If the motivation for funding for wheelchairs and appliances is clear, focused and timely, the battle is more than half won
I serve on the Management Committee of QASA and am also a medical adviser to a number of medical aid providers. I often review applications for ex gratia assistance for wheelchairs and other disability appliances, where medical aid benefits are not sufficient. So I am exposed to both sides of the problem: I experience the frustrations of rehabilitation staff and individuals with a spinal cord injury (SCI) when they are unable to convince organisations to fund appliances. But I also see the often inadequate ways in which the argument for these appliances is put forward.
In an effort to find a helpful way forward, I recently interviewed a few SCI individuals, a manufacturer of disability appliances, and physiotherapists and occupational therapists working in rehabilitation hospitals.
I also reviewed the commitments of the four major funding organisations; the State, the Road Accident Fund (RAF), Compensation for Occupational Injuries and Diseases (COID) and medical aid providers. They all expressed a commitment to meeting the needs of persons with disabilities, but I discovered two factors that were common to all four. These were:
A poor understanding of the needs, including:
- “One size fits all” benefit specifications
- Incomplete benefit specifications (essential appliances not covered)
- Inappropriate training (compounded by high staff turnover)
- Long replacement cycles
Administrative inefficiencies, including:
- Long waiting lists
- Delays in authorisation
- Delays in payment
- Budget constraints
To this, I’d add:
- Inability to adequately motivate the needs of the SCI individual
The reality of “a poor understanding of needs” is that the actuaries who design benefits as well as the medical and nursing staff who assess requests for assistance generally have had little exposure to the realities of quadriplegia and paraplegia. They do not understand why, for example, a C5 quadriplegic needs a chair with tilt-in space and recline facilities, a sophisticated (expensive) cushion as well as chest straps, back and arm support and other essential accessories.
Or that the wheelchair of a SCI person who lives in a shack in an informal settlement with uneven terrain will have a much shorter lifespan than the wheelchair of someone who resides in an independent living centre.
To address this, the South African Spinal Cord Association (SASCA) introduced a two-part booklet at its congress in April of this year. The first part explains what is needed per level of injury in terms of wheelchairs, wheelchair accessories, bathroom appliances, and so on. The second part explains why these are needed, by illustrating the level of the SCI, the fallout (extent of paralysis) and the impact of the paralysis. My view? The booklet is a good reference, but case-specific needs still need to be motivated further. (The SASCA Assistive Devices Guidelines for Persons with Mobility Impairment is available on the SASCA website www.sasca.org.za in printable PDF format.)
Most motivations detail what is required but make no mention of why. The nature of the injury is often just stated as paraplegic or quadriplegic, with no further explanation. And rehabilitation hospitals often send extensive progress reports, hoping to express the extent of the severity of the injury.
Compounding the problem is that different funders require different types of motivations. Some require short, succinct motivations while others require more detailed documents. I’d propose a motivation in the form of an executive summary with a more detailed report added as an annexure, where required.
For example, start with a brief description of the person and the nature/source of the injury: A 21-year old male with a C4-5 fracture following an MVA. Add a short description of the extent and nature of the paralysis and the impact on mobility, bowel, bladder, etc. Mention the home circumstances and sum up with what is required and why it is essential to have. (Funders don’t like “nice-to-haves.”) Cite the SASCA Guide as reference.
Remember to motivate timeously. Don’t wait till a week before discharge. As soon as the outcome of rehabilitation is known with reasonable certainty, start motivating. Be honest. If a funder feels you are going overboard, you’ll damage your own case.
When claiming from a medical aid, bear in mind that wheelchairs and daily living appliances are not Prescribed Minimum Benefits (PMB). Any above-benefit requirements will require ex gratia consideration. Ex gratia funding comes directly from the reserves of the medical aid. So the committee must weigh up the needs of the individual against the fairness to the collective membership. If the committee feels that the requests are excessive or could set an inappropriate precedent, they will not approve.
The inescapable fact is that, at every opportunity, we need to advocate, advocate, advocate…
Ida’s Corner is a regular column by George Louw, who qualified as a medical doctor, but, due to a progressing spastic paralysis, he chose a career in health administration. The column is named after Ida Hlongwa, who worked as caregiver for Ari Seirlis for 20 years. Her charm, smile, commitment, quality care and sacrifice set the bar incredibly high for the caregiving fraternity.
email: georgelou@medscheme.co.za
