How to play by medical scheme rules to get the care you need
“This is an exceptional case and we do not have any other option,” an ophthalmologist wrote in her motivation for an alternative treatment for a man who was rapidly losing his vision as a result of glaucoma.
Despite this, Discovery Health Medical Scheme refused funding for a stent implant at less than the cost of the treatment for which the scheme was willing to pay.
It's not uncommon for schemes to deny requests for treatment, despite motivation from medical practitioners.
But few members successfully challenge them.
Not knowing how to challenge the decision, being too sick to do so and lacking the financial wherewithal to pay for denied treatment while arguing for the funding, are the reasons few members mount a successful challenge, says Dr Johann Serfontein, a senior consultant at specialist consultancy HealthMan.
In the case with Discovery Health, it took close on three years for the member, identified only as Mr C, to win his battle. The matter went all the way to the medical scheme regulator's appeal board.
Schemes use managed care entities to decide on and monitor funding for cost-effective treatments. They draw up and apply what are known as a scheme's treatment protocols, basket of benefits or care packages. However, these entities are not accountable, Serfontein says. This was an issue highlighted last year by the Competition Commission's health market inquiry.
Here are five things you should know if you plan to challenge your scheme's treatment protocols:
l Any treatment plan for a prescribed minimum benefit (PMB) must comply with minimum treatment standards in regulations under the Medical Schemes Act.
Where these refer vaguely to, for example, “medical and surgical management”, the regulations further say treatment should be at least equal to or better than prevailing practices.
If there are significant differences between how the public and private sector deal with the condition, schemes should provide treatment in line with the predominant practice in the public sector, the regulations say.
Mr C's doctor recommended surgery to place a Xen-stent or valve in Mr C's eye as he was not responding to standard treatment and his eye was scarring.
Discovery Health argued that this treatment was not available to state glaucoma patients, and therefore it did not need to fund this treatment.
Appeal board judge Bernard Ngoepe eventually found this argument to be irrelevant in Mr C's case.
The judge cautioned against applying this prevailing state hospital practice test in a narrow way to determine if a treatment constitutes a PMB level of care. He said factors beyond affordability or cost-effectiveness, such as budgetary processes, delayed tendering, skills shortages and administrative challenges may well be reasons for state hospitals not using a treatment.
l Regulations provide that you can ask for a copy of your scheme's treatment protocols. Lee Callakoppen, principal officer of Bonitas Medical Fund, says you can get an electronic copy of your care plan, but protocols may depend on the “clinical setting”, so in each case you or your doctor should check with your scheme.
Dr Ryan Noach, CEO of Discovery Health, says treatment protocols for the chronic illness PMBs are available on the Council for Medical Schemes (CMS) website, and you can view the state's treatment guidelines on the health department website. Care for about 60 PMBs have been defined by the CMS in its PMB definition project.
But Serfontein says even doctors struggle to get protocols out of schemes, which argue that these are their intellectual property. And they aren't typically written for ordinary members to understand. You may struggle to authoritatively challenge the protocols your scheme is applying and will probably need your doctor's help.
If your doctor is not willing to engage, you should approach the relevant clinical society for help in reviewing the protocols, Serfontein says. Societies representing different medical fields have agreed to support members challenging their schemes to ensure appropriate treatment plans is funded, he says.
l The treatment plan must be based on medical evidence. In the recent appeal board case, Discovery Health argued the alternative treatment recommended by Mr C's doctor was experimental, unproven and not registered, but Ngoepe noted that Mr C's doctor had used it successfully.
He also said the stent was being used in 22 countries including SA and was approved by the Food and Drug Administration in the US and had the EU's mark of approval.
l Schemes must provide alternatives if the standard treatment does not agree with you. Mr C won his case because the standard treatment for his condition was harming him and the law says that, in this situation, the scheme must pay for alternative treatment.
Ngoepe found Discovery Health had failed to identify an alternative treatment for Mr C that would not be harmful, even when asked to do so by the CMS. Mr C's doctor argued that the alternative she provided was effective.
In the absence of evidence of cost-effective alternatives, the scheme's argument about the stent not being used in the state was irrelevant, the judge said.
Discovery has in the past had rulings against it for failing to pay for alternative treatments, notably ones involving biologics, but Noach says Discovery Health's role is confined to adjudicating funding decisions in line with the scheme's rules and guidelines. Discovery Health “may not direct care or make treatment decisions as this is the domain of registered health-care professionals treating a patient”.
Callakoppen says when you need individualised treatment, your doctor must contact the scheme's clinical team to review your case. Doctors can submit a motivation for your treatment, and may charge you for it, and this may or may not be covered by your scheme, he says.
l If your doctor's engagements with your scheme's managed care entity fail to get you the needed treatment, you can complain to the scheme. Noach and Callakoppen say schemes have defined review processes.
Noach says Discovery Health routinely gets advice from leading specialists, but Serfontein says super-specialists often struggle to convince the GPs who advise schemes.
If your dispute with your scheme fails, you can take your complaint at no cost to the CMS, but be prepared for a wait, as Mr C's case demonstrates.
The council's clinical department is dealing with more and more complex and contentious complaints, and underperformed its targets for dealing with complaints, the council noted in its last annual report. Complaints have 30-, 60- or 90-day turnaround targets, which can be a lifetime when recommended treatment for a life-altering condition has been denied.