MHM Magazine

"Health is a state of complete physical, mental, and social well- being and not merely the absence of disease or infirmity” (WHO). Promotion of Mental Health is of utmost importance for achieving good health. The Council of Medical Schemes as an agile, responsible, and transformative regulator seeking to promote affordable and accessible healthcare coverage leveraging towards universal health coverage. One of our core activities is to promote access to healthcare for beneficiaries of medical schemes and to develop Prescribed Minimum Benefit Definitions Guidelines. Importantly, these guidelines are targeted to provide up-to-date evidence-based recommendations to health professionals, medical schemes and beneficiaries of medical schemes. Our aim is to clarify the essential healthcare services that beneficiaries of medical schemes are entitled to. In 2023, the CMS for instance identified the need to clarify the prescribed minimum benefit entitlements for Mental Health Conditions to ensure beneficiaries obtain the necessary minimum benefits they are entitled to. By clarifying and enhancing the prescribed minimum benefit entitlements for Mental Health Conditions, the CMS aimed to improve access, quality, and outcomes in mental healthcare for beneficiaries. This stance or move reflects a commitment to addressing the growing need for mental health services and ensuring equitable healthcare coverage across all aspects of health, including mental health. The PMB Definitions Guidelines (Schizophrenia, Bipolar Disorder and Acute Mental Health Conditions) were developed through rigorous analysis of clinical studies and quality international guidelines to contextualise to the South African private sector ensuring that PMBs reflect current medical knowledge and practices, promoting effective and appropriate healthcare interventions for covered conditions. Furthermore, careful consideration was given to PMB cost effectiveness to ensure that resource allocation within medical schemes provides value in terms of health outcomes relative to the costs incurred. Altogether, the development of the guideline was to: • Balance the provision of comprehensive healthcare benefits for mental health conditions with the financial sustainability of medical schemes • Ensure continued access to affordable mental healthcare for beneficiaries to promote fairness and inclusivity in healthcare delivery • Address disparities and ensure that all beneficiaries have access to necessary and effective treatments for mental health conditions. Through this framework, the CMS savoured that medical schemes would implement the PMB Definitions guidelines holistically - balancing the financial implications of PMBs on medical schemes including their ability to sustainably fund healthcare benefits in terms of these mental health conditions while maintaining affordability for its beneficiaries. In conclusion, the objective is to empower healthcare professionals to use these guidelines appropriately and effectively manage mental health patients for improved mental health outcomes. References available on request. By Percy Daames Health Economist p.daames@medicalschemes.co.za PROMOTING EQUITABLE ACCESS TO MENTAL HEALTHCARE THROUGH PRESCRIBED MINIMUM BENEFIT (PMB) DEFINITIONS GUIDELINES MHM | 2024 | Volume 11 | Issue 4 | Promoting equitable access to Mental Healthcare through Prescribed Minimum Benefit (PMB) MHM Issue 4 | 2024 | MENTAL HEALTH MATTERS | 29 MHM