Concerned members, practitioners speak up online

1/19/2012 12:40:01 PM

By Reginald Tachie-Menson There is growing concern among members and health practitioners alike regarding Discovery Health's changes to the allied and therapeutic health care benefit. Members have turned to online petitions and Facebook to garner attention on an issue that many feel is unfairly curbing benefits while sustaining contributions. A Facebook group created to discuss coverage for 2012 had been joined by members who were voicing their concerns surrounding the proposed changes that would in some instances affect members with serious conditions. An online petition with 735 signatures at the time of publication read: "Discovery Health Medical Aid has drastically changed their coverage for all allied health professionals for 2012. "It is unreasonable to go from unlimited benefits to a low maximum. We are asking Discovery Health Scheme to appoint an independent commission of enquiry to investigate alternative ways of curbing abuse of benefits, without capping the limits." Dr Jonathan Broomberg, CEO of Discovery Health responded to enquiries about the issue, noting that the petition highlighted "one of the key challenges medical schemes faced: that of achieving the right balance between providing excellent, clinically appropriate healthcare benefits, while at the same time keeping contributions affordable for members on a sustainable basis. "Finding this balance is increasingly difficult as healthcare costs increase above CPI, due to ageing populations, more chronic diseases and cancer, as well as costly new treatments and drugs." Broomberg said, "We have identified an increasing trend towards abuse of some day-to-day benefits. While these services are often used appropriately for serious clinical conditions, these benefits are increasingly being exploited for services that are not clinically justified. "The long-term impact of such practices would severely impact any medical scheme's ability to provide sustainable funding for medically appropriate treatment. "The new benefit design ensures that approximately 98% of members will be fully covered. The restructured benefit also enhances cover: members needing psychiatry or home nursing, for example, will have unlimited cover. "The result is improved benefits for those who most need them, and effective management of abuse. For the vast majority of members who use their benefits judiciously, the changes will have no negative impact." "The Allied and Therapeutic benefit covers the vast majority of our members in full, because we have set the benefit limit to cater for more than 95% of our members, based on current benefit usage patterns." Broomberg said that certain benefits were anomalous and had also been restructured as part of this change. For example, psychiatry was now unlimited as was the case with other specialist healthcare services. In the past, psychiatry was grouped with psychology benefits as part of the Mental Illness benefit with a lower limit than that of the new Allied and Therapeutic Benefit. He said that the Allied and Therapeutic benefit offered better cover to members who need psychiatry and home nursing (which were previously subject to low limits), or members with severe clinical conditions and would most often need cover for various treatments over an extended period. In particular, members on the Executive and Comprehensive plans who had severe conditions got unlimited cover through the Allied and Therapeutic Extender Benefit. This extender would automatically be activated if the member suffered from a condition that was specified on our list and which he or she was registered for under the Chronic Illness Benefit. This ensured that members with the greatest medical need had full access to the healthcare that they need. "The vast majority of our members claim for hospitalisation, chronic and acute medication, specialists, GPs and chemotherapy. The medical services that fall under the Allied and Therapeutic benefit make up a very small proportion of our members' total claims. "We expect less than 1.5% of members of impacted plans (equivalent to less than 0.5% of total scheme members) to reach the revised limit. "A significant proportion of these affected members will have access to the unlimited Extender Benefit. We have designed this benefit with the intention that very few members should be impacted by it, while simultaneously curtailing abuse of health plan benefits."

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