SA’s medical schemes fail members on mental illness

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MEDICAL schemes are not providing adequate benefits for mental illness, leaving many members to dig deep into their own pockets to pay for the care they need or go without, according to University of Cape Town consultant psychiatrist Mike West, reports Business Day.

While medical schemes cover treatment for bipolar disorder and schizophrenia in full, many patients have fairly limited benefits for other mental health conditions, said Dr West.

He was speaking at a workshop organised by the not-for-profit South African Depression and Anxiety Group (Sadag) to mark World Health Day on April 7.

The Medical Schemes Act requires all medical schemes to pay in full for illnesses that fall within the definition of prescribed minimum benefits (PMBs), but they have discretion as to the extent to which they cover other conditions.

The PMBs include 270 health conditions with specific diagnostic and treatment criteria, emergency care, and 27 chronic diseases.

Medical schemes can take measures to limit their financial liabilities for PMBs, for example by requiring members to use designated service providers with whom they have negotiated preferential rates.

Bipolar disorder and schizophrenia are the only psychiatric conditions included in the list of chronic conditions. Medical schemes must provide cover for treatment for “affective disorders”, such as major depression and eating disorders, but the requirements are not extensive — e.g. the treatment provided for major depression is limited to hospitalisation for three weeks and 15 out-patient consultations.

“Medical schemes are afraid of expanding PMB’s, because they see it as a cost driver,” he said.

The lifetime risk of an anxiety disorder was 30.3% in SA, according to the 2009 South African Health and Stress study he said.

He said the South African Society of Psychiatrists had had limited success in lobbying medical schemes to expand their benefits for mental illness, but had managed to get schemes to increase the rates they were willing to pay for consultations with psychiatrists.


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