Members’ Right to Choose Undermined by Cost Management Considerations

Members’ Right to Choose Undermined by Cost Management Considerations
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I’m a member of one of the top two open medical schemes in South Africa, and my observations during the last few years is that my medical scheme just like many other medical schemes in South Africa has been hard at work devising creative ways and means to reduce the amounts of monies that they pay out to health service providers, whilst at the same time introducing above inflation annual increases to balance their books.

Year on year, the medical schemes benefit structures, including with my own medical scheme have been showing a steady reduction in the annual benefits for both day to day ‘out of hospital’ care, as well as ‘in hospital’ benefits including specialist care. The medical schemes have been introducing a variety of tools to limit or discourage utilisation of medical scheme benefits, for example, co-payments (levies); self-payment gaps; pre-authorisation of a variety of services, use of medicines formularies that ensure 100% payment for generic medicines and co-payments or rejection for original/ethical medicines.

For cheaper medical scheme options, all schemes have been introducing benefit structures that make use of a closed preferred provider network of medical doctors, pharmacies, dentists etc., where they would pay 100% of fees if the member makes use of network providers, and will get punished if they use non-network health care providers. In a way, the medical schemes trade-off affordable monthly premiums with limiting the member’s right to choose their own health service provider/s, and it has generally been grudgingly accepted by members who have chosen the low-cost options.

This past Saturday, as a member of one of the top open Medical Schemes, on a relatively expensive benefit option, I received an e-mail correspondence from my medical scheme entitled IMPORTANT NOTICE: EXCLUDED HOSPITALS. In the correspondence, the medical scheme begins by giving a context that schemes have been challenged during the past few years by receiving relatively higher medical claims than previously, and they have tried various cost management initiatives, but have now reached a point wherein they need to tackle head-on the costs of hospitalisation, which in their experience accounts for almost 50% of the annual scheme costs.

To this end, they were advising us that they are now introducing a national list of contracted hospitals that we must use in the event that we have to be hospitalised, if we want them to settle 100% of our hospital bills, and if we opt to use hospitals that are not on the national list for non-emergency care, we will then be liable to make a 30% co-payment of the resultant hospital bills. The contents of this e-mail correspondence irked me because whilst I understand their cost control imperatives, being in a relatively expensive medical scheme benefit option, as opposed to a low-cost option, I do not take kindly to my right to choose an own medical doctor, medical specialist or hospital being taken away just like that.The effect of this new benefit policy is that if one has been consulting a medical specialist who operates from or has consulting rooms in one of the hospitals that are not contracted to the medical scheme, and a non-emergency operation has been planned, one will have to either ask the medical specialist to admit one in another hospital, or if I insist on using my medical specialist because of long-standing doctor-patient relationship, then that will come at a hefty 30% co-payment, which is a high price to pay for loyalty to my medical specialist.

In a way, this new benefits policy directive violates the right of the patient to choose their own medical specialist or hospital in cases of hospital admissions. The potential impact of this policy directive is that It will lead to a breakdown of established doctor-patient relationships, with an unfortunate consequence that the medical specialists in such non-contracted hospitals will have to migrate to find consulting rooms in contracted hospitals, or risk dwindling patient numbers, and the affected hospitals will obviously have to agree to lower hospital tariffs with the medical scheme, or risk losses and possible business closure.

In my view, this policy directive reveals to us as members that our medical schemes have reached desperate times in their fight to remain afloat in terms of their financial reserves, and they are now introducing desperate measures that violate our patients’ rights to choose our own medical specialists and hospitals, which I think too heavy handed in my view, whilst I understand their need to balance books. As a member, I was not at all consulted about this possibility of encroachment on my medical scheme benefit, in order that I can choose to remain within this scheme or to move to another scheme, and its introduction happens in February, and it would have been better if they advised us in September or October last year in 2016, as that would have resulted in some of us switching schemes and start with new medical schemes in January 2017. Therefore, the timing of introducing this benefit policy change leaves a bitter taste in my mouth.

As members of various open or closed medical schemes, what are your views about this blatant abuse of power by medical schemes, which are violating your patient’s rights to choose? I would like to hear your views on this matter.

Comments (1)

  • My personal view is that the matter is complex. Yes our rights are being overlooked due to escalating costs. The costs are escalating due to the following several factors: 1. Profits driven pharmaceutical industry. They may need funds for R&D but they also want to make a kill. The price of medication may be capped, but I do not believe that Govt is able to stop the pharmaceutical industry from increasing costs as such medical schemes force patients are forced to opt for generics.
    Secondly the Netcare group seems to be in cahoots with medical schemes (Netcare and Discovery an acquisition in the pipeline), one will be forced to use Netcare hospitals and that means squeezing out the Mediclinic and Life groups. The competition commission needs to check that relationship out as it may end up being a monopoly and controlling pricing to the disadvantages of other medical schemes as well.


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