OPINION | Brenda Kubheka: Medical aid members strangled by pre-authorisation 'hassle factor'

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The writer questions if some processes are designed to discourage patients and their professionals from gaining access to benefits and the required care.
The writer questions if some processes are designed to discourage patients and their professionals from gaining access to benefits and the required care.
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After spending the whole day navigating the pre-authorisation process to get a patient admitted for in-patient care, Brenda Kubheka asks if this is a form of 'hassle factor'.

A few days ago, I spent almost the whole day navigating pre-authorisation processes, trying to get a patient admitted for in-patient care. This was for a medical condition covered by the medical aid scheme, at least according to the benefits guide and the Medical Scheme's Act.

This is the second episode from a service user perspective of being hassled by pre-authorisation processes in the past three months. These two incidents involve patients belonging to different schemes. I am unsure if I should applaud these patients for having me fight for their rights or take a step back and start thinking about those without loud voices, including others needing someone to advocate for them. 

I spent significant time in the medical aid industry during my corporate career. Being closer to the organs of the funders, "their hearts, souls and minds," was an eye-opener.

I learnt that medical aid members and some health professionals abuse and misuse medical aid benefits for financial gain and other reasons. These actions lead to schemes implementing risk management processes strangled by red tape, creating an invisible barrier to accessing benefits.

On the other hand, as a practitioner having managed an emergency department (ED) practice in Soweto for more than a decade, I began to wonder if some of these processes were designed to discourage patients and their professionals from gaining access to benefits and the required care.

We found ourselves questioning if some frontline decision-makers are equipped to process the information provided during pre-authorisation or maybe are being failed by guidelines and automated decisions from their computers. The practice doctors also became frustrated by the scheme's medical advisors, who happen to be doctors, who suddenly become evasive nameless and faceless people when needing to escalate matters.

One of the cases included a patient who had been attending a GP practice several times for a chest ailment and decided to seek a second opinion from our practice. A final diagnosis was made, and the patient met the criteria for in-patient care and intravenous antibiotics. The scheme pended the authorisation for hours, and the patient was not transferred to the ward. At some point, the patient requested to be sent home on oral medication. 

The hassle factor 

The hassle factor is a term coined in the United States. It is defined as 'arduous unpaid work that patients must do to get questions answered between appointments, or to understand and navigate pharmacy, lab testing, imaging, and speciality services'.

The administrative burden contributes to practitioners refusing to take medical aid as a payment method, at least those who can and typically work in big metros and suburbia. The factor also erodes the doctor-patient relationship because the experience of the hassle factor translates to patient experience. It is no surprise that patients might resort to paying for covered services from their own pockets and even pay more than the recommended scheme rate. The hassle factor is also associated with lowered job satisfaction for doctors.

READ | OPINION: Brenda Kubheka - Criminalising medical practice won’t make healthcare safer

Back to my case, we paid the co-payment applied by the scheme and later discovered that the scheme does not have a designated service provider (DSP) and should be funding the hospital event in full. They had requested that we call all the facilities on the scheme's DSP list to check for the one providing the required service.

I was perplexed that that scheme would have such arrangements and fail to keep a list that would assist patients in reducing out-of-pocket payments and complying with the scheme rules. This raises the following questions: What happens to members who do not have access to phones or adequate airtime to call all these facilities? What happens to patients and families who do not understand their rights? The hassle is so much that you give in and call around, pay illegitimate co-payments, or give up. For patients, the hassle may lead to delayed care or foregoing the care altogether.

One wonders how many scheme trustees actually ask for reports and qualitative explanations for the rejections or short-payment trends. Is the hassle factor celebrated and incentivised for reducing the cost of care or utilisation of services unlawfully? Again, it is understandable that schemes through managed care organisations put restrictions in place to manage the cost of care, waste, and abuse; at the same time, unintended consequences ought to be kept in mind.

Game the system

A series of studies cited the doctors' willingness to "game the system" and use deception on behalf of their patients to obtain specific healthcare benefits, especially very sick patients and in instances where appeals processes are daunting. Unfortunately, this benevolent act is unethical and alters the patient's medical records, including the data used for planning. After losing a day's work, I wonder how these processes get tested randomly and regularly by policymakers and those tasked with protecting the scheme members' interests. The unintended consequences of the strangling red tape ought to be considered by all relevant parties.

The information asymmetry between funders, professionals and scheme members is a significant challenge and a catalyst of the hassle. The recent experiences left me bruised because of the roughness caused by a lack of compassion and humanity.

Being ill makes patients more vulnerable, and it tilts the power dynamics. This power may be open to abuse during the pre-authorisation process. On both occasions, the process felt indifferent at a time when members and their families need a warm, humane, and reassuring approach.

- Dr Brenda Kubheka, Founder and MD of Health IQ Consulting focusing on Clinical risk, healthcare ethics and research. 

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