PSEMAS Groans under AIDS Burden

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By Frederick Philander WINDHOEK The third party road accident guaranteed payment system has created a blank cheque mentality among members, as well as a milk-the-cow attitude among health providers of the Government’s medical scheme, the Public Service Employees Medical Aid Scheme (PSEMAS). These accusations were yesterday made by Andreen Moncur, when she addressed a four-day AIDS in the Workplace conference of the Ministry of Education on behalf of the Ministry of Finance. About 20 senior managers in the ministry are attending the workshop in the capital. “The greatest challenge facing the Ministry of Finance as custodian of the government’s medical scheme for civil servants is ensuring its sustainability without eroding the reasonable benefit expectations of the members. Furthermore, until fairly recently the government has been complacent about demanding value for its employee health care spending, a study has shown,” Moncur said. According to her, the same study showed that the sustainability of PSEMAS on the current benefit structure is threatened by the increase in HIV-related claims and increasing claim costs as more AIDS-sick PSEMAS beneficiaries are being referred to private hospitals. “PSEMAS members without access to private health care facilities are starting to suffer poorer health in general due to increasing pressure on the already overburdened public health system. The medical scheme is further threatened by losing costs savings due to the absence of interventions. These losses can render the entire PSEMAS initiative financially unviable,” Moncur, who mentioned that the Ministry of Finance is in the process of putting measures in place to achieve fiscal health for the scheme, said. She further highlighted some of the problems the medical scheme is grappling with to sustain itself as: the “fee-for-service” system that perpetuates the perverse incentive for providers to over-service patients; over-prescribing medicines by primary health care providers such as GPs and clinics and over-servicing and over-treating of patients by service providers in most disciplines; member and service provider fraud; member over-utilisation of health care services and a focus on curative rather than preventative care. “The claims costs of PSEMAS are distorted due to the treatment of related symptoms/opportunistic infections such as tuberculosis, pneumonia, herpes zoster, persistent diarrhoea, and sexually transmitted infections; the majority of members are in high HIV prevalence areas and thus at greater risk of contracting the virus; patients traverse most of the disease cycle and only initiate treatment when they become AIDS-sick and exposure to the risk of double dipping, i.e. PSEMAS is paying for treatment for its beneficiaries without seeing the benefits of improved health on its claims patterns,” she said of the members who pay N$60 monthly to be part of the scheme. Moncur also mentioned that the Ministry of Finance is presently implementing certain measures to ensure fiscal health for the scheme. “These measures are to ensure that health care providers understand that their ability as practitioners is not being challenged but rather that the Ministry of Finance is engaged in managing scarce resources according to best practice. Health care providers must understand that all health-care initiatives must be founded on accessibility and afforda-bility; they must not act fraudulently or wastefully and they must stop over-treating and over prescribing; ensuring that the quantum of members’ benefits is not reduced while curbing over-utilisation and exerting increasing influence over pricing and choice of procedures in the interests of members,” she asserted. PSEMAS beneficiaries also have a vital role to play in ensuring that it will be sustainable. “Beneficiaries can help to ensure the sustainability of PSEMAS by having responsible expectations, i.e. they must understand that all health-care initiatives must be founded on accessibility and affordability. Beneficiaries must lower their expectations from “high” to “responsible”, not in terms of access to quality health care, but in terms of frequency of utilisation of health care services and in terms of utilisation of non-medically necessary services,” she urged the 135 000 members of the medical scheme.