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Communication Guidelines for Medical Schemes Discussion Document – 2012

The Council for Medical Schemes (CMS) is involved in a process of determining a set of guidelines for communication to beneficiaries within the private healthcare industry. The overall aim of this guideline is to clarify the minimum required information to be disseminated to beneficiaries and service providers and the optimum way of sharing it using various communication channels.

The presence of complex and incomplete information is a pervasive feature of the health care market. This situation leads to a phenomenon referred to as asymmetry of information (Atim, 2009). Providers and/or funders act as agents in determining what care is needed, at what level as well as the associated utilisation costs.

The information asymmetry problem is further exacerbated by the use of technical medical words and/or language to describe a medical condition. These words are not easily understood by a layman and this is made worse by the fact that many serious illnesses do not repeat themselves, so that the cost of gaining the information is very high.

It is also envisaged that this information will empower and to a large extent alter the conduct of beneficiaries, funders as well as services providers. For example beneficiaries will understand their entitlements, use of designated service providers (DSPs), prescribed minimum benefits (PMB), formulary medicine and associated exclusions and deductibles. Whilst funders using layman’s language will communicate with the beneficiaries explaining the use of DSP’s, PMB package etc.

These guidelines are critical since they will enable enforcement of section 57(4)(d) of the Medical Schemes Act which states that “ …schemes should ensure that adequate and appropriate information is communicated to members regarding their rules, benefits, contributions, and duties in terms of the rules of the medical scheme. ”

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