Health issues affecting women
August is Women’s Month and the 9th marks National Women’s Day, celebrating the care, courage, and everyday impact of women in shaping our society! To mark this special month, the CMS is raising awareness about important health issues that many women face and how Prescribed Minimum Benefits (PMBs) help ensure access to the right care at the right time.
From fertility challenges to reproductive health and cancer treatment, here is a look at how PMBs support women’s access to healthcare services throughout different stages of life.
Infertility
Infertility is a serious health issue affecting millions of people of reproductive age worldwide.
It is generally defined as the inability to become pregnant after one year of unprotected sex and after six months in women over age 35. It can sometimes present as irregular, very short (21 days), or very long (35 days or more) menstrual cycles, which may indicate that ovulation is not happening regularly.
The cost of infertility testing and treatment can be overwhelming. For many couples or individuals, affordability becomes the biggest concern. Therefore, it is important to know what kind of support is available through PMBs.
The PMB regulation includes infertility, but states that medical and surgical management shall be limited to nine procedures and interventions.
Ovarian cysts
Ovarian cysts are fluid-filled sacs that develop on or inside an ovary. They often go unnoticed and are usually discovered during a routine pelvic exam or ultrasound. However, in some cases, they can cause pain, especially if they rupture, grow large, or interfere with blood flow to the ovaries.
Ovarian cysts can sometimes make it harder to conceive. If surgery is needed to remove cysts, the doctor will perform the procedure while aiming to preserve fertility as much as possible. This may mean removing a cyst and leaving the ovaries intact or only removing one ovary. When both ovaries need to be removed, the body will no longer be able to produce any eggs. It is important to understand the effects of surgery on fertility before the procedure is done.
“Ovarian cysts” are included in PMB regulations under the Diagnosis and Treatment Pair (DTP) code 434M. This DTP refers to “Non-inflammatory disorders and benign neoplasms of the ovary, fallopian tubes and uterus”. The Treatment component specified for this DTP is “Salpingectomy; oophorectomy; hysterectomy; medical and surgical management”.
The medical schemes must pay for the full diagnosis, treatment, and follow-up consultations and treatment if the services were obtained from a designated service provider (DSP). In case of an emergency, healthcare services must be paid in full, even if a non-DSP was used.
Termination of pregnancy
Termination of pregnancy, or abortion, is the medical or surgical ending of a pregnancy before the fetus can survive outside the womb. This may be done for various medical or personal reasons.
Abortion in South Africa is legal on request. The Choice on Termination of Pregnancy Act No. 92 of 1996 gives all women the right to have a safe abortion, on request, with no conditions during the first 12 weeks of pregnancy. The procedure can be performed by a medical doctor, nurse, or registered midwife.
The Act also allows for the abortion to be performed between 13 and 20 weeks of pregnancy by a doctor if, after consultation with the pregnant woman, the healthcare practitioner believes that:
- Pregnancy poses a risk to the woman’s physical or mental health.
- The risk of severe physical or mental abnormality in the unborn baby is substantial.
- Pregnancy resulted from rape or incest.
- The continued pregnancy would significantly affect the social or economic circumstances of the pregnant woman.
After 20 weeks of pregnancy, abortion can be performed by a medical doctor if the pregnancy endangers the woman’s life or the unborn baby’s health.
“Voluntary termination of pregnancy” is a PMB condition under the Diagnosis and Treatment Pair (DTP) code 296M. The treatment component specified for this DTP is “Induced abortion; medical and surgical management”. The medical schemes must pay for the consultations, tests, medicines, medical or surgical abortion, and follow-up consultations and treatment in full if the services were obtained from a designated service provider (DSP).
Cervical cancer
Worldwide, cervical cancer is the fourth most common cancer in women. In South Africa, cervical cancer has been identified as a national priority, as 1 in every 42 women has a lifetime risk of being diagnosed with cervical cancer. However, it can be treated successfully if detected early.
Diagnosis and Treatment Pair (DTP) code 960M. Treatable cervical cancer is a PMB condition under DTP code 954M – Cancer of Cervix – treatable. According to the PMB regulation, treatable cancers are defined as follows:
- They involve only the organ of origin and have not spread to adjacent organs.
- There is no evidence of distant metastatic spread.
- They have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ.
- If points 1 to 3 do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
According to the PMB regulations, schemes must pay for the diagnosis, treatment and care costs of treatable cervical cancer, irrespective of the medical scheme option a member belongs to. This would include consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy and radiation therapy. If the cancer has spread, the only treatment that does not provide a five-year survival benefit of more than 10% is not PMB level of care. In such instances, clinically appropriate healthcare services must be funded.
Breast cancer
Breast cancer is a disease in which the cells of the breast do not grow normally; they grow out of control.
Treatable breast cancer is included in the Prescribed Minimum Benefits (PMB) regulations under DTP 950J. Treatable cancers are defined in the PMB regulations as solid organ malignant tumours where:
- They involve only the organ of origin and have not spread to adjacent organs.
- There is no evidence of distant metastatic spread.
- They have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ.
- If points 1 to 3 do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
Regardless of which benefit option a member or beneficiary is on, the medical scheme must pay for the diagnosis, treatment, and care costs of treatable breast cancer. Screening through a physical breast examination, consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy, radiation therapy, and breast reconstruction are included in what the medical scheme must cover
Ovarian cancer
Treatable ovarian cancer is a Prescribed Minimum Benefit (PMB) condition under Diagnosis and Treatment Pair (DTP) code 952M – Cancer of ovary – treatable. According to the PMB regulation, treatable cancers are defined as follows:
- They involve only the organ of origin and have not spread to adjacent organs.
- There is no evidence of distant metastatic spread.
- They have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ.
- If points 1 to 3 do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
According to the PMB regulations, schemes must pay for the diagnosis, treatment and care costs of treatable ovarian cancer, irrespective of the medical scheme option a member belongs to. This would include consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy and radiation therapy.
Council for Medical Schemes has published the PMB Definition Guidelines for ovarian cancer. These provide detailed information on the treatment options that are PMB level of care and those that are not.
