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Exhausted medical funds leave patients feeling sick

The writer wonders whether medical schemes have the best interest of the patient at heart.
The writer wonders whether medical schemes have the best interest of the patient at heart.

Two weeks ago, I wrote about how medical schemes are simply rogue and that the Council of Medical Schemes, which is a statutory body meant to regulate medical schemes, is a toothless watchdog.

My point was that it is concerning that medical schemes cause great havoc even though they are supposed to be regulated by law. Yet in a remarkable response, Medscheme claimed that it was medical schemes that were under siege, detailing how practitioners fraudulently abuse medical aid funds instead.

Perhaps I should clarify: I do not condone fraud by healthcare professionals. The roguishness, however, goes even deeper than that.

For instance, it is not only healthcare professionals who have expressed their discontent with medical schemes, even members of medical schemes are aggrieved.

During a visit to my doctor recently, I noticed how annoyed patients were to find out that their medical aid funds have become exhausted. It is well established that as early as May, even April, medical schemes may well report insufficient funds, meaning that a member's medical aid is exhausted for the year.

Patients feel cheated by their medical schemes.

I was saddened to hear a mother complain that she was forced to borrow money to bring her child to see the doctor again - an injustice considering she is a member of medical scheme. This made me wonder whether medical schemes had the best interest of the patient at heart.

A diabetic man, who was also blind, said paying cash on top of his medical aid premium was straining him financially. He is forced to fork out money from his own pocket for the rest of the year if he is to continue to see his doctor to manage his illness effectively.

We can surely agree that no patient should be forced to skip an appointment due to early exhaustion of funds, considering this may complicate a manageable illness further down the road.

Interestingly, another patient questioned why the benefits to consult general practitioners was limited yet hospital benefits were unlimited. Cross-ownership may be why, I told him.

Bluntly stated, it benefits certain medical schemes to pay less for visits to the general practitioner, while paying abundantly for hospital stays because they have a stake in those profits.

It was revealed by the Competition Commission that Discovery Health, MMI and Mediclinic cross-ownership enhances their scope for price fixing.

It appears that medical schemes are failing to ensure beneficiaries access to healthcare sufficiently both in quality and quantity and to do so equitably.

Medical schemes should also ensure financial risk protection to their beneficiaries on par with World Health Organisation standards.

But South African medical schemes appear to do none of that. It's a pay-as-you-go system for less than 20% of the population and no benefits accrue. You miss a payment, you lose all benefits, no matter how long you have paid. Co-payments and exhausted benefits do not benefit the members.

This private sector model is abusive and ineffective yet medical schemes are staunch critics of the impending National Health Insurance (NHI) that aims to provide equal healthcare to all South Africans.

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