A medical doctor’s opinion of Discovery medical aid

Dear current or prospective medical aid member
I, a doctor, write this email in the hope that it is circulated as far and wide as possible, to all those who are either members of Discovery medical aid plans, or who are thinking of joining. It is not my usual habit to do this, but the situation is becoming intolerable for the medical professional, and the consequences are bound to impact heavily on the public. This email offers reasons for why we doctors feel the way we do, and why we react negatively to medical aids in general, and to one in particular. Please, please take the time to read this through.
Discovery Health is the largest player in the South African medical aid market, announcing a profit last year of R 563 million. In spite thereof Discovery management continues to disregard the needs and requests of the medical profession with regard to better professional fees, and has taken more and more of a destructive hand when it comes to interfering with the doctor-patient relationship. In business dealings and negotiations with the medical profession, Discovery management comes across as 'arrogant and inflexible.' In short we are dealing with a business bully who sees little need to address serious problems within the health sector relating to those who do all the work, i.e. medical doctors and paramedical services.
Discovery has alienated itself from the medical profession for the following reasons:
Blackmail tactics: Discovery will pay doctors directly, but only if accounts are submitted at much lower rates, even if the member is fully covered for private rates. So pressure is put on the doctor to charge a fee far less than deserved, for the 'privilege' of guaranteed payment. This is nothing else but blackmail. The reality is that members paid directly often spend the money elsewhere, leaving the doctor unpaid. Discovery Health knows this and uses this situation in an effort to cut their costs and maximise profits.
Low consultation rates: Discovery believes that a surgical specialist's rate for an hour consultation should be in the region of R170.00. Practices cost more than that to run. As such, this recognition of a service value below its cost promotes deterioration in patient care as doctors scramble to keep their practices running. For next year, Discovery management plans to pay out at 20% below the 'medical aid rate’ for some disciplines! Remember if you please last year's profit of R563 million. What on earth are they thinking?
Hospital rating system: Discovery has taken upon themselves the task of 'rating' private hospitals for procedures, arguing that this allows their members to 'choose better quality.' So one can look up a procedure at a hospital, and see it rated as 'poor,' 'below average, 'average,' or 'above average.' This rating system has been severely criticised for being biased and unscientific. It is misleading, of no use whatsoever to the member, and libelous to the doctors working in the clinics. Quality in medicine costs more, not less.
KeyCare package: This is a low cost Discovery medical aid plan marketed to those who cannot afford comprehensive medical aids. In principle, a good idea, but one can only go to certain hospitals, so the plan is of little use in towns or areas which do not have designated hospitals. The patient has no choice of specialist, and may have to travel to other towns for hospitalisation. The main issue is that the local doctor is expected to manage the pain and postoperative complications, without doing the initial surgery. One way we, as specialists, have decided to deal with this manipulation is by refusing to see patients on these plans coming to us solely because we work in a designated hospital. (For once doctors are starting to stick together.) The result however is that if you have a KeyCare plan, you may not be able to get the treatment you need because no doctor is prepared to treat you in another town. Moreover, brokers are now moving members from better plans onto this one, based on cost. The broker gets his commission, and the member gets a nasty shock. This practice is unethical.
Motivations: Nobody from a medical aid may refuse a surgical procedure or special test without discussing the case with the doctor on a peer-to-peer basis. From a medical aid point of view, this means that the medical advisor has to ring the doctor up and discuss the case with him. Medical advisors are accountable for their decisions, according to Health Profession Council rulings. The reality is that Discovery and other funds simply ignore this. They don't have enough medical advisors to speak personally to each doctor, and as a result they unilaterally make decisions affecting their member's health and refuse authorisations for tests or operations.
What consequences will these bullying tactics have? Well, first of all, you are going to have to pay your doctor more out of your own pocket, over and above your increasing medical aid subscriptions, and probably at the time of service. (You pay your grocery, restaurant and petrol bills like this anyway, so it is probably a good thing.) Your relationship with your doctor may be at an instant disadvantage simply because of your medical aid. If you are on the KeyCare plan, you will not get the doctor you want, and may find the treatment you need is not available anywhere in your region. A third party, the medical advisor, is going become involved in every single decision affecting your treatment, able to deny investigations and quality treatment options, without the courtesy of discussing this with your doctor, and to date, without taking responsibility for your care should things go wrong.

Health Expenditure in the private sector in 2004

Where does my money go? It may surprise and shock you to know that of every rand you spend on medical aid, only 6 cents is spent on GP’s, and only 7 cents on medical specialists. The lion’s share of health expenditure (30.4%) goes to the hospitals, 15% on medications, 9% on radiologists and pathologists. Non-healthcare costs (NHCC) comprise 20% of the annual budget! This is what is spent on brokers’ commissions, and administration costs, more than all consulting doctors combined!
There is a popular image of the doctor as a rich, money grabbing professional who puts his patient’s needs lower than that of his pocket. The reality is very different. For most doctors in this country, financial rewards are low on their lists of priorities. The truth is that practices are so expensive to run, and that medical practice in general comes with a list of responsibilities and sacrifices so great, that to struggle financially on top of it all makes us question why we put ourselves through all this effort in the first place. The answer is still what made us become doctors, a sense of responsibility to a noble calling. This responsibility, I believe, is what has prevented doctors from mobilising in the past. In a way it has become a weakness that others try to exploit.
I hope the picture is starting to become clear. The public must ignore the advertising hype, the sporting sponsorships, and the mountaineering accomplishments, and realise what Discovery is doing to the medical profession. For the first time, there is a call for doctors to not see Discovery medical aid members for week. Call it, if you will, a strike. Nobody can refuse emergency treatment to a patient, but for non-urgent problems, that is a different story. I think it will be a sad day if this happens, but I speak for many medical professionals when I say that we have had enough of corporate greed and manipulation. I want the best technology, and the best outcome for my patient at a rate that is fair to me.
So what can you do? I think at the very least you must write to Discovery and demand an explanation from them. The only way I see change happening is when the public vote with their feet, and move to another company. See your broker, and put this to him. There are many other medical aid plans that are far more supporting of the medical professional, and do not cost more.
This link is very useful: http://www.health24.com/medical/Condition_centres/777-792-2002.asp. Alternatively email Discovery at healthinfo@discovery.co.za.
Please forward this to as many people as you can, whether you are a Discovery member or not. Many other medical aids are influenced by their business tactics. If Discovery's power is not limited, all medical aids will one day be in this situation, with the member paying the consequences.
If so, it may not matter to we medical professionals, because at that time we may all (reluctantly) be in Canada.

Name withheld for professional reasons
MBChB
FCS(SA)