The growing number of medical scheme members suffering from bipolar mood disorder (BMD), seems to go hand in hand with the use of prescribed minimum benefits (PMBs).
PMBs are a mandatory set of defined benefits that medical schemes must provide as cover to all medical scheme members, regardless of their benefit option.
The cost of PMBs weighs heavily on health care funders as all related treatments and services must be paid for in full by the medical scheme, with no co-payments or deductibles.
The average cost per age across all age groups for PMBs amounts to R512.80 per beneficiary per month.*
In its submission to the Competition Commission’s inquiry into the Private Health Care Market the Board of Healthcare Funders says that claims per event for PMBs are exponentially higher than they are for non-prescribed minimum benefits.
Making it worse is ‘up-coding’, also called the PMB creep. It basically boils down to the matching of illnesses to the PMB coding categories, thus ensuring payment for the provider and patient for a wide range of treatments.
“This refers to the practice of adopting an erroneous diagnosis that falls within a specific PMB category that is slightly more severe than the actual case,” the Department of Health (DOH) states in its submission document.
An example given by the DOH as well as Discovery Health (DH) is the apparent substitution effect between BMD, which is on the chronic disease list and therefore eligible for PMB coverage, and other forms of depression, which are excluded from the PMB list.
DH explains that diagnosing a psychiatry patient with BMD gives the patient and doctor access to scheme risk benefits which are not covered on all plans. “At the margin, this leads to a tendency to code depression as bipolar depression when this may not strictly be the accurate diagnosis.”
The 25 PMB chronic conditions were introduced to medical schemes in 2004, since then the rate of medical scheme members diagnosed with BMD compared to major depression are on a rising curve.
In fact, the prevalence of BMD as a chronic condition increased 173% between 2007 and 2012. (Graph below)
Percentage increase in prevalence of chronic conditions 2007 – 2012
Source: CMS Annual Report 2013/2014
Dr Azelle Mayne from the Panorama Psychiatry and Memory Clinic says there are generally many reasons for the increase in BMD diagnosis.
“Overall there is definitely a greater awareness of BMD. Psychiatrists are more attentive to it, but it is also interesting to see that some psychiatrists diagnose it more frequently than others.”
She says it could happen because BMD symptoms can be severe, but sometimes not as critical, but still observable. Hence the distinction between Type 1 and Type 2 BMD. Making diagnosis more difficult is the comorbidity of other diagnoses, for example anxiety disorders.
Since many celebrities are open about their BMD, the illness gets a lot of publicity. “People find it more acceptable to be diagnosed. The stigma associated with it as a mental illness is minimised with famous people also suffering from it.”
There are no blood tests or X-rays to diagnose BMD. Diagnosis is made on the basis of all signs and symptoms. Certain diagnostic tests, which includes blood and urine tests as well as scans, may be done to rule out medical conditions which could cause mood swings.
PMB Regulations specify that it should be treated with hospital-based management or outpatient psychotherapy sessions. According to the Council of Medical Schemes (CMS) the diagnostic tests which are ordered to exclude physical causes of the symptoms must also be funded as part of the PMB level of care for BMD.
Mayne says their clinic often get requests from patients to change the diagnostic code of their diagnosis to BMD for medical scheme reasons. “Some patients even claim they were advised by their medical scheme to do so. But of course we cannot do that unless the diagnosis is in fact BMD in our opinion.”
“The reality is that medicine is expensive and I believe it can influence the diagnosis if medical scheme funding is involved. Because of medical scheme payment structures and PMB’s, I think more people are diagnosed with BMD,” she says.
Statistics from Discovery Health Medical Scheme (DHMS) show that members with less out of hospital benefits in their plan type – for example those in the DHMS Core and KeyCare plans- are much more likely to have a bipolar diagnosis as opposed to a major depression diagnosis (see graph below).
Prevalence of Bipolar and Major Depression by option and year (per 1,000 relevant lives): 2008-2014
Source: DH calculations using DHMS data
The apparent substitution of BMD for other forms of depression is just one of many examples of up-coding. Up-coding is viewed as one of the drivers of medical inflation and costs and according to the DOH it seems to be congruent with profit-maximising behaviour.
The difficulties such as up-coding surrounding PMB claims seems to arise from a lack of regulation to standardise the implementation of treatment definitions and coding systems for PMB’s.
Dries la Grange, principal officer of BestMed, says it is challenging that PMB’s are open for different interpretations as no standardisation exists.
“Providers should not have a financial benefit in treating PMBs versus other non-PMB conditions. The ‘at cost’ interpretation is widely abused in this regard. Treatment guidelines are needed for all the PMB diagnostic treatment pairs.”
According to La Grange provider education is also necessary to emphasise the importance of trustworthy ICD-10 coding on claims.
With regard to BMD, Mayne reasons it would be more practical if medical scheme payment structures treated BMD and major depression in the same way. “Both are serious diseases which require treatment,” she says.