PMB Review – Council for Medical Schemes

Dear Colleague,

If you claim via medical aid and apply for PMB’s on behalf of your patients, then this review of the Prescribed Minimum Benefits will be relevant.

According to the CMS:

“A draft PMB benefit package framework was drafted and published for stakeholder comments. The recommended framework proposed a departure from the current package which is disease/condition based, to a service based package. The proposed benefits will serve as a minimum package that must be available in a primary care setting, and a hospital setting. Several submissions were received on the proposed framework. The submissions will be submitted to the priority setting committee. These categories will be expanded further to incorporate the specific service that should be covered, including the level of setting where the services should be accessed.”

You are invited to comment on the document. The CPF will dissemanate the information and report back to the CMS with your input.

Kindly register on the website if you want to comment (to disallow spam and for security reasons).
You can also email your submission/comments to us at cpf(at)healthman(dot)co(dot)za
 

Relevant CMS PMB Package Review Suggestion

4.5: Mental Health Services

• Screening of patients in need of mental health and substance abuse care
• Admission, observation and treatment including psychotherapy
• Management of acute psychiatric cases and referral
• Management of substance withdrawal
• Post-trauma (e.g. rape) counselling with appropriate medical follow-up
• Referral to appropriate higher level of care when required
• Out of hospital management / continuation of care especially
• Laboratory and Radiology tests

CPF submission to suggested review

1.Screening of patients in need of mental health and substance abuse (replace abuse with misuse as it is a more inclusive term).

• Admission, observation and treatment including psychotherapy, Occupational Therapy, Social worker.
• Post-trauma (e.g. rape) counselling with appropriate medical follow-up- we recommend sexual abuse as an all-inclusive term;
• The ‘hospital based management’ that includes the full service based package should be the same for both substance abuse treatment as well as all other mental illness.
• Alternatively, billing for substance abuse service based packages should increase dramatically to come in line with billing allowed for other mental health illnesses with removal of restrictions on billing for additional professional services.

2.Add Management of chronic pain as well as

• Palliative chronic psychiatric care
• Management of patients with personality disorders
• Management of psychiatric complications of medical and surgical illnesses
• Psychiatric care of the aged
• Care of assisted and involuntary psychiatric patients

3.It is recommended that Major Affective Disorders is stated in place of only Bipolar Mood Disorder. Bipolar Mood Disorder excludes a number of other disabling and chronic conditions better catered for in a more inclusive description of this category.

• Include Clinical Psychologist in Screening of patients in need of mental health and substance abuse care. Substance abuse care relies both on psychopharmacology and specialized psychotherapeutic interventions that can be provided by Clinical Psychologist/Psychiatrist, usually in collaboration.
• Include Clinical Psychologist Admission, observation and treatment including psychotherapy
• It is important to also take note that NOT all psychiatric conditions necessitate the use of psychopharmacology, therefore the clinical psychologist would be the primary provider of treatment to the patient with mental health difficulties.
• Include Clinical Psychologist in Management of acute psychiatric cases and referral
• The Clinical Psychologist is able to diagnose and manage acute psychiatric conditions pertaining to trauma, suicidal threats and loss.
• Management of substance withdrawal: The Clinical Psychologist can assist in supportive manner and communicate with the family or close support system.
• Post-trauma (e.g. rape) counselling with appropriate medical follow-up;
• On grass roots level, canals for referral should be made available for victims of trauma so that they can access higher level of care provide by clinical psychologist;
• Out of hospital management / continuation of care especially
• The importance of out of hospital care psychotherapy.
• Laboratory and Radiology tests: drug screening for substance abuse management, might even be more cost effective.

 
Attached is the formal document received from the CMS.

PMB Review Packages – Stakeholder Submissions Circular 6