CONSULTATIVE INVESTIGATION INTO LOW INCOME MEDICAL SCHEMES Comment by the South African Medical Association (SAMA) INTRODUCTION The South Africa Medical Association (SAMA) supports the investigation into a Low Cost solution for those who cannot afford the current medical schemes and the principles that underpin the development of a Low Cost solution. SAMA acknowledges and commends the task team’s efforts to produce the present version of the draft report. The proposals made in this document emanates from a request by the Ministerial Task Team (“MTT”) on the Low Income Medical Schemes (LIMS), that stakeholders should provide input on the Consultative Investigation into Low Income Medical Schemes. SAMA re-iterates its commitment to contribute towards the DoH’s responsibility to progressively realize the constitutional right of providing access to healthcare for everyone. This should be achieved through a sustainable public and private health sector, whilst ensuring that the interest of the patients' health remains paramount. Notwithstanding the above, the draft final report on the Consultative Investigation into Low Income Medical Schemes raises a number of areas of concern that require consideration, further deliberation and revision. COMMENTS ON RECOMMENDATIONS EMERGING FROM THE LIMS PROCESS Based on the recommendations made in the draft final report on the Consultative Investigation into Low Income Medical Schemes, SAMA wishes to provide the following comments: AD RECOMMENDATION 3.1: Establishment of a New Class of Medical Scheme for Low Income Members SAMA would support the establishment of a new class of medical scheme for LIMS. The functioning and modus operandi of this medical scheme should extend broader than the conventional medical scheme as provided for in the Medical Schemes Act, especially in light of the numerous problems encountered with current medical schemes vis-à-vis payment to service providers. AD RECOMMENDATION 3.2: Income Threshold for Membership of LIMS Schemes The contents of this recommendation have been noted. AD RECOMMENDATION 3.3: Administration of the Income Threshold The contents of this recommendation have been noted. AD RECOMMENDATION 3.4 : Establishment of a new prescribed minimum benefits for LIMS Schemes 1. SAMA believes that the compilation of the Prescribed Minimum Benefits (PMB’s) should be based on patients’ essential healthcare needs, quality of care and clinical outcomes in the long-term. 2. The LIMS minimum package should be progressively redefined and re- evaluated based on clinical outcomes and quality of healthcare. 3. The establishment of a new and reduced PMB and Chronic Disease List (CDL), from 25 to 14 for LIMS will place members of LIMS in a precarious position. This is particularly the case when compared to those persons that depend entirely on public health services and do not participate in the LIMS process. 4. Whilst noting the rationale for the reduced PMB and CDL benefits, SAMA is concerned about the business decision, as opposed to clinical decision, of deciding what benefits would be excluded e.g. Excluding glaucoma would result in blind patients, whereas this could be prevented. It is proposed that LIMS members should have the remaining CDL’s and PMB’s, that are excluded in the current LIMS proposal, provided in the public sector. 5. It is submitted that the proposed LIMS Minimum Package (LMP) categories were developed based on a Household Survey whose methodology may be contested and might reflect requirements from a lay perspective, as opposed to clinically informed needs. 6. The current draft final report on LIMS is not clear on the extent of the scope of practice of nurses and other service providers. It is proposed that the scope of nurses and other service providers who are utilized in GP networks must be clarified. 7. There is concern about the methodology that was used to design a formulary for acute medicine. In particular the inclusion of Tuberculosis (TB) therapy as acute medication is contentious. Currently TB therapy is provided at no cost to the patient by the public sector in the primary healthcare facilities. 8. It is also concerning that the LMP is almost completely directed at curative care, as opposed to preventative care. Attention to the latter will make LIMS much more affordable and sustainable in the long term. 9. It is believed that the content of the LMP can be expanded quite significantly within the constraints of affordability by the target population if alternative delivery and reimbursement models were to be deployed (employed??). SAMA is desirous to further engage with the LIMS Task Team on this particular aspect. 10 Total omission of specialist benefits does not appear to be justified. SAMA advocates for the progressive realization of making specialist services available in future. Any basic benefit package should include services delivered by both GP’s and Specialists within the scope of a basic healthcare package. The service areas cannot be demarcated to exclude certain provider groups simply according to the level of training. Consultative / diagnostic services should be freely available for Specialist services to evaluate patients before they are referred to the Public Hospital sector. Obstetrics should not be excluded from the LIMS proposal and is unique in that it is one discipline that lends itself to alternative reimbursive payment models. A "Shared Care" model where specialists GPs and midwives combine to provide a flexible package of care where quality is not compromised on the alter of economy, and where work devolves to the most appropriate level but always under specialist supervision is imminently feasible and should be explored AD RECOMMENDATION 3.5: Benefit Differentiation between LIMS Schemes and current PMB Regulated Schemes 1. SAMA proposes that this process must be informed by the basic healthcare package. 2. Benefit differentiation should be based on clinical needs and health outcomes. The current inputs into the draft final LIMS Report are based on cost considerations, budgetary constraints and not health needs. 3. SAMA proposes that the section that excludes emergency stabilization in private hospitals should be omitted as it contradicts the Bill of Rights of the SA Constitution, and Section 5 of the National Health Act which states that no one may be refused emergency medical treatment. AD RECOMMENDATION 3.6 : Underwriting of entrants into LIMS schemes The contents of this recommendation are noted. AD RECOMMENDATION 3.7: Prevention of adverse selection through buy-up from LIMS schemes to current market 1. The stipulated 3 year buy-up period is too long and must be reduced to 1 year maximum. 2. Restricting free buy-up is exclusionary. Members must be allowed to buy-up freely from LIMS Schemes to current market schemes to improve their cover. 3. This would imply that the current position with regard to separate Risk Equalisation Funds (REF) will require further consideration. AD RECOMMENDATION 3.8 : Linkage between LIMS schemes and REF The contents of this recommendation are noted. SAMA is not in total agreement with this recommendation and wishes to discuss this matter further. AD RECOMMENDATION 3.9 : Reducing the costs of healthcare goods and services 1. Every area of cost should be addressed including public hospital costs, administrators and brokers costs, distribution and managed care costs to provide the best medical care. 2. SAMA notes the centralization of training and scope of practices. It is however proposed that there should be strict monitoring of the expanded scopes of practice by the Forum of Statutory Health Councils in the interests of the public. Furthermore, healthcare professionals wishing to expand scopes of practice must be properly qualified and adequately trained, and proposed curriculums on expanded scopes of practice must be (prior) approved by all relevant statutory councils. 3. SAMA is extremely concerned with the proposal that non-health professionals should employ and share financial risk and rewards with health professionals. This is contrary to the Health Professions Act and Ethical Rules of the Health Professions Council of South Africa. It is submitted that further discussions between SAMA, HPCSA, and the DoH should take place on this matter. AD RECOMMENDATION 3.10 : Distribution of LIMS Scheme 1. Non healthcare costs as proposed in Table 2.9 for administration and distribution are conspicuously equivalent to GP visits. SAMA asserts that this is an inequitable method of distributing health benefits in LIMS 2. SAMA proposes that the maximum levels of distribution costs as prescribed by current legislation must be revised as they contribute to medical inflation in their current form and as it will apply to LIMS. CONCLUSION SAMA reiterates that it wishes to be part of future deliberations regarding the finalization of the draft report of the consultative investigation into low income medical schemes. SAMA respectfully requests an opportunity to enter into dialogue with the coordinator of the LIMS Project. Since the contents of the LIMS process would have far-reaching implications on individual practices and the future delivery of healthcare in SA. We would urge that further consultations with SAMA be held prior to finalization of the LIMS process.
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