Private Healthcare Inquiry

Medical schemes exploit patients’ ignorance

Written by Kerry Cullinan

Medical schemes avoid covering their members for treatment they are obliged to cover by law, and patients pay up because they don’t know their rights.

This emerged at the Competition Commission’s private healthcare inquiry into in Pretoria yesterday.

The “prescribed minimum benefits” (PMB) determines by law what medical aids have to cover, but patients are often unaware of what these cover and risk being exploited.

When a patient has a “cardiac emergency”, their hospital fees are supposed to be completely covered by their medical schemes, testified Dr Dave Kettles, president of the SA Society of Cardiovascular Intervention (SASCI).

Yet recently one of his patients mortgaged his house to pay a R70 000 co-payment that his medical scheme insisted he pay for his hospital stay.

“I got on the phone to the healthcare funder and that payment was reversed,” said Kettles, who added that many hours of doctors’ time was taken dealing with medical schemes.

“The doctor-patient relationship is undermined at every turn by funders, who decide what treatment we can use and what drugs we prescribe,” said Kettles.

“Funders also decide what we should charge, which is coercive in the extreme as, if we charge more, this cost will be passed on to the patient abd we risk bad debt,” he added.

Schemes were also resistant to new technology even when it could save them money, said Kettles.

A patient could be discharged soon after a heart attack if they were prescribed a new blood-thinning medication to prevent them from having another heart attack, at the cost of R1000 a month for six months. But medical schemes still insisted on paying only a cheap drug called Warfarin, which meant that the patient remained in hospital for another week to be monitored at an additional cost of around R25 000, said Kettles.

Cancer Association of SA (CANSA) representative Professor Michael Herbst said there were often long delays in getting scheme approval for cancer treatment and cover ran out while patients were in the middle of radiation or chemotherapy.

In addition, patients’ pain medication was often not covered.

The Society of Private Nurse Practitioners said that, despite a shortage of nurses, the private sector preferred to employ “minimal permanent staff”. Yet they used nursing agencies, which pushed up their costs by around 40 percent. In addition, many nurses on the agency books were also working in the public sector.

In the last presentation of the day, Cosatu’s Sidney Kgara in the last presentation of the day, Cosatu’s Sidney Kgara said private health insurance was part of neo-liberal commercialism of health and undermined the social security of ordinary people. – Health-e News.


About the author

Kerry Cullinan

Kerry Cullinan is the Managing Editor at Health-e News Service. Follow her on Twitter @kerrycullinan11