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Time to 'rise up' against medical aids‚ says specialist

Patients are not getting the full benefits of their medical aids.
Patients are not getting the full benefits of their medical aids.
Image: 123RF/ Andriy Popov

Patients are losing out on medical care as medical aid benefits reduce every year and it is time for patients to stand up to medical aids‚ specialist doctors claim.

Four doctors and the CEO from the SA Private Practitioners Forum‚ that represents 3‚500 specialists‚ held a round-table discussion with media on Thursday afternoon in Johannesburg. They detailed how medical aids were limiting the care patients received and what tests and operations doctors could conduct.

Medical aid interference in what doctors can and can’t prescribe has been an issue for years. But the doctors said it has recently gotten a lot worse.

Physician Adri Kok‚ who specialises in treating diabetic patients‚ said medical aid members “didn’t know what was waiting for them next year”‚ making reference to medical aid restrictions.

Kok said patients needed to “rise up”‚ as in the case of Nathan Ganas’ widow‚ Denise‚ who told the media how Momentum would not pay his death benefit after they claimed he failed to disclose his high blood-sugar levels at the time of signing the contract in 2014. Ganas was shot dead in a hijacking outside his Durban home in March last year.

The insurance company has since agreed to pay out the R2.4m life cover claim.

Kok said some medical aids had already emailed patients regarding what treatment they could and could not have next year and what drugs would be allowed.

She claimed medical aids dictating treatment had suddenly increased.

But in many cases the medical aid restrictions meant doctors couldn’t manage the disease correctly - and patients get sicker as a result. Diabetes is a risk factor for heart disease.

“We have a huge burden of heart disease because diabetes is so poorly managed‚” she said. Many medicines to treat diabetics are restricted by medical aids because they are too expensive.

But De Kok said a complication of kidney failure and blindness were more expensive to treat than using expensive chronic medicine.

In other cases‚ medical aids were pushing for the use of day hospitals for operations which could be money-saving. For example‚ more than 90% of eye operations were done in day hospitals with no problems at all‚ explained ophthalmologist Mark Deist.

“They don’t need to stay in a hotel‚” he said‚ referring to eye operation patients sleeping at a hospital unnecessarily.

But if a patient was high risk and could develop complications during surgery‚ they needed to be in a hospital and not a day hospital‚ said Kok.

She said doctors were concerned they were being forced to use day hospitals with patients due for complicated treatment.

“A hysterectomy can be done in a day hospital but it is high risk.”

She said these arrangements should not be forced onto doctors by medical aids.

Patients had to know what prescribed minimum benefits were and make sure diseases that fell under this category weren’t paid for out of their day-to-day savings accounts‚ she said.

They also needed to query and ask for money back when it was incorrectly spent by medical aids.

The increasing health costs that were above salary inflation were causing an environment where patients bought cheaper medical aids‚ and there was less money for everyone and for treatments‚ explained Dr Chris Archer‚ head of the specialists’ forum.

Kok said: “Our patients need more confidence that we are behind them and will advocate if they make a big noise.”

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