Discovery: Regulator's ruling doesn't change policy on prescribed minimum benefits

South Africa’s largest open medical scheme says its Prescribed Minimum Benefits policy remains centered around funding treatments where there is strong clinical evidence showing their effectiveness, even if they are more expensive than alternatives.

This comes after the regulator, the Council for Medical Schemes (CMS), ruled recently that Discovery Health Medical Scheme (DHMS) must fund alternative surgical treatment for glaucoma which Discovery argued did not meet "PMB level of care" treatment prerequisites.

In 2015, the scheme declined to fund XEN-stent, a surgical implant for a member with chronic glaucoma. But it offered to fund a more expensive treatment.

In its ruling, the CMS said because the treatment covered by DHMS was causing more harm to the member’s eyes and because the scheme failed to suggest an alternative that would not cause more scarring, it should pay for XEN-stent treatment. The CMS Appeals Committee had made the same ruling in March 2019, but DHMS appealed it.

On Tuesday, Discovery Health CEO, Dr Ryan Noach, said the scheme’s refusal to fund the treatment was not about cost-cutting - it was about reliance on evidence-based care, something it will continue doing. Noach said the scheme encourages doctors to submit published clinical evidence as motivation if its their patients required alternative and new treatments. But it will fund those only if information submitted is in accordance with principles of "evidence-based-medicine".  

"It is important to note that the appeal board ruling was based on the exceptional circumstances as they apply to the member concerned. In our view, this ruling therefore does not create a precedent for changing how the PMB guidelines are applied," said Noach.

Since medical schemes in SA were compelled to pay for PMBs at cost, many have adopted policies that outline "PMB level of care" that qualifies for full funding. They also use designated service providers to try and contain their costs. To meet its PMB obligations, DHMS implemented a rule that it would only fund treatments where there is enough established clinical evidence.

PMBs, a set of defined benefits covering 270 medical conditions, 25 chronic conditions and life-threatening medical emergencies, have been a bone of contention among players in the healthcare sector since they were introduced into the Medical Schemes Act in 2004 given the open-ended tariff implied by the regulation. Over the years, medical schemes blamed them as one of the contributors to spiralling private healthcare costs.

Late in 2019, CMS proposed a new affordable PMB package with a strong focus on primary healthcare. But working on its cost structure is expected to begin in March and until the new package becomes effective, medical schemes are still bound by the current PMB regulations.

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