The Discovery head office in Sandton. Picture: Masi Losi
The Discovery head office in Sandton. Picture: Masi Losi

In the past two months, the world of medicine has been turned on its head. Doctors, wanting to limit their own exposure to Covid-19 and keen to protect their patients, have been relying increasing on video consultations.

Until three-and-a-half weeks ago, the Health Professions Council of SA (HPCSA) had banned the use of telemedicine, which meant medical aids didn’t pay doctors for virtual consultations. But under pressure from doctors this ban was lifted for the duration of the pandemic, sparking a surge of interest from GPs, specialists and psychologists.

This opened the door to the greater use of digital medicine in SA. But if the wrangling over payment from SA’s largest medical aid scheme, Discovery, is any indication, there are likely to be teething problems.

In this case, a psychologist stumbled on a form on Discovery’s website about a week ago stating that they’d only be paid 65% of their face-to-face therapy rate.

Dr Linda Blokland, who heads the Clinical Psychology Forum, says that when her organisation contacted Discovery, the medical scheme “um-ed and ah-ed, and dragged their feet” on explaining why these payments were lower.

“None of us had been informed. Medical aid members didn’t know anything about it. A 35% cut [in pay] is massive.”

Discovery’s initial argument was that telemedicine costs less, since professionals don’t use rooms, gloves or consumables, or need a secretary to set up appointments. In many cases, it said, appointments are also shorter.

Blokland’s group rejected this reasoning. “We have not fired our admin staff,” she says. And besides that, the therapists must still pay for medical insurance, rent rooms and have secretaries.

Those who’d be hurt most by this rule would be the patients, says Blokland, as they’d have to make up the difference between the 65% paid by the medical aid and the full cost of the consultation.

On Thursday, Discovery relented, agreeing to pay 100% of video consultations. (The medical scheme, however, will only pay 75% of the cost of a face-to-face consultation to a GP, justifying this because it excludes a physical examination and is generally shorter.)

Dr Ryan Noach, CEO of Discovery Health, denied that his company hadn’t consulted the psychologists properly at the outset.

“[We] responded to individual psychologist requests for funding for virtual consults within 48 hours of the lockdown commencing, to enable an environment of billed virtual consults … Since then, Discovery Health has engaged repeatedly with psychologists, has listened to their constructive and valid points, and has revised the rates upwards,” he says.

Discovery says some of the details were just “lost in translations”, amid the turbulence of the fast-moving pandemic and the multiple psychologist associations it had to communicate with.

However, there have been long-standing concerns about how Discovery interacts with doctors and health professionals. Some critics say it gets in the way of the doctor-patient relationship by making unilateral payment rules that dictate how someone is treated.

Says Blokland: “Discovery needs to meet with us professionals. They don’t come to us. They need to consult with professionals.”

Discovery also blundered in initially requiring psychologists to fill out a form detailing the concerns their patients expressed during therapy, to prove that the telemedicine session took place.

This breached ethical rules, the psychologists said.

“I am sure you can imagine the situation if your CEO … had a tele-consult with a psychologist and the clinical notes were e-mailed to some random administrative clerk within the company,” wrote one psychologist.

Discovery replied that it didn’t intend to invade privacy. But in some cases, doctors had charged for a full session after just a two-minute virtual consultation. It now says psychologists needn’t include confidential information about patients’ problems.

This whole ordeal has been unfortunate for Discovery since, ironically, it was an early adopter of telemedicine.

For the past three years, the company has had a full digital medicine strategy. But until Covid-19, so few doctors used its DrConnect telemedicine platform that Discovery staff knew them all by name.

Other medical aid schemes are even further behind.

However, a few days after Discovery relented, Medscheme – the administrator of Bonitas, Fedhealth, Polmed and the Government Employees Medical Scheme – also agreed to reimburse psychologists up to 100% of their face-to-face consultations.

At the moment, the lifting of the HPCSA’s telemedicine ban applies only during the Covid-19 pandemic. But after it is over, SA might decide that the utility of the virtual service dictates it should become part of our medical infrastructure.

Services like Hello Doctor’s GP advice service, which is run by former Mr SA Dr Michael Mol, have long complained about the HPCSA’s stringent ban on a practice now used globally. In particular, telemedicine is particularly useful for allowing specialists to advise doctors in rural areas.

Dr Roshini Moodley Naidoo, Discovery Health’s GM of strategic risk management, says the virus has “been a catalyst locally and globally towards the shifting to digital care”.

Naidoo is right that the pandemic has resulted in similar rules against telemedicine being lifted across the globe.

On March 17, US President Donald Trump announced that Medicare, the US state-run health insurer, would now cover virtual consults for the 62-million Americans covered by it. Trump described it as “a historic breakthrough — this has not been done before”.

Alex Jadad, founder of the Centre for Global eHealth Innovation at the University of Toronto in Canada, told medical journal The Lancet this month that “the regulatory barriers that have held virtual health care back for all these decades were never justifiable – [Covid-19] is an opportunity to blow all these barriers away”.