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New Research on Depression in the Workplace.

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JOURNAL

Mental Health Matters Journal for Psychiatrists & GP's

MHM September 207x300

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SPEAKING BOOKS

suicide book

Literacy is a luxury that many of us take for granted.  We depend on written communication for information, guidance, and access to heath care information That is why SADAG created SPEAKING BOOKS and revolutionized the way information is delivered to low literacy communities. It's exactly what it sounds like.a book that talks to the reader in his or her local  language, delivering critical information in an interactive, and educational way.

The customizable 16-page book, accompanied by local celebrity audio recordings, ensures that vital health and social messages can be seen, heard, read and understood..

We started with books on Teen Suicide prevention , HIV, AIDS and Depression, Understanding Mental Health and have developed over 30 titles, such as TB, Malaria, Polio, Vaccines for over 30 countries.

depression book

Click here to view PDF version

By Allan Sweidan
CEO Akeso Clinics & Psychologist
Johannesburg
This email address is being protected from spambots. You need JavaScript enabled to view it.

• What is PMB ?
• Debunking myths about PMBs
• Understanding chronic conditions benefit?
• Which mental illnesses are covered by PMB's and which ones are not?
• Which is the medical aid that caters best for mental health?
• What is the PMB for different medical aids or different schemes?

It’s my experience that PMB’s are not generally well understood by the general public, by many practitioners and in some cases even by medical schemes' case managers. Unfortunately, there’s not a lot of easily accessible information regarding PMB’s that can guide members along the way. In this article, I make references to certain documents which will be made available on SADAG’s website or are already available on the Council for Medical Schemes website.

PMB’s are an acronym for Prescribed Minimum Benefits - an important feature of the MedicalScheme’s Act. According to the Council for Medical Schemes (CMS) website (http://www.medicalschemes.com), PMB is a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. What this last bit means is that the benefits associated with a PMB condition are not dependent on the plan you have selected: PMB’s apply to all members of a scheme, regardless of the plan, even if it’s just a hospital plan.

Any emergency medical condition is covered under the PMB guidelines, as well as 270 medical conditions and 25 chronic conditions. When a condition is listed as having prescribed minimum benefits attached to it, this condition will be listed together with the minimum benefits associated with it. Together, the condition and treatment are referred to as Diagnosis Treatment Pairs. PMB’s as listed by the CMS, trump the benefits listed by any medical scheme if the benefits listed by the scheme are less than the benefits defined by the CMS. So it’s really important for scheme members to familiarise themselves with the PMB’s as they’re paying for these benefits, which, according to the CMS, are designed to provide patients with continuous care and to make healthcare more affordable!

Debunking Myths About PMB’s

Myth 1- Everybody knows the PMB’s

The biggest myth about PMB’s is that everyone who is supposed to be familiar with them is in fact familiar with them! This is a myth, and if there’s one message I can convey to the reader it’s this: Know Thine PMB Rights!

Myth 2 – The PMB for mental health is 21 days in hospital per annum

There are in fact 11 different PMB mental health conditions, and each has its own Prescribed Minimum Benefits. However, the myth remains that there’s one benefit for mental health - 21 days in hospital per annum. This is not true, but more about that later.

Myth 3 – Despite being legislated, all medical aid schemes will honour the PMB’s

Despite losing a case last year in which it challenged an important aspect of the PMB’s, a certain minor Medical Scheme, continues to dishonour mental health PMB conditions. After the Life Esidemeni tragedy, it’s unfathomable to me how a medical scheme might act in such a way. Know your rights and fight for them!

Understanding chronic conditions benefits

There are just two chronic mental health PMB conditions: Bipolar Mood Disorder and Schizophrenia. There are treatment algorithms for these two conditions, and for the purposes of most of the readers of this journal, the relevant bits are about the medical management of these two conditions, which by their chronic nature, require ongoing and not acute or short term treatment.

For Schizophrenia, the guidelines state:

1. Medical management reasonably necessary for the delivery of treatment described in this algorithm is included within this benefit, subject to the application of managed health care interventions by the relevant medical scheme.

2. 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.

3. This algorithm may not necessarily always be clinically appropriate for the treatment of children. If this is the case, alternative paediatric clinical management is included within this benefit if it is supported by evidence-based medicine, taking into account considerations of cost-effectiveness and affordability.

Bipolar guidelines are worded slightly differently so as to include allied health interventions (psychologists, occupational therapists etc.)

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 when indicated, but is subject to the application of managed health care interventions by the relevant medical scheme.

2. 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.

3. This algorithm may not necessarily always be clinically appropriate for the treatment of children. If this is the case, alternative paediatric clinical management is included within this benefit if it is supported by evidence-based medicine, taking into account considerations of cost-effectiveness and affordability.

The full algorithms for schizophrenia and BMD can be accessed via the SADAG website Bipolar Mood Disorder Chronic Benefit Algorithm - http://www.sadag.org/images/pdf/Bipolar-Mood-Disorder-Chronic-Benefit-Algorithm.pdf
Schizophrenia Chronic Benefit Algorithm - http://www.sadag.org/images/pdf/Schizophrenia-Chronic-Benefit-Algorithm.pdf

What does ‘medical management for the delivery of treatment actually mean?

After trawling through the web pages of medical schemes, it remains unclear what the schemes will or won’t pay for regarding the necessary medical treatment for BMD or Schizophrenia. My suggestion to members of schemes, is to contact your scheme after being diagnosed with a chronic condition to find out what they will cover. Remember to remind them that the condition has PMB’s attached!

Which mental Illnesses are covered by PMB’s and which are not?

The box below details the mental health conditions associated with the PMB’s. My understanding of the table (taken directly from the CMS website) is that there are separate and discrete mental health conditions that have PMB’s.

Which is the medical aid that caters best for mental health?

In the past few years, most medical schemes have recognised that mental illnesses have a profound impact on their members’ disability profiles and if untreated, can complicate the treatment and increase the costs of covering some general medical conditions by up to 600%. As a consequence, most schemes honour the PMB’s and will authorise treatment for mental illness in line with the PMB’s. The primary differentiating factor between the schemes, is whether they have contracts in place with Designated Service Providers (DSP) for PMB conditions. Because the CMS rules state that the cost of treating a PMB condition must be covered ‘in full’ by the schemes, the schemes will sometimes enter into relationships with DSP’s (DSP’s can be hospital networks, practitioner networks and pharmacies) to provide this treatment. In this way, the DSP’s will have more patients as the schemes channel their members to them, and the scheme can in turn negotiate better prices and sometimes higher levels of quality. Whether a scheme has entered into a contract with a DSP or not is something members should ask at the beginning of every renewal period, as these relationships are negotiated annually. If a member receives (nonemergency) care related to a PMB from a provider that is not a DSP, then the member can be liable for a co payment. So, the best medical schemes are the ones that provide the most convenient access to care.

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