Healthcare workers might be reluctant to challenge funders, but their oath to P prevent harm should come first. Mariska Morris reports
Patients and doctors often face the challenge of securing adequate funding for medical services. In the public sector, there is little to be done as facilities are under resourced. However, in the private sector, patients have the opportunity to challenge their medical aid on funding decisions. But, they need a little help.
Unfortunately, many healthcare workers are reluctant or hesitant to enter a debate with medical aids for a host of reasons. Some are non-confrontational by nature, tired or disinterested. But many are also intimidated; afraid that by challenging the medical aid they might damage the relationship with the funders.
“The medical aid can’t discriminate against healthcare workers if they support the patient in getting funding,” Elsabé Klinck, from Elsabé Klinck and Associates, expressed during a webinar sponsored by the Southern African Spinal Cord Association and the QuadPara Association of South Africa in August.
The webinar, titled “Empowering features in health law pertaining to SCI patient rights”, aimed to educate healthcare workers on the laws that empower and protect them to assist patients in securing funding and, as a result, adequate care.
Klinck referenced the Medical Schemes Act, Chapter 5, regulation 15 E: “A participating healthcare provider may not be forbidden in any manner from informing patients of the care they require, including various treatment options, and whether, in the healthcare provider’s view, such care is consistent with medical necessity and medical appropriateness.”
The Act continues to state that an agreement between the healthcare provider and the medical aid maybe not be ended when the doctor expresses a disagreement with a decision to deny or limit benefits, or when assisting a patient in seeking out reconsideration. Medical staff are legally protected against any repercussions for assisting patients to get better care.
When to fight
Under the constitution, everyone has the right to access healthcare and social security – the latter of which is often misunderstood. Klinck provided some clarification: “Social security is the ‘safety nets’ that are put in place, the precautions taken, to ensure that someone can afford their healthcare services.”
Social security thus includes a medical aid scheme. While the schemes are entitled to limit the benefits of their clients, there are some basic services that they are legally required to cover – the prescribed minimum benefits (PMBs). These aim to avoid serious illness and improve the efficiency in allocating resources. PMBs need to be covered in full by the medical aid.
However, each patient is unique. Therefore, the regulations make accommodations for individual circumstances or substantive equality. As Klinck explained: “In order for people to be equal, we might need to do more.”
Some patients might need additional resources, time in hospital or support services. In such cases, the medical aid might need to pay for additional services with no co-payment to equal the playing field.
In addition to PMBs, healthcare workers and patients should always try to ensure that funders cover the costs of appropriate care. This can be a challenge as funders often pin the decision to support funding on out-dated practices or public healthcare provisions, which, for a number of reasons, aren’t sufficient.
“Appropriate care, efficiency and effectiveness need to be key in the decision to fund or not to fund specific care. The decision should also be based on current evidence-based medicine,” Klinck said. “There can be various reasons why certain care isn’t provided in the public healthcare services, but this doesn’t mean that the Act should be brought into the argument.”
Funders should consider the best practices or most current evidence pointing to the best practice. This also means that treatment options and PMBs should be updated on a regular basis as new evidence comes to light.
In addition, evidence that shows the potential for a patient to be harmed by a treatment is enough to challenge a funder’s decision. Klinck explained: “‘Would cause harm’ is reason enough to challenge the medical aid. Doctors are ethically responsible for avoiding harm.”
A funder, on refusing a treatment, needs to justify the decision. “If we want to limit rights, we need to be transparent and make clear what the basis is,” Klinck said.
Under the constitution, patients also have the right to keep their dignity in the treatment. Thus, healthcare workers and patients can consider how the care impacts the patient’s dignity. Klinck used the example of a patient who requested a funder pay for intermittent catheters.
“The funder suggested that the patient reuse the catheter without considering the circumstances of the person. We have to consider how what we do impacts on human dignity,” Klinck said.
Without adequate, reasonable justifications, healthcare workers and patient should question the funders decision to fund or refuse specific services to ensure that the patient receives appropriate care based on current evidence that protects their dignity.
How to fight
The task of challenging a medical aid could be very daunting for both the patient and the healthcare worker. Klinck recommended the safety in numbers approach: “The constitution allows for class action. The group class action gives safety in numbers and make it easier to research. As a group, you can pick one doctor and one patient to fight the fight. “We have a case with a patient group as they are all being detrimentally affected. We can prevent them from all getting more disabled.”
She added that there are fields where patients make better progress often because of healthcare workers who have a flair for activism.
However, other healthcare workers are less enthusiastic about the legalities of medicine or simply unavailable. A group class action would allow several patients to benefit from the passion of one healthcare worker.
The suppliers of medical devices could also be invaluable in providing current evidence to motivate the case.
When there’s no more fight left
For healthcare workers who are unable to support patients in seeking reconsideration for the funding of medical services, even the act of providing more insights and knowledge could enable the patient to approach the medical aid individually.
“Patients are often unaware of what is considered PMBs,” Klinck said during the webinar. “And, we have come to accept it when medical aids refuse to cover costs. Healthcare workers need to tell the patient when a medical service is a PMB and needs to be covered in full.”
Through this knowledge sharing, patients will know when they need to seek out support to challenge their medical aid in the form of their peers, NGOs, legal staff and others.
“Healthcare is not cookbook,” Klinck concluded. “Even if there is a ‘recipe’, we always do evidence-based medicine. Not everything works for all patients. Medicine is art.”