Low Cost Benefit Options (LCBO’s) – A Medical Lifeline for RSA, An opportunity for Family Practitioners to take the lead
In a rapid series of moves, the CMS (Council for Medical Schemes) announced their minimum requirements for the long awaited Low Cost Benefit Options on the 3rd of September 2015.
These options which will cater only for individuals earning a low income between approximately R5500.00 to R6200.00 per month, must, as per the CMS guideline, entitle the insured patients to a minimum of:
- 5 consultations, delivered via either a Family Practitioner, Nurse, Pharmacist or Clinic
- Pre and post-natal programs
- Preventative screening in high risk groups for Diabetes, TB, HIV, Hypertension, Prostate cancer, Cervical Cancer, Hypercholesterolemia and Breast cancer.
- Influenza and Pneumococcal vaccines
- Medication for 6 chronic diseases including asthma, diabetes, hypercholesterolemia, hypertension and hyper/hypothyroid conditions.
- Limited Acute medication from the EDL
- Emergency road transport
- Basic pathology
- Limited radiology
- Basic dentistry (fillings and extractions)
• One “Out of area” visit to a doctor or nursing sister who is not part of the network
• Refraction for spectacles and basic spectacles every 2 years
(More detail as to the exact medication, radiology, pathology, disease entities covered is beyond the scope of this short article but interested parties should refer to the CMS document on their website)
The other PMBs are not covered as the new low cost benefit option will be exempt from offering prescribed minimum benefits, including CDLs and the 270 conditions medical schemes otherwise are required by law to cover to a minimum standard.
It is important to note that there is no hospital cover in this set of benefits what so ever and patients will need to make use of the state hospitals should they require admission or hospital based treatment.
The cost to individuals is estimated at between R200 – R400 per month, per belly button, remembering that there is a restriction on joining if the patient’s income exceeds the threshold mentioned above. This is designed to prevent more affluent individuals on classic medical aid options, from buying down into this low cost benefit option category. No Late Joiner fees are applicable.
The consultation fee, as well as the method of payment has not been decided upon, however there is a provision that no co-payments will be permitted.
Funders will need to apply for an exemption from various current clauses in the MSA, in order to offer the new LCBO.
Furthermore, in the light of the new definitions of “the business of a medical scheme” it appears lightly that most of the current non-medical aid plans will probably need to approach formal funders in the Medical aid industry in order for these FSB products to come “on side” or be out lawed. There are 3 or 4 significant plans, many of which have over the past year requested you as providers join their networks.( You will no doubt remember that IPAF had previously queried the concept offered by some of these non-medical aid offerings, as we had been informed that they may be outlawed in their current format. You were however advised to use your own recognisances when making your final decision).
Many of the current funders and their administrators are now hurriedly putting low cost benefit options together. These options will however almost certainly require the use of doctor networks.
We request that you pause here, to reflect that many of you are already in the most comprehensive, well run and respected family practitioner network in the country, namely the IPA Foundation.
The IPA Foundation stands ready to assist funders and providers in conceptualising the necessary offerings and enter into contracts with one another, providing that these contracts are fair, equitable to both sides. We will not forget that you have fixed overheads to cover in your practices. We will continue to be fair and non-partisan to both sides and represent the best interests of doctors and patients in accessing the primary arm of the changing HCDS of RSA.
You will, no doubt, be assailed by numerous funder organisations to join their hastily forming networks, as they attempt to offer low cost benefit options through a doctor network.
Unlike IPAF, few of these administrators have actually built the family practitioner networks that they request you to join.
You are of course fully entitled to join which ever network you wish, work for whom you please, and negotiate whatever rate you feel that you are worth. This is the essence of free competition.
Remember however that the IPAF and its network of over 5000 FP’s is there for you, for patients both rich and poor, for all willing funders and for the entire country to use. We do NOT bargain or collude of fees but rather place all emphasis on bringing more health to more people in a cost effective, quality assured, fair and acceptable framework to all.
The IPAF network is mature, well run, efficient, and highly rated and our partnership with a world class actuarial firm has placed us in a most desirable position to produce meaningful peer review and peer profiling results.
Watch the IPAF website (www.ipafoundation.co.za) as well as the various constituent IPA’s of:
- SAMCC (and its constituent IPAs of Qualicare, KZNMCC, BIPA, Ecipa, etc),
- ASAIPA and its constituent IPAs and
- SP Net and their constituent IPAs.
We will, without questions, be approached to assist funders in forming networks in response to this announcement from the CMS. We will partner with all willing funder and provider groups and will continue to bring efficiency and effectiveness into the running of doctor networks.
We remain constructive, open minded and enthusiastic at the thought of bringing a further 5 – 7 million principle members into the new low cost medical aid net , and to the door of willing Family Practitioners.
Einstein’s comment the “We cannot solve our problems with the same level of thinking that created them”, has never been more appropriate to health un RSA as it is now!
Trust your team, as we are there for you.
Dr Tony Behrman
CEO IPA Foundation