In my practice, Medical Aid contracts are all cancelled

13-Apr-2014

As of the end of April all medical aid contracts will have been cancelled in my practice. 

Having a contract, especially one with Discovery, is considered mandatory for survival by some of my colleagues. And while I enthusiastically signed a range of contracts over the last few years motivated by the desire to please my patients by making their experience (financially at least) less painful when they need medical care, I have learned some painful lessons about how distorted the lines become when the doctor, patient and medical aid form a triangular relationship. 

This is in contrast with the straight forward linear relationship a doctor and his or her patient has when there are no contracts, DSP networks and direct pay arrangements to muddle the picture. In a linear relationship the patient understands they are responsible for their account. The patient interacts with their medical aid and gets direct feedback ito the medical aid as a company, their values, their attitudes and administrative prowess. The patient/main member can then make an informed choice when they renew their policy and perhaps change to a new plan or alternative medical aid. This in turn is a direct motivation for the medical aids to provide reasonable customer service.

But in a triangular situation (where the doctor is contracted to the medical aid)  the buck does not stop anywhere. The patient expects his medical aid to pay the bill directly to the doctor. The medical aid then tends to play games ito the cost of the doctor measured in terms of their own scheme rules and rates seemingly on purpose confusing what is a simple bill by endless changes in rules, benefits and new interpretations of rules. What worked yesterday as we as a practice, prepared a valid claim and submitted it with programs the doctor has to pay for using online submission services that the doctor also pays for the claim may well be rejected. The medical aid then swiftly goes into damage control and their communication to the patient makes the doctor look anything from incompetent to dishonest. The doctor and his staff can then spend more time trying to find the reason for the rejection, resubmit and hopefully get some money. The amount of admin expected of the doctor in a single surgeon practice in my experience amounts to a full time admin person. Imagine having a full time job just having to try to please medical aids enough so they pay what contractually they are obliged to do but will find an unending and expanding list of reasons why they do not have to pay. Now try explain to the patient that you have just spent several hours trying to get it sorted but the patient now has to take it up with the medical aid or pay themselves.

But for the patient there is also inherent risk. Do you even know when your doctor is only using the formulary drug list the medical aid will pay for? There may be other drugs the doctor in his or her experience find work a lot better with fever side effects but are a few cents more expensive. And if your operation is not approved for authorization, do you fully trust a doctor that has a large income stream from your medical aid each month to consider when they phone your medical aid on your behalf to ask for the operation to be approved? And when you have to go through the unpleasant experience of taking action against your medical aid at the Council of Medical Schemes and realize how the odds are stacked against you, perhaps consider how loyal your doctor is too.

So after being bruised and beaten by the systems of the medical aids, I find the linear doctor patient relationship is a lot simpler. And even ethical. 

Will I ever sign a medical contract again? I am already under pressure to do so for the staff in one of the local hospitals to be covered. Perhaps a gentleman's verbal agreement will suffice, but I may well feel I want to sign in order to serve people I feel are otherwise vulnerable. But it would have to be a dismal situation for me to try sign as many contracts as in the past. In fact, I wish the HPCSA would rule that contracts with doctors and DSP networks are unethical in their current form. And while a knee jerk reaction may be that doctors will simply take leave of their senses and charge ridiculous fees, the reality is that we are subject to the same economic forces all businesses are exposed to and really do feel the pinch of the current economy. And research has shown that the vast majority of doctors charge reasonable fees. I have faith that we will continue to feel a constraint to be affordable, accessible and reliable as part of our built in duty to care. Care is what motivated most of us doctors as we walked a very long road to get the skills we have today. 


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