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14 December 2015

Who should decide what medical treatment you need?

It has emerged that medical funders are dictating to private hospital groups what treatment should be offered by healthcare professionals who use their facilities in treating patients, leading to cheaper but probably inappropriate care.

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What guarantees would we have of the quality, efficacy and safety of our health care if decisions on treatment were made by professionals who are not trained for this, or as a result of decisions made by corporates?

That’s not a hypothetical question: this is happening right here in South Africa.

An essential part of rehabilitation

Schemes are apparently threatening hospitals that they would lose their "designated provider status" if they allow supporting health professionals into wards, or if they allow them to provide certain types of care.

These ancillary health professionals are trained, qualified medical professionals who are essential parts of the multi-disciplinary team needed to treat patients effectively – including dieticians, occupational therapists and physiotherapists.

Physiotherapists are health professionals whose therapies are often an essential part of rehabilitation. As first line practitioners, they operate independently of other healthcare entities such as hospitals.

A first line practitioner is a professional whom you may consult directly, without first seeking a referral.

He or she can, within their scope of practice, evaluate and assess your condition, diagnose and develop a plan of treatment as well as treat. This is a very responsible role and is in part the reason why physiotherapists spend four intensive years at university to earn their qualification.

Read: What to look for when choosing a medical scheme

In a hospital situation, the attending doctor or surgeon (usually the professional who admitted the patient to hospital) will normally refer a patient to a physiotherapist. The physiotherapist will evaluate the patient in the ward and decide what plan of action is most appropriate for the patient, based on his or her independent clinical reasoning, but very often in consultation with the doctor.

He or she may also offer health advice and draw up an exercise plan if necessary, all aimed at doing what physiotherapists are trained to do: restore the patient to optimum function.

'Each medical professional has a unique role'

There is abundant clear evidence from extensive research that without this function, in many cases recovery will be delayed or limited – in fact, the absence of physiotherapy during a stay in hospital can actually be detrimental (for example, an ICU patient who develops deep-vein thrombosis will be in much worse shape as a result)1.

Patients in maternity wards, to cite another example, may require physiotherapy for prevention of lung complications, urinary incontinence, breast feeding, and general mobilisation to reduce their stay in hospital.

“Each medical professional has a unique role,” says South African Society of Physiotherapy (SASP) president Dr Ina Diener. “Within a hospital setting, ours is crucial to ensure that the patient who has benefited from acute interventions such as surgery, is restored to the very best function and quality of life possible. We are the experts at assessing and treating patients in this context.

It will be a great disservice if this practice – of cutting corners on treatment to save money – becomes universal. And believe me, it will come back to bite the medical funders, when patients who have been inadequately treated as a result have to return to hospital, or seek endless specialist or physiotherapy treatment, because they were not properly rehabilitated in the first place.”

Read: 25 conditions your schemes must cover 

Medical schemes must, by law, develop their funding protocols on the basis of evidence-based medicine, that is, they must be able to show that the interventions they fund are appropriate and based on sound medical scientific principles.

The SASP has this information, demonstrating that it is to the benefit of patients to partner with hospitals and funders to ensure appropriate care. Unfortunately, the decisions made and communicated to hospitals have not incorporated this important partnership.

Scrimping on treatment in this way can compromise other care in the hospital. If a nurse is asked to perform some of the roles a support professional would otherwise have performed, it will be in contravention of their own ethical rules (that is, doing something s/he was not trained for).

Cutting costs

It would also add hugely to their work load. Most importantly, performing actions one is not registered for, constitutes an offence in terms of the 1984 Scope of Practice of Nurses and Midwives.

One of the key tenets of healthcare- and consumer rights, is the patient’s right to decide, with full information, on what treatment to accept or decline.

This right is entrenched in the National Health Act, and the Consumer Protection Act. It is not and never should be within the purview of either a hospital’s management or a medical funder to make that decision on the patient’s behalf. 

Read: Medical schemes - the basics 

In applying pressure to the hospital groups to cut costs by not allowing patients access to care supplied by supplementary healthcare professionals, schemes may fall foul of the requirements set in medical schemes legislation, i.e. “a participating health care provider may not be forbidden in any manner from informing patients of the care they require, including various treatment options, and whether in the health care provider’s view, such care is consistent with medical necessity and medical appropriateness”.

Schemes should therefore not pressurise hospitals in keeping healthcare professionals away from patients, where such care would be appropriate.

There are also questions as to whether this behaviour might be in contravention of competition law, in particular where the scheme and the hospital are agreeing to keep certain healthcare professionals out of reach of patients.

“In our view, this kind of vertical collusion is in direct contravention of the Competition Act,” notes Dr Diener.

“I do not believe this is the right route, to compromise patient care in order to reduce costs,” says Dr Diener. “And I do not believe the South Africans who pay high premiums to cover the healthcare costs of their loved-ones for illness and injuries, and to keep medical schemes afloat, will accept this type of interference into their healthcare rights.”

Read more: 

Why medical schemes are so expensive  

SA patients pay more for medicine  

Medical schemes: what matters most?

Reference:

  1. Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review. Peiris CL, Taylor NF, Shields N. Arch Phys Med Rehabil. 2011 Sep;92(9):1490-500. doi: 10.1016/j.apmr.2011.04.005.)
 
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