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Medical aids preventing quality care Interference a major concern for doctors

July 26, 2009 Edition 2

Eleanor Momberg

Interference by medical aids and medical administrators in clinical decisions by doctors is adversely affecting the care medical professionals are able to give their patients.

Doctors, specialists and medical bodies have expressed serious concern about the growing incidence of interference by medical aids in clinical care, saying such meddling often ended up costing them more because cheap medical care resulted in more costs being incurred in the long run.

Professor Morgan Chetty, CEO of the KwaZulu-Natal Managed Care Coalition, said interference may entail withholding approval of the use of certain drugs, rejecting requests for certain procedures, or demanding justification for a treatment to the extent that the clinician was forced to withdraw that treatment out of frustration.

"There are many ways of interfering clinically without having to spell it out," he said. As a result of interference, doctors were unable to make clinically sound decisions based on the latest research. Instead, they were forced to operate in an environment where costs associated with clinical care were managed down to rock bottom, while non-clinical costs soared skywards.

"Cheap medical care can be very expensive in the long term. Poor disease management results in further costs down the line that might have been avoided had the doctor been able to manage the patient optimally from the outset," said Chetty.

Dr Norman Mabaso, chairman of the South African Medical Association-affiliated Society of General and Family Practitioners, said interference manifested through prescriptive behaviour where medical aids decided how doctors could or could not treat their patients.

"It is a very serious problem. Part of it is the way benefits offered by medical aids are limited. This is done in a very calculated manner and you have a situation where the medical aids no longer cover certain services. "

Mabaso called it interference by deprivation that resulted in the crippling of decision-making by doctors on quality patient care.

Interference included medical aids withholding payment because a service rendered by a medical practitioner was either too expensive or not covered, or where a member''s benefits were exhausted by March.

This placed additional pressure on doctors who were then "forced" to only treat patients who had cash.

Money in hand was what people suffering from mental health problems required when seeking the help of psychiatrists and psychologists, and requiring medication, said the SA Depression and Anxiety Group.

Zane Wilson of Sadag said the placing of a cap on mental health care by medical aids was a massive problem for patients, who were then either forced to stop consulting a specialist, or taking medication. "Mental health is not being treated as substantial an illness as it is. "

A pharmacist, who asked not to be named, said her main concern was medical aids withholding treatments for premature and newborn babies, and insisting that chemists only dispense generic medicines for certain conditions. "The person who does not respond to generics is therefore responsible for the account, which in some cases can run to thousands of rands a month. Why are they paying for medical aid that does not provide for adequate care?" she asked.

Other doctors bemoaned the fact that medical aids often did not keep up with technology, refusing payment or authorisation for the most advanced treatment because it was "too expensive".

Mabaso said another concern was treating a new patient, discovering the person had a chronic disease and being unable to secure medical aid funding because the person had not belonged to the fund for more than a year.

Chetty said many doctors believed managed health care plans negatively impacted on the care they were able to give patients. "Doctors frequently have to haggle with health plans to obtain authorisation to manage their patients appropriately. This includes obtaining permission to undertake necessary procedures, use certain drugs and admit patients to hospital for optimal management. . . They then have to convince this intermediary, who has no medical training, of the clinical necessity of their request. "

Chetty said doctors were expected to deliver care designed by non-clinicians and may even be censured or "profiled" for not following their guidelines.

Medical aids, Mabaso pointed out, were spending more money on fraud and abuse prevention than on their members, claiming that the tight boundaries set by medical aids was contributing to fraud, as it caused doctors and patients to collude on changing a diagnosis so that certain procedures and medicines would be covered.

The Council for Medical Schemes or another independent body needed to look at the efficacy of medical schemes and investigate their prescriptive practices, he said.

Hospital groups and the Council for Medical Schemes refused to comment.

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