MHM Magazine

Issue 5 | 2022 | MENTAL HEALTH MATTERS | 33 MHM The medical schemes act, in section 29(1)(o) specifies that: “The scope and level of minimum benefits that are to be available to beneficiaries as may be prescribed” should be defined in the regulations to the act. The act stipulates a provisor in regulation 29(1)(p), that “No limitation shall apply to the re- imbursement of any relevant health service obtained by a member from a public hospital where this service complies with the general scope and level as contemplated in paragraph (o) and may not be different from the entitlement in terms of a service available to a public hospital patient.” Thus, the benefits available to a patient with a medical scheme membership should not be less that what is available to a patient in a public hospital. The regulations to the act, GNR.1262 of 20 October 1999, specifies 271 diagnosis treatment pairs (DTP’s) and 26 diagnoses on the chronic disease list (CDL). We thus have four groups of PMB’s: 1. The 271 DTP’s 2. The 26 CDL’s 3. All medical emergencies 4. The equivalent of all medical services available in public hospitals Bipolar Disorder is listed as a DTP and is on the CDL. The DTP specifies: “902T-Major affective disorders, including unipolar and bipolar depression. Hospital based medical management up to 3 weeks/ year (including inpatient electro- convulsive therapy and inpatient psychotherapy) or outpatient psychotherapy of up to 15 contacts”. The minimum benefits that should be available to a patient with Bipolar Disorder includes hospital OR outpatient care. The hospital care includes medical care. The benefit should be either in OR outpatient care. Medical schemes apply a calculation for in and outpatient care if the full benefit wasn’t utilised. The CDL has an algorithm with eight follow up consultations specified in addition to the 15 PMB outpatient psychotherapy contacts. The algorithm states: 1. “Medical management reasonably necessary for the delivery of treatment described in this algorithm. This management includes provision for allied health support, consultation(s) to collect collateral information and group therapy where indicated, but is subject to the application of managed healthcare interventions by the relevant medical schemes. To the extent that a medical scheme applies managed health care interventions in respect of this benefit for example clinical protocols for diagnostic procedures or medical management such interventions must a. Not be inconsistent with this algorithm b. Be developed on the basis of evidence based medicine, taking into account considerations of cost- effectiveness and affordability, and c. Comply with all other applicable regulations made in terms of the medical schemes act, 131 of 1998.” The full PMB available to patients with Bipolar Disorder in terms of the medical schemes act is: 1. 21 days hospital based care OR 15 outpatient psychotherapy contacts 2. At least 8 outpatient follow up consultations by a medical practitioner that can prescribe medication dependent on managed health care interventions i.e. the patient must be seen by a psychiatrist. 3. Consultations including getting collateral information and support by allied health practitioners which can include clinical or counseling psychologists, occupational therapists, physiotherapists, dieticians and social workers (the psychiatric multi- professional team). 4. Group therapy sessions, which are always indicated in patients with Bipolar Disorder. The most recognised group therapy intervention for bipolar disorder is the Colom model psych- education. This is a 21 session group programme. Medical schemes do not adhere to the prescriptions in the law in providing these benefits to patients with bipolar disorder as part of the minimum benefits that should be available. They selectively only include in their benefits 21 days in hospital OR 15 outpatient psychotherapy sessions. They apply a formulary for medication along the guidance specified in the CDL algorithm. Neither outpatient follow up consultations, nor other outpatient allied health support nor outpatient group therapy sessions are reimbursed as a PMB. This unlawful conduct of the medical schemes has been brought to the attention of medical schemes over years as well as the Council for Medical Schemes (CMS), the medical schemes regulator. In support of the CMS’s drive to root out fraud, waste and abuse, the failure of medical schemes to honour this entitlement should be seriously addressed and action taken. Working with medical schemes to provide funding for the MINIMUM benefits for patients with bipolar disorder has been rather unsuccessful.