Why do doctors hate medical aids?

We really, really do. You probably wonder about this. I’ve yet to meet any doctor in private medical practice who feels indifferent, let alone positive, about them. Sharing our reasons may offer an insight into why your doctor would prefer you to pay now please, and claim from your medical aid yourself.

Technically, it is not the medical aids we dislike — but rather the medical administrators. A medical aid is a not-for-profit fund offering insurance to its members, run by a board of trustees who make the decisions much like a company board of directors. A medical administrator is an entirely different beast, most definitely for profit, contracted by the medical aid with the task of administering its own affairs. Never mind that some medical aid trustees are directors or employees of the medical aid administrators themselves. Conflict of interest, anyone? Here I use the names interchangeably.

Medical aids should by law not spend money on items outside direct medical care for their members with the exception of the administration fees demanded by the administrators. Herein lies the problem I referred to in my earlier post, that the percentage of total members’ contributions used for administration is disproportionately large relative to the amount paid to medical professionals whose work is unarguably more important. Administrators also claim their percentage cut up front from the fund — what is left is then subject to the limitations and cuts set by the administrators. It is a relatively risk-free and profitable business model.

Medical aids are wary of doctors because we spend “their” money in a cascade of healthcare over which they have limited control. My decisions over my patients have huge cost implications for the medical aid. Any possibility of control of the decision-making process is hugely attractive to them. So they will institute limited drug formularies, insist on use of generic medications, demand motivation letters before special investigations or surgical procedures, limit the funds available, limit the number of consultations, dream up savings plans, Vitality plans — whatever it takes, all in the name of limiting costs.

I agree wholeheartedly with trying to keep the cost of medical care down. But there is a huge compromise to YOUR safety and YOUR health when those controls are initiated by third parties who do not have the required medical knowledge and do not bear the responsibility for your care. There are good examples where generic medications do not work as well as the originals. Some surgical implants are inferior to others. Some surgical techniques are easier for the surgeon and the anaesthetist, but because studies show minimal benefit for the patient, the medical aid will not fund them — like coblation for tonsillectomy. The effect of all this is that the medical aid places a direct limitation on how well I can care for my patient, how well I can do my job, and how well YOU will do under my care.

The frustration that this involves for a doctor is limitless. Medical aids employ medical advisers whose duty it is to analyse requests for treatments and to approve or deny them. That in principle is not a bad thing, but it presupposes that the medical advisers have the necessary knowledge and training to make an accurate and unbiased decision on every patient. It presupposes that they know as much as the specialist requesting authorisation. And they don’t, because almost without exception they have no specialist training or even experience in the field whatsoever.

The Council for Medical Schemes issued a directive that no request for authorisation may be turned down without direct “peer to peer” contact with the requesting doctor by a person with equal knowledge and experience. Bluntly put, this never happens.

As an example, I once had a medical aid demand a CT scan before they would authorise a septoplasty for my patient with a blocked nose. A deviated nasal septum is something you physically see, and a CT scan adds nothing to the process — it was a blatantly ridiculous and expensive request. I suggested in reply that it was my ethical duty to report the medical adviser to the Health Professions Council of South Africa as being so impaired as to be incapable of giving safe medical advice. The operation was approved immediately without a CT scan.

Luckily we’ve moved beyond the days when medical aid call centres tell our patients we are “overcharging’ them (who the hell are they to decide?). The same centres still say that they pay “100%” of accounts (without explaining it is 100% of their rate, not ours), or tell our patients that they will have to leave our towns, for surgery under another specialist in another town, because that is where the only authorised hospital for that medical aid is, unless “our” patient bleeds after the operation that we haven’t done, whereupon it will be our job to save his/her life as the closest surgeon. We doctors who do not sign “designated service provider” agreements are not paid for work directly into our accounts — a much cheaper process for the medical aids. The patients are paid directly, with the express intention of adding to our bad debt. It is explicit and coercive pressure to sign these agreements. Another good word would be “blackmail”.

For every case where a medical aid does step up and make a massive difference there will be a dozen events where patient care is made difficult. In every medical consultation there is a dispassionate, unqualified third party involved acting as judge, jury and sometimes executioner.

It’s not a new discovery to doctors. We’ve seen it all before, and it is getting worse. Our anger is rising, as seen in this letter which arrived as I write these last words. But to the patient in front of us, to whom we have to say “sorry, can’t help” — that discovery is awful.

That a medical administrator market leader should use the same name is nothing but ironic.