Medical schemes, healthcare cover and patients

Elsabė Klinck aims to empower patients on their rights in the funding of healthcare with a series of articles. This first article covers the basics of medical schemes, healthcare cover and patients.


A complex environment

Funding for healthcare is a controversial issue. It can lead to friction between healthcare funding companies (medical schemes or healthcare insurers), providers (doctors, hospitals) and patients.

Because no person chooses to be ill, the buying of healthcare services is rarely done on a purely voluntary basis. It is mostly begrudgingly. Add to this the aspect that some healthcare interventions are life-saving, the moral arguments on equal access to healthcare and a conflict-free discussion appears virtually out of the question.

With the Minister of Health’s recent announcements on changes to the healthcare system and to medical schemes, debates on co-payments have also been added to the above complexity.

The Health Market Inquiry has also found that patients find medical scheme options, benefits and the limitations thereto, daunting. Fighting for cover is also a difficult undertaking. Many patients simply give up, even if they feel they should have better cover.

The law as a patient’s guide

The legal frameworks do, however, protect patients, and the fund from which healthcare is paid. Understanding these frameworks will help patients, providers and funders to better communicate. They can then use the same reference points when discussing access to, or denial, of care.

Funding for healthcare services (doctors’ fees, hospitalisation, etc.) and goods (medicines, etc.) can be provided by:
  • Persons out of their own pocket (often these patients are called private patients);
  • Their medical scheme, subject to the provisions of the medical schemes law and the scheme rules;
  • Third party insurers, which sometimes provide lump sum cover for “dread disease” and/or “hospitalisation” or “gap cover”. These pay the difference between what another funder pays and what is owed.

Where third party funders (i.e. medical schemes or health insurers) pay healthcare services in part, co-payments may have to be paid by patients, to ensure that the full event, medicine or care is covered. In some cases, schemes call this levy a “penalty co-payments”. We will look at co-payments in the next articles of this series.

Knowing about the care you require

Whether funders would fund care or not, your healthcare journey must start with your healthcare professional (doctor, pharmacist, nursing professional, etc.) discussing your healthcare status with you. This includes how you feel, what they observe, and what the test results or physical examinations show them about your health.

Based on your healthcare status, your healthcare professional will discuss with you what your treatment options are, and what the benefits, risks and costs of each option will be. Regarding this, you must consider the arrangement of your funder.  Remember your funder makes rules for the general patient population under their cover. So, what they may fund, may not be what is appropriate for you.

Discuss the alternatives that your scheme will fund with your healthcare professional. Ask them to explain why you may require something your funder may not fund in full, or may not fund at all.

The same applies when you present a prescription at a pharmacy. Pharmacists must substitute products with generic alternatives. Ask the pharmacist if the product is substituted with another product. If you are uncertain, call your prescribing healthcare professional.

PMB conditions

For prescribed minimum benefit (PMB) conditions (we will address PMB in detail later), you are entitled to decline a product that would have been appropriate for you, in favour of something you choose voluntarily. But then there may be a co-payment levied. Some patients prefer to stick to treatment they know, or products they choose. Because of this choice, they will then only be reimbursed by the funder up to the price of the funder’s preferred product.

Right to decline care

You always have the right to decline care. For example, some patients do not want to co-pay, or they agree to swop treatment to what the funder is willing to reimburse. If a patient does this, she/he must understand what the implications (health and cost) of the refusal of care their healthcare professional advised is.

Ask your healthcare professional to explain why they would prefer or recommend a treatment that your funder does not pay for at all, or only pays for in part.

The medical schemes law states that a healthcare professional may never be incentivised to provide you with care that is inappropriate for you. It is therefore unlawful. For example, if your healthcare professional prescribes or dispenses a product because if they do so, they will get paid better by the funder, and such change is not in your interest.

Consumer legislation also prohibits any consumer (patient in this case) from being pressurised into accepting any service or goods. Therefore, take time when deciding on the right care for you, and consider the funding implications of the care you choose.

Paying for care

Medical schemes should, by law, pay for all conditions that are listed in the law as PMB conditions. There are 271 conditions listed in the law, and 25 chronic conditions.

Diabetes, its diagnoses, monitoring (e.g. through glucometers), and all treatment of (for example, diabetes-associated events, such as diabetic ‘highs’ or ‘lows’ where one lands in hospital) are included in the PMB.

The law says that this treatment must be funded “in full and without co-payment” (regulation 8, Medical Schemes Act). This, in short, means that the scheme must pay for all the care associated with living with diabetes.

Where a medical scheme limits the various aspects of healthcare, such as where you receive in-hospital care, or the medicine it would pay for, these limitations should take place within what the law allows. (We will go into the details of these circumstances on managed care, PMB, designated providers (DSP), etc. in future articles.)

 Medical scheme options or plans

Irrespective of your medical scheme plan or option, you are always entitled to appropriate care. Some scheme options do, however, limit the number of visits to healthcare professionals, limit your choice of hospital, or restrict the list of medicines from which your doctor may prescribe.

Normally, if you want more choices, you would have to belong to a higher option with a higher monthly contribution.

One should keep in mind that even if one is on a lower option, there may be circumstances where the law requires the full funding of care, not generally included in that option. For instance, circumstances that are outside of the control of the patient, such as a negative reaction to a medicine, or an emergency.

Where to seek help

Most medical schemes do have internal complaints and appeals systems. If you, as the patient and scheme beneficiary, do not come right at the scheme, you are entitled to lodge a complaint at the Council for Medical Schemes (CMS) – complaints@medicalschemes.com.

You should receive a case number within 48 hours. You will use that case number when communicating with the CMS. It’s important to include all information and dates, as well as any reports from your doctor, test results, how you were feeling or what you experienced, etc.

Do not forget to add that you have a PMB condition if that is the case. Also explain any instances where treatment was not successful, or where you had to switch treatments, and why that was the case.

Attach any reports or evidence of negative reactions or implications you have experienced to the complaint. Number all the attachments to your complaint and refer to each attachment by that number in your complaint letter.

If a ruling on a complaint is not in your favour, you can appeal that ruling. The details of this right, and the correct email address is always provided on the letter containing the ruling on your complaint.

Final thought

Patients should be aware of their entitlements in terms of the law. These entitlements override the medical scheme rules, if there is a conflict between the rules and the law.

The process starts with informed consent at your healthcare professional where your condition and the treatment options must be discussed.

You must consider the financial implications of your chosen care, or of the care that is necessary for you. Plan for your interaction with your funder, if you know they may not pay in full, or may not pay at all.

Ask your doctor for assistance to understand why you need a particular treatment, or why it may be good for you to choose a particular treatment freely.

MEET OUR EXPERT


Elsabė Klinck (B.Iuris, LLB, BA Hons (German), BA Applied Psychology) specialises in health law, -policy and -ethics. She owns a successful healthcare consulting firm, serving various clients in the pharmaceutical, medical device, healthcare professional and health facility markets.


What jobs can’t diabetes patients do?

There are certain types of jobs that diabetes patients are not allowed to do, especially if they are on insulin. Dr Louise Johnson explains the jobs that fall in this category and further discusses other concerns that diabetes patients could have while in the workplace.


Pilot

A Type 1 diabetes patient can’t be a pilot, however, a Type 2 diabetes patient, only treated with metformin tablets, can. The reasoning behind this is other oral medications and especially insulin could cause a sudden drop in blood glucose. This is dangerous for not only the pilot but passengers and public on the ground.

Mining industry

As soon as diabetes patients who work in the mining industry go on insulin, it becomes dangerous to go underground due to the risk of hypoglycaemia.

Public transport drivers

Since the driver controls the vehicle (taxi, bus, train) that carries passengers from point A to point B, it can be risky if the driver experiences hypoglycaemia. It can also be dangerous, if the driver has high blood sugar as it may lead to drowsiness and possible accidents.

Other concerns

Safety shoes

Diabetes patients working in industries where safety shoes are a requirement, need to ask their doctor to write a motivation to wear special safety shoes, suitable for diabetic patients. This is of importance to prevent their feet from injuries, such as scratches, pressure points and ulcers. Since injuries on the foot of a diabetes patient can lead to deeper ulcers and infection.

If it is not treated correctly and the patient has impaired sensation (peripheral neuropathy), it can contribute to the development of an amputation should the wounds not heal. Diabetes patients with impaired sensation often complain of burning feet, especially at night. They are the high-risk group for feet problems.

Writing exams

Diabetes patients that are on the go with studies should discuss their condition with the lecturers or invigilators. They need to inform them that their blood glucose can go incredibly high due to stress, and can cause severe drowsiness and a diabetic ketoacidosis (high sugar coma).


Diabetic ketoacidosis is a condition where the sugar rises exceptionally high due to insufficient insulin in the body. The body’s metabolism changes from using glucose as substrate for energy to using muscle breakdown products, called free fatty acids. The result is difficulty breathing, abdominal pain, nausea, vomiting, and confusion. This is a medical emergency, and can lead to death if not treated urgently.


Hence, why the lecturer/invigilator should also allow the diabetic student to take a sugar snack, glucose test machine, and insulin into the examination room. This is necessary to correct low or high blood sugar immediately to prevent any acute complications. Additional time should also be allocated to the student during exams, should the student have a low blood sugar event as it takes up to 30 minutes for the brain function to return to normal.

Driving

For many South Africans, driving forms part of their work – either by driving long distances to get to work or driving being one of their duties. Diabetes can affect driving due to hypoglycaemia. The low blood sugar may result in transient cognitive dysfunction or even loss of consciousness.

In a simulator, it was shown that cognitive functions critical to driving, such as reaction times and hand-eye coordination are impaired during hypoglycaemia. People experiencing hypoglycaemia ignored road signs and did not keep to lanes3.

Diabetes can also affect driving due to chronic complications associated with diabetes. The bleeding diabetic eye with decreased vision and the patient with an amputated limb has more difficulty to drive. The same can be said of the diabetic patient that had a stroke.

Type 2 diabetes is often associated with sleep apnea (stop breathing intermittently). This is a condition where a person has excessive daytime sleepiness due to snoring and a severe interrupted sleep pattern at night, which can be dangerous if the person is driving. Sleep apnea can be associated with obesity. It is effectively managed with a continuous positive airway pressure (CPAP) machine that increases the pressures in the airways at night and prevents the sleep apnea.

Any diabetic that had a severe hypoglycaemic event should not drive for at least six weeks thereafter. A severe low blood sugar event is where a person needs the help of a third party or is hospitalised due to hypoglycaemia. They can start driving again after six weeks or only after their awareness of hypoglycaemia has returned4.

Type 2 diabetes

People with Type 2 diabetes can do most occupations, if they follow a rigorous healthy lifestyle and diet to prevent going onto insulin.

Insulin is currently still needed after about 10 years of Type 2 diabetes but there are a variety of new drugs on the horizon that may help stretch this period even longer. Always take your HbA1c (average blood glucose value) into consideration to prevent complications and stay on target.

Managing your diabetes and workday

In the normal course of a workday, diabetes should be taken into consideration. Midday meals should not be skipped. If a person works at a company with a canteen, it would be reasonable to expect the company to cater for people with diabetes. Scholars and students attending academic institutions have the same requirements for special low-glycaemic index (GI) meals. Ideally, these institutions should cater for these scholars and students and their special needs.

The 2015 International Diabetes Federation (IDF) stats show that one in eleven people have diabetes, while the number of people suffering from diabetes in Africa was 14,2 million. This means that there are many diabetes patients at any company or academic institution.

One should take into consideration that obesity has epidemic proportions and healthy food consumption can help curb the diabetes epidemic. The South African National Health and Nutrition Examination Survey (SAHANES) data show that one third of men and two thirds of women are currently obese in South Africa1.

The data shows accordingly in Type 2 diabetes – an unhealthy lifestyle plays a major role in developing Type 2 diabetes and 80-90% of Type 2 diabetes patients are overweight. Data also showed that if obese people loose 5% to 10% of their weight, diabetes could be prevented2.

Any company should screen employees for diabetes at least once a year, since early detection of Type 2 diabetes can be excellently managed with lifestyle management such as moderate exercise and weight loss.


References:

  1. Shisana O, Labadarios D, Rehle T et. al. (2014) ‘The South African National Health and Nutrition Examination Survey. ( SANHANES-1)
  2. Wing RR, Lang W, Wadden TA et. al. (2011) ‘ Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes.’ Diabetes Care, 34(7) p1481-1486
  3. Cox DJ, Gonder-Frederick L, Kovatchev B et. al. (1993) ‘Driving decrements in type 1 diabetes during moderate hypoglycaemia.’ Diabetes, 42 p239-43
  4. SEMDSA Type 2 diabetes guideline expert committee. (2017) ‘The 2017 SEMDSA Guideline for the management of type 2 Diabetes.’ JEMDSA,22 (1)Supplement 1 (S1-S196)

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Loot
Dr Louise Loot is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.