Prescribed Minimum Benefits complaints: a five-year retrospective review.

BACKGROUND: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied. OBJECTIVE:  To determine and describe the pattern of PMBs complaints received by CMS from January 2014 to December 2018. METHODS:  This was a cross-sectional study that utilised the CMS' clinical complaints. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS' lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e., to only members of specific organisations) or open (i.e., to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software. RESULTS:  A total of 2141 complaints were retrieved and 1124 PMBs complaints were included in the study. The median of PMBs complaints per year was 225. Most of the complaints (43.6%, n=490/1124) were lodged by members themselves. Non-Communicable Diseases (NCDs) constituted most of the PMBs conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for more (73.8%, n=830/1124) of the complaints. CONCLUSION:  Chronic conditions are the main diseases that medical scheme members complained about. Member education and clear definition of PMBs should be prioritised by medical schemes and the Council for Medical Schemes.

Self-Management of Diabetes and Associated Factors among Patients Seeking Chronic Care in Tshwane, South Africa: A Facility-Based Study.

The burden of diabetes continues to increase in South Africa and a significant number of diabetes patients present at public primary healthcare facilities with uncontrolled glucose. We conducted a facility-based cross-sectional study to determine the diabetes self-management practices and associated factors among out-patients in Tshwane, South Africa. An adapted validated questionnaire was used to collect data on sociodemography, diabetes knowledge, and summaries of diabetes self-management activities measured in the previous seven days, and over the last eight weeks. Data were analysed using STATA 17. A final sample of 402 diabetes out-patients was obtained (mean age: 43 ± 12 years) and over half of them were living in poor households. The mean total diabetes self-management of score was 41.5 ± 8.2, with a range of 21 to 71. Almost two thirds of patients had average self-management of diabetes, and 55% had average diabetes knowledge. Twenty-two percent of patients had uncontrolled glucose, hypertension (24%) was the common comorbidity, and diabetic neuropathy (22%) was the most common complication. Sex [male: AOR = 0.55, 95% CI: 0.34-0.90], race [Coloured: AOR = 2.84, 95% CI: 1.69-4.77 and White: AOR = 3.84, 95% CI: 1.46-10.1], marital status [divorced: AOR = 3.41, 95% CI: 1.13-10.29], social support [average: AOR = 2.51, 95% CI: 1.05-6.00 and good: AOR = 4.49, 95% CI: 1.61-7.57], body mass index [obesity: AOR = 0.31, 95% CI: 0.10-0.95], diabetes knowledge [average: AOR = 0.58, 95% CI: 0.33-0.10 and good: AOR = 1.86, 95% CI: 0.71-4.91], and uncontrolled glucose [AOR = 2.97, 95% CI: 1.47-5.98] were factors independently predictive of diabetes self-management. This study emphasizes that the self-management of diabetes was mostly on average among patients and was associated with the aforementioned factors. Innovative approaches are perhaps needed to make diabetes education more effective. Face-to-face sessions delivered generally during clinic visits should be better tailored to the individual circumstances of diabetes patients. Considerations should be given to the options of leveraging information technology to ensure the continuity of diabetes education beyond clinic visits. Additional effort is also needed to meet the self-care needs of all patients.

Prescribed Minimum Benefits complaints: a five-year retrospective review.

BACKGROUND: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied. OBJECTIVE:  To determine and describe the pattern of PMBs complaints received by CMS from January 2014 to December 2018. METHODS:  This was a cross-sectional study that utilised the CMS' clinical complaints. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS' lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e., to only members of specific organisations) or open (i.e., to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software. RESULTS:  A total of 2141 complaints were retrieved and 1124 PMBs complaints were included in the study. The median of PMBs complaints per year was 225. Most of the complaints (43.6%, n=490/1124) were lodged by members themselves. Non-Communicable Diseases (NCDs) constituted most of the PMBs conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for more (73.8%, n=830/1124) of the complaints. CONCLUSION:  Chronic conditions are the main diseases that medical scheme members complained about. Member education and clear definition of PMBs should be prioritised by medical schemes and the Council for Medical Schemes.

High risk of occult hepatitis B virus infection in HIV-positive patients from South Africa.

This was a retrospective, unmatched case control, laboratory-based study, investigating the impact of human immunodeficiency virus (HIV) infection on the outcome of routine laboratory detection of HBsAg and prevalence of active HBV infection in 295 samples from 167 HIV-positive and 128 HIV-negative patients. The samples were tested for HBV (HBsAg, anti-HBc, anti-HBs, HBeAg and anti-HBe) and anti-HIV 1 and 2 (Axsym assays, Abbott Laboratories), as part of routine diagnosis. A nested PCR assay, with detection limit of 800 copies/ml and employing independent sets of primers to core and surface genes, was used to investigate HBV DNA. Quantification of HBV DNA was determined with the Cobas Amplicor HBV Monitor assay (Roche Diagnostics). Of the 295 samples, the frequency of anti-HBc was almost similar; 82% for the HIV-negatives and 85% for the HIV-positives, indicating that both groups were equally exposed to HBV infection. The HIV-positives had a higher rate of anti-HBs (76.0% versus 47.7%) and a lower rate of HBsAg carriage (16.2% versus 35.2%), suggesting that HIV-positive individuals are less likely to experience chronic HBV infection. However, analysis of HBV DNA indicated that many of the anti-HBs positives (20.5% versus 8.2%) and HBsAg-negatives (22.1% versus 2.4%) had active HBV infection in the HIV-positive group. There was a statistically significant difference in the prevalence of HBV DNA in the HBsAg-negatives between the two groups (Odds ratio: 11.52; chi-square: p=0.00006). Additionally, 33.3% (5/15) of sera with "anti-HBc alone" serological pattern were HBV viremic in the HIV-positive group, compared to 0% (n=31) in the HIV-negatives. Quantification of HBV DNA from HBsAg-negative/HIV-positive patients demonstrated low level HBV viremia (below 10,000 copies/ml). In conclusion, these findings strongly support that HIV infection is a risk factor for occult HBV infections.