Medical scheme members and healthcare providers are voicing their dissatisfaction with the way schemes have structured members’ benefits – and some are turning to social media to do so.
But members would do well to educate themselves about how medical schemes work, the benefits to which they are entitled and how they can participate in schemes’ decision-making.
Over the past few weeks, medical schemes have drawn public criticism over a range of benefits, including those for:
* Allied and therapeutic healthcare services, which cover psychologists, speech therapists, occupational therapists and home nursing (see “How Discovery has cut its mental health and occupational therapy benefits”, below);
* Expensive diagnostic scans, such as those for MRI (magnetic resonance imaging) and CT (computed tomography) scans (see “Members carry high costs for critical scans”, below);
* Dentistry (see “‘Big cavity’ in cover for essential dentistry”, below); and
* Cancer (oncology).
Annoyed members of Discovery Health Medical Scheme have even set up a Facebook group to record their criticism of the scheme’s recent change to its benefits for allied and therapeutic services, while a cancer advocacy group is using its website to track trends in cancer benefits and to educate members and potential members by relating members’ experiences.
The Discovery Health members’ “Medical aid forum to discuss coverage for 2012” on Facebook has attracted about 590 Facebook members, who could include annoyed healthcare professionals.
The group’s administrators have set up a petition to support their attempt to persuade Discovery Health to review the benefit changes it has made.
One of the members driving the forum says he and other concerned members have had numerous meetings with Discovery Health, and expect to have more meetings with the scheme’s trustees this year.
The changes introduced by Discovery were initially criticised by the South African Depression and Anxiety Group, and the group has subsequently held negotiations with the scheme over its concerns.
An advocacy group, Campaigning for Cancer, has set up a website, http://www.costofcancer.co.za, to inform current and potential members of medical schemes of what they need to know about the costs of treating cancer and what they need to check with regards to their benefits.
Members often do not consider what they are buying when they take out medical scheme cover, Lauren Pretorius, the chief executive of Campaigning for Cancer, says.
The group is calling on medical scheme members who have cancer, or who have a family member with cancer, to share their experiences of their schemes through the website or via the organisation’s call centre. Through this project, the group aims to identify trends in the problems that members experience with their schemes. The group will then work in collaboration with stakeholders to find solutions to these problems, Pretorius says.
She also hopes members and potential members will learn from the experiences that other members record on the website.
A medical scheme member who is active in the group told of her experience of being diagnosed with breast cancer in April and having exhausted her scheme’s R200 000 oncology benefit by September.
GET INVOLVED IN THE RUNNING OF YOUR SCHEME
Social media and the internet may well give voice to medical scheme members’ views on the benefits that their schemes provide, but members aggrieved by decisions taken by their scheme should also take the time to participate in the affairs of their scheme by attending annual general meetings (AGMs) and voting for trustees.
Traditionally, scheme members have been apathetic about participating in the affairs of their medical schemes – shying away from AGMs and not bothering to vote for trustees, Esmé Prins-Van den Berg, an attorney who consults in the healthcare industry, says. Schemes often struggle to get enough members to attend an AGM to make a quorum, she says.
The Medical Schemes Act says at least 50 percent of the trustees must be elected by the members, but members often don’t take the time to vote for fellow members.
Members can use AGMs to raise issues that are of concern to them, Prins-Van den Berg says. Scheme rules typically provide for members to place motions on the agendas of AGMs.
However, she says, the logistics of attending an AGM can be difficult if a scheme is national and its AGM is held in only one city or town. Members may not even know whom to contact to have their issues dealt with by proxy, Prins-Van den Berg says.
Members can approach the trustees and the principal officer of the scheme about issues that are of concern to them, she says.
HOW DISCOVERY HAS CUT ITS MENTAL HEALTH AND OCCUPATIONAL THERAPY BENEFITS
New benefit limits for allied and therapeutic healthcare services that Discovery Health Medical Scheme (DHMS) introduced this year on its higher options could affect members who last year enjoyed almost unlimited benefits for the services of professionals such as speech therapists, occupational therapists and physiotherapists.
The change has resulted in members crying foul on a Facebook group and lobbying the scheme. But Discovery Health says it expects that less than 1.5 percent of members on the affected higher-cost plans will reach the revised benefit limits for allied and therapeutic healthcare services, and many of these members will then qualify for extended benefits.
The new limits apply to certain plans’ above-threshold benefits once members have depleted their savings accounts. They will have to pay for the affected out-of-hospital services from their savings accounts until funds dry up and then from their own pockets while they are in “a self-payment gap”.
However, once a member’s claims for day-to-day services, which are typically paid from a medical savings account, exceed a threshold, the scheme once again pays the benefits.
When the scheme pays above-threshold benefits, it has rules that limit its liability for certain services, including those of allied and therapeutic healthcare professionals.
Dr Jonathan Broomberg, Discovery Health’s chief executive officer, says the changes to the limits for allied and therapeutic healthcare services were introduced to manage an increasing trend of abuse – often significant abuse – of previously unlimited benefits.
The restructured benefits will manage the abuse while ensuring that members who have the most pressing medical needs and who belong to the higher-cost options that have above-threshold benefits will continue to have access to unlimited cover, he says.
Benefits for home nursing, which were previously relatively low, have been increased, and benefits for psychiatry are now unlimited, he says.
However, one of the organisers of the Facebook group and petition, says a family that has one member who sees a psychologist, another who has occupational therapy and a third who has speech therapy could easily exceed the new limits without abusing the benefits.
The member says he and other concerned members believe that Discovery Health could have found ways to curb abuses by members who, for example, use the services of a biokineticist instead of paying to belong to a gym, without affecting members who genuinely need allied and therapeutic healthcare services.
The DHMS members who started the Facebook group say “it is unreasonable to go from unlimited benefits to a low maximum overnight”.
The change only affects members on the Comprehensive, Priority and Executive plans. Discovery’s other options – and those of many other schemes – limit the benefits for allied and therapeutic healthcare services to the balance available in members’ medical savings accounts.
Last year, Discovery Health members on its Comprehensive, Priority or Executive plans could:
* Enjoy cover for the services of registered counsellors, psychometrists, educational psychologists and clinical psychologists up to between R12 000 and R16 000 (depending on the option and the family size);
* Enjoy cover for home nursing up to R6 650 per family; and
* Enjoy unlimited cover for physiotherapy, occupational therapy and speech therapy.
This year, the scheme has introduced a single limit of between R4 000 and R21 000, depending on the option and the family size, for the services of healthcare professionals in all three of these categories.
At the same time, DHMS has introduced an extender benefit that provides unlimited cover for allied healthcare and therapeutic services for members and/or dependants with serious conditions.
Members or dependants with the likes of paraplegia, cerebral palsy, premature birth or birth with congenital abnormalities, or who are children requiring hearing aids or cochlear implants will immediately qualify for the extender benefit. In other cases, extended benefits can be applied for.
Broomberg says the allied and therapeutic service claims of a member or a dependant who qualifies for the extender benefit will not accumulate to the family limit for these services.
In-hospital claims and claims for prescribed minimum benefit (PMB) conditions are neither paid from your medical savings account, nor do they accumulate to your family limit for above-threshold benefits, he says.
The South African Depression and Anxiety Group (Sadag) met with Discovery Health over its concerns about how the new limits could affect mental health benefits.
Broomberg says several of the conditions about which Sadag was concerned are PMBs and will continue to be covered by the scheme’s risk benefits rather than from medical savings accounts and above-threshold benefits. Discovery Health is working on guidelines and protocols to address other concerns raised by Sadag.
MEMBERS CARRY HIGH COSTS FOR CRITICAL SCANS
The Radiological Society of South Africa (RSSA) has criticised medical schemes for requiring members to pay for scans when their conditions are covered by the prescribed minimum benefits and for setting such high co-payments for MRI (magnetic resonance imaging) and CT (computed tomography) scans that members have to pay the full amount for some commonly performed scans.
Patients often have to foot the entire bill for a critical CT scan, because the co-payment threshold is so high that the medical scheme does not have to contribute at all, says Dr Clive Sperryn, the president of the RSSA, which represents more than 600 radiology professionals.
CT scans are common after a member is involved in an accident, suffers a stroke or passes a kidney stone. An MRI scan may be required where a member has a slipped disc.
Discovery Health Medical Scheme has a co-payment of R2 300 for MRI and CT scans, while Momentum Health has a co-payment of R1 700, the RSSA says.
Dr Bates Alheit, the medical director of the RSSA, says a CT scan of the brain after a head injury costs about R1 900 – below or close to these schemes’ co-payment amounts.
The RSSA has called on schemes to apply co-payments that are a percentage of the cost of the scan, rather than high fixed amounts, but Discovery says, because the cost of a scan is unclear, a percentage-based co-payment will leave you uncertain about your portion of the bill.
Discovery says although a co-payment that is a fixed amount may be disadvantageous to someone who needs a single lower-cost scan, it can provide better cover to a member who requires many or higher-cost scans.
Momentum Health says expensive scans are often abused.
Discovery says that since 2008 the expenditure on scans has increased by an average of 20 percent a year as a result of an increase in both their cost and their utilisation, and this has necessitated the use of co-payments.
The scheme says in 2010 Discovery Health paid 97 percent of all its members’ in-hospital scans and 88 percent of all out-of-hospital scans.
The average cash co-payment paid by members for in-hospital scans was eight percent, and the average cash co-payment for out-of-hospital scans was 12 percent, Discovery Health says. But Alheit says these figures include amounts paid from members’ medical savings accounts.
Momentum Health says in 2010 it funded about 75 percent (depending on type of scan) of the total amount claimed for specialised radiology from its risk benefits.
In 2010, less than two percent, or one in 50, of all its MRI and CT scan claims were for less than the co-payment amount, Johan Lombard, a Momentum Health actuary, says.
‘BIG CAVITY’ IN COVER FOR ESSENTIAL DENTISTRY
Dentists have criticised medical schemes for not providing adequate cover for essential dental procedures.
The South African Dental Association (Sada), in a recent press release, accused medical schemes of failing to make basic dentistry accessible and said “scheme rates offered to dentists, in many instances, fall way below the actual costs of treatment”.
Many schemes provide cover for basic and advanced dentistry through members’ medical savings accounts, and pay for dentistry out of their risk benefits only for procedures that must be performed in hospital – for example, when you require surgery to correct your teeth, mouth or jaw after an accident or an illness, such as cancer.
Maretha Smit, the chief executive of Sada, says that with the increasing cost of medication and other benefits paid from medical savings accounts, members are running out of funds and are therefore deciding not to go to dentists for check-ups. As a result, bad oral health is perpetuated, she says.
Members should demand that their medical scheme provides a benefit paid by the scheme – not from a medical savings account – that at least covers basic dentistry: two consultations a year, basic fillings, sepsis control, cleaning and tartar control, and extractions, Smit says.
Schemes can then offer an additional benefit on their more expensive options for higher levels of dentistry, such as crowns, implants and orthodontics, and members who want this level of cover can pay the higher contributions, Smit says.
However, Discovery Health says such a proposal would take away members’ choice on how to use their benefits.
Smit says medical schemes are setting up networks of dental providers, and dentists are joining these for fear of losing patients if they do not. However, in some cases, dentists who have joined networks are losing money on more complex procedures, and, Smit says, if schemes do not pay dentists enough to cover their costs, they may not be in a position to treat their patients.
MAKE SURE YOUR SCHEME IS PAYING FOR PMB CLAIMS
You, as a medical scheme member, should always check whether your claims are covered by the prescribed minimum benefits (PMBs).
You may find that your medical scheme wrongly pays claims for diagnostic scans or allied and therapeutic healthcare services from your medical savings account, whereas these claims are covered by the PMBs.
The PMBs are defined in the Medical Schemes Act. They cover all medical emergencies, 270 serious health conditions, such as tuberculosis and cancer, and 25 chronic diseases, including epilepsy, asthma, diabetes and hypertension. The PMB regulations state the minimum level of diagnosis, treatment and care that your medical scheme is obliged by law to cover.
PMB claims must be paid from the scheme’s risk pool, not from your medical savings account.
Your scheme is entitled to appoint a designated service provider (DSP): a doctor, pharmacist, hospital or other healthcare provider that you must use to receive full cover for claims that result from the treatment or care of a PMB condition. There are limited exceptions, such as an emergency, and under these circumstances your medical scheme must pay in full for PMB services obtained from a provider other than the DSP.
Two mental health conditions are listed as chronic disease PMBs: schizophrenia and bipolar mood disorder. For these two conditions, treatment guidelines (known as algorithms) are published in the regulations under the Medical Schemes Act, a spokesperson for Medihelp says.
The guidelines include the chronic medicine to be used in the management of schizophrenia and bipolar mood disorder, he says.
Among the 270 serious health conditions listed as PMBs are common mental illnesses such as post-traumatic stress disorder, depression, paranoid delusional disorders, personality disorders, delirium and psychosis as a result of alcohol or drug abuse, and treatable dementia (excluding Alzheimer’s disease). The PMBs for these illnesses typically provide cover for hospital-based management or a limited number of out-patient consultations with a psychiatrist or a psychologist.
The treatment period is stipulated in the regulations.
Medical scheme rules usually require pre-authorisation in the case of a hospital admission for major depression that meets the PMB criteria, and the scheme will manage the length of your stay in hospital, the Medihelp spokesperson says.
The chronic medicine you require when you are discharged will be classified as a PMB only if your condition is confirmed as bipolar mood disorder or schizophrenia, he says. For any other diagnosis, chronic medicine will be funded according to the scheme’s benefits for non-PMB chronic conditions, he says.
If a diagnostic scan confirms your condition as a PMB and your scheme has imposed a co-payment or has not paid your claim, or has paid the claim or part of it from your savings account, take up the matter with your scheme. You may have to inform your scheme that you have been positively diagnosed with a PMB condition before it will, correctly, pay the claim from its risk benefits, without any co-payment.
Dr Bates Alheit, the medical director of the Radiological Society of South Africa, says claims for scans are often not paid as PMBs because they contribute to a diagnosis that has not yet been confirmed. However, once a PMB diagnosis has been confirmed, you can ask your scheme to re-process the claims related to the diagnosis, he says.