Download Mental Health Care Act

REACH
Health Portfolio
Committee
17 May 2005
Nusreen Khan
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
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.
Working Relationships
• Relationships with
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FPI
SAMA
BHF
Council Medical Schemes
HPCSA
Support Groups
Consumer Union
Diabetes SA
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
Working Relationships
• Relationships with
» Health Technology Assessment Steering
Committee
» PSSA
» Health Science Academy
» Foundation for Professional Development
» PMA
» IMSA
» SASOP
» Anti-Stigma Initiative
» SADAG
Working Relationships
• Relationships with
» Spesnet
» Private Healthcare Forum
» PCMA
Psychiatric Commission
Health Portfolio Committee
17 May 2005
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
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
“SHADOW” WHITE PAPER
ADDRESSING STIGMA AND
POSSIBLE DISCRIMINATION
OF PATIENTS WITH
MENTAL HEALTH PROBLEMS
IN
THE REPUBLIC OF SOUTH
AFRICA
Terms of Reference
To explore possible discrimination in the allocation of
psychiatric benefits
o To assess the impact of limited disease cover in terms of
ineffectual treatment of psychiatric disorders
o To assess the impact of formulary decisions on the effectual
treatment of
psychiatric disorders
o To question the focus of PMBs on hospitalised treatment
only
o
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.
Psychiatric Commission
PROJECT INVESTIGATORS
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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.
Consultations
DoH
SA Federation for Mental Health
Schizophrenia Foundation
SADAG
Bipolar Support Group
Alzheimers SA
Riverfield Lodge
Denmar Specialist Psychiatric Hospital
Vista Psychiatric Clinic
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
Endorsements
OCD Association
Lesedi Private Clinic
SAMA
HASA
Mental Health Information Centre
DENOSA
Endorsements
DoH
SA Federation for Mental Health
Schizophrenia Foundation
SADAG
Bipolar Support Group
Alzheimers SA
Riverfield Lodge
Denmar Specialist Psychiatric Hospital
Vista Psychiatric Clinic
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
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
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
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
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.
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.
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
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.
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
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”.
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)
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.
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
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;”
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.”
Medical Schemes Act
Limited coverage of diseases
The gap:
• No evidence-based explanation has been
provided to date for the capping of
psychiatric benefits
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
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.
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
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 Parkinson’s
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
Patients Rights Charter
2.
Participation in decision-making
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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 one’s health.
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Patients are not consulted in any decision making process
i.e. benefit design, formulary/protocol guidelines, choice of
treatment
Gap
Access to health care
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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.
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Insufficient efforts on the part of medical schemes to inform
members of new benefit designs and the impact of the
PMBs
Gap
Patients Rights Charter
4. Knowledge of one’s health
insurance/medical scheme
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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
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
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
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 case[1]
• 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
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[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.
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
Proposals
• The law as it pertains to the mental health
care user accordingly requires
reassessment in the following respects:
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how benefits are structured
how facilities are licensed
treatment protocols
formularies
PMBs
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
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
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
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.
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.
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.
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 – it’s 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.