June 12, 2010
By Laura du Preez
The medical schemes industry task team set up to address issues around the prescribed minimum benefits (PMBs) will not deal with the controversial issue of schemes paying for the PMBs at cost, the new Registrar of Medical Schemes said this week.
The registrar, Dr Monwabisi Gantsho, put out a circular saying the task team will continue with a view to developing a code of conduct on PMB compliance, but that the interpretation of regulation eight of the Medical Schemes Act will not form part of the team's terms of reference.
Regulation eight was intended to protect you, as a medical scheme member, by ensuring that your scheme provides you with certain essential healthcare benefits.
The regulation states that your scheme must pay all PMB claims in full without co-payments.
The Council for Medical Schemes Appeal Board has interpreted this to mean that schemes must pay in full regardless of the rate at which a doctor or other healthcare provider charges you for a PMB.
Schemes believe the interpretation given to this regulation gives doctors and other healthcare providers a blank cheque to charge members as much as they like for PMBs and they are concerned that this interpretation will lead to healthcare providers charging more and this will increase the schemes' costs and thus your contributions.
Last month, the Council for Medical Schemes called a workshop of stakeholders, including medical schemes, consumer groups, doctor and hospital associations, and administrators, to set up the task team.
The issue of the interpretation of regulation eight was one of the main issues raised at the workshop. At that forum, Moremi Nkosi, the director of health insurance in the Department of Health, said Health Minister Dr Aaron Motsoaledi does not believe that PMBs for medical schemes should be treated as a blank cheque for health- care providers.
Nkosi said then that if the law relating to the PMBs was a problem, the new PMB task team should discuss this and how to address it.
Representatives from each stakeholder group were elected to continue the task team's work and to set up its terms of reference.
But late last week, a meeting of representatives elected at the workshop was abandoned when a scheme representative, Neil Nair, the principal officer of Samwumed, a restricted medical scheme for municipal workers, asked for an undertaking that regulation eight would be reviewed.
When this was not forthcoming, Nair asked to temporarily withdraw to seek a mandate from schemes.
The task team meeting was then abandoned, but this week Gantsho said the team will continue its work to establish a code of conduct by July 15.
Gantsho says representatives on the team who want to withdraw from it should notify his office.
Best way forward
Nair said he would consult with other schemes, but he believed the best way forward was to approach a court and ask it for a declaratory order on how regulation eight should be interpreted and whether it did indeed mean that schemes must pay whatever doctors charge for PMBs.
The Board of Healthcare Funders, which represents a number of schemes, has also asked its members how they wish to proceed.
Gantsho told Personal Finance that the Council for Medical Schemes did not make the law or its regulations and does not have the authority to amend it.
He says the task team was formed to deal with issues arising out of regulation eight and many other problems with the implementation of the PMBs, and its aim is to try to resolve some of these issues by establishing a code of conduct for schemes and providers.
He says that should the task team need to discuss the problems of regulation eight, it could not be prevented from doing so, but neither it nor the council itself has the authority to amend the regulation.
The council can only, like other stakeholders, participate in a ministerial process that is considering the regulation, he says.
Motsoaledi appointed Gantsho as registrar on June 1. Gantsho is a medical doctor who has been the manager of the Private Practice Unit within the South African Medical Association (Sama) for the past five years.
In addition to his medical qualification, Gantsho has a Master's degree in political science and economics. He is a fellow at the Centre for Leadership and Public Values at the Graduate School of Business at the University of Cape Town and at the Terry Sanford Institute of Public Policy at Duke University in the United States.
The Registrar of Medical Schemes is the chief executive officer of the office of the Council for Medical Schemes, which is responsible for regulating your medical scheme.
Regulatory policies are set by members of the Council for Medical Schemes, who are also appointed by the Minister of Health.
The registrar's position has been vacant since the previous registrar, Patrick Masobe, left in February last year. Since then there have been two acting registrars. Patrick Matshidze, was acting registrar until November last year when he resigned from the council. Craig Burton-Durham, the head of the Council for Medical Schemes legal unit, has been acting registrar since November.
  
 
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