One of the main elements of the many changes planned for the healthcare industry is the matter of prescribed minimum benefits (PMBs). There has been a large amount of ongoing debate in this subject.

During February this year, a workshop was held with some 250 stakeholder representatives attending and this has established workgroups to resolve two main issues.

The first is the actual definition of PMBs, which involves the fine details of what is covered, what it costs and what limitations are placed on these benefits. What PMBs are built into schemes also has a bearing on how the equalisation fund (REF) will be structured and the outlines of the low-income schemes (LIMS).

The second workgroup will address the impact of PMBs on the REF and the complex relationship between the two. A third group has been tasked to look at sustainability so that, whatever benefits are finally defined, the whole system will be economically sound.

Since 1998, when the first legislation was put in place to enact healthcare reform, we have seen that the primary focus points have been extending coverage to a wider community and specifying what minimum benefits should be offered to everyone. Making this happen is a very detailed process but we are now nearing completion of the planning process.

A major concern is that charges are limited to a fixed amount but, under current legislation, if a practitioner charges more, the patient is still liable for those costs. The sustainability group is looking at how to structure benefits so that such costs can be controlled or eliminated. At present, there is a single PMB package for all schemes but there is discussion about having different packages for LIMS.

To make sure this complex process doesn’t go on forever, specific timelines have been agreed so that most of the essential decisions will be taken during this year. After that, it is in the hands of governing bodies and parliament to finalise the actual legislation.

The government has a firm commitment to reform the overall industry to achieve the goal of wider, more comprehensive coverage for everyone. This has been reaffirmed at recent meetings and by public statements on topics such as the costs of private healthcare services.

This will have an impact on the whole industry but, until the detailed discussions are completed, it is difficult to make a definitive prediction of what that impact will be.

(Pieter Grobler is General Manager: Actuarial Services with Medscheme Health Risk Solutions)