This article which appeared in the Cape Times, is a result
of much hard work done by REACH and input by our members.
Please if you have a medical aid problem or dispute in the field
of Psychology, Psychiatry, or medication for a mental health
problem please let us know. We are assisting REACH (which is the
consumer body for health issues) in trying to fight the Medical
Aids on decreased payments in psychiatric care
Medical aid revamp sees members lose freedom of choice
MEDICAL Aid members will have to be extremely vigilant from next month about which drugs they accept and in some cases which doctors' establishments they visit - or they will have to pay up themselves. Many schemes are to pay for medicines only from formularies. In another trend - which applies chiefly to the cheapest options or package of benefits offered - schemes are prescribing where members must seek treatment if they wish to claim expenses. Schemes are to pay out only if members consult doctors or have treatment at hospitals that are members of a designated service provider. In commenting on a member's need to establish whether a medical aid would pay for treatment, André Jacob of broker group Financial Planning Association said that patients would have to drive the process. It is expected that doctors will keep electronic lists of schemes' formularies and that they will be available on the Internet. If a drug is not covered, the patient must ask for an alternative or pay the difference. If, however, a doctor believes a patient should have a medicine that is not in the formulary, he may write a report giving the evidence that the patient would not benefit or would experience side effects. In such a case, the medical aid would be obliged to pay for the drug that the doctor chooses. Jacob said that patients did not know how their rights had changed. Members' medical aid premiums are to be 13% higher, on average, from January. The increase is far higher than the inflation rate for a host of reasons, according to Heidi Kruger, spokeswoman for the Board of Healthcare Funders. It is based on: the requirement that schemes pay prescribed minimum benefits; abuses of medical aids that cost between R4 billion and R8bn last year; the spiraling costs of drugs, visits to hospitals and specialists' fees; and schemes not being permitted to exclude high-risk people. An important change that is to the benefit of consumers is that next year all medical schemes will by law have to pay for unlimited treatment for 25 chronic conditions. The Medicines Schemes Amendment Act makes this obligatory and people who have signed on for even the cheapest medical aid options have the right to this unlimited treatment. Kruger said of the changes the prescribed minimum benefits would bring that next year would be a watershed year. She said that many people would be getting more benefits than they had had. Jacob said that the 25 chronic conditions accounted for 80% of all chronic cases. Kruger said that some schemes had chosen the state sector as their designated service provider for some conditions. Transnet and Spectramed, for example, would pay the prescribed minimum benefits only if members received the treatment they needed at state hospitals. Some medical schemes are negotiating whether members will be treated in private wards. Jacob said that the new arrangements were "fair" and "in the consumer's interests". Medical schemes had for several years been obliged to provide cover for 273 conditions that excluded chronic conditions. Nusreen Khan, national co-ordinator for Rights, Education and Activism for Consumer Healthcare, a section-21 company, said state hospitals might have inadequate resources to treat medical aid patients for these conditions. There were long queues. At times only old-generation medicines were given out and there was a lack of resources, she said. Also, not all hospitals would have established the necessary treatment protocols.
The Cape Times, 5 December 2003