How medical scheme members struggle to pay mental illness bills
Many medical scheme members with mental illness are being forced to dig deep into their own pockets to foot their bills and are delaying or stopping treatment when the money runs out, according to a survey conducted by the South African Depression and Anxiety Group (Sadag) advocacy group.
Sadag’s survey is not nationally representative but does nevertheless highlight significant inadequacies in medical scheme cover for even the relatively well-resourced middle-class families that responded to its questionnaire.
The survey included 604 respondents, 78% of whom were white women, and the majority of whom lived in Gauteng. More than half (59%) belonged to Discovery Health Medical Scheme (DHMS).
"Mental health is not in a good situation in South Africa," said Sadag founder Zane Wilson. "Almost 25% of respondents said their condition had worsened due to stress and anxiety."
More than half (55%) of the respondents said they were using their own money to fund the gaps in their medical scheme cover and 13% said they had turned to family and friends for help.
One of the most worrying findings was that a fifth of the respondents said they coped with limitations on their mental health cover by either delaying or stopping treatment, risking a decline or relapse.
Just over a third of respondents (35%) said they had reached their limits on counseling, and a similar proportion (34%) said they could not get medication once their medical scheme limits were reached.
Sadag’s operations director Cassey Chambers said the nature of mental illness made it particularly difficult for some patients to understand what benefits they were entitled to, and challenge their medical scheme when they ran into difficulties.
“It is a massive challenge. The nature of their illness makes people vulnerable, and we often have to do a lot of work educating people about their benefits, and what questions to ask about consultations and medication,” she said.
DHMS’s administrator Discovery Health said mental healthcare was among the top 10 cost drivers among its client schemes.
Discovery Health CEO Jonathan Broomberg said the diagnostic challenges associated with mental illness and with the high frequency of overlapping conditions made benefit design “extremely challenging”.
“Another challenge is that due to open enrolment and limited underwriting, it is not feasible for any single open scheme to offer materially richer benefits than the Prescribed Minimum Benefit (PMB) requirements, since this will very rapidly lead to anti-selection in which large numbers of those with significant mental illness will join that scheme in order to gain access to the richer benefits,” he said. PMB’s are the minimum basket of care that a medical scheme must provide to its members, and do not cover all mental healthcare conditions.