After publishing Discovery Health's reply to the article on changes in payouts for chronic medications, Health24 received the following interesting letter from Dr Wynand Smit, a GP in Grabouw in the Western Cape.
As a result of the obvious shock and unhappiness of Discovery members with regards to Discovery Health's "new" chronic medication regulations and costs, and the reply from the CEO of Discovery, I would like to make the following points:
- Fact: It is untrue that "..our members always have an option of full cover". According to their CIB list (of approved chronic medication) they do not approve a single one of the Biologics Medicine Group (for example Humira) for rheumatoid arthritis. The patient therefore has no option to obtain this as there is no alternative available (no CDA). And it is very expensive. It is prescribed for patients for whom the cheaper medications simply do not work. It is prescribed worldwide in every western country to modify the disease and to prevent long-term damage to joints. It is the most effective medication.
- Fact: It is untrue that ".. negotiates.. with the industry.. favourable medicine prices for our members..". It is currently illegal in South Africa for manufacturers to offer medication at reduced prices only to certain interest groups, hence the published price lists for medications.
- Fact: It is untrue that ".. exceptions can be applied for and full cover can be granted on the basis for clinical need". I have had a case where one of my patients in an advanced state of illness was being treated in hospital. He had a problem regarding abnormal pressure points and Discovery refused to pay for the use of a special mattress that would help prevent bedsores. (This mattress was prescribed by the physician.) The decision is taken by administrative staff, and is approved by their "clinical staff" without them having seen the patient themselves.
- Fact: it is untrue that ".. ensures.. a fair..basis..", because I do not see how decisions made by administrative staff, approved by a "clinical panel" without the patient having been seen, can veto decisions on what needs to be done, made by specialists in a hospital.
- Fact: it is simply untrue that the "...current medicine list....based on best available scientific evidence..". I dare you to ask the SA Rheumatism and Arthritis Association, an association of medical specialists, what the worldwide consensus is on the role of Biologics in rheumatoid arthritis. And the "..clinical appeals process.." of Discovery is actually a sick joke.
- Fact: there is no "..agreed Discovery Health rate.." as is being alleged. What is true is that Discovery decides completely unilaterally on an amount (lower than the norm) that they are prepared to pay. They then present this amount to service providers for contractual acceptance, so that these providers are then guaranteed direct payment by Discovery, otherwise the claim is paid out directly to the patient. These are pure bullying tactics that force service providers to accept these tariffs for business reasons.
- Fact: Discovery has been found guilty of misrepresentation in an advertising campaign, specifically relating to benefits they pay their members. Also take a look at other transgressions that have made the news.
- Fact: Adrian Gore, CEO of Discovery Holdings, is the 15th richest person in SA, according to the Sunday Times Rich List (the 11th according to Forbes) with a personal fortune estimated at R2,1 billion.
The question that I have to ask is whether I can trust Discovery Health that they will stand by me financially if I become really ill?
(Letter submitted to Health24's Contact us section on 25 January 2011)