REACH

1
REACH

• Health Portfolio Committee
• 17 May 2005
• Nusreen Khan

2
MISSION

• To assist in the provision of sustainable,
• transparent healthcare support to the South
• African consumer by
• Offering the consumer a platform to review their
  healthcare experiences
• Promoting the education of the consumer to create
  awareness on patients healthcare rights

3
VISION

• QUALITY HEALTHCARE
• Support lobbing efforts to ensure that the
  consumer receives treatment structured on sound
  clinical and evidence based data, so that the
  management of wellness as opposed to the
  treatment of illness is allowed.
•  AFFORDABLE HEALTHCARE
• Assist the consumer to receive quality
  healthcare that is affordable, by lobbying for a
  transparent health care environment..
• EDUCATION
• Assist in educating of the consumer thereby
  ensuring that informed decisions are made.

4
Working Relationships

• Relationships with
• FPI
• SAMA
• BHF
• Council Medical Schemes
• HPCSA
• Support Groups
• Consumer Union
• Diabetes SA

5
Working Relationships

• Relationships with
• National Osteoporosis Foundation
• Chamber Of Financial Advisors
• Aon
• Psychiatric Focus Forum
• HASA
• ABSA Health
• Cape Medical Plan
• Alexander Forbes
• Pricing Committee

6
Working Relationships

• Relationships with
• Health Technology Assessment Steering Committee
• PSSA
• Health Science Academy
• Foundation for Professional Development
• PMA
• IMSA
• SASOP
• Anti-Stigma Initiative
• SADAG

7
Working Relationships

• Relationships with
• Spesnet
• Private Healthcare Forum
• PCMA

8
Psychiatric Commission

• Health Portfolio Committee
• 17 May 2005

9
PSYCHIATRIC COMMISSION

• A commission initiated by
• Members of the Anti-Stigma Initiative,
• South African Society of Psychiatrists (SASOP)
• Rights, Education and Activism for Consumer
  Health Care (REACH),
• Hospital Association of South Africa (HASA)
  Psychiatric Focus Forum

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Anti-Stigma Initiative

• OBJECTIVES
• To enable patients with psychiatric disorders to
  receive appropriate treatment in both the public
  and private sector
• To destigmatise the perception that the public
  has of psychiatric patients and disorders

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SHADOW WHITE PAPERADDRESSING STIGMA AND
POSSIBLE DISCRIMINATION OF PATIENTS WITH MENTAL
HEALTH PROBLEMS IN THE REPUBLIC OF SOUTH AFRICA
12
Terms of Reference

•  To explore possible discrimination in the
  allocation of psychiatric benefits
• To assess the impact of limited disease cover in
  terms of ineffectual treatment of psychiatric
  disorders
• To assess the impact of formulary decisions on
  the effectual treatment of psychiatric
  disorders
• To question the focus of PMBs on hospitalised
  treatment only
•       

13
Stigma

• For centuries people with psychiatric disorders
  were kept away from the rest of society,
  sometimes locked up, often in poor conditions,
  with little or no say in running their lives.
• Today, negative attitudes lock them out of
  society more subtly but just as effectively.
•  
• Stigma is the biggest obstacle to the people who
  suffer from psychiatric disorders.

14
Psychiatric Commission

• PROJECT INVESTIGATORS
• Dr. Eugene Allers
• Prof. Margaret Nair
• Dr. Shaquir Salduker
• Mrs. Nusreen Khan
• Adv. Kurt Worrall-Clare
• PROJECT RESEARCHERS
• The researchers responsible for this project
• Mrs. Nusreen Khan
• Adv. Kurt Worrall-Clare.

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Consultations

• DoH
• SA Federation for Mental Health
• Schizophrenia Foundation
• SADAG
• Bipolar Support Group
• Alzheimers SA
• Riverfield Lodge
• Denmar Specialist Psychiatric Hospital
• Vista Psychiatric Clinic

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Consultations

• OCD Association
• Lesedi Private Clinic
• SAMA
• Health Professionals Council SA
• Council for Medical Schemes
• Board of Health Funders
• HASA
• Mental Health Information Centre
• DENOSA

17
Endorsements

• OCD Association
• Lesedi Private Clinic
• SAMA
• HASA
• Mental Health Information Centre
• DENOSA

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Endorsements

• DoH
• SA Federation for Mental Health
• Schizophrenia Foundation
• SADAG
• Bipolar Support Group
• Alzheimers SA
• Riverfield Lodge
• Denmar Specialist Psychiatric Hospital
• Vista Psychiatric Clinic

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Objectives of Presentation

• Shadow White Paper
• Discrepancies between legislation and practise
• To explore possible discrimination in the
  allocation of psychiatric benefits
• Impact of lack of understanding of illness
• Treatment decisions (formularies) made by
  individuals who do not understand illness
• To assess the impact of formulary decisions on
  the effectual treatment of psychiatric disorders
• Benefit design by individuals who do not
  understand illness
• To assess the impact of limited disease cover in
  terms of ineffectual treatment of psychiatric
  disorders
• To question the focus of PMBs on hospitalised
  treatment only
• Find a solution recognizing the economic
  challenges financing both the insured and
  non-insured population

20
Objectives of Paper

• achieve the provision of humane, sensitive and
  informed mental health care benefits
• Prejudices
• ensure that benefits are adequate, readily
  accessible, fair and equitable
• Capping of psychiatric benefits
• Specialist, GP and all allied health care
  professionals pool
• Current example

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Objectives of Paper

• ensure that benefits are approved by a peer
  review panel of practising psychiatrists and
  other relevant disciplines
• Long term repercussions of inadequate treatment
  overlooked for short term savings
• To assess the impact of limited disease cover in
  terms of ineffectual treatment of psychiatric
  disorders
• provide benefits within a sustainable and
  affordable financial framework, with due regard
  to inflation and the cost of health care delivery
• Different benefit packages for insured provides
  different level of access
• Cost restraints in public sector

22
Objectives of Paper

• work towards reducing mental illness in South
  Africa, within a framework that is sensitive to
  patients needs and free of all stigma and
  prejudice
• Adequate treatment of first episode
• Reduction of debilitating effects of illness
  (loss of productivity, effect on family and care
  giver)
• Visual impact of a psychiatrically impaired
  patient (cognitive impairment)
• cater for the need to treat certain psychiatric
  conditions on a long term basis and/or as chronic
  conditions, thus ensuring that patients are
  treated fully and effectively, with a reduction
  in ultimate cost
• PMBs

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The impact of psychiatric illnesses

• 14 of diseases worldwide are psychiatric and it
  accordingly ranks with heart disease and cancer
  as a major cause of illness.
• Ten of the top 20 chronic disabling conditions
  are psychiatric, including six of the top 10.
• 58 of visits to general medical practitioners
  are due to conditions caused or exacerbated by
  mental or emotional problems.
• 18 to 25 of senior citizens are in need of
  mental health care for anxiety, depression,
  psychosis or dementia.
• 1 of the population suffer from Schizophrenia.
  Another 1 suffers from Bipolar Disorder.
• One in 10 people will suffer from disabling
  anxiety and
• One in four will develop depression.

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The impact of psychiatric illnesses

• The annual rate of suicide worldwide is estimated
  to be 800 000.
• In South Africa it is estimated that the same
  number of people commit suicide that are killed
  in motor vehicle accidents every year.
• One in 33 children and one in eight adolescents
  may suffer from depression.
• The World Bank and the World Health Organisation
  predict that by the year 2020, psychiatric
  illness will be the leading cause of disability
  in the world.

25
Legislation

• Constitution of the Republic of South Africa, Act
  No.108 of 1996
• Mental Health Care Act, Act No. 17 of 2002
• Promotion of Equality and Prevention of Unfair
  Discrimination Act, Act No. 4 of 2000
• Medical Schemes Act, Act No. 131 of 1998
• Patients Rights Charter
• Batho Pele Principles

26
Constitution

• Section 9(1)
• the State may not unfairly discriminate
  directly or indirectly against anyone on one or
  more grounds, including race, gender, sex,
  pregnancy, marital status, ethnic or social
  origin, colour, sexual orientation, age,
  disability,
• Accordingly, nobody is to be denied the equal
  protection and benefit of the law.
• Funders, practitioners and other health
  professions should be aware that other
  legislation provides directly and indirectly for
  the mentally ill, some of which expressly
  prohibits direct or indirect discrimination
  against such individuals.

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Mental Health Care Act

• The stated objects of the Mental Health Care Act
  are
• To regulate mental health care in a manner such
  as makes the best possible mental health care,
  treatment and rehabilitation services available
  to the population equitably, efficiently and in
  the best interests of mental health care users,
  within the limits of the available resources
• To co-ordinate access to mental health care,
  treatment and rehabilitation services to the
  various categories of mental health care users
• To integrate the provision of mental health care
  services into the general health services
  environment

28
Mental Health Care Act

• 10(1) provides that
• (a) mental health care user may not be unfairly
  discriminated against on the grounds of his or
  her mental health status.

29
Mental Health Care Act

• The gap
• The Mental Health Care Act disallows
  discrimination against the psychiatrically ill
• Medical schemes isolate psychiatric benefits,
  lower allocations for psychiatry vs other
  disciplines
• Only eight of the 52 medical schemes evaluated by
  the Psychiatric Commission were found to have
  placed psychiatric benefits in the general pool
  of benefits. (2000)

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Mental Health Care Act

• The gap
• Department of Psychiatry at the University of
  Stellenbosch conducted a study
• Compared medical scheme benefits for major
  depressive disorder and ischemic heart disease
• Survey of the benefits of 57 schemes and 130
  options in South Africa revealed a 20-fold
  difference in in-hospital benefits, favouring
  members with heart disorder.
• The study showed that 73.8 had no limits on
  in-hospital benefits for the treatment of the
  heart disorder, while only 8.5 had no limits on
  in-hospital treatment of major depressive
  disorder.
• 7.7 offered unlimited out-of-hospital benefits
  for the heart disorder, but only 2.3 did so for
  the psychiatric disorder.
• The survey was based on schemes 2001 and 2002
  benefit schedules.

31
Promotion of Equality and Prevention of Unfair
Discrimination Act

• Promotion of Equality and Prevention of Unfair
  Discrimination Act, Act No. 4 of 2000, applies to
  persons with disabilities and protects such
  individuals against unfair discrimination based
  on such disabilities.
• In particular, such individuals are protected
  against being denied any supporting or enabling
  facility necessary for their functioning in
  society, as well as ensuring that they are
  afforded the right to enjoy equal
  opportunities.
• The Act goes even further, by specifically
  stating that it is an unfair practise to
  unfairly deny or refuse any person access to
  health care facilities or to fail to make health
  care facilities accessible to any person.
• Patient letter

32
Medical Schemes Act

• Medical Schemes Act (Act 131 of 1998), Section 24
  (2)(e)
•  
• The medical scheme does not or will not unfairly
  discriminate directly or indirectly against any
  person on one or more arbitrary grounds including
  race, gender, marital status, ethnic or social
  origin, sexual orientation, pregnancy, disability
  and state of health

33
Medical Schemes Act

• Regulations promulgated in terms of the Medical
  Schemes Act, Act No. 131 of 1998
• If managed health care entails limiting coverage
  of specific diseases
• a) such limitations or a restricted list of
  diseases must be developed on the basis of
  evidence-based medicine, taking into account
  considerations of cost-effectiveness and
  affordability and
• b) the medical scheme and the managed health care
  organisation must provide such limitation or
  restricted list to health care providers,
  beneficiaries and members of the public, upon
  request.

34
Medical Schemes Act

• Limited coverage of diseases
• The gap
• No evidence-based explanation has been provided
  to date for the capping of psychiatric benefits

35
The cost impact of uncapped benefits

• The effective treatment of patients with
  severe depression results in markedly
  reduced rates of visits to doctors for
  non-psychiatric services.
• Findings published in a report by the Department
  of Commerce of the United States of America in
  1992 and are reiterated in studies by Muneford et
  al 1984, Hankin et al 1985, Borus et al 1985,
  Stoudemirre et al 1986, Holder and Blose 1987A
  and B, Meien and Pittmann 1989, van Korf et al
  1990, Levenson et al 1992 and Rice and Miller et
  al 1993.
• All these studies have shown that initial
  adequate psychiatric treatment results in global
  savings of approximately 20, with up to an 85
  reduction of hospitalisation days.
• A South African pilot project of an average size
  medical scheme revealed a reduction of 50 of
  total utilisation cost, if patients with
  psychiatric disorders were treated adequately.
• Case report 2 of Shadow White Paper

36
Medical Schemes Act

• 15I. Formularies.If managed health care entails
  the use of a formulary or restricted list of
  drugs
• (a) Such formulary or restricted list must be
  developed on the basis of evidence-based
  medicine, taking into account considerations of
  cost effectiveness and affordability
• (b) the medical scheme and the managed health
  care organisation must provide such formulary or
  restricted list to health care providers,
  beneficiaries and members of the public, upon
  request and
• (c) provision must be made for appropriate
  substitution of drugs where a formulary drug has
  been ineffective or causes or would cause adverse
  reaction in a beneficiary, without penalty to
  that beneficiary.

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Medical Schemes Act

• 15I. Formularies.
• The gap
• Lists are not readily made available
• The basis of formularies is questionable (Stds
  for managed health care)
• Insufficient/no provision made for appropriate
  substitution

38
Medical Schemes Act

• 15I. Formularies.
• Accepted first line treatment for patients with
  panic disorder is SSRIs. Older Tricyclic
  Antidepressants (TCAs) are often recommended in
  formularies as first line treatment. Such
  patients are particularly sensitive to side
  effects and do not respond because of the side
  effect profile of TCAs. If such patients are able
  to take newer and improved medication, their
  overall treatment would be more effective without
  major side effects.
• The accepted first line treatment to control
  symptoms of behavioural and psychological
  symptoms of dementia is atypical antipsychotics.
  Medical schemes will only allow the use of
  typical antipsychotics. Often these patients are
  very susceptible to developing Parkinsons
  syndrome on the typical antipsychotics, as well
  as other side effects.
• The cost of non-compliance?
• The cost of controlling side effects?
• Case report 5 of Shadow White Paper

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Patients Rights Charter

• 2. Participation in decision-making
• Every citizen has the right to participate in the
  development of health policies and everyone has
  the right to participate in decision making on
  matters affecting ones health.
• Gap
• Patients are not consulted in any decision making
  process i.e. benefit design, formulary/protocol
  guidelines, choice of treatment
• Access to health care
• vii. Health information that includes the
  availability of health services and how best to
  use such services and such information shall be
  in the language understood by the patient.
• Gap
• Insufficient efforts on the part of medical
  schemes to inform members of new benefit designs
  and the impact of the PMBs

40
Patients Rights Charter

• 4. Knowledge of ones health insurance/medical
  scheme
• A member of a health insurance or medical aid
  scheme is entitled to information about that
  health insurance or medical aid scheme and to
  challenge, where necessary, the decisions of such
  health insurance or medical aid scheme relating
  to the member.
• Gap
• Members of medical schemes are not informed in
  good time of changes in benefit design so that
  they may change options
• Premium increases are effective before written
  approval is obtained from CMS

41
The Impact of PMBs

• Some medical schemes provide bare minimum of
  treatments- switching of medications that
  patients were stabilised on
• Some patients not covered for chronic illnesses
  that were controlled
• Patients needing to buy up in order to have
  access to treatments for illnesses not covered
  under 25 conditions

42
The Impact of PMBs

• No written agreements in place between medical
  scheme and DSP, hence patients not aware of what
  standard of treatment to expect and hence no
  recourse
• Price differential between accessing services
  from a non-DSP

43
Proposal

• In particular, South Africa should consider
• Whether parity in the allocation of health
  benefits and the prohibition of capped or limited
  benefits as currently practiced, would have a
  significant cost impact on the medical insurance
  industry, which international law reform suggests
  would not be the case1
• Whether the current capping of mental health care
  benefits constitutes a prohibited form of
  discrimination, both in regard to the
  Constitution and the Mental Health Care Act
• 1 According to the Timothy's Law Organisation
  figures, obtained from an actuarial study
  estimates that premiums for full coverage will
  only increase by 1.26 a month, according to
  estimates.

44
Proposals

• Research into the establishment of a
  comprehensive National Mental Health Strategy,
  comprising both the public and the private
  sectors, in which best practice mental health
  policy, treatment and protocols are the
  cornerstone of health care delivery for mental
  health care users
• Legislative change and development where it is
  found that either the interests or needs of the
  mentally ill are unsuitably and inadequately
  provided for

45
Proposals

• The law as it pertains to the mental health care
  user accordingly requires reassessment in the
  following respects
• how benefits are structured
• how facilities are licensed
• treatment protocols
• formularies
• PMBs

46
Proposals

• All medical schemes should use the Standard
  Treatment Guidelines for Common Mental Health
  Conditions issued by the South African Department
  of Health, as also other internationally
  recognised guidelines for the treatment of
  psychiatric disorders
• Matters which affect the professional
  relationship between doctor and patient and which
  influence the quality and level of care of the
  patient, should vest with the Health Professions
  Council of South Africa and not the Council for
  Medical Schemes or individual medical schemes
• The limitation of benefits should be considered
  as a matter of last resort in containing costs
• The effective treatment of psychiatric disorders
  should be dictated by treatment guidelines, as
  opposed to the availability of funds
• The Prescribed Minimum Benefits in Annexure 2 and
  the Algorithms in Annexure 3 to this document
  should be incorporated in the appropriate
  legislation

47
Public Sector Challenges

• Not all primary care clinics treat psychiatric
  illnesses
• Access to primary clinics that treat psychiatric
  illnesses is limited
• Specialist psychiatric clinics have been closed
• 84 Psychiatrists in public sector
• Access to medication severely impeded
• Tertiary EDLs
• Primary EDLs
• EDLs between provinces

48
Public Sector Challenges

• Case report 1 of Shadow White Paper illustrates
  the burden of the overflow of private sector
  patients on the public sector
• Also illustrates the lack of adolescent
  psychiatric facilities and impact of
  administrative duties on the delivery of
  treatment

49
Batho Pele Principals

• Consultation
• Citizens should be consulted about the level and
  quality of the public services they receive and,
  wherever possible, should be given a choice about
  the services that are offered.
• Service Standards
• Citizens should be told what level and quality
  of public services they will receive so that they
  are aware of what to expect.
• Access
• All citizens should have equal access to the
  services to which they are entitled.

50
Batho Pele Principals

• Courtesy
• Citizens should be treated with courtesy and
  consideration.
• Information
• Citizens should be given full, accurate
  information about the public services they are
  entitled to receive.
• Openness and transparency
• Citizens should be told how national and
  provincial departments are run, how much they
  cost, and who is in charge.

51
Batho Pele Principals

• Redress
• If the promised standard of service is not
  delivered, citizens should be offered an apology,
  a full explanation and a speedy and effective
  remedy and when the complaints are made,
  citizens should receive a sympathetic, positive
  response.
• Value for Money
• Public services should be provided economically
  and efficiently in order to give citizens the
  best possible value for money.

52
Batho Pele Principals

• Encouraging Innovation and Rewarding Excellence
• Innovation can be new ways of providing better
  service, cutting costs, improving conditions,
  streamlining and generally making changes which
  tie in with the spirit of Batho Pele. It is also
  about rewarding the staff who go the extra mile
  in making it all happen.
• Customer Impact
• Impact means looking at the benefits we have
  provided for our customers both internal and
  external its how the nine principles link
  together to show how we have improved our overall
  service delivery and customer satisfaction. It is
  also about making sure that all our customers are
  aware of and exercising their rights in terms of
  the Batho Pele principles.