Since the day I started my private practice, I promised myself that I would NEVER discuss finances with my patients. And as far as possible, I have kept that promise.

But, as the medical industry has become more complicated over the last number of years, patients have felt more and more that they need to discuss their financial concerns with me.

Unfortunately, I am the wrong person, as I honestly do not understand “THAT PART” of the practice at all. I am a medical specialist first and foremost, and I expand my knowledge and skills every day to focus on caring for my patients, and I leave the C-word of the practice to my practice consultant and my two practice managers. This does not mean that I am not fully aware of this vital and sensitive topic.

Amori has been working as practice manager from the beginning and has recently been re-deployed as practice management consultant. The success and failure of the administrative side of the practice rests squarely on her shoulders. She has a Ph.D. in Business Management, and has, since 2001, attended various courses to equip herself and to stay informed to ensure that we comply with all the myriad regulations governing the administrative side of a medical practice.

Amori proceeds to explain medical aids as follows:

When I became part of the medical world in July 2001, things were straightforward: The fees a doctor could charge were stipulated in “The doctor’s billing manual”, which was supplied by the South African Medical Association. Doctors were constrained to a maximum rate (MASA rate), or could charge medical aid rates (SAMA rates).

Elaborating on the history of why things changed, does not change today’s reality. Briefly, you may remember that there were several investigations by the Competition Board into large industrial groups, such as the motor vehicle industry, which concluded that manufacturers colluded on pricing of their vehicles, therefore making it difficult or impossible for smaller companies to compete against larger companies. The Competition Board subsequently decided to include the medical industry in their investigation, and as a result:

  1. SAMA, who for many years supplied guideline fees, were no longer allowed to do this, as this was deemed price collusion between doctors.
  2. Doctors no longer had a guideline billing list for fees, and effectively must determine fees to remain competitive – essentially becoming businesses. There is no longer a maximum fee which doctors may charge. Patients are therefore encouraged to become customers, to “shop around” to find the cheapest doctor - or the one that they can afford.
  3. Hospitals must act likewise – effectively competing against one another for business. To ensure that they retain patients of medical aids, hospital groups sign “designated service provider contracts” with medical aids. This means that your medical aid can prescribe to which hospital you must go, even if that is not necessarily the hospital closest to you.
  4. Medical aids are impacted similarly: medical aids are encouraged to become commercial enterprises, developing different plans or options for different patient groups, with different rates being negotiated with different hospitals, and indeed also with different doctors.

This might all seem straightforward, but what does it mean for you, as a patient?

You should stop thinking like a patient and think like a customer when you make decisions about your health. You also need to realise that making decisions about your health is not easy – you should equate it to buying a house, a vehicle, insurance cover or doing retirement planning.

You need to understand the choices you need to make when you choose a medical aid, and what implications those choices will have for you financially, BUT, most importantly, what implications those choices will have on your health. And you should ask all the right questions before you sign on the dotted line.

The monthly fee you pay to your medical aid cannot be your only consideration, because, as with everything in life today – you only get what you pay for.

The following is by no means an extensive guideline, but covers some of the important factors you should consider when choosing which medical aid to join and which medical aid plan or option to choose, and a handy guide to evaluate whether you have chosen the correct medical aid and medical aid option or plan.

  • You need to know which medical aid you belong to, but far more importantly, you need to know which plan or option you belong to. Your plan or option prescribes the benefits you qualify for.

Many patients remain on the same medical aid, but because of cost considerations move to a different plan or option on that medical aid, without considering the long-term implications in terms of cost.

I will use Discovery Health as an example, because most of our patients are members of Discovery:

If you are on a Keycare Plan, we cannot treat you at all – you need to go to a contracted Keycare Specialist at a contracted Keycare hospital, and you need to be referred by a GP to that specialist.

If you are on a Coastal Plan your medical costs will only be covered if you are admitted to a hospital.

If you are on a Classic Plan, our fees will be paid in full, because we are contracted in to Discovery for all Classic Plans. However, this excludes all out of hospital fees, such as consultations, wound care and dressings, which you would have to cover yourself. However, procedures in our rooms will be covered from hospital benefits. Furthermore, should you be on a Classic Delta Plan, you can only be operated at Vincent Pallotti Hospital (there might be others, but this is relevant to us), and if you are on a Classic Smart Plan, we cannot operate you in main theatre, because neither Life Vincent Pallotti or Netcare Blaauwberg are contracted in, but we can operate you in our rooms.

If you are on an Executive Plan, Discovery will pay us at Executive rates, which is far more than our normal practice rate.

So, telling us you are on Discovery and asking whether they will cover the procedure depends entirely on which plan you are on and what treatment or procedure you are undergoing, and at which hospital we operate you.

Now please consider that there is a myriad of medical aids, with an even bigger number of plans or options. You cannot expect your doctor to know the ins and outs of each of these plans – you need to know this for your plan, as you are the member.

  • Which medical conditions are NOT covered by your medical aid? (Which procedures are scheme exclusions?)
    Your medical aid, your broker or your financial advisor should have disclosed this to you prior to you joining the medical aid. Unfortunately, many patients find out too late that this was not disclosed to them, or that they did not read the fine print, or that they did not think it would be important.

    Did you know that there are medical aids that will cover your wife for her mastectomy and cancer treatment, but will not cover the reconstruction after mastectomy? We experience this weekly in our practice, and it is heart-breaking to console a female patient who has been stripped of her breasts, her femininity, and who had to fight for her life fighting breast cancer, but whose medical aid will not pay for her reconstruction. It is equally as heart-broken to have to console her husband, who loses all his dignity, because he cannot provide for the woman he has shared his whole life with, and for whom he cares deeply.

    You cannot be mad at the doctor, who cannot do the reconstruction because of the choices you made. You cannot verbally abuse his admin team, and declare them incompetent. You cannot be mad at the medical aid, who disclosed these facts to you prior to your joining them – you need to read the fine print, and make the right choices.
    And if you haven’t, log on to the internet tonight, venture over to your medical aid’s website and find out what is NOT covered by your medical aid (scheme exclusions), and make sure that this sits well with you.

    One way in which you can do this, is to be aware of and make a list of your family’s medical history. Certain conditions and diseases occur frequently in certain families, and can range from breast cancer, to prominent ears, skin cancer and high blood pressure. Make sure that your medical aid covers you for these conditions.

  • Does your medical aid prescribe to which hospitals you may go, in other words, do you have a specific hospital as a designated service provider?
    Many medical aids have negotiated fees with certain hospital groups, and often even with specific hospitals. This means that, should you need to be admitted to a hospital in the case of an emergency or for surgery, or even for routine check-ups, that you will have to go to that prescribed hospital, even if there is another hospital closer to you.
    Should you suffer a life-threatening emergency, you can go to ANY HOSPITAL, where you will be stabilized by the accident and emergency unit, and even admitted to that hospital, but only until your condition has stabilized, where after you will be transferred to another hospital – your medical aid’s designated service provider. This can be far from your family, or your spouse, who will then find it difficult to support you while you recover.

    Imagine rushing to the emergency unit of your closest hospital, because your child was bitten by a dog, to wait in queue until someone can attend to you, only to be informed that you need plastic surgery, but would have to go to another hospital, because your medical aid has prescribed to which hospital you may take your child. Alternatively, you could face paying a co-payment to the hospital, which can, in some cases, be as much as 30% of the hospital costs.

    Imagine making an appointment with a doctor, often having to wait a month or two until you have that appointment, paying for the consultation fee, being informed of the pre- and post-op surgical care required, forming a bond of trust with that doctor, only to be informed by his receptionist after the appointment that the hospital(s) where your doctor operates, are not designated service providers for your medical aid plan or option.

    Patients and their dependents often vent their frustration at hospital staff, doctors’ admin staff, nurses and doctors when they are informed of this. This is not our responsibility. We did not sign up for that medical aid or that medical plan or option – you did. You should be fully informed where you can go to when you need a doctor.
  • Can you make an appointment with a specialist, or go to a specialist directly, or do you need to be referred by someone else, most often your general practitioner?
    We have many patients that have been loyal to us over the years, who prefer to phone in, see Dr Struwig directly for the new lump or bump (most often a new skin cancer). But when we want to proceed with surgery, we must inform them that there is a huge co-payment because they weren’t referred by their GP.

    You belong to the medical aid – not your doctor – you need to know this information.

  • What are the implications if you have an emergency? Will your medical aid cover you if you are being treated in the accident and emergency unit, even if a plastic surgeon stitches up your laceration there, or do you need to be admitted to hospital?
    It is important to know that the accident and emergency unit, or trauma unit, of a hospital, does NOT count as a hospital if you are on a hospital plan. So, your son’s small laceration on his chin can be stitched up in the trauma unit by the plastic surgeon, of course! BUT, the plastic surgeon’s fees will not be paid, nor the trauma unit’s fees. These will be for your own pocket.

  • Do you have a waiting period for certain conditions or diseases?
    If you do, and you sustain these medical conditions or diseases BEFORE your waiting period is over, you will not be covered, and you will be liable for your own costs. This can become a huge problem if you are diagnosed with an aggressive skin cancer, for instance, and have a six-month waiting period.

  • Will your medical aid pay for dressings or medications required after surgery?
    Consultation fees cover the cost of the consultation, surgical fees cover the costs of surgery. Dressings and surgical after care are not included in the surgical fee. If you suffer a devastating injury like an extensive burn, you might require months of out of hospital dressings, which could be expensive, and which your medical aid will not cover, for instance, if you are on a hospital plan, or no longer have savings in your savings account. The same would apply for the out of hospital rehabilitation you might need.

  • Are there any co-payments that you will have to pay?
    Some medical aids require a co-payment to be paid to specialists if you consult them without a GP referral. Some medical aids require a co-payment to hospital upon admission as a standard rule.

It is important to realize that YOU are the member of your medical aid. Your doctor is not obliged to know what your medical aid will cover and to which extent – it remains your responsibility to inform yourself extensively about this.