Special Feature

Need to know: what are PMBs?

Did you know that if you have diabetes and you’re a member of a medical aid, they have to – by law – give you certain benefits for free? Nicole McCreedy explains all you need to know about PMBs.

If you’re a Type 1 or a Type 2 diabetic and you belong to a medical aid, you have the right to certain health services, known as Prescribed Minimum Benefits (PMBs). There are about 300 medical conditions where PMBs apply, and 26 of those are chronic conditions like Type 1 and Type 2 diabetes.

Your health is important

PMBs were introduced to the Medical Schemes Act to protect members. It doesn’t matter how old you are, how healthy you are, or which medical aid option you are on (yes – even hospital plan counts!) Your medical aid has to provide minimum healthcare if you have a chronic condition – at no extra cost. You shouldn’t have to pay extra (over and above your monthly medical aid contribution) for certain medical services for diabetes. Because the government has made this law, it is also impossible for medical aids to charge you more or force you to lose your medical aid cover because you have a serious medical condition.

When you can (and can’t) use PMBs

What does this mean? A medical aid must pay in full, without any co-payment from you, for the diagnosis, treatment and care costs of the PMB condition (your diabetes). The medical aid cannot use your medical savings account or day-to-day benefit to pay for PMBs. Remember, though, that PMBs are subject to pre-authorisation (you have to register your PMB with the medical aid first), protocols (specific treatment and medication guidelines), and making use of designated service providers (hospitals, pharmacies and doctors that they have chosen). So you can’t expect your medical aid to cover the costs of your diabetes care unless you play by their rules, and you may not be able to get the same doctors and medicine as you had before.

Sometimes, members will not have cover for PMBs from their medical aid. This can happen if you join a medical aid for the first time (without switching from another medical aid) or if you join a new medical aid more than 90 days after leaving the previous one. If this is the case, there is a waiting period, during which you won’t have access to the PMBs for any pre-existing condition for 12 months.

Diabetes treatment and PMBs

The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially nutrition and exercise, but most people with diabetes also use medicine (usually insulin) at some point. Treatment of other risk factors, like blood pressure and high cholesterol, is also very important.

Both Type 1 and Type 2 diabetes qualify as PMBs and must be treated according to PMB regulations for diagnosis, medical management and medication. You can ask your medical aid about the following treatments that should be covered:

  • Visits to your doctor (GP or specialist – if authorised).
  • Dietary and disease education.
  • Annual eye exam for retinopathy.
  • Annual comprehensive foot exam.
  • Blood tests every 3 to 6 months.
  • Disease identification card or disc.
  • Home blood sugar testing.

How to get your Prescribed Minimum Benefits:

Step 1: Register

Phone your medical aid and tell them you want pre-authorisation for diabetes PMBs. They will ask for a code that your doctor will be able to give you. It is very important that you have the right ICD-10 code – this gives the right information about your condition and helps the medical aid to know what benefits you are allowed. A PMB condition can only be identified by the correct ICD-10 codes. If you give the wrong ICD-10 code, your PMB services might be paid from the wrong benefit (like your medical savings account), or it might not be paid at all if your day-to-day or hospital benefit limits have run out.

Step 2: Your service will be pre-authorised

After you have registered your chronic condition for PMB, your benefits will be authorised and you can ask for your PMB schedule, which tells you exactly what you get for free.

 

The A to Z of PMBs

Chronic Diseases List (CDL)
A list of the 26 conditions (including diabetes) that qualify for PMBs.

Chronic Medicine
Medicine used for the long-term treatment (three months or longer) of a chronic condition. The chronic medicine must be used to prevent or treat a serious medical condition, to sustain life and to delay the progress of a disease. It must also be the accepted treatment according to treatment guidelines (protocols).

Co-payments
The difference between the cover provided by the medical aid and the cost of the medical service – payable directly to the service provider.

Designated Service Provider (DSP)
Doctors and other health care providers who have been chosen by the aid to “provide its members diagnosis, treatment and care” for PMB conditions.

Emergency Medical Condition
A medical condition that needs immediate medical or surgical treatment.

Formulary
An official list of the medication that can be prescribed for the treatment of the 26 conditions on the Chronic Diseases List (CDL).

ICD-10 Codes
An international clinical code that describes a disease diagnosis. If you want to qualify for PMBs, you must be sure your doctor puts the correct ICD-10 code on all your forms.

PMB Medicine
Medicine for the treatment of the 26 conditions on the Chronic Diseases List (CDL) qualifies for PMBs, as long as you provide all the necessary information. This can be anything from a diagnosis by a specialist to results of certain tests – your medical aid will tell you what you need.

Prescribed Minimum Benefits (PMBs)
The minimum benefits that must be provided to all medical aid members. These include diagnosis, treatment and care costs for a number of conditions, including diabetes.

Protocols (Treatment Guidelines)
There is a minimum standard treatment for each PMB condition. Medical aids use these guidelines to come up with protocols (treatment guidelines) and formularies (lists of approved medication) to manage PMBs.

This article was reviewed by:

  • Alain Peddle, Discovery Health
  • Herman van Zyl, Principal financial advisor, HVZ Financial Consultants
  • Rossouw van Zyl, Brokers, t/a Medinet, Authorised Financial Service Provider
  • Michael A.J. Brown, Accredited Diabetes Educator,
Centre for Diabetes and Endocrinology, Houghton

 

Gastric bypass surgery to “cure” diabetes

Recent research suggests that a certain kind of surgery may “cure” Type 2 diabetes. We find out more, and give you the facts.

One of the experts in the field of gastric bypass surgery is Professor Tess van der Merwe, the president of the South African Society for Obesity and Metabolism, who have been sharing information about the surgery. We found out what it could mean for Type 2 diabetes, then asked our experts to weigh in on the topic.

Is this surgery a cure for Type 2 diabetes?

Gastric bypass surgery has been used to help obese people lose weight since it was first performed 20 years ago. But now there is new research that this same surgery (specifically a type called “laparoscopic Roux–en–Y gastric bypass”) could cause Type 2 diabetes to go into long-term remission. What does this mean? Type 2 diabetes could be “paused” for a number of years. An international study shows that about 90% of obese patients with Type 2 diabetes who go for this surgery have normal blood sugar and no evidence of diabetes for three to fifteen years.

Is it a cure? No. But it is possibly a very long break from a chronic condition.

Some might say that any surgery that causes very overweight people to lose weight will have a good effect on blood sugar, but experts say the difference can be seen before the weight is lost. Professor Francesco Rubino (a leader in surgery for Type 2 diabetes) was in Johannesburg for the 3rd Centres for Metabolic Medicine and Surgery Workshop. He said that a few days after a gastric bypass, patients with Type 2 diabetes show normal blood sugar levels, even before any weight has been lost.

Ask the expert: Dr. Joel Dave, endocrinologist
“Bariatric surgery is becoming an important part of the treatment of diabetic patients with a BMI over 35. But although the results with this surgery are very good, it is still an invasive procedure with potential complications. It should not be considered a shortcut to weight loss and diabetes improvement, but a last resort after a low calorie diet and structured exercise programme has failed.”

 

What if the Type 2 diabetic ate badly and didn’t exercise, and returns to this same lifestyle – will the surgery still work?
The surgery doesn’t just help the patient by making their stomach smaller. It also triggers changes to the hormones, the appetite and the metabolism, so that long-term change is possible. But it is not a magical cure – the patient has to be ready to make changes to their diet and exercise. As Prof. van der Merwe points out, “There is not a single treatment in medicine that will be immune to an uncooperative patient.” In other words, if the patient goes back to a diet of fast food and no exercise, the same problems will return. One of the ways they guard against this in the Centres of Excellence (where they do the surgery) is by coaching the patient to start new, positive habits. They have a team of experts to help with this.

Ask the expert: Genevieve Jardine, dietician
“It is my opinion that gastric bypass surgery may be a good option for those who have a high BMI (above 35) and have tried for many years to lose weight. If they are managed well after surgery and take this opportunity to start over, it could mean a second chance at health. It is important to remember, though, that it still comes down to diet and exercise. Lifelong lifestyle changes are still the foundation of good diabetes management.”

How extreme is the surgery?

The surgery is minimally invasive. It is also known as laparoscopic surgery, keyhole surgery or bandaid surgery because the cuts made are so small – on average 0.5 to 1.5 cm. The doctor uses images on TV screens to magnify the surgery so they can see what they need to do.

Ask the expert: Dr. Joel Dave, endocrinologist
“Although the procedure is minimally invasive there are still some potentially serious complications. The patient’s decision to have this surgery must not be taken lightly.”

Is the surgery covered by medical aids?

That depends on how urgently you need it. In order to work that out, doctors look at your BMI (Body Mass Index), which outlines whether you are underweight, at a healthy weight, or overweight (see the box on this page). Diabetic patients with a BMI over 35 may be able to get the surgery covered if they have a motivation letter from a Metabolic Centre for Excellence, and if they are on the right medical aid option. There is usually a 20 to 30% co-payment that the patient would have to pay.

Have there been any local studies?

A South African study based at Netcare Waterfall City Hospital tracked 820 patients who had not been able to lose weight for up to 18 years before they had surgery. Three years later, 88.5% of the patients who had diabetes at the time of the surgery still had normal blood sugar levels.

Is there anyone it won’t work on?

This surgery is only an option for Type 2 diabetics who are very overweight – with a BMI greater than 35. They are doing research on lower BMI’s as well.

Want to find out more?
Visit www.sasomonline.co.za

How to work out your BMI

There are many websites (http://www.smartbmicalculator.com/) that calculate BMI for you, but if you want to do it yourself, here’s what you need:

  1. Your weight.
  2. Your height in metres.
  3. A piece of paper and a calculator!

First, find out the square of your height in metres (your height times your height, i.e. 1,5m x 1,5m).
Then do this sum: (Weight in kg) divided by (square of height in metres)
You should get a number between 18.5 and 40.

Results:

  • Less than 18.5 means you are underweight.
  • 18.5 to 25 means you are at a healthy weight.
  • 25 to 30 means you are slightly overweight.
  • More than 30 means you are very overweight (obese).

The low carb diet debate

Remember when low carb wasn’t as well known as it is today? We do! Here’s an article from Sweet Life magazine published a few years ago that explains all the ins and outs…

Professor Tim Noakes says that a low carb, high fat diet is the way to go. We gathered your questions and asked him how the low carb diet affects diabetics. Here’s what he had to say.

  1. What exactly is this diet?

    A low carbohydrate, moderate protein, high fat diet. This diet is most effective for people with diabetes – either Type 1 or Type 2, or pre-diabetes, like myself. It also helps treat obesity, but it’s obviously not the diet for everyone. The question is whether it’s for 10% of the population, or 90% of the population – I think it’s about 60% or more.

    Low carb means no bread, pasta, cereals, grains, potatoes, rice, sweets and confectionery, baked goods. You have to be resolute – and the more severely affected you are, the more resolute you have to be. If you’re already diabetic, you have every reason not to eat these foods.

  1. Can you explain what carbohydrate resistance is?

    My opinion is different from the traditional teaching. Carbohydrate resistance is traditionally described as someone who is unable to take glucose out of the blood stream and store it in their muscle and liver. I disagree with this explanation: I think we’re all born with varying degrees of carbohydrate resistance, and the children who get really fat very young are the ones who are most carbohydrate resistant. The carbs they take in they simply store as fat. That’s the first group.

    The second group are people who become pre-diabetic at 30 or 40, and then they become diabetic at 50. They are overweight, and that’s a marker of the high carbohydrate diet. They eat a high carb diet, they are carb resistant and it gets more and more severe until they become diabetic. I think it’s genetic, and the reason I think that is because in my case, although I’ve lost weight, I’m still carbohydrate resistant – I can’t go back to eating carbs.

  2. What if you have high cholesterol? Isn’t it dangerous to eat so much fat?

    Firstly, the theory that high cholesterol is a good predictor of heart disease is not true – it’s a relatively poor predictor. A far better predictor is your carbohydrate status. Everyone knows this – if you’re diabetic or pre-diabetic, your risk of heart disease is increased. Diabetes, hypertension and heart disease are linked, but most heart attacks occur in people with cholesterol below 5. It’s very frustrating, because the public has got the wrong idea.
    A high fat diet corrects everything, in my opinion – your HDL goes shooting up, your triglycerides come shooting down and that HDL to triglyceride ratio improves dramatically: that’s one of the better predictors of heart attack risk. The LDL small particles are the killers, and on a high fat diet, those go down. Your total cholesterol can go up, but that’s because your HDL has gone up, and the large, safe LDL particles have gone up. So unless you measure all those variables: HDL and LDL and triglycerides and glucose tolerance, you can’t judge the effects of the diet.

  3. What carbs do you eat?

    The good carbs are veg – that’s it. Sweet potatoes (not regular potatoes), butternut, squash and then I also eat dairy: milk, cheese, yoghurt. I don’t eat any fruit except apples, but that’s because I severely restrict my carbs. You’re not cutting out nutrients if you eat nutrient-dense foods like liver, sardines, broccoli and eggs – those are the most nutrient-rich foods you can eat. You can get vitamin C from meat if it’s not over-cooked. The key is that you eat lots of fat, and you don’t avoid the fat. I eat lots of fish, like salmon and sardines. And you want to eat lots of organ meats – that means liver, pancreas, kidneys, and brains if you can get them, but particularly the liver. Liver is very nutritious.

  4. Is this diet possible for people who don’t have a lot of money?

    You don’t have to eat meat every day – you can eat sardines and kidneys, for example, which are both very cheap.

  5. Could the positive effect of a low carb diet on insulin resistance be because of the weight loss and not because of the new diet?

    No, absolutely not. Because it happens within one meal – your insulin requirements go down within one meal, because you’ve shut off the production of glucose by not eating carbohydrates.

  6. What is wrong with the old fashioned idea of a balanced diet? Why does it have to be so extreme?

    If you’re diabetic, you have a problem with metabolising carbohydrates. You have to understand that if you want to live a long life and have minimal complications, you want to minimise your carb intake. Start at 50g a day. What that looks like is two eggs for breakfast, with some fish – salmon or sardines, and some veg. And dairy: cheese or yoghurt. That will sustain you until early afternoon. For lunch, I think you should have salad and some more protein and fat – and exactly the same for dinner. Chicken, cheese, nuts, salad, tomatoes, broccoli. It’s an incredibly simple way to eat, but you don’t get bored.

Last words:

Once you’re on this diet, you feel so good, and you get rid of all these aches and pains and minor illnesses: you won’t want to go back. If you do go back to eating carbs you’ll put on the weight again. It’s not a diet, it’s a lifelong eating plan. It’s not a quick fix.

I think the diabetics who live to 80, 90, 100 are the ones who eat this kind of diet.