Pharmacists welcome benefits ruling

2011-11-08 19:00
Johannesburg - The Pharmaceutical Society of SA (PSSA) has welcomed a court ruling that medical schemes must pay for prescribed minimum benefits (PMB) in full.

"We are absolutely sure that when it comes to the supply of medicines, the concern of medical schemes is not justified," PSSA executive director Ivan Kotze said on Tuesday.

"There isn’t an open cheque book because pharmacist’s fees are strictly regulated, both in terms of the dispensing fee and the services for which a pharmacist may levy a fee."

PMBs are the minimum level of diagnosis, treatment and care that a medical scheme is obliged by law to cover.

The PSSA said the Medical Schemes Act gave medical schemes an additional tool to control the cost of PMB, namely the appointment of designated service providers.

Penalty fee

Kotze said the consumer’s right to select suppliers, which forms an integral part of the requirements of the Consumer Protection Act, 68 of 2008, should be applied to the supply of medicines as well as other products and services.

"We are concerned that, in many cases, consumers are penalised for exercising their right to choose a supplier," he said.

Consumers who chose to visit a pharmacy of their choice rather than a designated service provider may be penalised by their medical schemes for doing so, said the PSSA.

It urged medical schemes to require consumers to pay only the difference in fees rather than a penalty fee.

The PSSA understood that the scheme may require the consumer to pay the difference between the designated service provider fee and the fee charged by another provider, but urged schemes not to penalise members who preferred to obtain their medicines from their usual pharmacy.

Negotiate on tariffs

The SA Medical Association (Sama) said medical schemes should be able to negotiate tariffs with hospitals, clinics and doctors.

Sama chairperson Dr Norman Mabasa welcomed Monday's ruling by the North Gauteng High Court in Pretoria, but said this was an issue that should never have ended up in court.

"This was not a misunderstanding of the PMB rules," he said, "but a development that can be directly attributed to absolutely no mechanism being available for providers and schemes to negotiate on tariffs and possible issues surrounding them."

He said he hoped medical schemes would join Sama in lobbying for a Competition Commission ban on health tariff negotiation to be revisited.

Protecting members

The court ruled that PMB, which protects members of medical schemes, would remain in place.

The Board of Healthcare Funders (BHF) had asked the court to rule on regulation eight of the Medical Schemes Act 131 of 1998. The regulation states that medical schemes must pay for the diagnosis, treatment and care of all PMB conditions in full, or at the price charged by the healthcare provider.

The scheme must pay for all PMB conditions in full and from its risk pool, not from a clients' savings account.

These benefits include 270 serious health conditions such as tuberculosis and cancer, any emergency condition, and 25 chronic diseases, including epilepsy, asthma and hypertension.

In court the BHF represented a number of medical schemes and administrators. It was later joined by the SA Municipal Workers' Union national medical scheme.


In a statement on Tuesday, the BHF said it was disappointed that the merits and principles of the matter had not been considered by the judge.

"There is therefore still no judicial pronouncement on the correct interpretation of regulation eight," the organisation said.

"Essentially, the judgment upheld the technical points raised by the respondents and the case was dismissed on the basis that BHF, as an industry body, lacks the necessary standing to have brought this matter to court."

It would consider the judgment and its legal options, and would seek a meeting with Health Minister Aaron Motsoaledi.

The Council for Medical Schemes, the first of 13 respondents in the case, welcomed the ruling on Monday.

"Prescribed minimum benefits are a cornerstone of the Medical Schemes Act and they were included in legislation for a good reason: to protect beneficiaries against unforeseen ill health that may prove financially catastrophic for them," council CEO Monwabisi Gantsho said. Gantsho is also the registrar of medical schemes.

"As the regulator tasked with looking after the best interests of medical scheme beneficiaries, we are happy that our courts have confirmed the need for such protection in law."

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