facial oncology, etc.

2. There is no provision for treatment of community acquired pneumonia in the outpatient setting.

They noted that under Communicable and Non-communicable diseases, provision is made for the involvement of all sub specialist groups but there is no provision made for the generalist Paediatrician. Surely the PMB service should be at the general or primary level rather than the sub specialist level.

3. Recommendation that Occupational Therapy is a profession that is recognised internationally for its involvement in all areas of healthcare including primary, rehabilitative and community-based services. They therefore recommend that each algorithm be updated to involve occupational therapy services.

4.Specification of a comprehensive set of benefits should be developed to cater for diagnostic testing and imaging and treatment of the various conditions with managed care at the core of the response for pathology, specifically those linked to risks for retinopathy, cataracts and glaucoma.

Abolish the current 2-year cycle for eye examinations and create a platform for continuity care to allow:

o Three (3) out of hospital consults per year, 1 pair of spectacles OR 1year supply of contact lenses annually and 1 in hospital consult available to optometrists with therapeutic privileges only.

o One (1) consult annually and 1 pair of spectacles OR a year supply of contact lenses to opticians and optometrists with diagnostic privilege.

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o These consultations should be closely linked with ICD 10 coding to assist as an output indicator and to prevent fraud and wastage.

5. consider medical progress to update some medically outdated definitions such as “treatable cancer”.

They highlighted that liver, pancreas and spleen have been excluded in the “referral to higher level of care”. Internal medicine has also been omitted from the list.

They proposed that the PMB review address inconsistencies in the current PMB list, e.g. the inclusion of hip fracture while fracture of the shoulder is excluded;

6. Add Psychiatry

7. Stakeholder would also like to suggest that there be a specific “Eye Care” Clinical Subcommittee established (Similar to a proposed Mental Healthcare Subcommittee) for the PMB review process, as the specialized nature of eye care does not lend itself to informed discussion inany general Clinical review committee, such as “Rehabilitation” or “Treatment ofCommunicable and Non-Communicable Diseases” committees.

4.5: Mental Health Services

Screening of patients in need of mental health

and substance abuse care

Admission, observation and treatment including

psychotherapy

Management of acute psychiatric cases and

referral

Management of substance withdrawal

Post-trauma (e.g. rape) counselling with

appropriate medical follow-up

1.Screening of patients in need of mental health and substance abuse (replace abuse with misuse as it is a more inclusive term)

Admission, observation and treatment including psychotherapy, Occupational Therapy, Social worker

Post-trauma (e.g. rape) counselling with appropriate medical follow-up- we recommend sexual abuse as an all-inclusive term

The ‘hospital based management’ that includes the full service based package should be the same for

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Referral to appropriate higher level of care when

required

Out of hospital management / continuation of

care especially

Laboratory and Radiology tests

both substance abuse treatment as well as all other mental illness.

Alternatively, billing for substance abuse service based packages should increase dramatically to come in line with billing allowed for other mental health illnesses with removal of restrictions on billing for additional professional services.

2.Add Management of chronic pain as well as Palliative chronic psychiatric care Management of patients with personality

disorders Management of psychiatric complications of

medical and surgical illnesses Psychiatric care of the aged Care of assisted and involuntary psychiatric

patients

3.It is recommended that Major Affective Disorders is stated in place of only Bipolar Mood Disorder. Bipolar Mood Disorder excludes a number of other disabling and chronic conditions better catered for in a more inclusive description of this category.

Include Clinical Psychologist in Screening of patients in need of mental health and substance abuse care. Substance abuse care relies both on psychopharmacology and specialized psychotherapeutic interventions that can be provided by Clinical Psychologist/Psychiatrist, usually in collaboration.

Include Clinical Psychologist Admission, observation and treatment including psychotherapy

It is important to also take note that NOT all psychiatric conditions necessitate the use of

psychopharmacology, therefore the clinical psychologist would be the primary provider of treatment to the patient with mental health difficulties.

Include Clinical Psychologist in Management of acute psychiatric cases and referral

The Clinical Psychologist is able to diagnose and manage acute psychiatric conditions pertaining to trauma, suicidal threats and loss.

Management of substance withdrawal: The

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Clinical Psychologist can assist in supportive manner and communicate with the family or close support system.

Post-trauma (e.g. rape) counselling with appropriate medical follow-up

On grass roots level, canals for referral should be made available for victims of trauma so that they can access higher level of care provide by clinical psychologist

Out of hospital management / continuation of care especially

The importance of out of hospital care psychotherapy.

Laboratory and Radiology tests: drug screening for substance abuse management, might even be more cost effective.

4.6: Rehabilitation

Diagnosis, medical management including

occupational therapy, physiotherapy and speech

therapy

Surgical management of impairments

Provision of basic assistive devices, including

wheelchairs, walking aids, hearing aids,

prostheses

Preparation for the use, maintenance and

servicing of assistive devices

Education on and facilitated access to social

grants, health and social services

Counselling and/or education (psychosocial

rehabilitation)

Referral for further care when necessary

1. Recommendation that Occupational Therapy is a profession that is recognised internationally for its involvement in all areas of healthcare including primary, rehabilitative and community-based services. They therefore recommend that each algorithm be updated to involve occupational therapy services.

2. Include Facilitation to social grants3. Add drug and alcohol rehabilitation including for

codeine abuse

4.7: Palliative services

Identification and diagnosis of patients requiring

palliative care

Individualized palliative care management plan

1. Include “Basic” assistive devices such as hearing aids and wheelchairs

2. Add Chronic psychiatric care

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by a multidisciplinary team

Provision of palliative care according to the

coordinated care plan

Referrals for symptom management

Referrals to palliative care specialist

Referrals for counselling for emotional support,

spiritual or bereavement care

Information & education to patient and family

Referrals to home-based and community based

palliative care services

Support to the community based psychiatric care services

4.8: Emergency services

“The sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part”.

Initial assessment and immediate stabilization

Immediate management of emergencies

Ultrasound, X-Rays and simple contrast studies

Emergency laboratory tests (basic biochemical

tests, haemoglobin, etc.)

Emergency cross-match and supply of blood and

blood products

Referral and transport to higher level of care

when required

1.Include radiology as a service, basket of radiological service for emergency is broader.

2.The proposed package provides for referrals, but it is not clear what aspects of care are included in such referrals.

3.Include Transport to higher levels of care (in emergencies)

4.Add Emergency support services to be enabled to manage and transport emergency psychiatric patients

Submissions on other regulatory / legislative concerns (Raised by all stakeholders)

Stakeholder supports improvements in the healthcare sector, but suggests that the PMB review process should be compliant with the law.

They however object to the complete revamping of the current PMB system as the new framework, in their opinion, would result in numerous patients with chronic and serious diseases no longer having any legal entitlements to the funding of treatment of those conditions.

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Stakeholder is concerned by the reassessment of the current PMB-package by the CMS with the objective of aligning it to the NHI service benefits as it could lead to reduced PMB cover for members.

They mentioned that paragraph 308 of the NHI White Paper states that the role of medical schemes will change once the NHI is fully implemented. Medical schemes will “…offer complementary cover to fill gaps in the service coverage offered by the NHI.”, in other words medical schemes will provide top-up care to the NHI and not the same or duplicate care.

concluded that they need clarification of the objective of the PMB Review, the relationship between the PMB’s and the NHI and the current rights and expectations of medical scheme members.

Comment that any overhaul of the PMBs as listed in Annexure A to the regulations of the Medical Schemes Act 131 0f 2008 would affect numerous rare diseases and their treatment.

They highlighted that the framework contained in circular 6 of 2018 is based solely on the NHI framework and does not make provision for conditions that were previously covered by the PMB legislation, and which in terms of regulation 8 of the Medical Schemes Act, must be treated in full.

The purpose of the PMBs is to ensure that patients are covered for chronic conditions, catastrophic and hospital-based care. Adoption of the proposed framework would leave such patients unfunded, thus resulting in deaths.

Stakeholder objects to the complete change of the PMBs as this cannot be a review. Implementation of this type of change would mean the CMS and NDoH are acting outside of what they are mandated to do in terms of the Medical Schemes Act.

They further went on to state that the proposed framework is the exact replica of the NHI benefit structure. This raised the following questions:

o What will schemes be required to fund?o What would be the point of obtaining extra medical scheme cover if members are reverted to NHI

cover? Stakeholder understood the PMBs to be there to ensure risk-pooling and adequate cover for conditions that the

average medical scheme member would not be able to afford to pay on their own. Therefore, the PMBs were mainly secondary and tertiary level care.

Mentioned that the proposed change will significantly shift from the original intention of the PMBs. They agree that the private healthcare sector should adapt, and better align, with a system of universal health

coverage. They highlighted that the proposed new package mirrors the NHI package rather than top-up care as stated in

the NHI policy. This creates severe uncertainty as to the role of medical schemes in an NHI environment. Stated that it would be impossible to decide what should be in the PMB package on the basis of an industry-

wide cost-effectiveness or sustainability in the absence of a risk equalization fund. They wonder whether it is appropriate to include additional care, not of a life-threatening, chronic or costly

nature, given the medical schemes limited funds, in particular in the absence of a common risk pool. The PMB Review criteria, as set in the law, should underpin the PMB Review assessment. Concern raised at

indications during the PMB Review process that these criteria are not relevant, and/or not binding. Mentioned that if public health education and awareness are main priorities, they need to be funded through

other activities. Resources should be spent on rendering healthcare services, and a person should not be denied care due to resources having been diverted away from it, to public health programmes.

Stakeholder stated that it seems impractical to achieve an entirely new, service based benefit structure of PMBs in the set time period (8 months), acknowledging that the previous PMB framework was developed over

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8 years. The PMB review should focus on addressing shortcomings in the current PMB framework, by reviewing the

Diagnosis and Treatment Pairs (DTP’s) and updating the associated protocols and baskets of care. They do not object to PMB review carried out in accordance to the Medical Schemes Act of 1998. Circular 6

does not appear to be a review but rather a complete overhaul of the existing PMBs to align with the NHI, which they do object to.

Stakeholder is concerned that entitlements of patients who suffer from PMB conditions will be removed, and patients with conditions that were explicitly listed before, will no longer have any legal entitlements to the funding of treatment of those conditions.

Furthermore, of a concern to stakeholder is where patients would obtain care and what would the outcome be if schemes fund more primary and preventative care and less catastrophic and tertiary care. They believe that this might lead to instances of death.

They are concerned about the proposed fundamental change in the PMBs from a package that covers catastrophic and costly care to a public health approach. They stated that this might have an impact on patients who cannot self-fund as they might be left unfunded for such conditions/events.

Stakeholder is of the opinion that the PMB review package appears to be a duplication of the NHI package, rather than developing a complementary package over and above the NHI package.

Stakeholder stated that the PMB package is empowered by the legal framework (Section 29(1) (o)). According to regulation 8, the law does not authorize the development of prescribed minimum benefit services, rather services for conditions.

They believe that the fundamental change of the PMBs to a service, and not a condition-based package, is not in line with regulation 8.

They further went on to state that it should be made clear as to what is being proposed as amendments. If the aim is to amend regulation 8 then stakeholders should be made aware of this proposal.

They proposed that until amended, the empowering legal framework should frame the current policy directive in relation to the PMBs. The PMB “service package” would be challengeable in law, if there is no alignment between the statutory provisions referring to conditions and the changed package referring to services.

Stakeholder stated that the purpose of the review must be clear – whether it is to update the package, as is envisaged by Annexure A, or to create a fundamentally different, and new.

They further went on to indicate that the purpose in terms of resource allocation should also be clear: to create multiple, separate pools (public and various medical schemes), which provide the same cover, or to create a system whereby certain cover is provided, funded by certain pools (or self-funded) under certain circumstances, and topped up by others.

The review does not yet appear to address one of the fundamental prompts for such a review, namely the “constant change in medical practice and medical technology”.

Stakeholder stated that the framework seems more like a list of services to be delivered by a public health system rather than a benefit list that is necessary to offer adequate care to a medical aid population. The open-ended points and vague inclusions suggest that every eventuality is covered.

Stakeholder would like to express concern at the limited time allowed for the project by the proposed timelines of the CMS. There is an inordinate amount of work required to overhaul the existing PMB system from a diagnosis based system to a service based system. The sheer volume of the required clinical input for such an extensive overhaul in such a short timeframe is simply not feasible from a provider perspective. Stakeholder would suggest that an incremental approach be taken, by first reviewing existing treatment protocols and

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thereafter initiating a process of gradually changing the benefits over a number of successive PMB Review processes. Stakeholder would also urge the CMS to consider that, especially in Mental Healthcare, current Prescribed Minimum Benefits are actually Maximum benefits for most scheme options in the funding industry. Any service basket proposed for PMBs should consider that it is unlikely that schemes will voluntarily offer any cover above what is legally required from them in mental health related PMBs. It is thus essential that the proposed PMB Services includes a comprehensive Mental Healthcare basket.

Stakeholder can agree in the principles of greater focus on primary healthcare, more preventative measures and a greater alignment with the National Health priorities, the process is not clear on how this will be achieved while still ensuring the legislative mandate of protecting the medical scheme beneficiaries from catastrophic costs. This is especially problematic in the Eyecare environment, as many current PMB conditions will be blinding if left untreated. The nature of Ophthalmic conditions is such that there is often no preventative and primary care that can be applied and delays in appropriate surgical management by the introduction of a primary care intermediary, can be catastrophic in certain conditions such as Retinal Detachments, Acute Glaucoma, Retinoblastoma and Choroidal Melanoma. This is only a few examples and is not an exhaustive list. Non-funding of conditions that are included in current PMB design, would be highly problematic, as most current Eye PMBs are blinding (even fatal) if left untreated due to non-funding by schemes in any new PMB service basket. Further, a focus on primary care cannot be done at the exclusion of catastrophic and blinding eye problems which are currently included for funding in the PMB environment. “The objective of specifying a set of Prescribed Minimum Benefits within these regulations is two-fold: (i)To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals.” (ii) To encourage improved efficiency in the allocation of Private and Public health careresources. There does not appear to be a regulatory requirement for inclusion of primary healthcare,especially if done at the expense of current serious illness cover and one would thus questionwhether PMB Regulations themselves need to be changed should this path be followed. One would also have to question how the current position of certain schemes to name the state as DSP fits in with (ii) as stated above. PMBs are there to remove the burden on state and yet allowing the State to be designated as the DSP does exactly the opposite. The PMB Review focus of a Service Based Package, in order to comply with the NHI Policy imperative is ambiguous, given the NHI Policy position that medical schemes will only cover complementary services once implemented. There will thus be the creation of a set of services which will be mandatory for funding by schemes, but will be excluded from funding by medical schemes once the NHI is implemented. It seems extraordinary that a PMB service basket is created as way of complying with National Health Policy, while the policy indicates that schemes will only offer complementary services in the future. Stakeholder agrees with the Specialist representative statement that was sent to the CMS, indicating that the there is concern that a change from the current PMB structures into a service based structure is too onerous to complete in a single PMB review process, while it is also questionable whether such a change would comply with the legislated requirements of a PMB review process. The Ophthalmological environment is a very technology dependent and fast evolving profession and there is an urgent need for the consideration of new treatment guidelines and the update of CMS guidelines in keeping with current treatment protocols as proposed by the various Sub Speciality Academic groupings in Ophthalmology. In the absence of an accepted PMB review since 2004, there is an urgent requirement for the CMS to accept updated treatment guidelines and protocols in Ophthalmology, before any consideration can be given for a radical change for the PMB structure to a service based package.The notion of a service based package is extremely vague, as the cover of ophthalmic care would still have to be specified per condition, as not all services are clinically appropriate for

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funding for all eye conditions. Funding of services would have to be reliant on condition specific treatment protocols. Diagnosis based funding could thus never be fully removed from the PMB process. Reverting to a service based package would lead to a much wider need for condition specific treatment protocols, for specifying the service basket funding, as full funding for every possible Ophthalmic service would never be sustainable for the funding industry, although such comprehensive cover would be preferred by providers and scheme members. The time constraints of the proposed timelines for the current PMB review will not leave sufficient room for such a comprehensive protocol design process.

Other concerns:

Radiology

Radiology and Imaging should be included in each Service Benefit Category. In the proposed framework, radiology is only mentioned in Sections A1, E, and H.

The type of imaging should be determined by internationally recognised, evidence based, radiology referral guidelines. Clinical Decision Support should facilitate this, where possible.

Funding should be linked to correct referral not diagnostic outcome. Referral of appropriate radiology should be allowable by primary care or specialist practitioners. There are routine screening radiological interventions that ought to be considered, these include

ultrasound and mammography.

Outpatient care

Hospital services must include outpatient care specialised, in addition to inpatient care. Current benefit design excludes out-of-hospital specialists, laboratory and radiology benefits with unintended increase in hospitalisations.

Primary Health Care

1.Primary Health Care PMB benefit must be explicitly defined, ring-fenced and monitored. This is to ensure that the CMS can ensure compliance as well as monitor expenditure and impact this would have on hospitalisations. Furthermore, the primary health care package should include the following broad categories of care

General Practitioner Specialist Family physicians Preventative services Reproductive health services for men and women Programmatic management of vulnerable people: Children, elderly and mental health, people living with HIV Chronic Disease Management Acute Care

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Medicines Procedures at PHC Allied health professionals Dentistry

2.Actions which should be undertaken to ensure the sustainability of the package include addressing the duplication of services currently offered by GP’s. Optometrists should be the gateway for eye care at primary level.

Mentioned that optometry is best placed within the construct of primary healthcare at the level of preventive care as this can offer significant support to the greater eye care team, rather than including it within a screening context as this poses limitation on the extent to services which could be provided.

Indicated that the PMB Review construct should include a clinical effectiveness assessment team, as well as an operational or implementation committee.

The South African Optometric Association would like the council to clearly define the role of optometry within the construct of primary health care as a level 1 preventive care service.

They suggest that a dedicated eye-care sub-committee is established to represent the roles, scope and reach of all participating healthcare providers.

3.Stakeholder indicated that podiatry services and skills have shown to be required in all 3 levels of health care; primary, secondary and tertiary levels, however, podiatry is not included in the NHI White paper nor is it included in the PMB Framework as part of the package of care that should be provided. They proposed that podiatry be duly incorporated in the benefit package since as mentioned above, plays an important role in all levels of healthcare.

Medicines and medical devices

Indicated that the status of the goods required to render services effectively and efficiently is not clear since the proposed package is service-oriented.

The position in law of primary care providers, which include nursing professionals, pharmacists, general practitioners and other first line providers, should be addressed, as the lawfulness and appropriateness of their services are determined by legislative frameworks outside of the Medical Schemes Act and Regulations.

Require clarity as to whether mandatory medical scheme cover as well as the Risk Equalisation Fund will still be implemented as part of health policy reforms. This will link to the proposed multiple funds to provide the NHI package of care to the total population.

Add: Old age health services

Management of Major Neurocognitive DisordersPsychiatric care of the aged

Add: Special psychiatric populations

Mentally ill prisoners

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Psychiatric state patientsPersons sent for observation in terms of the criminal procedures actPost-traumatic stress disorder in vulnerable populations including members of the SAPS,emergency services, pathology services

Need for specific “Eye Care” Clinical Subcommittee (Matter also raised above)

Stakeholder would also like to suggest that there be a specific “Eye Care” Clinical Subcommittee established (Similar to a proposed Mental Healthcare Subcommittee) for the PMB review process, as the specialized nature of eye care does not lend itself to informed discussion in any general Clinical review committee, such as “Rehabilitation” or “Treatment of Communicable and Non-Communicable Diseases” committees.

Oregon prioritized list

Stakeholder proposed that the revision of the PMB service package be based on an adapted Oregon Prioritised List as a starting point.

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