Medical Schemes

Luke

Loved this show~!

Medical proffession is rotten to the core

Medical schemes abuse us, doctors charge rediculous rates and these are not negotiable - name one other industry in which this will go down well? They can kill you and you still have to pay!! If they make a worng diagnoses, you have to pay.

Great

At last - someone who is not scared to apeak the truth. Well done, doc.

Thanks, Doc

Thanks Doc, for having the guts to speak up and helping the rest of us understand what Discovery's waffly response really said.

Question the doc's 'Facts" 

Hi Doc - some questions to your purported 'facts':
- Is Humira approved by the MCC for use in SA for the treatment of RA?
- Not true - the state receives significant drug discounts from manufacturers. I know Discovery has negotiated better prices on certain drugs which then benefit ALL patients (not just Discovery members)
- Considering that R12bn of medical aid fraud occurred last year, and more than 50% of that was by medical professionals, surely risk management is warranted by Discovery?

WTH

What the hell?! Did Discovery really think that they would never get caught? Thanks doc for making sense out of that ludicrous response. And thank you Susan for looking into this in the first place.

Adrian Gore

How is it relevant that Adrian Gore is the 15th richest person in SA? As stated he is CEO of Discovery HOLDINGS, ie the entire Discovery stable which includes the (by law, not-for-profit) medical aid, plus all the other subsidiaries which are profit-making.

DeeCee

Actually DeeCee - Humira, Actemra, Revellex, Enbrel and Orencia are all registered and approved by the MCC for Rheumatoid Arthritis - Fact! I work with all of these products daily. As for Dr. Smit - I would advise getting forms from SARAA and completing these and sending these to Discovery. Without the SARAA auth - it will come off the patient savings.

Full disclosure

A quick reality-check for the good doctor: please will you provide full disclosure in terms of the incentives you receive from pharmaceutical companies to prescribe certain drugs. Please also disclose any and all benefits you may have received from these companies in any dealings you may have had with them (lunches, gifts etc.) Please also warrant that you have never over-prescribed nor over-treated a patient.

Pagel

Pagel, you need to see a psychologist re your aggression. But then, no, they are not negotiable regarding their fees.
Oh wait, as are lawyers, hairdressers, retail....

@ Brendan

Thanks for the info, Brendan. Quick question - what is the average monthly cost of these drugs versus non-biologics? Next question - what is the average profit margin for the pharma companies of these biologic drugs versus non-biologics? Next question - what is the price of these biologics in other countries compared to the price charged here in SA?

how it works

a medical aid is simply a platform through which hundreds of people (the members) pay somone to manage their funds collectively so that they will be able to afford to pay for the most likely conditions and events experienced by their members. There are simply some things that are too expensive to pay, or too rare to budget for. The actual profit they make is in the region of 2%. Get over it.

DeeCee

You must be working for Discovery as you are fighting teeth and nails to protect them.

@DeeCee

How much did Discovery pay you to comment on this article...

DeeCee

I can say that the prices are much more than the usual Methotrexate/Cytotoxic agents - exact figures I'm not sure of - however I must add that most of the patients receiving these meds are as a result of the non-biologicals being ineffective after a while. In SA we also have Single Exit Prices and that is not determined by us - we just have the dispensing fee structure. The Pharma companies that produce/import these meds will be able to assist you with the pricing locally compared to overseas.

@Rstorm &  Eddie

No, sorry guys - don't work for Discovery - I'm an investment analyst that researches the medical industry and I have a pretty good insight into the dynamics of the industry. If any of you were remotely interested in the facts, go and look at what the ROE's for the Pharma companies and Healthcare companies was last year and make up your own mind where the most profit gouging is taking place. I defend Discovery purely on the basis that I dislike uninformed, lazy opinions.

@ Brendan

Thanks again, Brendan. My info shows that biologics are often 3-4 orders of magnitude more expensive than non-biologics. Given the extreme costs of these drugs, one would expect significantly better patient outcomes, would you agree? Unfortunately, all the data suggests that, at best, these drugs improve patient outcomes by less than 10%. Given that the drug costs 1000% more, and (at best) delivers a 10% better outcome, do you think it wrong that medical aids should be reluctant to fund them?

DISCOVERY HEALTH

Humira is a life saver and I am lucky that my medical aid pays 100% for it on chronic. Before Humira I was walking with crutches. Also, Discovery does not treat psoriases or psioratic arthirits as crhonic illnesses.

DeeCee

My last comment: from your first comment, it is clear you know very little about Medicine, although you think you do. For your interest: This drugs are extremely expensive, and cost about the same overseas (I am currently working in Ireland). They do however cost less than many Chemotherapeutic drugs. And you know what: they can also totally stop the progression of the illness, making the future multiple operations for joint replacements unnecessary, not even mentioning the pain relief it gives.

DeeCee

Also, think of the increase in productivity of these people! Please do the honourable and go to a Rheumatologist's practice. Ask the patients it the improvement is only 10%? Until then, I think you should leave this forum.

Smit

Actually, I do know alot about medicine - and I know alot about the economics of medicine (my PhD in Health Economics gives me that). I see you haven't seen fit to respond to Pete's request, yet. Strange that. Thank-you for your polite request to me to shut-up - I think I'll pass on that. As for the 10% improvement - real-world outcomes-based data tends to be more accurate than anecdotal data provided by medical professionals with vested interests and perverse incentives to over-treat patients

DeeCee

Hmmm...I would rather believe the doctor. If you are so passionate about sharing your knowledge, why the need to write under a pseudonym...

Discovery

We were forced to discontinue our previous medical aids and go over tp Discovery, in fear of losing our jobs we did so. Now only have problems as Discovery does not cover half of what old medical aid provided. Really disappointed and wish I had never joined, or forced to join.

To everyone on this forum

Guys, we should never forget that it's about healing people. That's the important issue.

Eddie

Eddie, for goodness sake, don't simply believe either the doctor or me - do some basic research and develop an informed opinion of your own. By dint of my job, I get special insight into the medical industry value-chain, and I can tell you that medical schemes (and their administrators) are the least rapacious in a very crooked industry. When R6bn of medical fraud is perpetuated by medical professional in SA, you need to ask yourself whose interests are best served if medical schemes paid more?

Not sure

I am no expert when it comes to medical schemes, and I am sure there are fruadulent doctors out there, but I cannot see how that problem can be solved by cutting my chronic medication payouts. Don't the schemes have people who check up for fraudsters rather than simply paye out R6bn?

DeeCee

You may know something about health care economics, but please try and walk a mile in the shoes of RA suffers for whom the non-biologics only give severe side-effects and no improvement. It is a horrible, systemic disease that can, and still do, kill people and cause severe disabilities. NONE of the approved or experimental treatments can cure RA, but for some people biologic treatment makes the difference between leading a near-normal life and being disabled. In my mind this is priceless.

Pills

I dont see why sick p[eople must b e punished for those who steal.

comment

Credit and not admonishment should be given to Adrian Gore for being an entrepreneur and creating a great business and in turn doing well for himself. With that said we all have free choice as to which scheme we are a member so if you are unhappy why don't you move.

@Nightlife

Medical schemes absolutely have entire departments to try and detect fraud. Across the industry roughly 10-15% of gross premiums are used for fraud detection and prevention, and around 15% of all claims have an element of fraud associated with them. However, it still happens on a huge scale - mainly based on " code"  fraud (services are charged for using special codes and the medical professionals manipulate these codes to charge for more than the service they provided). Google " Medical Fraud SA" 

@Walkamile

Walkamile - you are correct, to a sufferer of any chronic disease, it is priceless. However, unfortunately, in the real world a price IS put to this treatment (the price that doctors and pharma companies set). This is the price that medical schemes have to evaluate when deciding if the scheme can afford to pay for the treatment or not.

Don't get it

My medical scheme costs me just over R2500 per month. I have been a member for 7 years and in that time probably claimed a total of about R10 000. Never been in hospital. But if my scheme won't pay when I get really sick and the costs are high, there really is no point for me to continue with this. That is exactly what I hoped it would protect me against, but now it doesn't look like it will. A basic hospital plan will cost me about R1200 - I am now just wasting my money.

Forum

Thanks Dr Smit for setting the cat amongst the pigeons. A rather lively and informative debate which I hope will continue.

Humira

Suffered with Crohn's for 15 years. Near continuous pain &  nothing helped. Humira gave me my life back and the the chance to have a normal life with my family. " Improve patient outcomes by less than 10%" ??? It improved my outcome by 100%. I wouldn't wish the pain I've been through on anyone but perhaps people like DeeCee should try it for a couple of years.

@Michael Swart

If you are not forced to have medical -aid, why don't you take your money and invest it in some or other fund and build up your medical kitty. You must be disciplined at it however. Personally I think the whole insurance industry is an immoral industry build on the fears of the population. Change your mindset and quit giving you money away. Deposit your instalments in an interest bearing account. That way you are not loosing out like Michael

To Will

I wish I was disciplined enough to do that, but knowing my luck, I will be hit by a bus two months after I start paying into my savings scheme.

What?

I would like to know how they evaluate things, my husband has been on a medication for hyperlipidaemia (high cholesterol) for a number of years. Now that we have moved back to Discovery they suddenly say he does not qualify for chronic benefits as his " readings"  are fine. Is this not due to the fact that he has been taking this for a while, or instead of paying R200 a month for medication that prevents heart attacks are they saying they would rather wait for the worst.........

DeeCee

Regarding your 10% statistics
If it helps 10% of patients, so 10 out of 100.... well thats damn good for them and medical aids as 90% are on the cheaper meds.
so lets look at this effectively.... cheap medicine = 1 unit... expensive = 4 units
Expensive = 10 patients x 4 =40
Cheap = 90 patients x 1 = 90
Total = 130
So effectively accros the group medication costs = 1.3 units.
Thats 30% more .... on effective costs.

Got to love analysts :) didnt they create financial crisis's

Utterly misguided article and comments

only one comment referenced the fact that Discovery Health Medical Scheme is a non-profit entity. More claims paid to one member mean less for another or higher contributions for all. The administration company charges a fee for admin and doesn't benefit through not approving medicines. This ENTIRE letter is meaningless.

For more, check -|-//twentythirdfloor.co.za/2012/01/25/more-utterly-misguided-criticism-of-medical-schemes/

Kickass

It' sad that your simplistic exercise in numbers showcases the best reasoning from contributors to this forum. However, I need to clear up your unfortunate misconception of my 10% comment. The data shows that use of biologic class drugs improve outcomes by around 10% compared to non-biologics. This means that if normal (significantly less-expensive drugs) successfully treated 50 out of 100 patients, then the biologics would work for 55 patients (10% improvement in outcome). Continued below...

Kickass

Biologics cost about 3 orders of magnitude more than most non-biologic drugs. Therefore, if a scheme were using non-biologics drugs which cost R100 per month, the equivalent bioloigc would cost around R100,000 per month (this is not a random number - depending on body weight a month treatment of Herceptin can cost around R100k per patient). Therefore the scheme must evaluate the cost-to-benefit of a drug. Once again, look at the value-chain and ask who benefits most from more expensive drugs.

B4UGO

Hyperlipidaemia is a chronic disease listed as a Prescribed Minimum Benefit. Discovery (and every other medical scheme) is obligated to fund the treatment for this if diagnosed by a doctor. I can only assume that becuase you have just moved back to Discovery they are " underwriting"  your husband becasue of a pre-exisitng chronic condition at the time of joining the scheme. Normally this underwriting period is for a maximum of 12 months, but normally less.

DeeCee

may i please ask you to post a link to the research article that you quoted previously (" only 10% improvement" ) on biological treatment benefit...and if you can please clarify the term " improvement" . you are using imprecise terms very loosely and then claiming to be very scientific correct.

ps. statistics/evidence based medicine is a neccessity in current day clinical practice yet irrelevant to the patient sitting in front of me.

Man in the street perceptions

All these arguments mean diddly squat to the man in the street - all we see is our fees going up and our benefits going down and the profits rising.

Public perception is a real dog - look at what happened in the Arab countries when the public decided to stand together and fight what they perceived as injustice

Right now you can all enter with howls of protest or applause

Discovery

Discovery's subs have gone up by 8.9%. My monthly chronic medication's levy has increased from around R150 to over R900!!
Some medication that was paid in full last year Discovery refuses to pay for this year. Who's milking who?

Humira

DeeCee I am a RA sufferer, after 6 years on non-biologics and endless pain and endless sickdays at work I changed from Discovery to Medihelp and still belongs to the most expensive option BUT now I receive Humira. What a change!! For 3 years no sickleave taken, no " sorry kids mummy cannot join you" , no more old ladie-shoes without heels - 100% improvement!! And best of all: no joint-replacement operations in my future.
Stats is just academic talk to real patients!!!

Comment on article and Discovery

Thank you doc and well done!! High time someone speaks out loud and clear. I have been battling with Discovery for a long time now - and they are ripping the public off!!! Bad service, exhorbitant fees and diminishing benefits year after year. I've left them, i've taken my mom off and went to their competition and have MUCH better cover and MUCH better service!!!

Medical SCHEME

scheme
[skeem] Show IPA noun, verb, schemed, schem· ing. noun
1. a plan, design, or program of action to be followed  project.
2. an underhand plot  intrigue.
3. a visionary or impractical project.
4. a body or system of related doctrines, theories, etc.: a scheme of philosophy.
5. any system of correlated things, parts, etc., or the manner of its arrangement.
Nr 2 rings so true. It is UNETHICAL to dictate prices and what is covered, they get loads of money from members... a money making SCHEME!

Discovery

Interestingly, Dr. Smith's comments where all aimed for improved medical care for his patients. Only once did he mention unilateral pricing towards Service Providers. I think we can accept that he has his patient's interests at heart. The same cannot be said about Discovery and DeeCee.